Ear, Nose & Throat
Notes compiled for PediatricsEar, Nose & Throat(Med I, Block 3, ET)
ContentsClass numberClass NameTypeDepartmentInstructorET006Embryology of the Head and NeckLANDr. M TorchiaET009General ENT I - PharyngitisLETDr. D SutherlandET010General ENT II - AirwayLETDr. D LeitaoET012Ear II - Disaeses of External and Middle EarLETDr. L GarberET013NoseLETDr. LeitaoET016ENT tutorialT5ETDr. D Sutherland
Development of the Head and Neck – ET006, Block 3Dr. Mark TorchiaDepartment of SurgeryObjectives:1. Explain branchial apparatus, pharyngeal arch, pharyngeal pouch, andpharyngeal groove (cleft)2. Describe the adult derivatives of the pharyngeal arches, pouches, andgrooves3. Describe the development of the tongue, including its innervation4. Describe the origin and development of the thyroid gland5. Discuss the development of the face and the palate6. Explain the embryological basis of: ectopic thyroid gland, branchial cysts,clefts of the lip and palate, thyroglossal duct cyst and sinusLecture Notes:1. Recallooothe layers of the trilaminar embryo:ectoderm (outside)mesodermendoderm (inside)2. During weeks 5-8 inclusive (embryo period), the structures of the headand neck are developed.3. Tissue prominences (Pharyngeal Arches) develop in the location of theprimordial neck. This development results from the infiltration of neuralcrest cells from the head into the mesodermal tissue of the neck.(Note: in embryology the terms Branchial and Pharyngeal are usesomewhat interchangeably however pharyngeal is the preferred term.Branchial gill, pharyngeal throat.)4. The processes involved in the formation of the pharyngeal arches andtheir products are (as always) proliferation and selective control of theinitiating factor (neural crest cells) into specified locations (Hox genes),followed by differentiation of the mesoderm (Hox genes) into tissuetypes (e.g. nerves, ligament, bone, etc.) followed by morphogenesisinto specific structures (e.g. facial nerve, stylohyoid ligament, stapes). Theexquisite control of these mechanisms is not yet completely understood.5. These pharyngeal arches (numbered 1,2,3,4 (-6) are separated fromeach other by an internal (endodermal) pouch and an external(ectodermal) groove. The arches, grooves, and pouches have distinctroles although not each results in the formation of an adult structure.1
Development of the Head and NeckET 0066. The arches supply the cranial nerves, cartilage and bone, muscles, andligaments to structures in the head and neck (see Table 10-1, pg 221)7. The 1st pharyngeal groove forms the external acoustic canal.Surrounding tissue hillocks (6) form the auricle. Remaining grooves areobliterated by overgrowth of 2nd arch during neck development.8. Clinical correlates:a. Branchial cyst – painless enlarging neck mass, anterior triangle,typically anterior border SCM, remnant of pharyngeal groovesb. Accessory auricles.c. Branchial Sinus (blind tunnel) and Branchial Fistula(connecting duct structure – 2nd to the tonsillar fossa, 3rd to thepiriform sinus) to small opening at external anterior boarder of SCMwith mucus discharge.9. The derivatives of the pharyngeal pouches are:a. 1st – tympanic cavity and auditory tube; with 1st branchial groovebecomes the tympanic membraneb. 2nd – tonsillar fossac. 3rd – inferior parathyroid gland, thymusd. 4th – superior parathyroid gland10. Development of the tonguea. Origins lay in arches 1-4 therefore innervation is complexb. Landmarksi. Median sulcus – fusion of L/R distal tongue buds (1st arch)ii. Distal suclus (circumvallate papillae) – 1st arch/2nd archiii. Foramen cecum – see Point # 11 below11. Development of the thyroida. Endoderm (1st - 2nd arch) proliferates (thyroid diverticulum)b. Invagination of tissue leads to formation of thyroglossal duct(remnant is foramen cecum)c. Path of tissue is first to anterior hyoid then cricoidd. Duct obliterates; thyroid C cells derived from 4th pouch12. Clinical Correlatesa. Thyroglossal duct cyst (sinus, fistula) – midline neck massb. Ectopic thyroid – located along path of descent (base of tongue)2
