ENT Flashcards
Function of the nasal cavity
= most superior part of the respiratory tract
- Warms and humidifies inspired air.
- Removes and traps pathogens and particulate matter from the inspired air.
- Responsible for sense of smell.
- Drains and clears the paranasal sinuses and lacrimal ducts.
Respiratory vs Olfactory regions of nasal cavity
Respiratory region = lined by a ciliated pseudostratified epithelium, interspersed with mucus-secreting goblet cells.
Olfactory region = located at the apex of the nasal cavity. It is lined by olfactory cells with olfactory receptors.
What are the nasal conchae?
= curved shelves of bone projecting out of the lateral walls of the nasal cavity.
They project into the nasal cavity, creating four pathways for the air to flow
What are the four pathways of air flow created by the nasal conchae?
- Inferior meatus – between the inferior concha and floor of the nasal cavity.
- Middle meatus – between the inferior and middle concha.
- Superior meatus – between the middle and superior concha.
- Spheno-ethmoidal recess – superiorly and posteriorly to the superior concha.
What is the aim of the nasal conchae creating different paths of air flow?
to increase the surface area of the nasal cavity
to disrupt the flow of air to make it turbulent (so that it spends longer in the nasal cavity).
What structures drain into the nasal cavity?
Paranasal sinuses - frontal, maxillary, ethmoidal, sphenoid
Nasolacrimal Duct
Auditory (Eustachian) tube
Cribriform Plate
Sphenopalatine foramen
Incisive canal
What is the purpose of the Auditory (Eustachian) tube opening into the nasal cavity?
Connects the middle ear to the nasopharynx (opens onto the lateral wall of the nasal cavity)
It allows the middle ear to equalise with the atmospheric air pressure.
What is a problem that can occur due to the Auditory (Eustachian) tube opening into the nasal cavity?
Provides means for infection to spread from the upper respiratory tract to the ear.
Incisive Canal of nasal cavity
Pathway between the nasal cavity and incisive fossa of the oral cavity.
Transmits the nasopalatine nerve and greater palatine artery.
Sphenopalatine foramen of nasal cavity
Located at the level of the superior meatus
Sphenopalatine artery, nasopalatine and superior nasal nerves pass through
Cribriform plate of nasal cavity
part of the ethmoid bone
forms a portion of the roof of the nasal cavity
contains very small perforations, allowing fibres of the olfactory nerve to enter and exit.
Arterial Supply of nasal cavity
Internal carotid branches:
- Anterior ethmoidal artery
- Posterior ethmoidal artery
External carotid branches:
- Sphenopalatine artery
- Greater palatine artery
- Superior labial artery
- Lateral nasal arteries
These arteries form anastomoses with each other, especially in the anterior portion of the nose.
Little’s / Kiesselbach’s area
An area in the anterior portion of the nose, where there are lots of anastomoses of arteries
common site for nosebleeds (~90% from this area)
Venous drainage of the nose
The veins of the nose tend to follow the arteries.
They drain into the pterygoid plexus, facial vein or cavernous sinus.
How can the innervation of the nose be divided?
Special = the ability of the nose to smell
General = sensory innervation
Special sensory innervation of the nose
OLFACTORY NERVE
The olfactory bulb lies on the superior surface of the cribriform plate
Branches of the olfactory nerve run through the cribriform plate to provide special sensory innervation to the nose.
General sensory innervation of the nose
Innervation to the septum and lateral walls is delivered by the nasopalatine nerve (branch of maxillary nerve) and the nasociliary nerve (branch of the ophthalmic nerve).
Innervation to the external skin of the nose is supplied by the trigeminal nerve.
Parts of the external ear
Auricle
External Acoustic Meatus
Tympanic Membrane
Auricle
Functions to capture and direct sound waves towards the external acoustic meatus.
A mostly cartilaginous structure:
=> Helix, anti-helix, concha, tragus, antitragus
External acoustic meatus
A sigmoid-shaped tube
=> Initially superoanterior, then superoposterior, then inferoanterior.
Extends from the deep part of the concha to the tympanic membrane.
