ent lectures 1

8/13/2019 ENT Lectures 1

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PRIMARY EAR, NOSE &

THROAT CAREA TRAINING MANUAL FOR

PRIMARY HEALTH CARE

WORKERS AND PRESCRIBERS

DR. DANIEL ASARE MD,MA,DLOWACSMEDICAL SUPERINTENDENT

ENT SURGEONREGIONAL HOSPITAL SUNYANI


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OUTLINE OF LECTURES

LECTURE

Anatomy, physiology,

Signs and symptoms of ear disease

Management of common eardiseases


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LECTURE 2

Hearing is a Public Health and asocial issue

Prevention of deafness

Causes of hearing Treatment of hearing loss


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LECTURE 3

Anatomy physiology of nose andparanasal sinuses

Signs and symptoms of nose andparanasal diseases

Sinusitis, rhinitis, epistaxis Treatment of common nasal

diseases


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LECTURE 4

1.Practical session Otoscopy Rhinoscopy

Technique of syringing Examination of buccal cavity2.Radiology Interpretation of x-rays of common ENT

emergencies3.Quiz end of session exams on E.N.T

Disease


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LECTURE1


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INTRODUCTION TO

OTORHINOLARYNGOLOGY

FOR NURSES


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THE FIELD OF OTORHINOLARYNGOLOGYCOVERS DISEASES OF THE

1. Ear2. Nose3. larynx4. Pharynx5. Buccal cavity6. Oesophagus (upper )


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Most of the Ear, Nose Throat (ENT) area is

accessible to direct visualization and a goodpart can be examined normally and digitally.Certain structures such as pharynx larynx

nasopharynx requires light for clearvisualization, head lamp. Both hands areneeded to expose and visualize thesestructures with appropriate instruments. Forthese reason a reflected light using the head

mirror and light source is used .


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INSTRUMENTS

Examination of the ear can be

done with otoscope


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ROUTINE EXAMS A routine examination covers the followingregions:

Oral and buccal cavily and oropharynxnasophrynx and posterior part of nose

Hypopharynx and larynx.

Nose

Ears

Neck


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Examine as well adjacent structures. Tonguedepressors are used in the buccal cavity the

pharynx and posterior nasal pharynx

Nasal speculum

Ear specula

Nasopharyngeal and laryngeal mirrors

Cotton applicators

Tuning fork


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THE EAR

A brief outline of the

anatomy and physiology


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ANATOMY

The ear can be divided into the following 3 parts:

1. External Ear Consisting of the pinna

(Auricle),Tragus, Antetragus,

External Auditory Canal/Meatus

2. Middle Ear 3 Ossicles - Incus

- Malleus

- Stapes


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Eustachian Tube Connects The

Middle Ear To Pharynx

Mastoid Air Cells Facial Nerve

Muscles (Stapedius/Tensor

Tympani )


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3. INNER EAR:

Consisting of the three semi circular canals

The Cochlea

The vestibula containing the utricle and

saccule

Nerves connecting the inner ear to the central

nervous system.


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THE EXTERNAL EAR

Pinna

External Auditory Canal

The outer third of the external auditory canal iscartilagenous and the medial 2/3 bony.

Average length (31m and 25mm respectively).The canal has a slight curve, directed forwardand a bit downward in the Adult.


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In a child the curve is more in a

forward direction. Hence to visualizethe ear drum one must pull the pinna

upward and a bit backward in the

adults whereas in the child the pinna

needs to be pulled backward and

slightly downward.


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The Cartilagenous part of the ear

canal contains hair follicles andsebacious and ceruminous glands

and hence is a site for furunculosisand other skin disease.

WAX is an essential part of theceruminous glands.


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It has Bacteriocidal

- Anti fungal- Water proof properties

And also serves as a fly paper for

flies. Dont enthusiastically clean

your ear you will be predisposing the

ear to infections and insection.


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In case insects enter some ones

ear what will you do at home?The pinna is highly visualized. So

if it is cut off it can survive whensutured back even after 48 hours.