Development of the Head and NeckET 00613. Development of facea. Key Landmarksi. Frontal prominenceii. Nasal prominences – medial and lateraliii. Maxillary and mandibular prominences – 1st archiv. Philtrum – fusion of the L/R medial nasal prominencesv. Nasolacrimal duct – furrow at the junction of the frontaland maxillary prominence14. Clinical Correlatesa. Cleft lip – incomplete fusion of medial nasal prominence andmaxillary prominence (unilateral 1:1000 M F)15. Development of the palatea. Key landmarksi. Primary palate – anterior maxillary and nasal prominencesii. Secondary palate – lateral palatine processes from lateralmaxillary prominences (soft palate by 11th week)iii. (Nasal Septum)16. Clinical Correlatesa. Cleft palate – incomplete formation/fusion of palatine processesSample Exam Question:Which would be a likely diagnosis for a 3 month old child presenting with amucous secreting lesion on the posterior border of the sternocleidomastoid?1.2.3.4.5.1st branchial groove cystthyroglossal duct cyst2nd branchial groove cyst2nd branchial groove sinusnone of the aboveThe nasolacrimal duct is formed by the fusion of the:1.2.3.4.5.left and right frontonasal prominenceslateral nasal prominence and the maxillary prominencefrontonasal prominence and the maxillary prominencemedian nasal prominence and the maxillary prominencethe nasal and otic placodes3
University of ManitobaOtolaryngologyMED 1/ET009(L)L. Garber/2006-2007ET 009:GENERAL ENT I - PharyngitisObjectivesThe student will:1. Know the etiology, presentation and management of pharyngitis, acute tonsillitisand peritonsillar abscess2. Know the indications for tonsillectomy and adenoidectomy3. Know the risks of tonsillectomy and adenoidectomy4. Be aware of deep neck space infections, their presentation and managementReferenceHall & Colman – Diseases of Ear, Nose and Throat, 15th ed, Chapter 26 & 27, pg 177186, 139 - 140GENERAL ENT I - NOTESWaldeyer’s ring of lymphoid tissue consists of the adenoids, palatine tonsils (pharyngealtonsils or “tonsils”) and the lingual tonsils (located at the tongue base).Palatine tonsils: lymphoid tissue with prominent germinal centers. They sit in thetonsillar fossa bordered by three muscles and separated from the lateral pharyngeal wallby connective tissue.- palatoglossus – anterior tonsillar pillar- palatopharyngeus – posterior tonsillar pillar- superior constrictor – lateral border of tonsillar fossaBlood supplyarterial – branches from ascending palatine, descending palatine, facial, lingual,and ascending pharyngeal arteries- venous – venous plexus drains into lingual and pharyngeal veins interiorjugular veinNerve supply (sensory)- glossopharyngeal nerve branches – (IX)- lesser palatine (V) (sensory fibers from (VII) via pterygopalatine ganglion)- tympanic branch of (IX) – the reason for referred ear pain (referred otalgia)4
General ENT I - PharyngitisET 009PharyngitisDefinition: inflammation of pharynx- prevalent in winter months – overcrowding (?)