External 1/3 formed by cartilage
Internal 2/3 formed by the temporal bone.
Tympanic Membrane
Connective tissue structure; covered with skin on the outside and a mucous membrane on the inside
Connected to the surrounding temporal bone by a fibrocartilaginous ring
On the inner surface, the handle of malleus attaches to the tympanic membrane, at the umbo
Vasculature of external ear
Supplied by branches of the external carotid artery:
- Posterior auricular artery
- Superficial temporal artery
- Occipital artery
- Maxillary artery (deep auricular branch) – supplies the deep aspect of the external acoustic meatus and tympanic membrane only.
Venous drainage is via veins following the arteries listed above
Sensory innervation of external ear
Greater auricular nerve (branch of the cervical plexus) – innervates the skin of the auricle
Lesser occipital nerve (branch of the cervical plexus) – innervates the skin of the auricle
Auriculotemporal nerve (branch of the mandibular nerve) – innervates the skin of the auricle and external auditory meatus.
Branches of the facial and vagus nerves – innervates the deeper aspect of the auricle and external auditory meatus
Why can some individuals complain of an involuntary cough when cleaning their ears?
due to stimulation of the auricular branch of the vagus nerve (the vagus nerve is also responsible for the cough reflex).
Lymphatic drainage of external ear
The lymphatic drainage of the external ear is to the superficial parotid, mastoid, upper deep cervical and superficial cervical nodes.
Middle Ear
Lies within the temporal bone
Extends from the tympanic membrane to the lateral wall of the inner ear.
Main function = to transmit vibrations from the tympanic membrane to the inner ear via the auditory ossicles.
Divided into two parts - Tympanic Cavity and Epitympanic Recess
Middle Ear - Tympanic Cavity
located medially to the tympanic membrane,
contains the 3 auditory ossicles
Middle Ear - Epitympanic Recess
a space superior to the tympanic cavity,
which lies next to the mastoid air cells
What are the bones of the middle ear?
- Malleus
- Incus
- Stapes
Middle Ear - Malleus
Attaches to the tympanic membrane, via the handle of malleus.
The head of the malleus lies in the epitympanic recess, where it articulates with the next auditory ossicle.
Middle Ear - Incus
Consists of a body and two limbs.
=> The body articulates with the malleus,
=> The short limb attaches to the posterior wall of the middle ear
=> The long limb articulates with the stapes
Middle Ear - Stapes
The smallest bone in the human body.
It joins the incus to the oval window of the inner ear.
It is stirrup-shaped, with a head, two limbs, and a base.
=> The head articulates with the incus, and the base joins the oval window.
Mastoid Air Cells
Located posterior to the epitympanic recess.
A collection of air-filled spaces in the mastoid process of the temporal bone.
The mastoid air cells act as a “buffer system” of air – releasing air into the tympanic cavity when the pressure is too low.
Middle Ear - Muscles
two muscles - serve a protective function
=> tensor tympani and stapedius
They contract in response to loud noise, inhibiting the vibrations of the malleus, incus and stapes, and reducing the transmission of sound to the inner ear.
Acoustic reflex
The contraction of the tensor tympani and stapedius in response to loud noise, inhibiting vibrations of the bones and thereby reducing transmission of sound to the inner ear.
Why are middle ear infections more common in children?
The auditory tube is shorter and straighter in children, so there is an easier pathway for a URTI to spread to the middle ear.
Inner Ear - contents, location, connections to middle ear
Houses the vestibulocochlear organs
Located within the petrous part of the temporal bone.
Has two openings into the middle ear – the oval window and the round window
What are the main functions of the inner ear?
- To convert mechanical signals from the middle ear into electrical signals, which can transfer information to the auditory pathway in the brain.
- To maintain balance by detecting position and motion
Bony Labyrinth of inner ear
= a series of bony cavities within the petrous part of the temporal bone.
It consists of three parts – the cochlea, vestibule and the three semi-circular canals.
Bony Labyrinth - Vestibule
Central part
Separated from the middle ear by the oval window.
Communicates anteriorly with the cochlea and posteriorly with the semi-circular canals.