QUESTION


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THE MIDDLE EAR

Starts with the Tympanic membranewhich reflects the situation in the

middle ear cavity.The three ossicles

Incus Malleus

Stapes


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Are joined in an ossicular chain. The

stapes footplate covers the ovalwindow. The tympanic membrane

has two parts the parts tensa andflaccida.


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Attached to the tympanic

membrane is the handle of

malleus.

Flaccida has two layers one

devoid of fibrous layer. Tensa has three layers.


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The middle ear is connected to the

Nasopharynx by way of the Eustachiantube approximately 38mm in lengthconsist of lateral third which is bony andmedial two thirds which Cartilaginous.

The Eustachian tube is normally closedand opens only during swallowing and

yawing or pronouncing koka, kuku etc


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THE INNER EAR

Situated in the petrous part of the temporal bone andconsist of three semicircular canals

One horizontal

Two vertical The vestibule containing the utricle and saccule and

the cochlea.

The Cochlea contains the organ of corti which is theorgan of hearing.

The semicircular canals is responsible for signal

charges in position of the head balancing.


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THE FINAL PART

Nerves connecting the central nervous

system from the inner ear through the

internal auditory canal. The Center of

Hearing is the Auditory Cortex.


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PHYSIOLOGY

THE PHYSIOLOGY OF HEARING

Sound is conducted through the Ear

Canal, the tympanic membrane and the

ossicles to the cochlea. From here

impulses are carried in the Cochlear nerve

and its Central Connections.


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The Ear Canal the tympanic membrane

and the ossicles form the conductivecomponent of hearing and the cochlea

and its neural connections from thesensory neural mechanism of hearing.

Conductive hearing loss

Sensoneural hearing loss

Mixed hearing loss


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THE PHYSIOLOGY OF BALANCE

The sense of position is obtained from severalsensory mechanisms: visual, vestibular andproprioceptive.

The three are important for maintenance ofbalance. Loss of one can be compatible withadequate maintenance of posture. Loss of twogreatly impairs posture and locomotion. Thecerebellum is closely related to the vestibularsystem. Vertigo spinning result from loss of

vestibular function.


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SIGNS AND SYMPTOMS OF EAR DISEASE

Otalgia - Primary- Secondary Otorrhea/Otorrhagia Tinitus Hearing loss Vertigo Facial paralysis Itch

Congenital deformities


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Otalgia or painful ear, results from

Involvement of ear structures or

In the absence of ear disease,

pain referred from other

structures (referred otalgia)


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REFERRED OTALGIA

Parts of the ear and several structures on the headand neck have a common source of sensory supplyGTVF C2, C3

The commonest sources of referred otalgia are:1. The teeth

2. The temperas mandibular joint

3. The tongue

4. The pharynx

5. The Nasopharynx and the hypophaynx and neck.


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Otalgia due to disease of the ear primary otalgia are due to

Trauma/Foreign Bodies

WAX Obstruction

Otitis Externa

Otitis Media Acute

CA of Ear Canal


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WAX OBSTRUCTION

The Ear Canal may be occluded withWAX and cause pain. Small amountof wax can be easily removed withWAX curette under direct vision. Nomaneuver should be carried outblindly in the Ear.


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WAX can be syringed with tap water

at body temperature. Cold or hotwater will cause caloric stimulation vertigo.

Technique of syringing syringing

that causes pain must be stopped. Drape patient

Direct stream posteriorly


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INDICATION FOR SYRINGING

WAX Obstruction FB in Ear (inanimate objects)

Debris in Ear

CONTRAINDICATION

Perforation of T.M Acute Ottitis Media

Chronic Ear Discharge


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Sometimes WAX needs to be

softened with olive oil or glycerine

warm to body temperature 3x daily

for 3 days after which syringing is

repeated .


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Acute ottis external is theinflammation of the skin linningthe external auditory canal it canbe acute or chronic.

Acute external ottis usuallypresents as a very painful earwhile chronic external ottis is oftencharacterized by itchness and

discharge .


