Otolaryngology

for Medical Students

Orientation, Goals, Tips and Key
Topics

Itinerary

Welcome ENT Department

Tips

and Resources
The ENT History
The head and neck exam
Important ENT Topics

Tips for ENT Rotation

Goal is to gain exposure to the breadth of ENT, not
mastery of every subject
Your personal objective should be to gain proficiency
with ENT history and exam, and familiarity with a range
of Primary Care ENT topics
Review your 1st and 2nd year lecture notes, ENT for
Primary Care text, emedicine, mdconsult
Try to review appropriate lecture / notes prior to related
clinic/OR

The ENT History

Briefer than the Internal Medicine history (think
surgical)
Key points (especially important in ENT):

Smoking/alcohol history
Numbers of infections (e.g. ear, sinus, throat) in last
1, 2, 3 yrs

previous treatments (e.g. which Abx and how recently)

Ears: hearing loss, pain, d/c, tinnitus, vertigo

Previous ENT surgeries/ Trauma

Nose : Epistaxis, block, rhinorrhea, sneezing,
Asthma
Throat : Ody/Dysphasia, Hoarseness of voice/
stridor

The Head and Neck Exam

As with other specialties, the head and neck exam is to

be used to supplement clinical information acquired from
a detailed history
Have an approachbe effective and make sure it can be
replicated so as not to miss findings
Most of all, practice, practice, practice

You wont know what is normal until you see it many times

The Ear - History

Otologic:

Obstruction, discharge,sneezing
spoting of blood, facial pain etc
Onset and rate of progression

Hearing loss

Nasal:

Otalgia

Drugs:

Otologic vs. referred

Otorrhea

Consistency?, types

Tinnitus
continuous / intermitent
Vertigo

Family History

Differentiate from dizzyness

Noise exposure

Ototoxic agents and warfarin

Of hearing loss, malignancy, TB etc.

The EAR - Examination

Inspect auricles and

mastoid region

size, shape, symmetry,

landmarks, color, position,
deformities or lesions

Palpate auricles and

mastoid/Tragus

tenderness, swelling,
nodules

The Tympanic Membrane

Inspect external auditory canal
(with pneumatic otoscopy)

cerumen, color, lesions like

swelling/ granulations, d/c,
foreign bodies

Inspect tympanic membrane

landmarks
color, contour

perforations, mobility
all 4 quadrants
Dont miss annulus, Attic

Examples of Abnormalities...

Normal Tympanic Membrane

Pars
flacida
Attic

Lateral
process of
malleus

HOM
Cone
Of
Light

Pars
tensa

Acute Otitis Media

Lateral
process of
malleus

HOM

Bulging
of PF

Tympanosclerosis

Tympano
sclerotic
patch

Perforation with Tympanoscleros

Pars
Flaccida
Perforatio
n
Tympanoscler
osis

Osteoma

TM

Bony
canal
floor
with
osteom
a

Otitis Externa

Fungus
and
debris

Necrosis
HOM

Cholesteatoma
ME
Cholesteatoma

ET

ME Cavity Granular
Dry

The Ear Hearing Assessment

Formulation:
Conductive Hearing Loss

1.

2.

Disease affecting
outer/middle ear

Sensorineural Hearing Loss

Disease affecting cochlea or

CN VIII

Mixed Hearing Loss

3.

Disease involving both

middle & inner ear

The Ear Hearing Assessment

Response to questions
during history
Response to a whispered
voice

Tuning fork air/bone

conduction

Rinne (image above)

Weber (image below)

Interpretation of Tuning Fork Tes

Expected
Test

Weber

Findings

CHL

SNHL

No LateralizationLateralization to ear Lateralization to

with loss
better hearing ear

Air Conduction betterBone conduction

than bone conduction better than air
Rinne (Rinne positive) conduction (Rinne
negative)

Air Conduction
better than bone
conduction

The Audiogram -- the Basics

Bone conduction line

Air conduction line
Air-bone gap =
conductive hearing
loss
Depressed bone
conduction line =
sensorineural loss