Bony Labyrinth - Cochlea
Houses the cochlear duct of the membranous labyrinth
It twists upon itself around a central portion of bone (the modiolus), producing a cone shape.
Branches from the cochlear portion of the vestibulocochlear (CN VIII) nerve are found at the base of the modiolus.
The presence of the cochlear duct creates two perilymph-filled chambers above and below:
i. Scala vestibuli
ii. Scala tympani
Bony Labyrinth - Semi-circular Canals
There are 3 canals – anterior, lateral and posterior.
Contain the semi-circular ducts, which are responsible for balance (along with the utricle and saccule).
Inner Ear - Membranous Labyrinth
= a continuous system of ducts filled with endolymph.
It lies within the bony labyrinth, surrounded by perilymph.
It is composed of the cochlear duct, three semi-circular ducts, saccule and utricle.
Membranous Labyrinth - Cochlear Duct
Triangular shape
Separated from the scala vestibuli by Reissner’s membrane
Separated from the scala tympani by the basilar membrane
The basilar membrane houses the epithelial cells of hearing – the Organ of Corti.
Membranous Labyrinth - Saccule and Utricle
= Two membranous sacs located in the vestibule.
They are organs of balance – detect movement or acceleration of the head in the vertical and horizontal planes
=> The utricle receives the three semi-circular ducts.
=> The saccule receives the cochlear duct.
Endolymph drains from the saccule and utricle into the endolymphatic duct.
Membranous Labyrinth - semi-circular ducts
Located within the semi-circular canals
Upon movement of the head, the flow of endolymph within the ducts changes speed and/or direction.
Sensory receptors detect this change, and send signals to the brain, allowing for the processing of balance.
Inner Ear - innervation
Innervated by the vestibulocochlear nerve (CN VIII).
At the internal acoustic meatus it divides into the:
- Vestibular nerve – supplies the utricle, saccule and three semi-circular ducts.
- Cochlear nerve – supplies the receptors of the Organ of Corti
Bones of the neurocranium
Four singular bones centred on the midline (frontal, ethmoid, sphenoid, and occipital).
Two sets of bones occurring as bilateral pairs (temporal and parietal).
Bones of the viscerocranium (facial skeleton)
Three singular bones lying in the midline (mandible, ethmoid, and vomer)
Six paired bones occurring bilaterally (maxilla; inferior nasal concha [turbinate], zygomatic, palatine, nasal, and lacrimal bones).
Muscles of face
Occipitofrontalis
Obicularis Oculi
Obicularis Oris
Buccinator
Nose:
- Nasalis – transverse and alar parts
- Procerus
- Depressor septi nasi
Platysma
Sensory innervation of face
provided mainly by the trigeminal nerve (CN V) via the:
- The ophthalmic nerve (CN V1) – only sensory
- The maxillary nerve (CN V2) – only sensory
- The mandibular nerve (CN V3) – sensory and motor
Motor innervation of face
- Mandibular nerve (CN V3) – the muscles of mastication (masseter, temporal, medial and lateral pterygoids).
- Facial nerve (CN VII) – the muscles of facial expression.
Where does the facial nerve emerge from the cranium?
stylomastoid foramen
Superficial lymph nodes of head and neck
Receive lymph from the scalp, face and neck
- Submental
- Submandibular
- Superficial parotid/pre-auricular
- Mastoid / retroauricular
- Occipital
Deep (cervical) lymph nodes of head and neck
Receive all of the lymph from the head and neck – either directly or indirectly via the superficial lymph nodes.
They are organised into a vertical chain, located within close proximity to the IJV within the carotid sheath.
Parotid gland - location
enclosed within a tough fascial capsule – the parotid sheath
apex = posterior to the angle of the mandible base = related to the zygomatic arch
Parotid duct
The parotid duct passes horizontally from the anterior edge of the parotid gland.
At the anterior border of the masseter, it pierces the buccinator and enters the oral cavity through a small orifice opposite the second maxillary molar tooth.
Sensory innervation of the parotid sheath
greater auricular nerve (C2 and C3) provides sensory innervation to the parotid sheath and overlying skin.
