Viva ENT
Viva ENT
Viva ENT
RICARDO AP PERSAUD
FRCS ORL-HNS (Eng) CCT Otol. (UK)
MBBS MSB CBiol MPhil MRCS (Gen) DO-HNS
Consultant ENT Head Neck & Rhinoplastic Surgeon
Al Zahra Medical Group, Sharjah and Dubai, UAE.
OWEN JUDD
FRCS ORL-HNS (Eng) CCT Otol. (UK)
MRCP FRCS (Edin) PGDipClinEd DCH
Consultant Neurotologist and Laryngologist
Royal Derby Hospital, Derby, UK.
YOGESH M BHATT
FRCS ORL-HNS (Edin)
MB ChB (Hons) BSc (Hons) 1st Neuroscience (Lond)
Interface Fellow in Head and Neck Surgical Oncology
University Hospitals Birmingham NHS Foundation Trust, UK
Council Member for the British Association for Paediatric
Otolaryngology.
JULIAN A GASKIN
FRCS ORL-HNS (Edin) CCT Otol. (UK)
MBChB DO-HNS
Fellow in Paediatric Otorhinolaryngology
University of Manchester Medical School Examiner
Royal Manchester Children's Hospital, Manchester, UK.
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Viva Guide in ENT Surgery:
The traffic light approach
CONTENTS
• Preface x
• Foreword x
• Acknowledgements x
• Dedication x
CHAPTER 1: PAEDIATRIC ENT SURGERY x
1.1 Periorbital cellulitis x
1.2 Hypovolaemic shock X
1.3 Epiglotitis X
1.4 Foreign body wheezing x
1.5 Acute otitis media (AOM) x
1.6 Acute mastoiditis x
1.7 Neonatal nasal obstruction x
1.8 Retropharyngeal abscess x
1.9 Juvenile respiratory papillomatosis x
1.10 Pre-auricular sinus x
1.11 Microtia x
1.12 Otitis media with effusion (Glue ear) x
1.13 Branchial cleft sinus x
1.14 Drooling x
1.15 Laryngomalacia x
1.16 Down syndrome x
1.17 Haemangiomas x
1.18 Cystic hygroma x
1.19 Thyroglossal duct cyst x
1.20 Lingual thyroid x
1.21 Congenital midline nasal mass x
1.22 Cleft lip and palate x
1.23 Congenital cholesteatoma x
1.24 Waardenburg syndrome x
1.25 Ranula x
1.26 Cervical lymphadenopathy X
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1.27 Traumatic perforation of tympanic membrane
and non-accidental injury (NAI) x
1.28 Caustic ingestion and NAI x
1.29 Juvenile nasopharyngeal angiofibroma (JNA) x
1.30 Airway foreign body x
1.31 Sleep-disordered breathing in a child x
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CHAPTER 3: HEAD AND NECK x
3.1 Salivary gland neoplasm x
3.2 Neck lumps x
3.3 Hoarse voice x
3.4 Carcinoma of unknown primary (CUP) x
3.5 Tonsil carcinoma x
3.6 Nasopharyngeal carcinoma x
3.7 Laryngeal carcinoma and neck dissection x
3.8 Supraclavicular metastatic squamous cell carcinoma x
3.9 Black hairy tongue x
3.10 Benign parotid lesion x
3.11 Malignant parotid lesion x
3.12 Vocal cord dysplasia/early glottic SCC x
3.13 HPV and oropharyngeal lesion x
3.14 Facial pain x
3.15 Pharyngeal pouch x
3.16 Parapharyngeal mass x
3.17 Hemi-tongue atrophy x
3.18 Cervical mycobacterial lymphadenitis (scrofula) x
3.19 Pseudomenbraneous colitis (C. Diff infection) x
3.20 Reinke’s oedema x
3.21 Radiotherapy and side effects x
3.22 SCC Tongue x
3.23 Vocal process granuloma x
3.24 Parapharyngeal space abscess x
3.25 Goitre X
3.26 Nasolabial cyst x
3.27 Frey’s syndrome and Botox x
3.28 Giant plexiform neurofibroma of scalp x
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4.7 Meniere’s disease x
4.8 Benign paroxysmal positional vertigo x
4.9 Temporal bone fracture x
4.10 Noise induced hearing loss x
4.11 Non-organic hearing loss x
4.12 Drug induced hearing loss x
4.13 Bone anchored hearing aid (BAHA) x
4.14 Cochlear implant x
4.15 Chronic otitis externa x
4.16 Vestibular schwannoma x
4.17 Ramsay Hunt Syndrome x
4.18 Mastoidectomy fistula x
4.19 High jugular bulb x
4.20 Glomus tympanicum x
4.21 Meningioma x
4.22 Bell’s palsy x
4.23 Chronis otitis media active mucosal disease x
4.24a Otoacoustic emissions (old graph) x
4.24b Otoacoustic emissions (new graph) x
4.25 Universal Neonatal Hearing Screening x
4.26 Auditory Brainstem Response x
4.27 Presbyacussis x
4.28 Sudden sensory neural hearing loss x
4.29 Tinnitus x
4.30 Clinical anatomy of the temporal bone x
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CHAPTER 1
CLINICAL
PHOTOGRAPH
Introductory Answer
question
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Competency Answer
question(s)
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local protocol and intranasal steroid and
decongestants. Initially, hourly eye
observations and 4-hourly neuro-obs
until evidence of disease resolution.
