Ln1 for llnals

Slmon Lloyd
ConsulLanL Ln1 Surgeon
3 SepLember 2013
Ln1 for llnals
7 Loplcs lmporLanL for flnals
1. neck lumps
2. laclal palsy
3. 1he dlscharglng ear
4. 1he deaf paLlenL
3. 1he runny or blocked nose
6. Sore LhroaLs
7. ulfflculLy breaLhlng
neck Lumps
AnaLomy
AnLerlor/ posLerlor
Lrlangles
1hlnk anaLomlcally
Lymph node levels
Pow Lo Lxamlne a neck
ulfferenLlal ulagnosls
Surglcal
sleve
CongenlLal
Acqulred
lnfecLlve (18, Syphllls)
lnflammaLory (1hyroldlLls)
neoplasLlc (8enlgn/ MallgnanL)
uegeneraLlve (Mnu/ CysLs)
AuLolmmune (Crave's)
urug lnduced (LlLhlum)
Skln
Lymph nodes
1hyrold
vascular
Muscular
nerve
Sebaceous cysL
Llpoma
8eacLlve lymphadenopaLhy
MulLlnodular golLre
8enlgn Lhyrold neoplasla
8ranchlal cysLs
Lymphoma
Cervlcal meLasLasls
revalence
AnaLomlcal
neck Lumps
Case 1
18 year old glrl
6 monLh hlsLory of
palnless rlghL neck
swelllng
no oLher sympLoms
CLherwlse well
lnvesLlgaLlon and 1reaLmenL
8ranchlal CysL
resenL ln early adulLhood
CommonesL congenlLal neck mass
May become lnfecLed
LplLhellal llned cysL
aLhogenesls
lncompleLe obllLeraLlon of second branchlal clefL
CysLlc degeneraLlon of lymph node
lnvesLlgaLlon: u/S or C1
1reaLmenL: Lxclse
SL1
Slide 9
SL1
Simon Lloyd, 06f01f2010
neck Lumps
Case 2
42 year old lady
9 monLh hlsLory of
palnless rlghL neck mass
no oLher sympLoms
CLherwlse well
lnvesLlgaLlon
llne needle AsplraLlon
1hy1 unsaLlsfacLory
1hy2 non-neoplasLlc
1hy3 osslble neoplasm
1hy4 SuspecLed mallgnancy
1hy3 MallgnanL
Also 14, 1SP and Lhyrold
auLoanLlbodles
lnvesLlgaLlons
ulLrasound Scan
1hyrold Mass
ulfferenLlal ulagnosls
lbysloloqlcol eg. uberLy, pregnancy, lodlne deflclency
ueqeoetotlve eg. Slmple cysL, mulLlnodular golLre
8eolqo oeoploslo eg. lolllcular adenoma
Mollqooot oeoploslo eg. aplllary carclnoma, lolllcular
carclnoma, Medullary carclnoma, AnaplasLlc
carclnoma, Lymphoma
Aotolmmooe eg. Crave's dlsease
loflommototy eg. 1hyroldlLls
useful nuggeLs
aln usually equals LhyroldlLls or
haemorrhage. Check auLoanLlbodles
lnA cannoL dlfferenLlaLe beLween benlgn and
mallgnanL folllcular dlsease. ulLrasound
someLlmes can.