Tympanogram
Recorded as pressure-versus-compliance curve
Curve Types
Type A Curve: Pressue near 0 with normal curve width
Type Ad curve: High peak height (high compliance)
Tympanic Membrane thinning (healed post-rupture)
Ossicular disarticulation (increased pressure also)
Type As curve: low peak height (low compliance)
Middle ear effusion
Ossicular fixation decreasing TM mobility
Type B Curve: Flat curve (low compliance)
See decreased compliance below (based on volume)
Normal volume (e.g. middle ear effusion, sclerosis)
Low volume (e.g. Cerumen Impaction)
High volume (e.g. TM Perforation or tube)
Type C Curve (high negative pressure): Retracted TM
Eustachian tube dysfunction
Upper Respiratory Infection

The Nose and Paranasal Sinuses

History
Sinuses

Nasal
Rhinorrhea
Nasal obstruction
Sneezing
Discharge
Olfaction
Allergies

Facial pain
Dental pain
Hearing loss
Post nasal drip
Olfaction
Congestion
Discharge

The Nose & Paranasal Sinuses

Exam

Inspect the external nose

outer contour, shape, size, color, nares

Palpate the ridge and soft tissues of the nose

tenderness, displacement cartilage/bone, masses

Evaluate patency of nares

Inspect nasal mucosa and septum

color, alignment, discharge, swelling of turbinates, perforation

Inspect and palpate regions of the sinuses

Flexible/Rigid Endoscopy

Sinusitis

Examples - Polyps

polyp

Septal Perforation

Nasopharyngeal Carcinoma

Upper Aerodigestive Tract - Histo

Oral Cavity/Oropharynx:
Hypopharynx/Larynx
Pain
Bleeding
Dysarthria
Numbness/Dysgeusia
Referred otalgia
Dry mouth

Dysphonia
Dysphagia
Cough/hemoptysis
Pain
Shortness of breath
Stridor
Globus

Swallowing:

Dysphagia

Solids vs
liquids

Odynophagia
Aspiration
Reflux

The Oral Cavity - Examination

Inspect lips and vermilion borders

symmetry, color, edema, surface abnormalities

Inspect and palpate gingiva

color, lesions, tenderness

occlusion, caries, loose or missing teeth

Inspect and palpate tongue and buccal mucosa

Inspect teeth

color, symmetry, swelling, ulcerations

Inspect palate, floor of mouth, uvula, tonsils, oropharynx

The Neck - Examination

Inspect the neck

symmetry, alignment of trachea, fullness, masses, webbing, skin

folds, jugular vein distribution, carotid artery prominence

Evaluate range of motion of neck

Palpate the neck

tracheal position, tracheal tug, movt hyoid bone and cartilages

with swallowing

Lymph Node Groups

Palpate lymph nodes

size, shape, consistency,

tenderness, warmth,
mobility
Pre-auricular
Post-auricular
Occipital
Jugulodigastric
Submental/submandibular
Facial
Anterior&Posterior Cervical
Supraclavicular

The NECK

Palpate the thyroid gland

Size, shape, configuration,

consistency, tenderness,
nodules

Examine on deglutition

The Larynx
Indirect laryngoscopy

hold pts tongue wrapped in guaze

with one hand
hold mirror in other hand against
soft palate
assess vocal cord mobility, lesions
in region

Direct laryngoscopy

posterior pharyngeal wall,

posterior cricoid region, piriform
recesses
vocal cord mobility and
appearance
arytenoid mucosa/cartilages,
aryepiglottic folds
epiglottis, valleculae, base of
tongue

Examples of Oral Cavity - Toru

Oral Cavity Traumatic Fibrom

Oral Cavity - Hemangioma

Oral Cavity - Papilloma

Oral Cavity - Squamous Cell

Carcinoma

Leukoplakia

Examples - Hypopharynx/Larynx
Foreign Body (Fish Bone)

Vocal Cords

Cyst
Papilloma

Nodule
Polyp

Vocal Cord - SCC

Leukoplakia

Hypopharynx/Supraglottis

Pyriform Sinus Ca

Epiglottitis

Cranial Nerves

Examine cranial nerves II - XII

Consider screening
neurological exam in dizzy
patients:

Mental Status
Cranial Nerves
Gross Motor
Gross Sensory
Reflexes
Cerebellar Tests (Rhomberg,
finger-to-nose, heel-shin, rapid
alternating hand movements)

