head and neck*
What structures form the External Ear
Pinna, External Auditory Canal and Tympanic Membrane
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What Questions would be asked to a Patient complaining of Hearing Loss in a Clinical History?
- Hearing Loss: Was it Gradual or Sudden
- Otalgia (Ear Pain): Was it referred otalgia (pain from outside the ear) or Primary Otalgia (pain from within the ear)
- Otorrhea (Any Ear Drainage, and if so describe it)
- Tinnitus (Perception of noise or ringing in the ears)
- Any Vertigo (Dizziness)
Alongside Ear Problems the patient may complain of Nasal Problems like Nasal Discharge.
Take a Drug History, some Drugs can be Ototoxic.
Also take a Social History to find out the patients occupation and Noise Exposure.
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What is Perichondritis
Skin and Soft Tissue Infection of the Pinna
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What is the Microbiological cause of Perichondritis
Pseudomonas Sp.
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What is Otitis Externa
inflammation of external auditory canal aka "swimmer's ear"
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What is the Microbiological Cause of Otitis Externa (2)
1) Pseudomonas
2) S.Aureus
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What is the treatment of Otitis Externa
1) Analgesia
2) Aural Toilet (Cleaning of External Auditory Canal)
3) Topical Antibiotic +/- Packing
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What is Herpes Zoster Oticus
Also Known as Ramsey Hunt Syndrome
a shingles outbreak affects the facial nerve near one of your ears. In addition to the painful shingles rash, it can cause facial paralysis and hearing loss in the affected ear
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How does Herpes Zoster Oticus present
Acute Lower Motor Neurone (LMN) facial palsy with Otalgia and Varicella like Cutaneous Lesions
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Which Cranial Nerves may be affected by Herpes Zoster Oticus
CN V, IX, X and cervical branches may be simultaneously affected due to Anastomotic Communications
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What is the treatment for Herpes Zoster Oticus (5)
1) Oral Steroids
2) Oral Antivirals
3) Analgesia
4) Eye Care
5) Topical Emollients
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What is Otitis Media with Effusion
Persistent mucoid/serous middle ear effusion for 3 months or more due to mucous overproduction or under clearance.
fluid accumulation that can occur in the middle ear and mastoid air cells due to negative pressure produced by dysfunction of the Eustachian tube. This can be associated with a viral upper respiratory infection or bacterial infection such as otitis media
fluid in the middle ear, but no signs of acute infection
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What are the Symptoms of Otitis Media with Effusion
1) Asymptomatic
2) Hearing Loss
3) Delayed Speech for Children
4) Recurrent Infections
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What are the two types of Acute Otitis Media
1) Non-Suppurative
2) Suppurative
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What is Non Suppurative Acute Otitis Media
Inflammation of Middle Ear Cleft with no Effusion or Sterile Effusion
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What are the Microbiological Causes of Suppurative Acute Otitis Media
1) S.Pneumoniae
2) H.Influenzae
3) M.Catarrhalis
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What are intracranial complications of Acute Otitis Media (5)
1) Meningitis
2) Extradural Abscess
3) Subdural Abscess
4) Intracerebral Abscess
5) Lateral Sinus Thrombosis
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What are the Extracranial Complications of Acute Otitis Media (6)
1) Mastoiditis
2) Petrositis
3) Lower Motor Neurone VII Palsy
4) Labyrinthitis
5) Hearing Loss (Conductive/Sensineural)
6) Tympanic Membrane Perforation.
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What is Chronic Otitis Media
Persistent or Intermittent Discharge through a Non-Intact Tympanic Membrane
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What is the Treatment for Chronic Otitis Media
1) Aural Toilet
2) Topical/Oral Antibiotics
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What is Cholesteatoma
Destructive and Expanding Keratinised Squamous Cell Debris Stuck inside the Middle Ear
Can be Congenital or Acquired
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What is the treatment for Cholesteatoma
1) Aural Toilet (Keep the Ear Dry!)