ulagnosLlc SLraLegy
laclal alsy
AnaLomy
Sensory
1asLe
osLerlor ear canal
AuLonomlc
arasympaLheLlc Lo:
Lacrlmal gland
Submandlbular gland
Subllngual gland
MoLor
laclal expresslon
SLapedlus
osLerlor belly of dlgasLrlc
AssessmenL
Pouse 8rackmann Cradlng (l Lo vl)
l = normal
ll = normal aL resL, mlld weakness on
acLlve movemenL
lll= Cood eye closure
v = Some Lone
vl= no movemenL
Lyes open Lyes closed
AeLlology
Puge dlfferenLlal (use surglcal sleve)
CongenlLal
neurologlcal eg. Moeblus syndrome
1raumaLlc eg. lorceps
Acqulred
ldlopaLhlc eg. 8ell's palsy
1raumaLlc eg. 1emporal bone fracLure
laLrogenlc eg. Surgery
lnfecLlon eg. AcuLe oLlLls medla, mallgnanL oLlLls medla,
8amsey PunL syndrome
neoplasLlc eg. aroLld mallgnancy
laclal alsy
Case 3
32 year old lady
8apld onseL lefL faclal
weakness
LefL faclal numbness
no ear sympLoms
CLherwlse flL and well
Crade lll weakness
no oLher abnormallLles
8ell's alsy
ldlopaLhlc (probably vlral - Perpes slmplex)
AcuLe unllaLeral faclal palsy (perlpheral)
Cccaslonally oLher cranlal nerve palsles eg. 1rlgemlnal
8esolves wlLhln 3 monLhs ln 80 of cases
10 recur (lncludlng conLralaLeral)
Plgher lncldence ln dlabeLes
1reaLmenL
Lye Care (lubrlcaLlon)
Cral sLerolds
no evldence for beneflL from anLlvlrals
5olllvoo et ol. New oqlooJ Iootool of MeJlcloe 2007
laLrogenlc
May come up ln exam as long sLandlng
Assess faclal funcLlon
Lxamlne neck and paroLld
Ask Lo examlne Lhe ear
Scars from surgery
MasLold cavlLy
8llnd sac closure
Ask Lo examlne oLher cranlal nerves
Look for evldence of faclal reanlmaLlon
Llkely operaLlons lnclude masLold surgery, vesLlbular
schwannoma surgery, paroLld surgery
1reaLmenL
Complex
Lye
LubrlcaLlon
8oLox
1arsorraphy
Cold welghL
laclal nerve surgery
Lnd Lo end anasLomosls
CrafLlng
laclal Pypoglossal anasLamosls
laclal reanlmaLlon
asslve
AcLlve
1he ulscharglng Lar
AnaLomy
Lar SympLoms
3 sympLoms
CLalgla
CLorrohoea
1lnnlLus
lmbalance
Pearlng loss
LxamlnaLlon - lnna
- SlL Lhe paLlenL sldeways Lo Lhe
examlner
- Ask whlch ls Lhe beLLer hearlng
ear and examlne Lhls flrsL
- Ask wheLher Lhe ear ls Lender
- lllumlnaLe Lhe ear wlLh a head
llghL
Look for: ueformlLy
ulscharge
Scars
Slnuses
Skln condlLlons
Lar Canal
- ull Lhe plnna upwards and
backwards ln adulLs and
downwards and backwards
ln lnfanLs
- Pold Lhe auroscope llke a
pen
- Pold Lhe auroscope ln Lhe
lefL hand for Lhe lefL ear
and Lhe rlghL hand for Lhe
rlghL ear
- SupporL Lhe hand on Lhe
skln over Lhe paroLld gland
Lar Canal
- lnLroduce Lhe auroscope
passed Lhe halr bearlng skln
- 1ry noL Lo Louch Lhe
halrless, very senslLlve deep
canal skln
Look for: ulameLer
uebrls
Swelllngs
1ympanlc Membrane
- ldenLlfy Lhe handle of Lhe
malleus
- Lxamlne all quadranLs of Lhe
ear
- use a Slegle speculum lf
requlred Lo assess Lympanlc
membrane moblllLy
Look for: erforaLlons
8eLracLlons
keraLln
CavlLy
1unlng lorks
- 312 Pz Lunlng fork
