Chapter 4
The Pharynx and Infections of the Tonsils, Pharynx, and Oropharynx 195 The Head and 252 This painting shows the austere Scottish physician and surgeon who founded Ear, Nose and Throat as a specialty and wrote the first standard textbook on Rhinology and Laryngology. Sir Morrell MacKenzie also founded one of the first hospitals for Nose and Throat diseases in London in 1863 today the Royal National Throat Nose and Ear Hospital . The most common condition he treated in this hospital was laryngeal...
Mr Jeremy A Lavy
Many of the photographs in this book were taken by myself but I am grateful for the expertise of the Photographic Department of the Royal National Throat Nose amp Ear Hospital for many of the better illustrations. My thanks also go to my colleagues who have contributed illustrations to this edition Professor Lund, Mr Croft, Mr Nasser, Mr Gault, Mr Bailey, Mr Howard, Professor Ramsden, Mr Proops, Professor Weerda, Professor Wright, Dr Glyn Lloyd, Dr AH Davies, Dr Van Hasselt, Dr J Brennand, Dr G...
The Tongue
Fig. 4.21 Tongue tie. This is due to a short frenulum linguae, and apart from the defect of being unable to protrude the tongue, the patient is almost always symptom-free. Speech defects can rarely be attributed to tongue tie necessitating division of the frenu-lum. Fig. 4.21 Tongue tie. This is due to a short frenulum linguae, and apart from the defect of being unable to protrude the tongue, the patient is almost always symptom-free. Speech defects can rarely be attributed to tongue tie...
Aphthous Ulcers see p 172 ff
An area of white superficial ulceration is surrounded by a hyperemic mucous membrane. These commonly occur in crops of two or more, and heal spontaneously in about one week. They are also acutely tender, and affect the nonkeratinizd oral mucous membrane. Although there is no induration on palpation, the histological inflammatory changes are not superficial, and may extend into the underlying muscle. Hydrocortisone pellets to suck, or triamcinolone with Orabase ointments applied to the ulcer,...
Chronic Otitis Media With Effusion
Middle-ear fluid, if persistent, may cause permanent changes in the drum. An otitis media with effusion can cause hearing loss for decades, and the diagnosis is frequently overlooked in a long-standing hearing loss. Impedance audiometry helps in diagnosis. Fig. 2.81 Crossly altered drum. A brown color, with retraction of a flaccid membrane onto the ossicles and promontory, is seen with long-standing middle-earfluid. Bottom arrow indrawn drum onto the promontory top arrow incudostapedial joint....
The Patulous or overpatent Eustachian Tube
Obstruction of the eustachian tube is a common and frequently diagnosed disorder. Abnormal patency of the tube the patulous eustachian tube , however, is also not uncommon, and the diagnosis is frequently missed. The condition tends to occur in people who have lost weight or women who are taking the pill or are pregnant. The symptoms are of a sensation of blockage in the ear, with normal hearing or minimal loss. Patients may comment that they hear themselves breathe and eat, and hear their own...
The Oropharynx Mouth and Lips
Fig. 4.3 Lip ulcers. Lip ulceration has numerous causes, eithertraumatic, inflammatory, or neoplastic. The provisional diagnosis can be made from the history and type of ulcer. Biopsy is necessary to confirm the diagnosis. This lesion is a pyogenic granuloma. Although these lesions are frequently small and related to trauma, they may enlarge from secondary infection see Fig. 4.4 and take several weeks to heal. lip. Mucoceles are cystic, nontender swellings presenting on the lips or in the oral...
Malignant Nasal Tumors
A nasal polyp that does not appear gray and opalescent should arouse suspicion, as should a polyp that bleeds spontaneously. A solid-looking hyperemic polyp may be an inverted papilloma. Granulation tissue in the nose may be malignant granuloma or carcinoma, and biopsy of any suspicious nasal lesion is necessary. Fig. 3.86 A pigmented polyp may be a Prognosis when radiotherapy is followed by maxillectomy is quite good for an early maxillary carcinoma, but poor when there is extensive invasion....
Epistaxis
Fig. 3.80 Epistaxis. Anteriorly on the septum there is anastomosis of several arteries the sphenopalatine, the greater palatine, the superior labial, and the anterior ethmoidal . This site is called Little's area or Kiesselbach's plexus, and is the commonest site of nose bleeds. Although associated with alarm, most epistaxis is short-lived and trivial. It is better to sit upright since the blood tends to be swallowed, causing nausea on lying down. There are numerous causes of epistaxis. Some,...