2) Mastoid Surgery
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What is Acute Mastoiditis
Infection of the Mastoid Air Cells as a complication of an Acute Otitis Media infection.
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How does Acute Mastoiditis present
Presents with Mastoid Tenderness, Pyrexia, Oedema and Erythema of Postauricular Soft Tissue.
There may also be Antero-inferior displacement of the Pinna
A Thickened Hyperaemic Tympanic Membrane
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What is the Treatment for Acute Mastoiditis
1) Broad Spectrum IV Antibiotics
2) CT Scan to look for Abscess
+/- Cortical Mastoidectomy
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What are Otoconia
crystals of calcium carbonate with mechanic forces to the sensory hair cells in the utricle and saccule.
Essential for Bodily Balance.
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What is Menieres
Vertigo lasting minutes to hours due to fluid imbalance within the middle ear.
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What are the symptoms of Menieres
1) Fullness of the Ear
2) Vertigo
3) Tinnitus
4) Hearing Loss
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What is the Treatment for Menieres
1) Low Salt Diet
2) Medications: Furosemide, Stemetil, Betahistine
3) Surgical: Grommets and Labyrinthectony
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What is Labyrinthitis
inflammation of the inner ear
Acute Debilitating Vertigo that lasts days to weeks followed by gradual recovery/compensation
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What are the two different types of Hearing Losses
1) Conductive
2) Sensorineural
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Which Arteries are Likely to be involved in Epistaxis (4)
1) Labial Artery
2) Ethmoid Artery
3) Greater Palatine Artery
4) Sphenopalatine Artery
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What Packing Materials can be used to Stop Epistaxis (5)
1) Balloon Tamponade
2) Absorable Packs (Nasopore)
3) Haemostatic Packs
4) Posterior Packs (Foley Catheter, Rapid Rhino, BIPP, Vaseline)
5) Flow Seal
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What is Rhinosinusitis/Nasal Polyposis
Inflammation of the Nose and Paranasal Sinuses with at least 2 symptoms of
- Nasal Congestion or Nasal Discharge
- Facial Pain/Pressure
- Ansomia
- Endoscopic Signs of Mucopurulent Discharge or Polyps
- CT Evidence of Sinus Disease
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What is the Treatment for Rhinosinusitis (4)
1) Nasal Douching
2) Topical Steroids (in form of Nasal Spray)
3) Course of Antibiotics
4) FESS (Flexible Endoscopic Sinus Surgery)
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What are the 2 Different Types of Nasal Carcinoma
1) Undifferentiated Non-Keratinising Squamous Cell Carcinoma
2) Differentiated Keratinising Squamous Cell Carcinoma
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What are the causes of Undifferentiated Non Keratinising SCC
EBV Virus
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What is the cause of Differentiated Keratinising SCC
- Smoking, Alcohol, HPV
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What are the Symptoms of Nasal Carcinomas
1) Epistaxis
2) Nasal Obstruction
3) Middle Ear Effusion
4) Cranial Nerve Palsies
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How does a Patient with Periorbital Cellulitis present
Swollen Eye, Red Skin, Unable to open eye, Eye Secretions
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What are the Bacterial Causes of Tonsilitis
1) B Haemolytic Streptococci
2) Pneumococcus
3) Haemophilus Influenzae
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How are Patients assessed using the Centor Criteria
Patients are Assessed on 4 Criteria
1) History of Fever
2) Tonsillar Exudate
3) Tender Anterior Cervical Adenopathy
4) Absence of Cough
The Modified Centor Criteria add the patient's age to the Criteria
- Age <15 add 1 point
- Age >44 Subtract 1 point
The Point System dictate the management.