- 8lnnes LesL
- Webers LesL
CLher ConslderaLlons
Cranlal nerve LxamlnaLlon
8alance 1esLs
8omberg
unLerbergers
nasal and posLnasal space examlnaLlon
lnvesLlgaLlon
ure 1one AudlomeLry
1he ulscharglng Lar
ulfferenLlal ulagnosls
LxLernal Lar
CLlLls LxLerna
8acLerlal
lungal
vlral
Mlddle Lar
CLlLls medla
AcuLe
Chronlc
WlLh cholesLeaLoma
WlLhouL cholesLeaLoma
(1ympanlc membrane perforaLlon)
1he ulscharglng Lar
Case 4
23 year old male
PlsLory of pyrexlal lllness assoclaLed wlLh lefL
oLalgla followed by oLorrhoea followed by
resoluLlon
SubsequenL recurrenL oLorrohoea and mlld
hearlng loss
1he ulscharglng Lar
1ympanlc Membrane erforaLlon
Causes
1rauma
CLlLls medla
laLrogenlc eg. CrommeLs
SympLoms
none
8ecurrenL oLorrhoea
Pearlng loss
1ympanlc Membrane erforaLlon
1reaLmenL
none
MyrlngoplasLy
+/- osslculoplasLy
CrafL ls placed under
perforaLlon Lo allow
eplLhellum Lo regrow
MyrlngoplasLy
1he ulscharglng Lar
Case 3
23 year old female
!usL reLurned from hollday ln Spaln
1 week hlsLory of lefL oLalgla, oLorrohoea and mlld
hearlng loss
CLherwlse well
1he ulscharglng Lar
CLlLls LxLerna
lnflammaLlon of exLernal ear canal
8acLerlal, fungal, vlral, chemlcal
Mlnor Lrauma
ConLamlnaLed waLer
lmmunosupressed (MallgnanL CLlLls LxLerna)
CLlLls LxLerna
Cllnlcal leaLures
CLalgla (domlnanL sympLom)
CLorrohoea
Pearlng loss
CedemaLous,
molsL ear canal
CLlLls LxLerna
1reaLmenL
Analgesla
keep ear dry
1oplcal anLlbloLlcs eg. Sofradex
MlcrosucLlon
+/- SLenLlng of ear canal
lungal CLlLls LxLerna
Asperglllus nlger
CfLen less palnful
1reaLmenL
MlcrosucLlon
1oplcal anLl-fungal
agenLs
1he ulscharglng Lar
Case 6
2 year old boy
resenLs Lo C wlLh acuLe pyrexlal lllness for 3 days
ulls aL ear
lracLlous
1he ulscharglng Lar
AcuLe CLlLls Medla
ueflnlLlon
lnflammaLlon of Lhe mlddle ear clefL
uemographlcs
MosLly chlldren (age 3-7)
AeLlology
vlral (ma[orlLy)
8acLerlal (1
y
or 2
y
) - SLrep. neumonlae, P. lnfluenzae, 8ramhamella
caLarrhalls)
8lsk lacLors
oor sanlLaLlon/ hyglene and parenLal smoklng
Lxposure Lo oLher chlldren
LusLachlan 1ube uysfuncLlon
? allergy
naLural PlsLory
lnfecLlon vla L1 Lube ( lnfecLlon vla L1 Lube (Iever Iever) )
Mucosal oedema Mucosal oedema
Pyperaemla of Lympanlc membrane & Pyperaemla of Lympanlc membrane &
purulenL mlddle effuslon purulenL mlddle effuslon
8ulglng Lympanlc membrane ( 8ulglng Lympanlc membrane (a|n a|n) )
ressure necrosls of Lympanlc membrane ressure necrosls of Lympanlc membrane
resulLlng ln perforaLlon resulLlng ln perforaLlon
Mucopuru|ent d|scharge Mucopuru|ent d|scharge
AcuLe CLlLls Medla
1reaLmenL
LxpecLanL
araceLamol/nSAluS
Cral amoxyclllln
+/- myrlngoLomy
CompllcaLlons
AcuLe
MasLoldlLls
laclal palsy
LabyrlnLhlLls
MenlnglLls
lnLracranlal abscess
LaLeral slnus Lhrombosls
- Long Lerm
1ympanosclerosls
1ympanlc membrane perforaLlon
Csslcular damage
AcuLe MasLoldlLls
PlsLory of acuLe oLlLls medla
lnfecLlon spreads Lo