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AOE

May be localized (circumserbed ottis

ext. furuncle. Or diffuse otitis ext.


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PREDISPOSING FACTORS

Wet ears swimmers ear

Ear trauma caused by pricking of the ear Or by use of cotton swabs or features

Or somehow as a result of systematicdiseases eg. Diabetes mellitus.


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ORGANISMS

1. Bacteria eg.

Staphylococci

Steptococci Pseudomanas


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Fungi otomycosis due toaspergillus Niger or Canada

Herpetic eruptions

Herpes zooster oticus Ramsay-hunt-disease


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Clinical features commonest symptoms

Pain in the ear

Swelling of the ear

There may be hearing loss.

Pre-or-post auricular lymph needsenlargement. Fever may be

present .


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ON EXAMINATION

Movement of pinna painful, tragal

tenderness, stenotic canal.Tympanic, membrane normal, canal

red or with pus/erythema.Theremay be a discharge .


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COMPLICATION

Extension to perichondrium as

gabbage ear in older people ordiabetic may lead to malignant

ottis, ext. destruction of bonesets in.


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TREATMENT

Antibiotic

Local treatment wick ribbon gauze

Topical ear drops (neomyxinpolyxin)

Not CED/Gentamycin Ear drops

Anti inflammatory drugs


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Ear drops should not be kept in a

refrigerator. Some of the topicalpreparations have steroid base

anti inflammatory Properties.

In otomycosis use antifungal drugs- Thorough cleaning of the ear


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In chronic otis ext the skin

involvement is pronounced eg.Eczematous or seborrheic

dermatitis from irritation by the

discharge. The causative agent is

pseudomonas aeruginosa.


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TREATMENT

Local treatment

Swabs for C/S

Tropical ear, ear drops polymyxin Neomycin

Cream of these topical drugs andsteroid base for the skin condition.

Surgery for canal stenosis


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TRAUMA

Haematoma - Bony

- Blow

- Dress

Foreign Bodies

Cutlass Cut/Bite

Suture


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ACUTE OTITIS MEDIA AOM

Acute infection of the middle ear

include acute viral otitis media,

acute supurative

Otitis media (ASOM) acute serous

otitis media.


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ETIOLOGY

Children by virtue of shortness of Eustachiantube, feeding cultures, cold

Blockage of the eustachian tube exudationof serous fluid in middle ear bulging oftympanic membrane

Resolution or natural spontaneous rupturedischarging blood and mucous or chronicotitis media hearing loss other

complications.


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SYMPTOMS Fever Pyrexia Chills

Convulsion Ottalgia Cattarrh Discharging Ear Mucoid General Malaise

- All signs of Malaria except few.


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OTOSCOPIC FINDINGS

Reddened Tympanic Membrane

Bulging and injected tympanicmembrane

Ruptured T.M with perforation

Canal normal

In ASOM Mucopurulent discharge


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TREATMENT

Depending on stage Myringotomy

Antibiotic Nasal decongestant

Analgesics Clean pus

Treat other diseases adenoids sinusitis.

CHRONIC OTITIS MEDIA/CSOM


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CHRONIC OTITIS MEDIA/CSOMPersistent of discharge on/off from 6weeks onwards to years

SYMPTOMS

Tinitus

Hearing loss

Discharge off/off

FINDINGS


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FINDINGS

Perforation in T.M central or peripheral withor without pus.

Very difficult to treat

Antibiotics

Antihistamines

Keep ear dry

Clean ear of discharge

Tympanoplasty reconstructive surgery


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COMPLICATIONS OF AOM/COM

Meningitis Otitis hydrocyphalus Chronic otitis media

Serous otitis media Deafness Facial nerve paralysis

Cerebellar asscess Lateral sinus thrombophlebitis Temporal lobe abscess

larbyrinthitis


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LECTURE2


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HEARING LOSS

May be a symptom of its own

or associated with tinitus,

vertigo (triad of symptomsmeneres).

TYPES OF HEARING LOSS


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TYPES OF HEARING LOSS A.