Boundaries of anterior triangle of neck
- Superiorly – inferior border of the mandible (jawbone).
- Laterally – anterior border of the sternocleidomastoid.
- Medially – sagittal line down the midline of the neck.
suprahyoid muscles
located superiorly to hyoid bone:
Stylohyoid
Digastric
Mylohyoid
Geniohyoid
infrahyoid muscles
located inferiorly to hyoid bone:
Omohyoid
Sternohyoid
Thyrohyoid
Sternothyroid
Contents of carotid triangle
Common carotid artery (which bifurcates within the carotid triangle)
Carotid sinus
Internal jugular vein
Hypoglossal and vagus nerves.
Contents of submental triangle
the submental lymph nodes
=> filter lymph draining from the floor of the mouth and parts of the tongue.
Contents of submandibular triangle
- The submandibular gland (salivary), and lymph nodes.
- The facial artery and vein also pass through this area.
Boundaries of posterior triangle of neck
- Anterior – posterior border of the sternocleidomastoid.
- Posterior – anterior border of the trapezius muscle.
- Inferior – middle 1/3 of the clavicle
Contents of the posterior triangle of neck
- many muscles (including a number of vertebral muscles which are covered by the pre-vertebral fascia)
- the EJV
- the accessory nerve (CN XI)
- the cervical plexus
- the trunks of the brachial plexus
Path of the external jugular vein
Formed by the retromandibular and posterior auricular veins
Lies superficially, crosses SCM muscle to reach posterior triangle.
Within the posterior triangle, the EJV pierces the investing layer of fascia and empties into the subclavian vein.
What are the 3 main distinct features of the cervical vertebrae?
- Triangular vertebral foramen.
- Bifid spinous process – this is where the spinous process splits into two distally.
- Transverse foramina – holes in the transverse processes.
=> They give passage to the vertebral artery, vein and sympathetic nerves.
C-Spine - C1
= the atlas.
- Has no vertebral body and no spinous process.
- Has lateral masses which are connected by an anterior and posterior arch.
- Each lateral mass contains a superior articular facet (for articulation with occipital condyles), and an inferior articular facet (for articulation with C2).
- There is a transverse ligament of the atlas to secure the articulation with the dens of the axis.
C-spine - C2
= the axis.
- Has the dens/odontoid process, which extends superiorly to articulate with the anterior arch of the atlas, in doing so creating the medial atlanto-axial joint.
- The axis also contains superior articular facets, which articulate with the inferior articular facets of the atlas to form the two lateral atlanto-axial joints.
What and where is the pharynx?
a muscular tube that connects the oral and nasal cavity to the larynx and oesophagus.
It begins at the base of the skull and ends at the inferior border of the cricoid cartilage (C6).
Consists of:
- Nasopharynx
- Oropharynx
- Laryngopharynx
Nasopharynx - location, contents, function
• Located between between the base of the skull and the soft palate
• Performs a respiratory function by conditioning inspired air and propagating it to the larynx.
=> Lined with respiratory epithelium
• Contains the adenoid tonsils.
Oropharynx - location, contents, function
- Located between the soft palate and the superior border of the epiglottis
- Contains the posterior 1/3 of the tongue, the lingual tonsils, the palatine tonsils and superior pharyngeal constrictor muscle.
- Involved in the involuntary and voluntary phases of swallowing.
Laryngopharynx - location, contents
- Located between the superior border of the epiglottis and inferior border of the cricoid cartilage (C6)
- Continues inferiorly as the oesophagus
- Contains the middle and inferior pharyngeal constrictors
Waldeyer’s ring
= the ring of lymphoid tissue in the naso- and oropharynx
formed by the paired palatine tonsils, the adenoid tonsils and lingual tonsil.
Motor/sensory innervation of the pharynx
MOTOR
Most muscles are innervated by the vagus nerve (CN X).
the only exception being the stylopharyngeus (glossopharyngeal nerve).
SENSORY
Receives sensory innervation from the glossopharyngeal nerve (CN IX)
What are the two main groups of pharyngeal muscles?
CIRCULAR - contract sequentially from superior to inferior to constrict the lumen and propel the bolus of food.