masLold
osL-aurlcular abscess
1reaLmenL
CrommeL
CorLlcal masLoldecLomy
Chronlc CLlLls Medla
- WlLhouL cholesLeaLoma
- 1ympanlc membrane perforaLlon
- Chronlc mlddle ear lnfecLlon
- May resolve wlLh Loplcal or oral
anLlbloLlcs
- lf no resoluLlon - myrlngoplasLy +/-
corLlcal masLoldecLomy
- CLorrohoea for more Lhan 3 monLhs
- May occur wlLh or wlLhouL cholesLeaLoma
Chronlc CLlLls Medla
- WlLh cholesLeaLoma
- LusLaclan Lube dysfuncLlon resulLs ln Lympanlc membrane reLracLlon
(aLLlc)
- AccumulaLlon of keraLln ln reLracLlon pockeL
- Cradual enlargemenL and ad[acenL bony desLrucLlon
- CompllcaLlons as for ACM above
CholesLeaLoma
Chronlc CLlLls Medla wlLh CholesLeaLoma
1reaLmenL ls surglcal
Alms of surgery
8emove all dlsease
ury ear
+/- 8esLore Pearlng
1ypes of operaLlon
Modlfled radlcal masLoldecLomy
Canal wall up masLoldecomy
Chronlc CLlLls Medla wlLh CholesLeaLoma
osL-aurlcular lnclslon
MasLold alr cells
drllled away
osLerlor ear canal
removed Lo leave
masLold cavlLy
1he ueaf aLlenL
1he ueaf aLlenL
Case 6
3 year old glrl
8orn normally
CLherwlse well
Speech delay
Cccaslonal bllaLeral oLalgla and oLorrohoea
1he ueaf aLlenL
CLlLls Medla wlLh Lffuslon
ueflnlLlon
lluld presenL ln Lhe mlddle ear as a resulL of lnflammaLlon
uemographlcs
CommonesL cause of acqulred hearlng loss
18 monLh - 6years 21 affecLed
8lsk lacLors
As for ASCM
CLlLls Medla wlLh Lffuslon
AeLlology
LusLaclan Lube dysfuncLlon LusLaclan Lube dysfuncLlon
negaLlve mlddle ear pressure negaLlve mlddle ear pressure
lnflammaLory response lnflammaLory response
LxudaLe formaLlon LxudaLe formaLlon
- Cr secondary Lo ACM
Cllnlcal leaLures
Chlld pulls aL ears
Pearlng loss
CLalgla
Slow speech or menLal
developmenL
1ympanlc membrane
shows:
uull or yellowlsh
dlscolouraLlon
Alr bubbles/ fluld level
8ulglng/ reLracLlon
CLlLls Medla wlLh Lffuslon
- CfLen resolves Lherefore LreaL
expecLanLly
- no medlcal LreaLmenL of proven
beneflL
- lf no resoluLlon afLer 6 weeks Lhen
venLllaLlon Lubes lnserLed or hearlng
ald flLLed
- Conslder adenoldecLomy lf
sympLomaLlc or recurrenL CML
ConducLlve Pearlng Loss
LxLernal ear
Wax
lorelgn bodles
CLlLls exLerna
Mlddle ear
Mlddle ear effuslon
1ympanlc membrane perforaLlon
Csslcular damage/flxaLlon
Sensorlneural Pearlng Loss
Cause Examples
Hereditary Pendreds syn.,Alports syn., NF2, Pagets
Infection Ramsey Hunt syn., Syphilis, meningitis
Ischaemia CVA, Sickle cell disease
Inflammation Autoimmune disease eg. Rh. Arthritis
Neoplastic Vestibular Schwannoma
Trauma Head injury, ototoxicity
Degenerative Presbycusis
Others Menieres syn., noise induced
1he 8unny or 8locked nose
1he 8unny or 8locked nose
Case 7
18 monLh old boy
oor soclal
clrcumsLances
PlsLory of perslsLenL
purulenL bllaLeral nasal
dlscharge and mouLh
breaLhlng
Snores and occaslonally
holds hls breaLh aL nlghL
Adenold
SympLoms of hyperLrophy and chronlc
lnfecLlon:-
A) nolsy eaLlng.