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What is Glandular Fever (Infectious Mononucleosis)
an infection usually caused by the Epstein-Barr virus
In Children, it produces few or no symptoms
In adults the disease often results in fever, sore throat, enlarged lymph nodes in the neck, and tiredness
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What is Epiglottitis
Inflammation of the epiglottis and/or supraglottic tissue
medical emergency
Rarely Adult (Diabetic > risk)
Typically affects children (1-6 year olds peak age) Less commonly in children now due to H.Influenza B vaccine
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What are the Signs and Symptoms of Epiglottitis
1) Dysphagia
2) Drooling
3) Dysphonia
4) Fever
5) Pooling of Saliva
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What type of Cancer is Laryngeal Carcinoma
Squamous Cell Carcinoma
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What Anatomical Considerations should be made for Head and Neck Swellings (4)
1) Prominent Landmarks
2) Triangles of the Neck
3) Carotid Bulb
4) Lymphatic Levels
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Knowing the Levels of the Lymph Nodes is important because knowing their location can help us determine the cause of the Lymphadenopathy
Which structures drain at the Neck Level II (4)
1) Oral Cavity
2) Oropharynx
3) Tonsil
4) Parotid Gland
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Why is the patients age considered in the diagnosis of Head and Neck Swellings
The age of the patient can help determine the type of swelling present
90% of Lesions found in Paediatric (0-15 year olds) is Benign
In Late Adults >40, every lump/swelling should be considered as Cancer first and appropriate tests should be done.
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What are the effects of Quinsy (4)
- Trismus (Difficulty Opening Mouth)
- Bulging of Peritonsillar Area
- Deviated Uvula
- Severe Pain
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Where is the Parapharyngeal Space
Extends from Skull to base of Hyoid Bone
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Where is the Retropharyngeal Space
Extends from Skull to Base of T1-T2
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What is Ludwig's Angina
infection of the submandibular and sublingual glands
source of infection is most commonly an infected tooth, usually the 2nd or third mandibular molar.
type of severe cellulitis involving the floor of the mouth
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Which Microbiological Species cause Ludwig's Angina
1) Streptococcus
2) Staphylococcus
3) Fusobacterium
4) Actinomyces
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What are the Symptoms of Ludwig's Angina (6)
1) Pain
2) Trismus
3) Drooling
4) Tongue Protrusion
5) Fever
6) Neck Swelling
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What is Acute Viral Parotitis
swelling of one or both of the Parotid salivary glands with Viral Causes
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What is the Presentation of Acute Viral Parotitis
- Mild Pain
- Swelling (90% Bilateral)
- Pyrexia
can progress to Meningoencephalitis, Pancreatitis, Orchitis, Deafness
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What is the cause of Acute Viral Parotitis
Paramyxovirus
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How does Acute Bacterial Parotitis Present (4)
- Pain
- Swelling
- Pyrexia
- Dehydration
Mortality Rate is 80% if untreated.
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What is the Bacterial Causes of Acute Bacterial Parotitis (2)
1) S.Aureus
2) Anaerobes
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What is a Ranula
Mucocele on the floor of the mouth
a fluid collection or cyst that forms in the mouth under the tongue. It is filled with saliva that has leaked out of a damaged salivary gland
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What is the Clinical Presentation of Ranula
Painless Masses that do not change in size in response to chewing, eating or swallowing
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How does Raised Lymph Nodes due to infection feel
Tender
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How does Raised Lymph Nodes due to Neoplasm feel
Painless
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When are PET scans done
Normally Done in Patients with Metastatic Lymphadenopathy where we cannot localise the primary tumour
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What are the Indications for Core Needle Biopsy/Fine Needle Aspiration
Any Neck Mass that is not an obvious abscess
Persistence after a 2 week course of antibiotics.
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What is the use of CT Scans in Diagnosis of Head and Neck Lumps
Distinguish Cystic Lumps from Solid
Tells you the extent of the Lesion with Vascularity
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When is MRI used in the diagnosis of Head and Neck Lumps
Better for Upper Neck and Skull Base Lumps
Defines Soft Tissue Masses better
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When is Radionucleotide Scanning used
In Investigations of Thyroid and Parathyroid Masses.
Nowadays FNAC is used for Thyroid Mass Investigations.