Conductive

Sensomanual

Mixed hearing loss

The auditory and vestibular nerves (VIII) areintimately related to CN VII. In the internal auditorymeatus

B.

Acquired

Congenital H.L


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The following can cause hearing loss

Lesions of the external auditory canal Congenital atresia

WAX, foreign body

Otitis ext

Trauma

Tumours Stenosis

Exostosis


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LESION OF THE MIDDLE EAR

AOM, COM, CSOM, ASOM

Trauma

Tumors

Glue ear

The above two produces conductive H.C


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The following lesions produce sensoneural hearing loss

Familial Congenital

Presbycusis Noise induced H.L

Ototoxic drugs Head injury

labyrinthitis


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Commonness infectious disease causehearing loss leading cause in Ghana

Meningitis CSM

Measles

Febrile Convulsion

Parotitis unilateral H.L

CSOM


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MANAGEMENT OF H.L

Examine ext, middle ear

Text of hearing turning fork test.

Audiometry

Treat disease

Rehabilitation. Hearing Aid

Cochlea implant

OTOTOXIC DRUGS


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OTOTOXIC DRUGS Aminoglycosides antibiotic

Quinine

Salicylates

With some drugs the damage is corrected if

withdrawn early others progresses. A patient

with renal failure on Aminoglycoside issusceptible to ototoxicity Hearing loss is usually

bilateral and symmetrical.

NOISE INDUCED H L


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NOISE INDUCED H.L

Acoustic trauma sudden exposure Nose induced H.L gradual over a long period in a

noisy environment.

Noise damages the cochlea hair cells can be due tosudden, sharp, laud noise or from prolonged

exposure to noise. Eg. Rifle fire, expolosion or blast. Prolonged noise occurs in industrial setting

Airports, Sawmills, Dickos

PREVENTION OF DEAFNESS/TREATMENT


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PREVENTION OF DEAFNESS/TREATMENT

EPI Primary prevention Secondary prevention

Use of ear protection Minimizing industrial and domestic noise Screening with hearing test for all such workers

School screening to detect early treatablecauses

New born screening


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Hearing AIDS are valuable in thetreatment of many types of Hearing loss

Surgical treatment for many types

Hearing AID has a Microphone, an

amplifier, and receiver.


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FACIAL PARALYSIS

LMN paralysis of all half of face

UMN intact emotional movements Bells palsy

CSOM as a complication

Ramsay hunt disease


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TINITUS

Noise Ototoxic

Laribynthitis WAX

Treat cause

Prevent offending cause

Maskers of noise


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PRESBYCUSIS

Sensoneural H.L due to the aging

process is referred to apresbycusis.


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LECTURE

3

THE NOSE AND PARANASAL SINUSES


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THE NOSE AND PARANASAL SINUSES

The nose and the paranasal sinuses lie in theupper part of the upper respiratory tract. The

paranasal sinuses connect with the nose

through various ostia. The nose is continuous

posteriorly with the nasopharynx and is

connected to the eustachian tube and the

middle er by way of the nasopharynx.


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The anterior and middle cranial

fossa, the orbit and the roof of

the mouth together with the

teeth are closely related to

certain parts of the nose and thesinuses.

The function of nose and paranasal


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The function of nose and paranasalsinuses are

Cosmetic

Upper part of respiration

Makes (the sinuses) the head lighter

Take part in resonance Nose filters, warm air

Olfaction

THE NOSE


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THE NOSE

The external nose it formed by bones andcartilages. The anterior and posteriorapertures of the nose are called anterior and

posterior choans, respectively. The lateralwall of the nose contains the opening of theparanesal sinuses. It is marked by threeturbinates. The interior (independent bone),the middle and superior conchae or

turbiantes


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The area below the turbinate is called

meatus. The nasolacrimal duct opens

into the inferior meatus. The middlemeatus contains the openings of the

frontal, maxillary and anterior enthmoid

sinuses .

Th i i h


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The superior meatus contains the

opening of the posterior ethmoidcells. The sphenoid sinus opens

posteriorly in an area called thesplenoethmoidal recess. The

mose contains olfectory cells andnerve.