Common Topics in ENT

(based on the clerkship objectives)

Otitis Media and Otitis Externa

Tinnitus and Hearing Loss
Vertigo
Facial Paralysis
Epistaxis
Acute and Chronic Sinusitis
Obstructive Sleep Apnea
Cancers of the Head and Neck

Otitis Media

Otitis Media

Most common disease diagnosed by clinicians

Incidence rapidly increasing each year, almost 90% of kids have at

least one bout by their 2nd b-day

Presentation: fever, pain, irritability (in kids) also conductive HL,

behavioural changes,
otorrhea, anorexia,

Organisms: Strep. Pneumoniae (40%)

Haemophilus influenzae (25%)
Moraxella catarrhalis (12%)

Risk Factors: day-care, passive smoking, family history, non-breast

fed, no vaccine

Otitis Media

Why?

Eustachian tube dysfunction in children

skull)

(ie. Anatomy of infant

Treatment considerations: antibiotics for AOM, OME,

RAOM
antbx 7-10 day regime vs 6-8 weeks
role of tympanostomy tubes +/- adenotonsillectomy (see
Bluestone figures)

When to refer

Otitis Media - complications

Features of high risk: neonate, immunocompromised

state (diabetes, HIV, neutropenia)

Symptoms of intracranial pathology:

fever, severe headache, meningeal signs, seizures

Symptoms of otologic pathology:

pain (retroorbital, mastoid), vertigo, SNHL, displaced pinna,

cranial nerve 6,7,8

Otitis Media - complications

Otologic
Mastoiditis/subperiostel
abscess
Petrous Apicitis
Labyrinthitis
Facial Paralysis

Intracranial
Meningitis
Epidural abscess
Sigmoid sinus
thrombosis
Brain abscess

Otitis Externa

Otitis Externa

Presentation: otalgia, fullness, pruritis, hearing loss

Etiology: Otitis media, water exposure, canal trauma
Organisms: pseudomonas, proteus, Staph, fungal
Treatment:
Debridement
ototopical agents (Ciprodex, Garasone, Sofracort) 3-7 days
PO antibiotics if severe (cellulitis/nodes)
analgesics
water precautions, pt education

Tinnitus

Tinnitus - DDx
Cardiovascular dz - pulsatile
Meniers
- assocd with / episodic
vertigo, aural
fullness , hearing loss
Brain Neoplasm - esp CPA tumors
Trauma / Noise - assocd with temporary
hearing loss
Psychosocial Dz - aural hallucinations esp
Schiz
Drug induced ASA most common,
usually high
pitched, reversible
Otosclerosis otospongiosis of cochlea,
labyrinth

Hearing Loss

Hearing Loss

Conductive Hearing Loss

impedes amplification and/or transmission of sou

to cochlea
can involve external ear, EAC, TM, middle ear
space, and/or contents

Sensorineural Hearing Loss

involves inner ear (i.e. cochlea), acoustic nerve

and/or central auditory pathways

Hearing Loss: DDx

Conductive

External Ear

Sensorineural

congenital atresia
cerumen
foreign body
malformations
infections

neoplasms

congenital
effusions (serous OM)
acute OM
neoplasms
otoclerosis
TM perforation
ossicular discontinuity
tympanoscerosis
otosclerosis

ossicular fixation
mastoiditis

presbycuisis
noise-induced HL
head trauma
drug toxicity
Menieres
sudden SNHL
tumor
perilymphatic leak
CNS disease (e.g. MS)
labyrinthitis

Middle Ear

congenital
acquired

Vertigo

Vertigo
false perception of movement
important Qs: onset, duration, frequency,
associated ear symptoms, positional
triggers, hx ear dz/head trauma
ENT exam, plus Hallpike maneuver,
CN+cerebellar testing

Common Causes of Vertigo

Menieres Dz

episodes lasting mins-hrs

roaring tinnitus, aural
fullness, low-pitched
hearing loss

Benign Paroxysmal
Positional Vertigo (BPPV)
most common cause
episodes lasting secs
triggered by head movt

Labyrinthitis/Vestibular
Neuronitis
sudden onset
lasts hrs, subsides over
days
hx viral infection

