Week 1

ENT – Pre-placement

This module uses a common ENT condition, acute follicular tonsillitis, to:

1.    Revise the most important, clinically relevant elements of ENT anatomy and physiology

2.  Give you an introduction to how to take a history and examine the ears, nose, and throat.

Guidance and Resources – ENT Pre-placement – 

Introduction – ENT Pre-placement – 

Further Material – ENT Pre-placement – 

Background Science – ENT Pre-placement – 

Formative Assessment – ENT Pre-placement – 

Guidance and Resources – ENT Pre-placement – MED 36

In case ENT – Pre-placement555

Learning Resources

1.    Diseases of the Ear, Nose and Throat by Mohan Bansel First Edition: 2013

2.    ABC of ENT Fifth Edition By Harold Ludman and Patrick J Bradley Chapter

0.    Pain in ear Page 1-2

1.    Chapter 2: Discharge from the ear page 6-9

3.    BNF Chapter 12 Ear, Nose and Oropharynx

Introduction – ENT Pre-placement 

Case 1 – Amy

Amy is a 19-year-old medical student. For the last 2 years she has struggled with bilateral nasal obstruction, a watery anterior rhinorrhoea and sneezing during the summer months. During the winter she has no symptoms.

You are the resident in out patients and she has just come in to your consulting room.

The following tables show causes and types of nasal obstruction and nasal discharge:

Although her symptoms are related to the nose it is important to take a full history and ask about the ear and the throat as one system can often affect another. For example, someone with an acute rhinosinusitis may also have Eustachian tube dysfunction that results in the development of a middle ear effusion. This causes deafness.

The following table summaries the causes of conductive hearing loss:

There are other elements to the history that are important as well as whether the patient does or does not have a symptom.

You should ask when the symptoms started and whether there was anything that precipitated the symptoms.

It is important to know whether the symptoms are constant or intermittent and whether anything makes them better or worse.

Sometimes it is also important to look further afield than just the ears, nose and throat. Diseases often affect more than one system. In fact, many ENT conditions are part of more systemic disease.

For example, asthma is very common in patients with chronic rhinosinusitis.

Further Material – ENT Pre-placement 

Case 2 – Jack

Jack is a 24-year-old accountant. He has been complaining of intermittant sore throats associated with fever and difficulty swallowing over the last year. They usually last a week and he has been to the GP for antibiotics on a number of occasions. He often gets right ear ache when he gets a sore throat. You have just seen him in the out patient clinic following a referral from his GP and you would like to examine him. You start with the neck examination.

The video below demonstrates how to examine the neck.

Anatomy of the neck

The neck can be divided into anatomical triangles, the borders of which are determined by the muscles of the neck. This compartmentalises the neck and makes it easier to remember what structures are present and where they are situated.

The neck can be divided into anatomical triangles, the borders of which are determined by the muscles of the neck. This compartmentalises the neck and makes it easier to remember what structures are present and where they are situated.

The head and neck is rich in lymphatics and there are many ways of classifying them. ENT surgeons think about lymph nodes of the neck in terms of levels as defined by the Memorial Sloan Kettering Cancer Centre. If you’re interested in learning a bit more about this then the Medscape Neck Dissection Classification provides a useful overview. The levels are based on the areas that they drain. The levels are:

Level 1: Submental and submandibular

Level 2: Upper deep cervical

Level 3: Mid-deep cervical

Level 4: Lower deep cervical

Level 5: Posterior triangle

Level 6: Paratracheal

Level 7: Upper mediastinal

Lymph node levels in the neck

This is important because the site of any lymph node enlargement gives an indication of where the pathology might lie particularly when it comes to tumours of the upper aerodigestive tract.

The anatomy of the neck can seem daunting but if you use the system of triangles and remember the structures that are within each of them then it becomes easier to remember. For further information please refer back to your phase 1 anatomy.

You do not find any abnormalities in Jack’s case.

The next step is to examine the oral cavity. In order to so, it is important to use adequate illumination. The ideal is to use a head light. This frees both hands and, with a tongue depressor in each hand, the cheeks can be retracted to maximize the view.

You should examine systematically:

·       The mucosa of the cheeks

·       The roof of the mouth

·       The dentition and gums

·       The dorsum of the tongue

·       Ask the patient to lift their tongue to the roof of their mouth and inspect the floor of the mouth.

·       Ask the patient to move their tongue to the right and then to the left and examine the sides of the tongue

·       In some cases, it is also helpful to put on a pair of gloves and palpate the structures in the oral cavity.

·       Attention should then be turned to inspecting the oropharynx. Again a systematic approach should be taken, inspecting:

·       The anterior and posterior faucial pillars

·       The tonsils

·       The soft palate and uvula

·       The posterior oropaharyngeal wall

In Jack’s case the oral cavity looks normal although the tonsils are quite large.

ENT surgeons often use endoscopes to inspect areas of the nose, pharynx and larynx that would be otherwise difficult to see. In someone with throat symptoms the upper aerodigestive tract would be inspected with a flexible nasendoscope. The picture below shows a typical nasendoscope. As a student you wouldn’t be expected to be able to use these but you should have the opportunity to see one in use during your attachment.

A typical nasendoscope

In Jack’s case you make a diagnosis of recurrent acute tonsillitis.

Below is shown the typical appearance of the oropharynx during an acute tonsillitis.

You discuss whether or not he should have his tonsils removed and you decide to observe him over the coming 6 months to see whether his sore throats continue.