LONGITUDINAL - act to shorten and widen the pharynx and elevate the larynx during swallowing
Circular pharyngeal muscles
Superior pharyngeal constrictor (oropharynx)
Middle pharyngeal constrictor (laryngopharynx)
Inferior pharyngeal constrictor (laryngopharynx)
Longitudinal pharyngeal muscles
Stylopharyngeus (styloid process to pharynx)
Palatopharyngeus (hard palate to pharynx)
Salpingopharyngeus (Eustachian tube to pharynx)
Vascular supply to the pharynx
ARTERIAL SUPPLY
via branches of the external carotid artery:
- Ascending pharyngeal artery
- Branches of the facial artery
- Branches of the lingual and maxillary arteries.
VENOUS DRAINAGE
Achieved by the pharyngeal venous plexus, which drains into the IJV.
Where is the Larynx?
- Suspended from hyoid bone
- Spans between C3 and C7
- Covered anteriorly by the infrahyoid muscles
- Covered laterally by the lobes of the thyroid gland.
Function of the larynx
Several important functions:
=> Phonation, cough reflex, protection of the lower respiratory tract.
Sections of the larynx
- Supraglottis – from the inferior surface of the epiglottis to the vestibular folds (false vocal cords).
- Glottis – contains vocal cords and 1cm below them.
- Subglottis – from inferior border of the glottis to the inferior border of the cricoid cartilage.
What epithelium is there in the larynx?
Lined by pseudostratified ciliated columnar epithelium.
An important exception to this is the true vocal cords, which are lined by a stratified squamous epithelium.
Vascular supply to the larynx
ARTERIAL SUPPLY
- Superior laryngeal artery (from the external carotid)
- Inferior laryngeal artery (from the thyrocervical trunk)
VENOUS DRAINAGE
- Superior laryngeal vein (=> IJV)
- Inferior laryngeal vein (=> left brachiocephalic vein )
Motor/Sensory innervation of larynx
via branches of the vagus nerve:
- Recurrent laryngeal nerve – provides sensory innervation to the infraglottis, and motor innervation to all the internal muscles of larynx (except the cricothyroid).
- Superior laryngeal nerve – the internal branch provides sensory innervation to the supraglottis, and the external branch provides motor innervation to the cricothyroid muscle.
Cartilages of larynx
UNPAIRED:
Thyroid
Cricoid
Epiglottis
PAIRED
Arytenoid
Corniculate
Cuneiform
What is Adam’s apple?
= laryngeal prominence of thyroid cartilage
where the two sheets of cartilage joints anteriorly
Cricoid cartilage
= a complete ring of hyaline cartilage, completely encircling the airway
Articulates with the paired arytenoid cartilages posteriorly and thyroid cartilage superiorly
Epiglottis
= a leaf-shaped plate of elastic cartilage
Marks the entrance to the larynx
During swallowing, the epiglottis flattens and moves posteriorly to close of the larynx and prevent aspiration.
What are the laryngeal folds?
- Vocal folds (= true vocal cords)
- Vestibular folds (= false vocal cords)
Vocal folds / true vocal cords
Abducted, adducted, relaxed and tensed under control of the muscles of phonation to control the pitch of the sound created.
Relatively avascular, appear white in colour
Space between the vocal folds is called the rima glottidis.
Vestibular folds / false vocal cords
Pink in colour
Act to provide protection to the larynx
Groups of muscles of the larynx
- External muscles
=> Act to elevate or depress the larynx during swallowing - Internal muscles.
=> Act to move the individual components of the larynx
=> Play a vital role in breathing and phonation.
Innervation of the intrinsic muscles of the larynx
All innervated by the inferior laryngeal nerve, which is the terminal branch of the recurrent laryngeal nerve
(except the cricothyroid – innervated by external branch of superior laryngeal nerve).
Thyroid gland - location and structure
Spans the C5-T1 vertebrae
Two lobes (left and right); connected by a central isthmus anteriorly.
Lobes are wrapped around the cricoid cartilage and superior rings of the trachea.