8) 8hlnorrhoea
C) Snorlng
u) nocLurnal obsLrucLlon - AnCLA
L) CLlLls Medla wlLh Lffuslon
AuLnCluS nA88CWlnC 1PL Al8WA?
CSl1lCn lC8
1CnSlLLLC1CM? Anu
AuLnCluLC1CM?
AuLnClu Au 8LlnC
LnCACALu" 8?
Cu8L11L
Chlldren
ulfferenLlal ulagnosls
8hlnoslnuslLls
AcuLe
Chronlc eg. Allerglc
Adenoldal hyperLrophy
lorelgn bodles
Choanal aLresla
lorelgn 8odles
PlsLory of puLLlng
forelgn body up nose
unllaLeral purulenL
nasal dlscharge
vlslble forelgn body
1reaLmenL
8emove
AdulLs
ulfferenLlal ulagnosls
AcuLe rhlnoslnuslLls
Chronlc rhlnoslnuslLls
Allerglc (perennlel or seasonal)
ldlopaLhlc
vasomoLor
lnfecLlve
SysLemlc dlsease
Sarcoldosls
Wegeners granulomaLosls
nasal olyps
SamLers Lrlad
neoplasla
8enlgn eg. lnverLed papllloma
MallgnanL eg. Squamous carclnoma
Chronlc Allerglc 8hlnoslnuslLls
CommonesL medlcal condlLlon ln Lhe world (10-
20 of global populaLlon)
lnLermlLLanL or perslsLenL sympLoms
1wo or more of:
WaLery anLerlor rhlnorrhoea
nasal obsLrucLlon
Sneezlng
lLchy eyes
Also poor sleep and reduced quallLy of llfe
Chronlc Allerglc 8hlnoslnuslLls
Common allergens:
Seasonal
Crass pollen
1ree pollens
erennlel
Pouse dusL mlLe
uogs
CaLs
Mould eg. Cladosporlum
lungus eg. Asperglllus
78
1reaLmenL
Allergy avoldance
Medlcal LreaLmenL
1oplcal sLerolds eg. lluLlcasone
1oplcal anLlhlsLamlnes eg. AzalasLlne
Cral anLlhlsLamlnes eg. LoraLldlne
lmmunoLherapy
ln[ecLlon
Subllngual
Conslder C1 +/- surgery for LreaLmenL fallures
Sore 1hroaLs
ulfferenLlal ulagnosls
Chlldren
AcuLe pharynglLls
AcuLe LonsllllLls
Clandular fever
AdulLs
As above
Smoklng
osLnasal drlp
CasLroesophageal reflux
Mollqooocy
lndlcaLlons for 1onslllecLomy
8ecurrenL 1onsllllLls - 6x aLLacks ln 1 year C8
> 3 aLLacks for 2 consecuLlve years.
Chronlc LonsllllLls
CbsLrucLlve sleep apnoea
AsymmeLrlc Lonslls ll susplclous (removed as
blopsy.
CLnlnC ln1C
LAnL Cl
1CnSlLLA8
ulSSLC1lCn
1CnSlLLA8
ulSSLC1lCn
PaemosLasls wlLh
blpolar
PaemosLsasls wlLh
Lles
CompllcaLlons of 1onslllecLomy
rlmary Paemorrhage
8eacLlonary Paemorrhage
aln (unlversal)
Secondary Paemorrhage (3-7 days posL op).