Referred Ear Pain
If examination of the drum and meatus is normal in a patient complaining of earache, the pain is referred. Referred ear pain may be from nearby structures such as the temporo-mandibular joint, neck muscles, or cervical spine. It may also be from the teeth, tongue, tonsils, or larynx. Cranial nerves V, IX, and X which supply these sites have their respective tympanic and auricular branches supplying the ear. Earache also frequently precedes a Bell's palsy. Fig. 1.15 Siegle's speculum has been...
The Pinna
Fig. 2.2 Hillocks or accessory lobules . These are commonly found anterior to the tragus, and are excised for cosmetic reasons. A small nodule of cartilage may be found underlying these hillocks. Fig. 2.1 Minor deformities. These are of little importance. This shows duplication of the lobule. Fig. 2.2 Hillocks or accessory lobules . These are commonly found anterior to the tragus, and are excised for cosmetic reasons. A small nodule of cartilage may be found underlying these hillocks. Fig. 2.1...
Chapter 1 ENT Examination
Fig. 1.1 The instruments needed for an ENT examination The laryngeal and postnasal mirrors require warming to avoid misting, and hot water or a spirit lamp is necessary. An angled tongue depressor or wooden spatula is needed for examining the oropharynx and postnasal space. Angled forceps are used for dressing the nose or ear. A tuning fork is essential for the diagnosis of conductive or sensorineural perceptive hearing loss. A C1 or C2 256 or 512 cps is needed. The very large tuning forks used...
Mucocele Extraction
Fig. 3.54a-c Acute rhinitis. In the common cold, the nasal mucous membrane is edematous, so the inferior turbinate abuts against the septum to result in obstruction and an excess of mucous which causes the running nose. A similar appearance is seen in nasal allergy, either seasonal hay fever or perennial allergy, but the edematous turbinate mucous membrane appears gray c rather than red b . A persistent purulent nasal discharge usually means that there is a sinusitis. Corticosteroid nasal...
Lj
Fig. 2.72 Otitis media with effusion with minimal drum change. The drum may look only slightly different, with a brown color and some hyperemia. A confident diagnosis of middle-ear fluid can only be made if reduced mobility is demonstrated and impedance audiometry Figs. 1.30, 1.31 is needed for confirmation. Fig. 2.73 Otitis media with effusion glue ear . a The color change in this condition is often diagnostic, as well as the reduced mobility. The golden-brown color showing through the...
Facial Palsy
Facial palsy may follow skull fracture or facial nerve laceration near the stylomastoid foramen, and is also an uncommon complication of middle-ear surgery and superficial parotidectomy. An extensive cholesteatoma or middle-ear carcinoma may also damage the facial nerve. In the absence of a careful examination of the tympanic membrane, such a case may be wrongly diagnosed and treated as Bell's palsy. All facial palsies should have an otological assessment. Bilaeral facial palsy is an...
Inflammation nasal vestibulitis
Fig. 3.47 Vestibulitis presents as crusting and irritation in the anterior nares with resulting nasal obstruction. Examination shows excoriated vestibular skin and septal mucous membrane. Rubbing or over-diligent cleaning of the nose by the patient usually causes vestibulitis, particularly if, as in this case, the septum is deviated anteriorly and impinges on the lateral wall of the nose. Advice and the use of antibiotic and corticosteroid ointment are effective in controlling vestibulitis....
Glue Ear
Glue ear is common between the ages of three and six years, and uncommonly persists after 11 years. The hearing loss is often slight and varies with colds. The self-limiting nature of the condition calls for conservative treatment, but glue ears are not to be ignored. A marked and persistent hearing loss, interfering with schooling, necessitates surgery. Episodes of transient otalgia are common with glue ears, and frequent attacks of acute otitis media may occur. The drum may also become...
Deviated Nasal Septum
A congenital or traumatic dislocation of the septal cartilage into one nasal fossa causes unilateral nasal obstruction. If the obstruction is marked, or complicated by recurrent sinusitis, a septal correction is effective surgery. The time-honored operation for this is a submucous resection SMR , but a septoplasty in which cartilage is preserved and repositioned rather than removed is now used. The SMR operation involves removal of much of the septal cartilage and loss of nasal support with...
Acute Otitis Media
Earache with conductive hearing loss and fever accompanying a head cold characterize acute otitis media. The drum is red and the landmarks are obscured drum distension and pulsation may be seen. Otitis media is common in children, probably due to their short, wide eustachian tube and the presence of adenoids which may be infected near the orifice. Rupture of the tympanic membrane in acute otitis media is not uncommon and muco-purulent otorrhea ensues with a pulsatile discharge. Penicillin is...