- most caused by viruses (rhinoviruses, enteroviruses, adenoviruses)Clinical Features-sore throat and dysphagia – less severeafebrile, not toxic or “ill”, associated s/s of URTIcervical lymphadenopathy, if present – small, mildly tenderpharynx – erythematous soft palate, pharynx, tonsilstonsils not enlarged, no pus/exudateInvestigations - throat swab, monospot (if concerned re diagnosis)Treatment-symptomaticanalgesics, saline gargle, soft diet, ample fluid intakeno role for antibiotics for treatment of viral pharyngitis / URTIself limited infection – resolves with timecold remedy preparations are a billion dollar industry!!!Acute Tonsillitis (acute pharyngotonsillitis)-inflammation of the tonsilsetiology – viral or bacterial infectionbacterial infection – Group A- β hemolytic streptococcus, Group G streptococcus,pneumococci, staphylococci, haemophilus influenza , M. catarrhalisClinical Features-very sore throatodynophagia (pain with swallowing)fever, malaisereferred otalgia (ear pain)tonsils uvula , soft palate edematous, erythematouspus or membrane on surface of tonsilscervical adenopathyInvestigations – CBC, throat swab, monospotTreatment-fluids, analgesics, antipyreticsantibiotics if throat swab positive or clinical presentation severe or persistingantibiotics may reduce the length of time of illness5
General ENT I - Pharyngitis-ET 009antibiotics are used mainly to avoid the sequela of rheumatic fever followingGroup A-β hemolytic strep infectionantibiotics do not alter post-streptococcal glomerulonephritisfirst line antibiotics- Penicillin or Amoxicillin x 10 days – (erythromycin if penicillinallergic)10 – 18% treatment failure rate (penicillinase production by oral anaerobes)Infectious Mononucleosis-Epstein Barr Virus (EBV)systemic illnesssevere tonsillitis – grey membrane covers tonsilsmassive adenopathy (classically posterior triangle of neck)odynophagia, malaise, feverhepatosplenomegalyspread by droplet transmission (saliva exposure)Diagnosis – atypical lymphocytes in the blood, monospot test – detects se high dose steroids for markedly ill individuals or massive tonsillarhypertrophy- antibioitics only if 2 bacterial infection supervenesAmoxicillin causes characteristic rash in patients with mononucleosis-Complications of tonsillitis Peritonsillar abscess (quinsy)-infection passes through tonsil capsule into peritonsillar tissue causing cellulitis,then abscessbacteriology – mixed, aerobes and anaerobes-Clinical Features- severe sore throat and otalgia (unilateral)- trismus *(inability to open mouth)- bulging soft palate, uvula displaced to opposite sideTreatment- cellulitis treated with antibiotics- abscess requires incision and drainage (done in clinical setting) Sepsis -Sequela of beta-hemolytic strep infectionscarlet fever, rheumatic fever, glomerulonephritis6
General ENT I - Pharyngitis -Scarlet Feversecondary to acute streptococcal infection with endotoxin productionrash, severe lymphadenopathy, bright red tonsils, strawberry tonguetreatment – IV penicillin -Suppurative Cervical Adenitisrarecentral liquification of lymph nodeerythema, warm to touch, tender, fevertreatment – incision and drainage, antibioticsET 009Deep Neck Space InfectionThe fascial planes in the head and neck form potential spaces that can become involvedin bacterial infection creating collections (abscesses). The fascial planes play a role inboth confining and providing potential routes of spread of these infections. Theseinfections typically develop as a result of tonsillitis, dental infection or salivary glandinfection. Bacteriology of the abscess fluid reveals mixed aerobes and anaerobes.These patients are usually severely ill and may develop upper airway obstruction due tolaryngeal edema. Airway obstruction can progress rapidly (within a few hours).Treatment requires I & D and IV antibiotics with special attention to management of theairway. -Retropharyngeal Abscesscommonly the result of a suppurating lymph nodeinfection can tract down into the chest causing mediastinitis -Lateral Pharyngeal Abscess (parapharyngeal)diffuse unilateral neck swelling and oropharyngeal findingsfluctuance may be absent due to deep nature of abscess -Ludwig’s Anginaacute cellulitis / abscess of submandibular, submental and sublingual spacesDiptheria-rare due to immunization programscorynebacterium diphtheriaegray membrane – tonsils, palate, tongue – attempted removal causes bleeding“bull neck” appearance due to adenopathymay lead to airway obstruction or cadiotoxicityTreatment-antitoxin and systemic penicillin7
