Comprehensive Notes on Common ENT Disorders and Surgical Management
Introduction to Common ENT Disorders
Ear, Nose, and Throat (ENT) problems are remarkably prevalent in clinical practice, accounting for approximately of patients visiting a General Outpatient Department (GOPD). These issues encompass a wide range of pathologies arising from trauma, infections, and neoplasia, among others. While many ENT conditions primarily impact the quality of life, some can progress to become life-threatening if not properly managed.
Thyroidectomy Indications and Anatomy
The indications for thyroid surgery are systematically categorized by the "4 Cs" framework: Cancer, Control of thyrotoxicosis, Compression, and Cosmesis. Specific surgical conditions include benign thyroid nodules that produce compressive symptoms or present cosmetic concerns. Thyrotoxicosis cases involving Graves' disease, toxic multinodular goitre, or toxic adenoma causing hyperthyroidism are also primary indications for surgical intervention. Surgery is mandated for thyroid cancers, including papillary, follicular, medullary, and anaplastic varieties. Retrosternal goitre, which can lead to tracheal compression, and suspected malignancies based on Fine Needle Aspiration Biopsy (FNAB) or indeterminate cytology, provide further clinical grounds for thyroidectomy.
Anatomically, the thyroid consists of the right and left lobes connected by an isthmus, sitting anterior to the trachea and inferior to the thyroid cartilage (TC) and cricothyroid muscle. Critical structures identified during surgery include the superior and inferior parathyroid glands, the Inferior Thyroid Artery (ITA), and the Recurrent Laryngeal Nerve (RLN). Maintaining the integrity of these structures is paramount to preventing post-operative complications such as hypocalcaemia or vocal cord paralysis.
Parathyroidectomy and Neck Dissection
Parathyroidectomy is indicated for primary hyperparathyroidism accompanied by symptomatic hypercalcaemia, as well as secondary parathyroid hyperplasia in patients suffering from chronic kidney disease. Asymptomatic primary hyperparathyroidism may require surgery if specific criteria are met, such as a serum calcium level above the upper limit of normal, reduced creatinine clearance, osteoporosis, or nephrolithiasis. Other indications include recurrent or persistent hyperparathyroidism following previous surgery, as well as parathyroid carcinoma or atypical adenomas.
Neck dissection procedures (Selective, Modified Radical, or Radical) are performed for several reasons. Therapeutic indications include metastatic cervical lymph node involvement in head and neck malignancies or nodal recurrence after previous radiation or chemotherapy. Elective neck dissection serves as prophylactic treatment for patients at high risk of occult cervical metastasis. Furthermore, neck dissection provides necessary access to neck vessels for microvascular free flap reconstruction. A Modified Radical Neck Dissection involves the removal of all lymph nodes in the lateral compartment (levels I–V). In contrast, a Radical Neck Dissection removes lymph nodes in levels I–V along with the Sternocleidomastoid muscle (SCM), the internal jugular vein (IJV), and the spinal accessory nerve.
Glandular and Laryngeal Surgeries
Submandibular gland excision is performed for benign or malignant tumours, recurrent sialadenitis, or sialolithiasis resistant to conservative management. It is also indicated for enlarging asymptomatic masses or when FNAC results are inconclusive. Anatomical considerations in this region include the marginal mandibular branch of the facial nerve, the facial artery, and the facial vein. Parotidectomy follows similar indications, including tumours and recurrent parotitis. It is also used to diagnose suspicious lesions or parotid involvement in autoimmune disorders like Sjögren’s syndrome. Key landmarks for parotid surgery include the tympanomastoid fissure, the facial nerve trunk, the sternocleidomastoid muscle, and the stylomastoid foramen.
Laryngectomy (Total, Partial, or Supraglottic) is reserved for advanced laryngeal cancer not suitable for organ preservation therapy, or recurrent cancer following radiation or chemoradiation. It is also a solution for persistent aspiration, severe airway obstruction due to laryngeal dysfunction, or severe laryngeal trauma. Post-operatively, a permanent stoma in the trachea is created to facilitate breathing, as the operative site (larynx) is removed or altered, separating the airway from the esophagus and affecting speech.