Located within the visceral compartment of the neck (along with the trachea, oesophagus and pharynx) which is bounded by the pre-tracheal fascia.
Thyroid gland - arterial supply
= two main arteries (and one additional one)
Superior thyroid artery
- 1st branch of the external carotid a.
Inferior thyroid artery
- Arises from the thyrocervical trunk (branch of subclavian a.)
(Thyroid ima artery)
- Only ~10% of people have this additional artery
- Arises from brachiocephalic trunk
Thyroid gland - venous drainage
Superior, middle, and inferior thyroid veins, which form a venous plexus around the thyroid gland.
Superior and middle veins drain into the IJV
Inferior vein drains into the brachiocephalic trunk.
Thyroid gland - innervation
Branches of sympathetic trunk
Thyroid gland - lymphatic drainage
To the paratracheal and deep cervical nodes.
Parathyroid Glands - location
Located on posterior aspect of thyroid gland (external to the thyroid but within the pretracheal fascia)
Most people have 4 parathyroid glands (although variation from 2-6 is common)
=> Superior – located in the middle of posterior border of each thyroid lobe.
=> Inferior – usually found near the inferior poles of the thyroid gland, but location is inconsistent (can be found as far inferiorly as superior mediastinum)
Cervical Plexus
Located in the posterior triangle of the neck, within the prevertebral layer of cervical fascia
Formed from the anterior rami of cervical spine nerves C1-C4
Muscular branches lie deep to sensory branches
Sensory branches of cervical plexus
Greater Auricular Nerve (C2 and C3) => external ear and skin over parotid gland
Transverse Cervical Nerve (C2 and C3) => anterior neck
Lesser occipital Nerve (C2) => posterosuperior scalp
Supraclavicular Nerves (C3 and C4) => skin overlying supraclavicular fossa
Stertor
= noisy breathing due to partial obstruction ABOVE the larynx (tonsils, adenoids, tongue, angioedema)
Stridor
= noisy breathing due to partial obstruction BELOW the larynx
NEEDS ENT REFERRAL.
Signs of severe airway obstruction
- Tracheal tug/recession
- Tachycardia
- Hypoxia
- Use of Accessory mm.
- Confusion
Differentials of stridor
CONGENITAL
Laryngomalacia
VC web / VC Palsy
Subglottic stenosis
ACQUIRED (acute) Laryngeal trauma Foreign body Croup Epiglottitis Allergic reaction
ACQUIRED (chronic) VC Palsy VC polyp/cyst Tumour Thyroid mass Subglottic stenosis
Laryngeal trauma - presentation and management
Stridor, neck bruising, surgical emphysema
Mx = intubation +/- tracheostomy
Foreign body in airway - presentation, Ix, Mx
Feel something “stick” in throat,
sharp pain,
cannot eat/drink/swallow saliva
Ix = lateral neck X-ray and CXR
Mx = flexiscope and removal
Management of Stridor
- Basic Hx and assess severity (cyanosis, RR, etc.)
- A-E assessment
- Secure Airway
Methods of securing airway in stridor
a. Endotracheal Tube = 1st line
b. Cricothyroidotomy
c. Tracheostomy
Cricothyroidotomy - method
Brown IV cannula through cricothyroid membrane & connect high flow O2
Incision in midline of cricothyroid membrane and insert ET tube with O2 bag
Tracheostomy - method and complications
Tube inserted between 2nd and 4th rings of cartilage
Complications = tube blockage, wound infection, pneumothorax
Indications for tracheostomy
Stridor,
Drain/prevent over-spilling of secretions,
Respiratory failure.
What is tonsillitis?
= an acute bacterial infection of the tonsils
Caused by:
- strep. pyogenes,
- staphylococci
- m. catarrhalis
Tonsilitis - symptoms
- Sore throat + odynophagia
- Pyrexia, malaise, etc.
- Lymphadenopathy
+/- pus on tonsils
Tonsilitis - Centor Score
(1 point each): C – absence of [C]ough E – tonsillar [E]xudate N – tender cervical [N]odes T - >38oC [T]emperature
If Score >3 = high chance of strep A and need ABX
Tonsilitis - complications
Peritonsillar abscess (quinsy) Deep neck space infection
Tonsilitis - management
IF UNILATERAL Sx => ENT Referral
Analgesia, fluids, soft food.