General ENT I - PharyngitisET 009Tonsillectomy - IndicationsAbsolute Indications-acute airway obstructionexcisional biopsy for suspected malignancy (squamous cell carcinoma/lymphoma)Relative Indications-Recurrent Acute Tonsillitis (adults and children) 7 episodes within 1 year 4 -5 episodes per year x2 years 3 episodes per year x3 yearsEpisodes should be well documented and have one or more of the following:o positive throat culture for group A strepo elevated temperature ( 38.3 C)o cervical adenopathyo requiring significant time off work/school- Chronic Tonsillitis (adults)oooless severe sore throat 6 mo, associated cervical adenopathyno response to antibioticsassociated halitosis / debris in tonsillar crypts- Adenoid and Tonsillar Hypertrophy (children)oomalocclusion 2 to chronic mouth breathingsleep disordered breathing in children (there is no role of tonsillectomyin the treatment of obstructive sleep apnea in adults)Risks of Tonsillectomy-bleeding (2-4%) – primary – within 24 hours- secondary or delayed – (7 to 14 days post-op)- usually minor, can be severe resulting in transfusion and rarely deathairway obstruction – swelling, clotrisk of anesthesiainfection – localApproximately 2000 tonsillectomies done in Manitoba per year (compared to 1970 – 6500tonsillectomies done)8
General ENT I - PharyngitisET 009Indications for Adenoidectomy (pediatric)Adenoid hypertrophy-nasal obstruction resulting in chronic mouth breathing and malocclusionnasal obstruction resulting in sleep disordered breathingrole in otitis media – serving as a reservoir for infection rather than causingobstruction. Adenoidectomy considered as adjunctive treatment in patientsundergoing repeat insertion of t-tubes for recurrent AOM or OMERisks of Adenoidectomy-bleedingrisk of anesthesiavelopharyngeal insufficiency (i.e. incomplete closure by palate during drinking /eating / speech)cleft palate and submucous cleft palate (bifid uvula, notching of hard palate) arecontraindications to adenoidectomy9
Med I - General ENT II - AIRWAYObjectivesThe student will know: The anatomy of the larynx and trachea Indications for tracheostomy Risks of tracheostomy Causes of sleep apnea in childrenLaryngeal Anatomy – see anatomy notes ET002 Strap Muscles Blood SupplyFramework- arterial- venous- hyoid bone- thyroid cartilage- cricoid cartilage- trachealaryngeal nervInnervation-(sensory and motor)- superior laryngeal nerve- inferior (recurrent)Terminology Tracheotomy vs tracheostomy“tome” – greek – to cut“stoma” – greek – to finish with mouth or opening to skin Terms are used interchangeablyIndications for tracheotomy Upper airway obstructionRespiratory insufficiency / Prolonged intubationRetained secretions / Pulmonary toilet10
General ENT II – AirwayET 010(access for suctioning trachea)Cricothyroidotomy - Emergency Surgical Airway Procedure of choice when total airway obstruction is presentOpening into airway at cricothyroid membranePotential for laryngeal injury is highRequires re-evaluation once pt is stableTracheostomyWhenever possible tracheostomy should be performed in theoperating room or similar environment under controlledconditions.Complications of Tracheotomy –Intra-operative Complications BleedingSurgical traumaLoss of Airway / Airway obstructionApneaSubcutaneous emphysemaPneumothorax / PneumomediastinumDeathPost-op ComplicationsEarly:Late: BleedingDecannulation (displaced or blocked tube)Infection - Bleeding- Infection- Granulation tissue- Tracheomalacia- Tracheostenosis- Tracheoesophageal fistula- Psychological issues11