He re-presents to you Emergency room (ER) one night when you are on call with severe sore throat for 3 days that is worse on the right side. He has a fever and is unable to eat or drink. He has right earache. You examine his throat. This is what you see:

This is a quinsy, also known as a peritonsillar abscess and can occur as a complication of severe bacterial acute tonsillitis. They do not normally respond to antibiotics alone and, as with any abscess, should be drained. This can be done under local anaesthetic either by aspiration of pus or by incision and drainage with a knife. It is not a pleasant procedure but the patient feels almost immediate relief.

Patients with bacterial infections of the pharynx can also develop abscesses in the parapharyngeal space and retropharyngeal space. Thankfully, with modern antibiotics, it is rare to see these. 

Causes of referred otalgia

Because he has been complaining of earache with the sore throats you should also examine the ears.

The diagram below shows the main structures of the ear. Please revise your phase one anatomy for more detail.

The ear can be divided into outer, middle and inner ears. It is not possible to examine the inner ear but the outer ear and tympanic membrane are readily accessible for examination.

The Tympanic Membrane

The picture below shows a normal tympanic membrane.

The diagram below shows the important structures of the middle ear. The middle ear can be considered as a box and the walls have various structures in them. As you will see in the ‘otorrhoea’ module, it is important to have a broad understanding of these structures as they may be affected by infection spreading from the middle ear.

The main structures in each wall

How To Examine The Ear

Sit the patient sideways to you

Ask which is the better hearing ear or the ear with pathology and examine this first

Ask whether the ear is tender

Inspect the outside of the ear including the pinna and the surrounding skin. Look behind the ear in the post-auricular sulcus.

Look for:

·       Deformity

·       Discharge

·       Scars

·       Sinuses

·       Skin conditions

Pull the pinna upwards and backwards in adults and backwards in infants

Hold the auroscope as if it were a pen and hold it in the left hand for the left ear and the right hand for the right ear

Support the hand holding the auroscope on the skin over the parotid gland

Introduce the Otoscope passed the hair bearing skin

The video below demonstrates physical ear examination

Video Player http://www.taibahumbbs.com/wp-content/uploads/2017/12/Physical-examination-examination-of-the-ear.mp4?_=2

The video below demonstrates how to introduce Otoscope

Video Player http://www.taibahumbbs.com/wp-content/uploads/2017/12/Ear-Pain-5_-Otoscope-Examination.mp4?_=3

Try not to touch the hairless, very sensitive deep canal skin

Inspect the external auditory canal looking for:

·       Diameter

·       Debris

·       Swellings

Inspect the tympanic membrane systematically in quadrants including the pars flaccida (also called the attic).

Look for:

·       Perforations

·       Retractions

·       Keratin

·       Cavity

Background Science – ENT Pre-placement – MED 36

In case ENT – Pre-placement555

The physiology of the ears nose and throat is complex and it is not possible to cover this adequately here. Please refer back to your phase one notes to refresh your memory.

Here we will refresh your knowledge of the physiology of the inner ear.

Sound waves pass in to the external auditory canal and hit the tympanic membrane. The pinna is designed to optimize the collection of sound waves and acts to amplify the sound a little.

The sound waves are then transferred to the ossicular chain which acts as a system of levers to maximize the passage of the sound wave to the inner ear from the relatively large tympanic membrane to the small oval window.

The Cochlea

The cochlea consists of 3 fluid filled channels, the scala tympani, the scala vestibuli and the scala media. The scala tympani and the scala vestibuli are filled with perilymph. The scala media is filled with endolymph. The cochlea is arranged like a snail shell. The scala tympani connects with the scala vestibuli at the apex of the snail shell and sound waves pass into the scala tympani at the oval window and travel up the length of the scala tympani and then travel back down to the round window via the scala vestibuli.

Diagram showing the gross structure of the cochlea.

As the sound wave travels along the scala tympani it deflects the basilar membrane in the scala media. On the basilar membrane sits the Organ of Corti, the structure that converts the mechanical sound wave to an electrical signal that can be interpreted by the brain

The Organ of Corti

The Organ of Corti has inner and outer hair cells. The hair cells have stereocilia that are deflected as the sound wave passes. This deflection results in opening of potassium channels, facilitated by tip links that connect the sterocilia. Because of endolymph is rich in potassium and calcium, these positive ions pass into the top of the hair cell. This triggers depolarization and the opening of voltage gated calcium channels at the base of the hair cell that then results in the release of the neurotransmitter glutamate. This causes depolarization of the cochlear nerve that is connected to the basilar membrane sending an electrical signal to the brain.

The outer hair cells act to modulate the signal generated by the Organ of Corti. They are able to amplify the signal through increased deflection of the basilar membrane.

Central Auditory Pathways

The auditory cortex is situated in the superior temporal gyrus of the temporal lobe and extends in to the lateral sulcus and the transverse temporal gyri (Heschl’s gyrus). The auditory signal passes along the cochlear nerve to the cochlear nucleus in the brainstem. Here, most of the signal crosses over to the contralateral side. The signal then passes up the brainstem through the superior olivary nucleus and onwards through the lateral lemniscus in the midbrain to the inferior colliculus. It then passes through the medial geniculate body to the auditory cortex. This is shown in diagrammatic form below.

Central auditory pathways

This module has given you the information you need to start assessing patients with ENT problems adequately. Through taking a good quality history and carrying out a thorough examination, most ENT problems can be diagnosed. The subsequent modules will build on these skills and allow you to formulate an appropriate treatment plan.

Formative Assessment – ENT Pre-placement