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When is a Panedoscopy indicated
In cases of Core Biopsy of a lymph node that is positive but we cannot detect the primary lesion on repeat exam.
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How are Thyroid Masses diagnosed
thyroid blood work studies (TSH, T3, T4), radioactive iodine uptake studies (hot nodules typically benign- taking up iodine=functional), Imaging (US/CT), biopsy masses greater than 1 cm
FNAC
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What are signs and symptoms of Lymphoma (4)
1) Lateral neck Mass Only
2) Fever
3) Hepatosplenomegaly
4) Diffuse Adenopathy
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In which Salivary Glands does Salivary Gland Tumours predominantly occur
Parotid (80% overall, of which 80% are benign)
Submandibular (15% overall of which 20% are benign)
Sublingual (5% of which 20% are benign)
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How do Benign Salivary Gland Tumours present
Asymptomatic with no Pain or Facial Palsy, no Skin Fixation. They tend to Grow a lot slower
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How do Malignant Salivary Gland Tumours present
Rapid Growth, Skin Fixation and Cranial Nerve Palsies.
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What is Carotid Body Tumours
a tumor located on the side of the neck, where the large carotid artery branches into smaller blood vessels to carry blood into the brain
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How does the Carotid Body Tumour Present
Pulsatile, Compressible Mass
Can be Mobile Medial/Laterally but not superior/inferior.
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What is the Treatment for Carotid Body Tumors
Irradiation or Close Observation in the Elderly
Surgical Resection for Small Tumours in Young Patients
Hypotensive Anesthesia
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What is Lipoma
benign tumor of adipose tissue
Soft, Ill-Defined Mass
Asymptomatic
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When is it recommended to Remove Lipomas
When they reach big dimensions of 8-10cm as it can then become Malignant
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In which age group does Lipoma commonly present in
>35 Years of age
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Where do Neurogenic Tumours arise from
Neural Crest Derivatives
Include Shwannoma, Neurofibroma and Malignant Peripheral Nerve Sheath Tumour
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List 4 Congenital and Development Masses
1) Epidermal and Sebaceous Cysts
2) Branchial Cleft Cysts
3) Thyroglossal Duct Cysts
4) Vascular Tumours
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How are Epidermal and Sebaceous Cysts diagnosed (3)
Elevation and Movement of Overlying Skin
Skin Dimple or Pore
Excisional Biopsy Confirms
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What is 1st Branchial Cleft Cysts associated with
Close Associated with Facial Nerve
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How does Thyroglossal Duct Cysts present
Presents as a mass in the midline inferior to the hyoid bone
It elevates on swallowing and protrusion of the tongue.
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What are the Two types of Vascular Tumours
Lymphangiomas and Hemangiomas
occur usually within 1t year or life
Hemangiomas often resolve spontaneously which Lymphangioma remain unchanged
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What is Granulomatous Lymphadenitis
Infection that develops over weeks to months
inflammation of the lymph node with caseation necrosis
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What are the common Aetiologies of Granulomatous Lymphadentitis
1) TB (Typical and Atypical)
2) Cat Scratch Fever
3) Actinomycosis
4) Sarcoidosis
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What structures make up the Anterior Eye
1) Cornea
2) Iris
3) Lens
4) Ciliary Body
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What structures make up the Posterior Eye
1) Vitreous
2) Retina
3) Optic Nerve
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Labelled Eye Photograph
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Describe the Visual Pathway
Temporal Visual Fields Falls on Nasal Retina. Nasal Visual Fields Fall on Temporal Retina.
Nasal Retina Fibres cross over (decussate) at the Optic Chiasm
The right side of the visual field is represented on the left side of the brain and vice versa.