+/- hx injury, infection

Central

assocd other neuro S+S

+/- LOC
vascular
temporal lobe
cerebellar

Facial Paralysis

Acute Facial Paralysis

History: onset, duration, rate of progression, recurrence (Bells , MR

syndrome)

Associated symptoms: numbness middle and lower face, otalgia,

hyperacusis, diminished tearing, taste alteration Bells; intense ear
pain and vesicular eruption HZ infection

Recall/review anatomy of the facial nerve; its intra-extracranial

components

Complete Head and Neck exam/ CN assessment, palpation of

parotid gland and neck

Facial palsy; complete vs incomplete, segmental vs uniform involvt,

unilateral vs bilateral (<1%)

Acute Facial Paralysis:

Investigations
CBC with diff and ESR
Serum antibody tests; serum ANA and RF

Electrophysiologic tests

nerve excitability test (NET)

maximal stimulation test (MST)
Electroneurography (ENoG)
Electromyography (EMG)

CT, MRI+/- CXR

Acute Facial Paralysis Bells

Rapid onset palsy, minimal assoc symptoms,

spontaneous recovery

1/3 pts develop only paresis, 95% total recovery

2/3 complete paralysis, facial tone/movt 85% in 3 wks;
expect 3-6 months

The longer the delay in recovery, the greater the liklihood

of adverse sequelae

? HSV evidence for etiology

Acute Facial Paralysis Treatment

Treatment must be initiated promptly for maximal efficiency delay

of > 3 days decreases efficiency
Medical tx:

Prednisone 1mg/kg/day for 7-10 days

Acyclovir 400mg po 5 times daily for 7 days

Surgical Tx:

Decompression (>90% degen on ENoG w/in 14 days onset + no

voluntary motor unit potentials EMG)

avoid vents, liberal use of ophthalmic lubricants, shielded glasses

Potential gold weight implants, canthoplasty, tarsorrhaphy for long term

Eye Care

Epistaxis

Epistaxis

Most common bleeding d/o of head and neck

Seasonal incidence Winter > Summer

Very common 60% incidence through ones life

10% seek medical attention; 6-10% ENT consult

POTENTIALLY LIFE THREATENING

Etiology consider local and systemic factors

Site of bleed -

Anterior 90%
Posterior 10%

Epistaxis first things first

History: side, duration, amount, temporal pattern,

trauma

PMHx: liver disease, coag d/o, family hx, HTN, previous

epistaxis, nutrition

Medications: ASA, NSAIDS, warfarin, heparin,

chloramphenicol, dipyridamole
Examination:
- ABCs and vitals (orthostatics)
- General exam (purpura, petechiae)
- Nasal exam (head light, suction, decongest,
determine bleeding site)

Epistaxis Acute Management

Reassure patient
IV hydration depending on extent of bleed
control HTN
Bloodwork CBC, INR/PTT, Group and Cross
Treatment
- depends on etiology
- those with systemic factors, conservative,
noncauterizing, cartilage-sparing techniques for
initial therapy
correct coags, d/c meds

Epistaxis Acute Management

Anterior : localize bleed
- silver-nitrate cautery
- surgicel/oxycel (cellulose),gelfoam (gelatin)
- anterior packing (merocel vs impreg guaze)
- PO antibiotics with packing (TSS)

Posterior: difficult to see etiology

- posterior packing (foley/rockets/formal pack)
- embolization
- IMAX , ethmoid ligation
- endoscopic cauterization

Consider ENT referral if posterior pack required

Sinusitis

Sinusitis

Inflammation of mucosal lining of the sinuses

Pathophysiology: patency of ostia
function of cilia
quality of nasal secretions

Predisposing factors: local, regional, systemic

Be aware of complications very serious

GET CULTURE for diagnosis

Treat for at least 10 days 3 weeks to prevent relapse

Sinusitis - Classification
Rhinosinusitis classified according to 5 axes:
clinical presentation: acute, subacute, chronic
sinus involved: ethmoids, maxillary, frontal,
sphenoidpansinusitis
causative organism: bacterial, viral, fungal, protozoan
presence of complication: extrasinus extension
modifying or aggravating factors:
immunosuppression, diabetes, malnutrition, NG tube,
IgG deficiency