ABX – PO penicillin V (or clarithromycin if pen allergic)
Tonsillectomy if recurrent/complications
When is a tonsillectomy done?
Done if tonsilitis is recurrent/complications:
7x in 1 year 5x in each of 2 years 3x in each of 3 years 2 episodes of quinsy
Tonsillectomy - complications
1-2 weeks of pain post-op
Complications:
a. 1o post-op haemorrhage – needs surgery
b. 2o post-op haemorrhage – from infection => IV ABX
What is peritonsillar abscess / Quinsy?
= pus between the tonsil capsule and lateral pharyngeal wall
Caused by strep. pyogenes
Presentation of peritonsillar abscess / Quinsy
SYMPTOMS
- Sore throat, odynophagia, dysphagia
- Trismus
- “Hot potato voice” (muffled voice)
- Referred otalgia
SIGNS
- Usually unilateral (DDx = tumour)
- Unilateral swelling, LATERAL to tonsil.
- Deviated tonsil and uvula to opposite side.
What is trismus?
= restriction of the range of motion of the jaws
Management of peritonsillar abscess / quinsy
ENT referral
- Needle aspiration or incision & drainage
- IV ABX +/- steroids for swelling
- Analgesia, fluids, soft food.
What is infectious mononucleosis?
“glandular fever”
= EBV infection affecting LNs, tonsils and liver.
Infectious mononucleosis - symptoms
- Prodromal illness: fever, malaise
- Sore throat, dysphagia
- Cervical lymphadenopathy
- Abdo pain
- Hepatosplenomegaly (50%)
Infectious mononucleosis - investigations
FBC
LFT
Blood film
Monospot test
Infectious mononucleosis - management
Self-resolves in 2-4 weeks
Supportive Tx – analgesia, fluids
ABX ONLY if tonsilitis (but NOT amoxicillin)
Monitor LFTs
Advice
- Avoid intimate contact
- No contact sport => splenic rupture
- No alcohol => liver damage
What ABX should be avoided in a patient with glandular fever?
ABX are not routinely given as EBV is a virus
=> should only be given if there is evidence of bacterial tonsillitis
Avoid ampicillin and amoxicillin => rash
Pharyngitis - acute/chronic
- Acute:
Sudden-onset sore throat
Usually viral (rhinovirus, coronavirus, influenza, HSV, VZV)
May be bacterial (group A strep) - Chronic:
Long-standing sore throat
Specific (syphilis, TB, toxoplasmosis)
Non-specific (GORD, tobacco, chronic sinusitis).
Pharyngitis - management
fluids, analgesia,
gargle warm salty water.
What causes epiglottis?
H. influenzae
Epiglottitis - Sx
PHARYNX NORMAL O/E
Very sore throat + high fever
Dysphagia, drooling
Stridor
Epiglottitis - Mx
Immediate admission
Airway protection – intubation/tracheostomy
IV ABX and steroids
DO NOT TRY TO EXAMINE THROAT/MOUTH
How do deep neck space infections occur?
Due to spread of throat infections (pus/abscess) via para or retro-pharyngeal space.
Deep neck space infection - symptoms
Sore throat + odynophagia Dysphagia, drooling Fever Trismus Reduced neck movements “Hot potato voice”
Deep neck space infection - signs
Poor Head Movement
Neck mass
Septic
Deep neck space infection - investigations
CT – shows deep neck spaces
USS – shows abscesses
OPG – dental x-ray
Deep neck space infection - management
Emergency A - E Assessment
Airway protection
IV ABX
Surgical drainage
Deep neck space infection - complications
- Airway compromise
- Empyema
- Pneumonia
- Mediastinitis (50% mortality)
- Carotid artery erosion
Why can you get referred otalgia with a sore throat?