General ENT II – AirwayET 010Do Not Change a Fresh Tracheostomy Tube for 72Hours Unless Absolutely NecessaryPossible reasons to need to change a tracheostomy tube prior to 72hours: Displaced tracheostomy tube Blockage of tracheostomy tube Cuff leak Different type of tube requiredDON’T MAKE A STABLE SITUATION AN UNSTABLE ONE !!!Pediatric Airway Subglottic Stenosis- congenital- aquiredLaryngomalacia Foreign bodies - bronchial- esophageal - laryngealInfection - Acute Supraglottitis- bacterial (Haemophilus Influenzae)- Croup - viralTumors - Respiratory Papillomatosis- Hemangioma- LymphangiomaSleep Apnea Severe Chronic Upper Airway Obstruction can result in sleepapnea or cor pulmonaleHypoxia, CO2 retentionPulmonary hypertension12
General ENT II – Airway ET 010Right heart failureDeathSleep Apnea-Central- Obstructive- MixedPediatric Obstructive Sleep Apnea Adenotonsillar HypertrophyObesityCraniofacial abnormalitiesNeuromuscular diseaseAcute onset or rapidly progressive – be suspicious of underlyingserious pathology13
University of ManitobaOtolaryngologyMED 1/ ET012(L)L. Garber/2006-2007ET 012: Ear II – Diseases of the External and Middle EarObjectives1)Be familiar with the etiology, clinical presentation, diagnosis and treatment ofdiseases of the external ear including:- cerumen impaction- otitis externa- exostoses- malignant (necrotizing) otitis externa2)Be familiar with the etiology, clinical presentation, diagnosis and treatment ofdiseases of the middle ear including:- acute otitis media- otitis media with effusion- mastoiditis- chronic suppurative otitis media- cholesteatoma- otosclerosis3)Be familiar with the indications for myringotomy and tympanostomy tubeplacementReference: Hall & Colman: Diseases of the Ear, Nose and Throat (Ch. 4 & 5, pp 29-58)Definitions / AbbreviationsTMOMOEAOMOME-tympanic membraneotitis media – inflammation of the middle earotitis externa – inflammation of the external ear (ie. ear canal)acute otitis media – acute inflammation of the middle earotitis media with effusion – presence of fluid in the middle ear without signsor symptoms of infectionCSOM - chronic suppurative otitis media - chronic / recurrent infection of the middleear associated with a persistent TM perforationMyringitis - inflammation of the tympanic membraneMyringotomy - an incision in the tympanic membraneTympanostomy tube(t-tube / ventilation tube) – a tube placed in the TM to ventilate themiddle earCholesteatoma - a cyst composed of keratinizing squamous epithelium in an abnormalplace (eg. middle ear, mastoid, temporal bone)14
Ear II – Diseases of External and Middle EarlET 012External Ear Diseases / ProblemsCerumen Impaction-ears are naturally self-cleaningcerumen is protective to the ear canal skinSymptoms- hearing loss- pain (otalgia)- aural fullnessTreatment- debridement-} - dependent on experiencesyringingceruminolytics – olive oil, glycerineNote: cerumen removal is indicated only if EAC is completely occluded, with associatedpain or decreased hearingSyringing - contraindicated in previous ear surgery, TM perforation, t-tube, only hearingearComplications of syringing-trauma (EAC, TM, ME)otitis externaTM perforationVertigoExostoses-Definition – benign boney outgrowthEtiology - ?repeated cold water exposureUsually an incidental findingIf large can be symptomatic (cerumen impaction, OE) and surgical excision canbe performedOtitis Externa - inflammation of external auditory canalEtiology - infectious – bacterial ( 90 %) – pseudomonas aeruginosa, staphylococcusaureus- fungal ( 10 %) – aspergillus, candidaRisk Factors - swimming, EAC cleaning (Q-tips), local dermatitis, ear canal occlusion( hearing aid use)15