Sinusitis - bacterial
Acute
lasts 1 day 4 weeks
- management antbx for at least 7 days post-sx
- surgery rarely necessary
complications
Subacute
lingers 4 weeks 3 months
- inflammation still reversible med.
managet
Chronic - persisted disease > 3 months
- generally irreversible damage to sinus drainage
- surgical managet

Sinusitis

Viral sinusitis:

follows viral URI

damage cilia from cilia ciliotoxins
predisposes to bacterial sinusitis

Fungal sinusitis:

noninvasive (mycetoma, AFS)

invasive ( fulminant FS,

indolent)

orbital
Complications
of sinusitis

intracranial
need aggressive medical AND surgical tx

Obstructive Sleep
Apnea

Obstructive Sleep Apnea

repeated reductions/cessations in airflow, w/ apnea index >=

respiratory disturbance index (RDI) of at least 10 on
polysomnograph

central apnea: absence of airflow assocd w/ lack of inspirat

effort

Snoring: 28% of women, 44% of men aged 30-60

OSA: 9% of women, 24% of men (RDIs of 5 or higher)

OSA: Pathophysiology

tongue contacts the soft palate and posterior pharyngeal wal

the presence of lateral collapse of the pharynx, thus generat
occlusion

risk factors: obesity, redundant tissue in the neck, ,structural

bnormalities in nose, nsphx,
etrognathia, craniofacial anomalies

Alcohol and other sedating medications may contribute

OSA Management

Investigations: Gold standard Polysomnogram PSG(Sleep Study)

Treatment

Conservative Measures: weight loss, avoid sedatives, sleep on side

Gold Standard - Continuous Positive Airway Pressure (CPAP)

Oral Appliance

Surgery in select patients: Uvulopalatopharyngoplasty, septoplast

Neoplasms of the
Head and Neck

Neoplasms of the Head and

Neck

6-8 % of all malignancies in the body

historically M>F but ing in women due to

smoking

90% Squamous Cell Ca

H&N Tumors: Risk Factors

Nose/Sinuses: asian descent, hardwood dust, nickel, chromi

Lip: UV exposure, poor oral hygiene, smoking/EtOH
Salivary Gland: smaller gland, risk malignant
Oral Cavity: smoking, EtOH, poor oral hygiene, chronic den
irritation, betel nut chewing
Pharynx: smoking, EtOH
Thyroid: family history, radiation exposure

Peritonsillar
Abscess

Common complication of tonsillitis in adolescents and

young adults

Symptoms: trismus, painful swelling in throat, dysphagia,

odynophagia, fever, otalgia, hot potato voice

Classic findings:

unilateral swelling peritonsillar region with bulging soft palate

Deviation of midline of palate and uvula to contralateral side

Hx: sore throat > 5 days with ineffective antbx tx

Peritonsillar abscess

Clindamycin 300mg QID x 7 days + analgesics

Needle aspiration and I&D (effective >90%)
- risk of recurrence 10-15%
- pts younger than 40 yrs with hx of recurrent tonsillitis @
greatest risk
>2 bouts of peritonsillar abscess candidate for tonsillectomy
Inability to swallow fluids, poor airway, immunosuppression,
young patients may be factors for admission
Tonsillectomy for some surgeons

Management:

Upper Airway Obstruction

Can present as a life-threatening hypoxemia and

hypercapnia

First priority is to establish airway; dont forget about the

nasopharyngeal a/w
Signs: inspiratory stridor (decreased intraluminal
pressure compared to atmospheric pressure Bernouille
principle

Most important step in initial evaluation is determining

whether an airway needs to be established immediately

Upper Airway Obstruction Diagnostics

History/Symptom
Features
Severity of symptoms

Considerations
? Immediate a/w

Hx tobacco/ETOH

? Cancer in upper a/w

Fevers/chills/pain

? Infection ? site

Recent neck/chest surgery

RLN injury VC paralysis
Hx previous intubation Post. Glottic closure or
subglottic scar tissue
Hx HTN or fam. Hx obst
n angioedema
Severe hoarseness