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BLOOD SUPPLY

The turbinates are erectile tissues.

The nasal septum contains many blood

vessels and is called littles area a

frequent spot for epistaxis.

h d h


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There is an area around the nose

known as the danger zone.Where internal carotid and external

carotid branches meet and anysmall infection can result in

extension of infection to the brain

or cavernous sinus.

SYMPTOMS DUE TO NOSE


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SYMPTOMS DUE TO NOSEINVOLVEMENT

Nasal obstruction

Nasal discharge increased

Loss of smell anosmia Sneezing excessively

Symptoms due alteration of the


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Symptoms due alteration of thenasonator of the nose NASAL

speech.

Dryness to crust formation Pain in the nose

Nose bleeding

Trauma: Fracture Nasal Bone

SINUSE SYMPTOMS


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SINUSE SYMPTOMS

Halitosis

Sinus headache

Tumours of sinus

Symptoms of nose and sinus disease can be apart or a manifestation of systematic disease.

For example epistaxis can be due to ableeding diatesis nasal and sinus allergy mayoccur on a patient with bronchial asthma.


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Polyp formation in a child may

be due to cystic fibrosis: facial

and nasal deformity and

asymmetry may be to congenitalor familial.

d b ld


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Read about common cold/coryza

Pharyngitis

Acute chronic pluritis

Unilateral offensive smell in a

child is a foreign body in the

nose unless proven otherwise.

EPISTAXIS


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EPISTAXIS Nose bleed is common. Minor

instances are easily treatable or

controlled at home.

Bleeding is unilateral, or bilateralanterior or posterior.

CAUSES


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CAUSES Local and systemic causes local attributable to

nose and its structures

Trauma

Nose prick to littles area FB

Tumors

Infection Rhinitis, Sinusitis

Vicarious Menstruation

Congenital - teleangioectasia

GENERAL CAUSES


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GENERAL CAUSES

SCD

Bleeding diathesis

Leukemia Arterial hypertension Climatic condition such as harmattan

Altitude

The common cause is nose prick at littles area

MANAGEMENT


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MANAGEMENT

At home pinch nose for 5 mins, sit uprightapply ice pack.

IN THE HOSPITAL

FIND CAUSE Canterize bleeding part littles area- Chemical

- Electrical Cantery

Anterior Nasal Packs with Gauze


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Anterior Nasal Packs with Gauze

Treated BIPP (Vaseline Gauze) Posterior Packing

Catheter in Posterior Nasal Space Sedation + Rest

Replacement of Blood Loss

Ligation of Vessels

ACUTE/CHRONIC SINUSITIS


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ACUTE/CHRONIC SINUSITIS

Acute sinusitis can involve all thesinuses in one or both sides

pansinusitis all.

Abology often 20

nasal infectionfollowing acute viral infection.

catarrh

PREDISPOSAL


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PREDISPOSAL

Dusty environ

Excessive dryness

Instillation of concussion

BACTERIAL INFECTION


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BACTERIAL INFECTION

Henophilis Influenza

Stephylococci

Sometimes fungi

SYMPTOMS Feeling of fullness on the side of face

Dull headache

FINDINGS


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Tenderness Hyperemia over affected sinus

Pus under the meatus in the nose

X-ray shows opacity in the sinus

TREATMENT

Treat infection

Decongest nose

Most will resolve if note

Anthral lavage - AWO is scheduled six


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Anthral lavage AWO is scheduled six

weeks later Frontal Trephination

Chronic sinusitis from

1. Unresolved Acute Sinusitis or recurrentSinusitis. Duration 6 weeks or more.

SYMPTOMS


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SYMPTOMS

Nasal obstruction

Halitosis

Post nasal drip

Headache

FINDING


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FINDING

Polyps

Caries tooth (if chronic maxillary sinusitis)

Allergy

X-ray - opacity

TREATMENT


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TREATMENT

Antibiotic

Decongestant

Antilustamine

Anthral Lavege

Intranasal Anthrotomy

Coldwell Luc Operation

COMPLICATION OF SINUSITIS


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Can come from acute of chronic sinusitis