Otology: Myringotomy, Tympanoplasty, and Mastoidectomy
Myringotomy and tube placement (ventilation tubes) are indicated for middle ear effusion causing hearing loss that affects speech and language development in children. It is also used for recurrent acute otitis media (defined as episodes in the last or at least in the last with at least 1 in the last ). Advanced cases involving mastoiditis, sigmoid thrombosis, or meningitis may require this procedure in combination with cortical mastoidectomy. Other indications include chronic otitis media with effusion (OME) unresponsive to treatment, barotrauma, and a retracted tympanic membrane.
Tympanoplasty is the reconstruction of the tympanic membrane (TM) and involves steps like selecting a surgical approach, elevating the tympanomeatal flap, and freshening perforation edges. Common graft materials include temporalis fascia (the most used due to ease of harvest and integration), cartilage, or perichondrium. Ossiculoplasty may be performed alongside to address conductive hearing loss from ossicular chain discontinuity using interposition techniques (e.g., PORP, TORP, or Incus interposition).
Mastoidectomy is indicated for cholesteatoma (active squamous chronic otitis media), which is an abnormal growth of squamous epithelium. It can be categorized as active mucosal (ongoing inflammation/discharge), inactive mucosal (dry perforation), or active squamous. Other reasons include acute mastoiditis, complications like facial nerve palsy or intracranial involvement, and providing access for cochlear implantation. The Canal Wall-Up (CWU) technique preserves the posterior ear canal wall, while the Canal Wall-Down (CWD) technique removes it for extensive disease. Surgeons often use a diamond drill for precision near the facial nerve and dura, as it generates less heat and reduces thermal injury risks.
Rhinology: FESS, Septoplasty, and Rhinoplasty
Functional Endoscopic Sinus Surgery (FESS) is the standard for chronic rhinosinusitis refractory to medical treatment, nasal polyps, mucoceles, and even extended approaches to the orbit or pituitary. Preoperative CT scans are evaluated using the CLOSED formula to identify critical anatomy: 1. Cribriform plate height, 2. Lamina papyracea integrity, 3. Optic nerve, Orbit, and Onodi cells, 4. Sphenoid sinus, 5. Anterior Ethmoidal artery and ethmoidal roof, and 6. CT Dental assessment.
Septoplasty addresses a deviated nasal septum causing obstruction, sleep apnoea, or epistaxis. Turbinectomy or turbinoplasty is performed for inferior turbinate hypertrophy (often due to allergic rhinitis) or concha bullosa to improve airflow. Rhinoplasty is indicated for aesthetic improvement (size, symmetry), correction of deformities (dorsal hump, saddle nose), or functional repairs post-trauma. Incision patterns include Inverted "V", "W", Staircase, Gullwing, and Mid or Low columellar.
Microlaryngoscopy (ML) provides diagnostic evaluation and biopsy for laryngeal lesions such as nodules, granulomas, polyps, pedunculated papillomas, or carcinomas. It is also used for injecting Botox, steroids, or fillers, and managing laryngeal stenosis.
Tonsillectomy, Otoplasty, and Pharmacology
Tonsillectomy is indicated for recurrent tonsillitis, obstructive sleep apnoea, peritonsillar abscess, or suspected malignancy. It is also a treatment for Periodic Fever, Aphthous stomatitis, Pharyngitis, and Adenitis (PFAPA) syndrome. Otoplasty corrects congenital ear deformities, such as protruding or asymmetrical ears, for aesthetic purposes.
In surgical management, adrenaline (often lidocaine with adrenaline) is used for its vasoconstrictive effect. This effect is most potent during the first of operation to provide a clear surgical field. However, as the duration of surgery increases, the hemostatic effect of the adrenaline diminishes.
Questions & Discussion
Q: How do you manage a patient who is dissatisfied with their rhinoplasty results?
The management involves listening carefully to the patient’s concerns and performing an objective assessment of the surgical outcome. If the dissatisfaction stems from post-operative swelling, the patient should be advised to wait for resolution, which can take several months. If the issue is a genuine surgical complication or anatomical concern, revision surgery may be discussed. However, revision should only be performed after an appropriate healing period, typically at least after the initial surgery.