Obstn @ glottic level

Upper A/W obstruction - Dx

Main points in hx: timing, age, PMHx, other systemic d/o,

ability to sleep lying down
Physical exam: pt may need antihistamines, epinephrine,
steroids, antbx during dx evaluation
Pulse oximetry demonstrates end-point obstn, no info
during progression
Hypercapnia, acidosis early signs of hypoventilation
Agitation, cyanosis, resp effort on inspection
Nasal flaring, neck retractions, accessory muscle use
signs of fatigue; listen to chest for symmetry/noises

Upper A/W obstruction - Dx

Complete head and neck exam: nose, oral cavity, larynx

highlight exam

Radiology: may not be time for soft tissue lateral views,

generally not great aid to dx

CT and MRI useful

Management related to diagnosis and urgency

Differential Diagnosis
Upper A/W obstruction
MISI BOVO

Malignant tumours (SCC, Adenoid cystic of trachea, thyroid Ca)

Infections (Epiglottitis, supraglottitis, Tracheitis, cellulitis FOM
Lugwigs, Retropharyngeal abscess)

Subglottic stenosis (hemangioma, intubation)

Inflammatory (GERD larygospasm, Angioedema)
Benign tumours (recurrent papillomas, chondromas, lipomas,

fibromas)

Body (Foreign)

Differential Diagnosis
Upper A/W obstruction

Other Vocal Cord lesions (polyps, glottic webs)

Vocal cord paralysis (recurrent nerve injury, systemic neurologic

disorder, idiopathic)

Other Vocal Cord Mobility D/O (cricoarytenoid joint fixation,

inspiratory adduction functional laryngospasm, scar tissue in
interarytenoid region)

Angioedema
Presentation: acute painless mucosal edema
- face, lips, tongue, larynx
- airway obstruction 20%
Etiology ACE Inhibitor sensitivity most common
- see chart
Treatment aggressive
- high humidity oxygen, epinephrine,
antihistamines, steroids
- secure airway (observe, ET Tube, tracheotomy)
- D/C ACE inhibitors and Med consult (HTN)

Temporal Bone Fractures

Blunt and penetrating trauma MVA, fall
Three types : longitudinal, transverse, mixed
Longitudinal: most common 70-80%
- facial nerve injury 10-20%
- ruptured TM, hemotympanum, CSF leak
- persistent conductive HL (ossicular
chain)
- profound
SNHL
Transverse: # usually
involves
bony labyrinth
- facial nerve injury (~ 50%)
- CSF otorrhea/rhinorrhea, meningitis

Temporal Bone Fractures

Management:
- trauma protocol ABCs, C-spine
- Ear exam
- Assess facial nerve early (immediate vs
delayed)
- Assess hearing Audiogram, tuning forks
- Radiology Head CT (brain injury) + CT
temporal bone windows

Temporal Bone Fractures

Treatment:
immediate facial nerve paralysis OR to repair
delayed FN paralysis observe, steroids, eye
protection
CSF leak conservative bed rest, >90% resolve
in two weeks
SNHL hearing aid
conductive HL ossicular reconstruction
vertigo tx symptomatically, Serc, Meclizine, PT

Nasal Fracture
Very common; most common facial fracture
High index of suspicion for fracture
- mechanism, appearance, epistaxis,
obstruction
Examine entire
face (nose,
orbit, zygoma,
mandible)
- instability,
mobility,
crepitation
- septal hematoma,
lacerations
Facial
x-rays if variable
reliability
CT face
indicated
other fractures
present
ENT REFERRAL
- < 5 days for closed reduction
- > 12 days for septorhinoplasty

Sudden Sensorineural Hearing

Loss
Hearing Loss sudden, usually unilateral
no trauma history
rapidly progressive (<3 days)
Etiology Uncertain
- Viral (30-50% assoc viral URTI)
- see chart
Associated Symptoms Aural fullness, tinnitus, vertigo

Sudden SNHL
Diagnostics: 90% no etiology found
- normal P/E
- Audiogram, ABR, Otoacoustic emission
- Lab tests (see chart)
- possible MRI with
gadolinium (1-3% AN)
Management:
2/3 recover spontaneously
- Antiinflammatory
steroids
- vasodilators carbogen, histamine, papaverine
- rheologic agents LMW dextrans, heparin
- antivirals/diuretics/triiodobenzoic acid deriv
- surgery
Bottom line: EARLY REFERRAL