Ear II – Diseases of External and Middle EarlET 012Clinical Features-otorrheapain (aggravated by movement of pinna or pressure on tragus)conductive hearing loss (secondary to EAC swelling and/or debris causingobstruction)Treatment-clean ear under magnificationswab for C & SBacterial- antibacterial ear drop with or without steroid component – (ie. Gentamicin,Ciprofloxacin, Garasone, Ciprodex)- do not use aminoglycosides if the TM is perforated (risk of ototoxicity)- placement of gauze wick if EAC is edematousFungal- debridement- topical antifungals (ie. Lococorten-Vioform, Gentian violet / mycostatin powder)Chronic Otitis Externa-pruritis without obvious infectionuse topical corticosteroid aloneMalignant (Necrotizing) Otitis ExternaOsteomyelitis of the temporal bone that occurs in immunocompromised patients ordiabetics. It is caused by pseudomonas infection. Patients have severe pain. Classicfinding is granulation tissue along the floor of the ear canal. Patients require hospitaladmi
Hall & Colman – Diseases of Ear, Nose and Throat, 15th ed, Chapter 26 & 27, pg 177-186, 139 - 140 . GENERAL ENT I - NOTES . Waldeyer’s ring of lymphoid tissue consists of the adenoids, palatine tonsils (pharyngeal tonsils or “tonsils”) and the lingual tonsils (located at the tongue base).
Furuncle of external ear. H60.00 Abscess of external ear, unspecified ear. H60.01 Abscess of right external ear. H60.02 Abscess of left external ear. H60.03 Abscess of external ear, bilateral. H60.1 Cellulitis of external ear. Cellulitis of auricle Cellulitis of external auditory canal. H60.10 Cellulitis of external ear, unspecified ear
as the eyes, nose, and skin. The most common effect of overexposure is irritation of the eyes, nose, and throat. Eyes, Nose, and Throat. The eyes, nose, and throat are irritated by formaldehyde vapors at levels as low as about 0.3 part formaldehyde per million parts of air (0.3 part per million, or 0.3 “ppm" — see “Legal Exposure Limits").
Ear Cough on scratching the external auditory canal is due to auricular branch of vagus nerve (Arnold’s nerve) Nerve responsible for referred otalgia:- Glossopharyngeal nerve Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 3, 15 ) Textbook of Ear, Nose and Throat, BS Tuli (Pg 3, 19) [NEET118T [MEET 2020]
problems in the middle ear. It’s possible for infection to spread from the nose and throat area through the Eustachian tube to the middle ear, which is one of the causes of middle ear infections. The third part of the auditory system is the inner ear. The inner ear has two sections: one that is responsible for balance and the other for hearing.
Massachusetts Eye and Ear (Mass. Eye and Ear) is a specialty hospital dedicated to excellence in the care of disorders that affect the eye, ear, nose, throat, and adjacent regions of the head and neck. Mass. Eye and Ear also provides primary care and serves as a referral center for outpatient and inpatient medical and surgical care.
whole middle ear space is the ear drum and the tympanic membrane the drum skin. 2.2.2. The Middle Ear The middle ear is an air filled space connected to the back of the nose by a long, thin tube called the Eustachian tube. The middle ear space houses three little bones, the hammer, anvil and
Care of Ear Cleaning Equipment 7. Ear Cleaning Equipment Single-use [(e.g. Tips (Elephant Ear Washer tips , Otoclear tips)], Syringes) Multi-patient reusable Patient owned or dedicated to a single patient (e.g. Elephant Ear Washer or Rhino Ear Washer ) (e.g. Elephant Ear Washer , Rhi
H53.10 Unspecified subjective visual disturbances H53.1 1 Day blindness Ear Diseases H61 .20 Impacfed cerumen, unspecified ear H61 .2t Impacted cerumen, right ear H6t 22 Impacted cerumen left ear H61 23 Impacted cerumen bilatera H60.00 Abscess of external ear, unspecified ear H60.01 Abscess of right external ear