1. Orbit involvement leads to proptasis, Ostcitis Osteomylitis Mucocele Orbital Cellulitis

Oroanthral Fistula Intracranial Spread

Cavenous Sinus Thrombosis

Chronic Pharyngitis Laryngitis


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LECTURE 4

LARYNX AND

PHARYNX

LARYNX


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LARYNX

The Larynx forms the lower part of the upperrespiratory tract. Apart from the gradual

increase in size as childhood progresses, themajor change in the Larynx during adolescence

the anterior posterior length of the glottis

increases by approximately 1cm in males and

3mm to 4mm in females.

The former increase accounts for the


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voice change in adolescent males. The

thyroid cartilage forms the central andanterior walls of the larynx and producesthe prominence in the neck referred to asthe Adams Apple.

Paired cartilages Thyorid Cricoid,Epiglotis. Form the framework of thelarynx.

THE NERVE SUPPLY OF THE


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THE NERVE SUPPLY OF THELARYNX

Significant nerve supply of the

larynx is derived from the

superior and recurrent laryngealnerve.

FUNCTIONS OF THE LARYNX


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FUNCTIONS OF THE LARYNX

Sphincter action: prevents entry of food

and drink into trachea during deglutation

Passage for air

Voice production defecation and

parturation

SYMPTOMS OF LARYNGEAL PATHOLOGY


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Hoarseness Stridor Nerve Paralysis Asphyxia

Causes Inflammation Acute Laryngitis

Ltb Acute Epigloltitis Laryngeal Dyptheria

CHRONIC


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CHRONIC

Non specific

Polyp Singers node

Chronic laryngitis

Hoarseness of voice in an adult of more


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Hoarseness of voice in an adult of more

than 4 weeks is cancer until provenotherwise.

Laryngea paralysis can give rise toHoarseness of voice respectivelydifficulty and aspiration of liquids orsolids into the trachea and bronchialtree.

TRACHEOSTOMY


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TRACHEOSTOMYOpening into upper trachea as a result of

airway obstruction.

INDICATION respiratory obstruction

To bypass obstruction Lung toileting Reasons

accumulation of secretion in tetanus Ventilation for assisted respiration in coma Poisoning

TYPES


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TYPES

Emergency

Elective

Intubation

THE PHARYNX 3 PARTS


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THE PHARYNX 3 PARTS

Oro, Naso, Hypo Pharynx

Tonsils

Adenoids disappear in adolescents Waldeyers ring formed by palatine tonsils

adenoid (pharyngealtonsil) ligual tonsils andsubmuscosal follicles

FUNCTIONS OF PHARYNX


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FUNCTIONS OF PHARYNX

Deglutition

Speech Airway

Taste

SYMPTOMS


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Sore Throat

FB throat

Tonsillitis

Common cold

Leukemia and tumour

diptheria

DYSPHAGIA CAUSES


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DYSPHAGIA CAUSES

FB

Tumour

Infection

Trauma Ulceration

SORE


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Tonsillitis

Inflammation of tonsils Bacterial infection

Beta haenolytic streptoco

SYMPTOMS


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SYMPTOMS

Fever, Malaise, Odynophagia, Ottalgia

TREATMENT

Antibiotic Analgesic

COMPLICATIONS


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Peritonsillar Abscess (Quinsy) Parapharyngeal Space Infection

Chronic Tonsillitis Aom

Glomerulonephritis Pericarditis Rheumatic Fever

SURGERY


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TONSILECTOMY Absolute indications

Repeated attack 3 x a year Rec. tonsillitis

Huge tonsils causing airway obstruction

Snoring

History of quinsy

ADENOIDECTOMY


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ADENOIDECTOMY

If adenoids so hypertophied, that

causing airway obstruction orfeeding problems. Snoring and

sleeping apnea.

1. Practical Exercises


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Otoscopy Radiology Interpretation

Turning Fork Test

Discussion

ent lectures 1

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