Ear has shared nerve supply with oro/laryngopharynx
Globus Pharyngeus
Painless sensation of “sticking” / lump in throat even when not swallowing
Causes – LP reflux, stress/anxiety, minor inflammation
Globus Pharyngeus - Mx
Must exclude pathologies like cancer
Mx –
Treat any underlying cause,
Avoid caffeine/smoking,
Sip icy sparkling water
Definition of sleep apnoea
30 or more episodes of cessation of breathing, each lasting at least 10 seconds, over a period of 7 hours of sleep
Sleep Apnoea Index
measures the number of episodes to determine the severity.
Causes of sleep apnoea
- OBSTRUCTIVE – due to upper airway collapse (decreased O2 causes reflex of waking slightly and taking deep breath).
- CENTRAL – fault with central respiratory drive (e.g. cerebral palsy, cognitive defect).
Risk factors for sleep apnoea
Old age Male Down’s Syndrome Sedatives OBESITY Smoking/alcohol Craniofacial abnormalities Neuromuscular Disease
Sleep apnoea - Sx
- Snoring/choking in sleep and witnessed apnoeas
- Restless/non-refreshing sleep
- Daytime sleepiness and decreased concentration
- Irritability and decreased libido
Kids – poor school performance
Babies – poor feeding as blocked nasal breathing.
Sleep apnoea - Ix
- History
- Examination – upper airway endoscopy
- Sleep Studies
- Measure pulse, ECG, O2 overnight
- Audio/video recording of sleep
- Polysomnography = gold-standard version
Sleep apnoea - Mx
- Lifestyle – weight loss, smoking/alcohol reduction
- Conservative – nasal splints/tape & jaw advancers
- Medical – CPAP via mask
=> Noisy and uncomfortable - Surgery – adenotonsillectomy, polypectomy, uvulopalatopharyngoplasty
Management of snoring
- Lifestyle – weight loss, smoking/alcohol reduction
2. Conservative – nasal splints/tape & jaw advancers
Major salivary glands
= 3 paired glands
- Parotid – serous
- Submandibular – mixed
- Sublingual – mucous
Why is the parotid gland painful if swollen?
it has a fibrous capsule which is painful if stretched
What is xerostomia?
What are some causes?
= dry mouth
Causes: • Depression/anxiety • Drugs – antimuscarinics/sympathomimetics • Radiotherapy to head/neck • Sjogren’s Syndrome
Sjogren’s Syndrome
= an autoimmune disorder of decreased saliva/mucous.
What is there increased risk of in people with Sjogren’s Syndrome?
increased risk of non-Hodgkin’s lymphoma.
Sjogren’s Syndrome - symptoms
DRY MOUTH + EYES (+ vagina)
Glossitis
+/- Parotid gland enlargement
Sjogren’s Syndrome - investigations
HLA, B8, DR2
Specific antigens – SSA, SSB
Labial biopsy = diagnostic
Sjogren’s Syndrome - management
Steroids
Artificial saliva/tears
(Parotidectomy if recurrent parotitis)
What is Sialadenitis?
What are the causes and risk factors?
= inflammation of salivary gland
Causes – infection, stones, malignancy
RFs – dehydration, poor oral hygiene, elderly.
Sialadenitis - Sx
Swollen, tender gland
+/- pus from duct
+/- fever and systemic Sx
Sialadenitis - Mx
Hydration & analgesia
High dose ABX +/- pus drainage
(Gland removal)
Parotitis
= inflammation of parotid gland
Causes:
- Infection (measles, mumps, HIV, TB, candidiasis)
- Sarcoid
- Drugs
Sialolithiasis
= Calculi in salivary glands
scialectasis
Dilation of salivary ducts
Sialolithiasis - Sx
Post-prandial swelling & pain
+/- palpable calculi in gland
Sialolithiasis - Ix
CT/X-ray
Sialogram
Sialolithiasis - Mx
Hydration & analgesia
Duct massage
Surgical stone removal (if necessary)
Non-salivary causes of facial swelling
Masseter hypertrophy Lymphadenopathy Dental infection/abscess Mastoiditis Cysts
Salivary causes of facial swelling
Sialadenitis
Sialolithiasis
Sjogren’s Syndrome
Neoplasm – benign/malignant