Rhinoplasty
Fig. 3.29 Rhinoplasty. The appearance of a nose with a congenital or traumatic hump of the nasal bones can be improved with rhinoplasty a, b c, d . A deviated nose may be straightened e, f . Fig. 3.29 Rhinoplasty. The appearance of a nose with a congenital or traumatic hump of the nasal bones can be improved with rhinoplasty a, b c, d . A deviated nose may be straightened e, f . Fig. 3.30a-f Nasal tip rhinoplasty. Bulbous or bifid nasal tips can be modified a, b . Incisions for rhinoplasty are...
Deformities
Abnormal fusion of the nasal processes is uncommon, and may result in varying degrees of deformity. In this case, the nose is bifid with hypertelorism the distance between the eyes being greatly increased . In milder cases, the bifid appearance of the nose is less marked, and may just appear as a rather wide nose. Abnormal fusion of the nasal processes is uncommon, and may result in varying degrees of deformity. In this case, the nose is bifid with hypertelorism the distance between the eyes...
Persistent snoring in a child is the main symptom of enlarged adenoids
In day-time there is mouth breathing. Purulent rhinorrhoea if there is secondary sinusitis and epistaxis also occur, with or without nasal symptoms. There is hearing loss due to otitis media with effusion, or earache from recurrent acute otitis media. Adenoids normally regress before puberty and adults with large adenoids are rare. If an adult has nasal obstruction due to postnasal lymphoid tissue, the histology is essential to exclude a lymphoma. Nasal obstruction may occur from birth due to...
Cysts
Fig. 3.6 Nasoalveolar cysts have a constant anatomical site and spot diagnosis is possible. Externally, there is flattening of the nasolabial fold and flaring of the alae nasi. In the anterior nares the cyst extends into the floor of the nose and displaces the inferior turbinate upwards. Excision via a sublabial incision and enucleation is the treatment. Surgical rupture of the cyst usually means incomplete removal, and predisposes to recurrence. The arrow indicates flaring of ala. Fig. 3.6...
The Tympanic Membrane and Middle Ear
Fig. 2.52 Chalk patches. White areas of tympanosclerosis arrows are common findings on examination of the drum. They are of little significance in themselves, and the hearing is often normal. A past history of otorrhea in childhood or grommet insertion is usual. Chalk patches do occur with no apparent past otitis media. Extensive tympanosclerosis with a rigid drum is a sequela of past otitis media, and the ossicles, too, may be fixed or noncontinuous. Fig. 2.53 Scarring of the drum. a A...
Examination of the Pharynx and Larynx
SFig. 1.59 Examination of the pharynx. A tongue h depressor is necessary to I obtain a clear view of the tonsil region in most cases. I Patients vary however in how easily the fauces and posterior aspects of the tongue can be seen. On occasion a very clear view is obtained Fig. Fig. 1.60 Circumvallate papillae. These are often prominent on the base of the tongue. A patient may be alarmed when looking at the tongue to notice these normal structures and mistake them for a serious disease. The...
Examination of the Nose
Fig. 1.44 Examining a child. Instruments are best avoided in children. A good anterior view of the nose can be obtained simply by pressing on the tip of the nose. In this case, a clear view is obtained of a pedunculated papilloma of the nasal vestibule arrow . Fig. 1.44 Examining a child. Instruments are best avoided in children. A good anterior view of the nose can be obtained simply by pressing on the tip of the nose. In this case, a clear view is obtained of a pedunculated papilloma of the...
Hearing Loss
Most hearing loss is easy to diagnose as either a well-defined conductive or sensorineural type. Mixed hearing loss may occur, but this diagnosis is usually non-contributory, and the term is better avoided. Lesions to the left of the red line Fig. 1.16 cause conductive hearing loss, and are frequently curable. Hearing loss to the right of the blue line is due to a sensorineural lesion, and is usually not so amenable to treatment. Fig. 1.16 Conductive and sensorineural hearing loss. Hearing loss...
Examination of the Ear
meatus is S-shaped. To see the drum more clearly, therefore, the pinna is retracted backwards and outwards. The index finger may be used to hold the tragus forward. If this step of straightening the meatus accentuates the pain in someone presenting with an earache, one can be virtually certain that the diagnosis is either a furuncle or furunculosis see Fig. 2.43 . Fig. 1.5 Head mirror and speculum. These are used for the initial examination of the meatus and drum. Fig. 1.5 Head mirror and...