Clandular lever
AeLlology
LpsLeln-8arr vlrus
Cllnlcal leaLures
Any age buL commonly Leenager
6 weeks lncubaLlon
Sore LhroaL (prolonged duraLlon)
Malalse
Clandular lever
LxamlnaLlon
WhlLe fllm over Lonslls
lnvesLlgaLlon
MonospoL
1reaLmenL
LxpecLanL
no anLlbloLlcs (parLlcularly amoxyclllln - rash)
no conLacL sporLs - Splenlc enlargemenL
Pead and neck Mallgnancy
Large Loplc
Squamous carclnoma
Arlses from squamous eplLhellum of upper
aerodlgesLlve LracL
Larynx (mosL common)
1onsll
1ongue base
Cral cavlLy
naso and hypopharynx
AeLlology
Smoklng
lncreases relaLlve rlsk by x10
Alcohol
lncreases relaLlve rlsk by x2.3
SynerglsLlc
Comblned rlsk x13
Cllnlcal leaLures
uepends on slLe
Sore LhroaL (harynx)
PAvL PlCP lnuLx Cl SuSClClCn
uysphonla (Larynx)
uysphagla (Cral cavlLy and pharynx)
ShorLness of breaLh (alrway obsLrucLlon)
Cllnlcal leaLures
LxamlnaLlon
vlslble Lumour
llexlble endoscopy
mandaLory
8e aware of unknown
prlmary
Cervlcal
lymphadenopaLhy
nodal level
uyspnoea or sLrldor
uue Lo alrway obsLrucLlon
lnvesLlgaLlon
SLaglng
1nM ClasslflcaLlon
11-4 = 1umour Slze
N0-3 = LxLenL of lymph node lnvolvemenL
M1-2 = resence or absence of meLasLasls
1reaLmenL
Surgery
Cpen
Lndoscoplc laser
+/- 8econsLrucLlon
8adloLherapy
8adlcal
alllaLlve
ChemoLherapy
neoad[uvenL
Ad[uvenL
rognosls
SlLe and slze dependenL
Cverall 3 year survlval
Larynx 60
Pypopharynx 30
ulfflculLy 8reaLhlng
ulfferenLlal ulagnosls
Chlldren
CongenlLal
Laryngomalacla
SubgloLLlc sLenosls
vocal cord palsy
SubgloLLlc haemangloma
Choanal aLresla
CloLLlc web
Acqulred
lympbolJ bypetttopby eq. oJeootooslllot
lofectlve
vltol eq. ctoop
8octetlol eq. plqlottltls
lotelqo boJy
SubgloLLlc sLenosls
neoplasLlc
ulfferenLlal ulagnosls
AdulLs
lnfecLlve
SupragloLLlLls
neoplasLlc
Alrway mallgnancy
ulmonary mallgnancy
Str|dor
SLrldor - AssessmenL
wbot level ?? PlsLory - WhaL sorL of sLrldor
now sevete ?? Accessory muscles
1racheal Lug / 8ecesslon
ulse
pCC
2
8eLenLlon
uoes tbe oltwoy oeeJ secotloq ??
Severe C8 paLlenL geLLlng Llred.
SLrldor -managemenL
Sl1 A1lLn1 u
Cx?CLn
8L-P?u8A1lCn (l.v.)
S1L8CluS (nebullsed, l.v. or oral)
Au8LnALlnL nL8uLlSL8
PLLlCx - Pellum / oxygen mlxLure
An1l-8lC1lCS
Al8WA? ln1L8vLn1lCn
lotobotloo
8toocboscopy
1tocbeostomy
"Croup" vs Lp|g|ott|t|s
Croup LplgloLLlLls
Age 1-3years 3-6 years
uuraLlon u81l (days) ShorL(hours)
Cllnlcal vlral" unwell*
SLrldor Loud CuleL
* uecreased consclous level, clrcumoral palor, rapld
deLerloraLlon.
CuesLlons?