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List Common Symptoms of Visual Disturbance
1) Loss of Vision
2) Double Vision (Diplopia)
3) Drooping Eyelid (Ptosis)
4) Flashing Lights
5) Pupil Size Inequalities
6) Visual Field Defect
7) Pain/Headache
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What are the Eye Causes of Visual Disturbance
1) Cataract
2) Macular Degeneration
3) Glaucoma
4) Retinal Detachment
5) Eye Infections
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What are the Brain Causes of Visual Disturbance
1) Stroke
2) Inflammation
3) Migraine
4) Papilledema
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What are the Systemic Causes of Visual Disturbance
1) Diabetes
2) Vessel Occlusions & Atherosclerosis
3) Giant Cell Arteritis
4) Accelerated Hypertension
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What is Conjunctivitis
Inflammation of the Conjunctiva
Most commonly Viral (Adenovirus) but can be Bacterial
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How can you tell if Conjunctivitis is Bacterial or Viral
Viral Conjunctivitis will result in a Watery Eye
Bacterial Conjunctivitis will result in Purulent Discharge from the Eye
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What are the Characteristics of a Corneal Abrasion
1) Very Painful
2) Often Due to Trauma
3) Heals within 2-3 Days
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What is Subconjunctival Haemorrhage
Bleeding from a small blood vessel over the whites of the eye. It results in a red spot in the white of the eye. There is generally little to no pain and vision is not affected. Generally only one eye is affected.
Often caused Spontaneously or After Trauma
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What is Anterior Uveitis
inflammation of the iris and ciliary body
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What conditions is Anterior Uveitis linked to
1) Ankylosing Spondylitis
2) Crohn's Disease
3) Ulcerative Colitis
4) Rheumatoid Arthritis
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What are the Symptoms of Anterior Uveitis
1) Pain
2) Photophobia
3) Decreased Vision
4) Irregular Pupil
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What is Acute Angle Closure Glaucoma
The angle in the anterior chamber between the iris and the cornea becomes shallow or narrow due to blockage
High Pressure in the Eye which must be lowered before Optic Nerve undergoes irreversible Damage.
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What are the Symptoms of Acute Angle Closure Glaucoma
1) Often Affects Older Patients
2) Very Painful Red Eye with Decreased Blurred Vision
3) Accompanied by Nausea & Vomiting
Commonly Affects Longer Sighted Patients also.
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What are the symptoms of Scleritis
Deep Red Inflammation
Intense Pains, Wakes Patient from Sleep
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What is Cataract
An opacity of the lens, often due to ageing.
Occurs earlier in Diabetics, Trauma Patients and Patients using Steroids
Results in a Gradual Loss of Vision
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In which patients is Cataract common (4)
1) Elderly
2) Diabetics
3) Trauma Patients
4) Patients using Steroids
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Macular Degeneration can result in a Dry Eye or Wet Eye.
Describe the Differences
Can be Dry with deposits called Drusen found in Macular Region
Can be Wet with a new blood vessel growth at the macular area and leakage of fluid
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Diabetes causes changes in the Microvasculature. In the eye, it can cause Diabetic Retinopathy.
What is Diabetic Retinopathy
Retinal Vessels become Leaky resulting in Retinal Oedema
Retina Vessels can shut down resulting in Retinal Ischaemia and New Blood Vessel Growth which can bleed and cause Visual Loss
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What is Giant Cell Arteritis
It is an inflammatory disease of blood vessels most commonly involving large and medium Arteries of the head.
Results in Severe Headache, Scalp Pain, Jaw Pain, Tender Temporal Artery.
Can cause Strokes & Bilateral Blindness
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What is Papilloedema
swelling of the optic disc
Raised intracranial pressure can cause optic nerve swelling and visual disturbance.
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List 6 Ophthalmic Conditions causing Red Eye
1) Conjunctivitis
2) Sub-conjunctival Haemorrhage
3) Scleritis
4) Corneal Abrasion/Ulcer
5) Acute Angle Closure Glaucoma
6) Acute Uveitis
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List 6 Ophthalmic Conditions causing Visual Loss
1) Cataract
2) Chronic Open Angle Glaucoma
3) Macular Degeneration
4) Retinal Generation
5) Central Retinal Artery Occlusion
6) Diabetic Retinopathy