• Thin medial subperiosteal collections
may be managed conservatively if
regular reliable acuity assessment is
available. All other collections must be
drained immediately.
• Drainage may be performed externally
to allow drain insertion or if expertise
available, endonasally.
• Maxillary antrum may be washed out
and aspirate sent for MC&S
Advanced Answer
question(s)
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and frontal sinus surgery may be
hazardous. Frontal sinus trephine may
represent an effective compromise.
Bony sequestra occasionally require
open debridement.
Introductory Answer
question
Competency Answer
question(s)
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blood loss (cf. dehydration)
• When compensated blood flow to vital
organs is preserved but the child may be
agitated with raised HR and CR. Low BP is
a pre-terminal sign of decompensation
and circulatory collapse may quickly
follow.
• Seek input from an experienced
anaesthetist/paediatrician and
simultaneously assess and treat the child
using APLS protocol in an appropriate
setting eg RESUS bay, theatre recovery
or HDU with oxygen and fluids.
• A – clear clots and administer high flow
oxygen, B – assess effort, efficacy and
effect of breathing, C – reassess signs
and urine output and obtain 2 wide bore
IV access lines whilst obtaining blood for
cross-match, FBC, coagulopathy screen.
• Administer a 20ml/kg normal saline
(0.9%) bolus and check for response. If
bleeding continues and once 40ml/kg
had been administered, colloid/blood
products must be given next.
• Once stabilised the child should be taken
to theatre to formally control the bleed.
Advanced Answer
question(s)
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pyrexial? administer cefotaxime at 80mg/kg.
How would it be • If no IV access was achievable
changed if IV immediately, obtain intra-osseous
access could not access. With a knee flexed at 30degree
be obtained? over a towel clean the skin over either
antero-medial surface of tibia 3cm below
the tibial tuberosity or antero-lateral
femur 3cm above the lateral condyle.
Rotate an 18G IO needle at 90 degrees to
the bone until a ‘give’ is felt. Aspirated
to confirm position and 20ml of
crystalloid pushed through the syringe
and line secured.
1.3 EPIGLOTITIS
Introductory Answer
question
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• Airway foreign body
• Severe pharyngo-tonsillitis (bacterial or
viral aetiology)
Competency Answer
question(s)
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and child to remain intubated on
paediatric ITU until tube leak present or
reassessed with laryngoscope in
48hours. Sepsis treated in conjunction
with paediatric intensivists.
Advanced Answer
question(s)
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radiological occasional cough and sneezing. His parents
image) became concerned after he developed a high
temperature over the weekend.
Competency Answer
question(s)
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effect
Advanced Answer
question(s)
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1.5 ACUTE OTITIS MEDIA (AOM)
CLINICAL
PHOTOGRAPH
Introductory Answer
question
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Competency Answer
question(s)
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prevalence of beta-lactamase producing
organisms or at higher risk of
complications. Ensure Prevenar
(Pneumococcal Conjugate Vaccine) has
been considered.
Advanced Answer
question(s)
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1.6 ACUTE MASTOIDITIS
CLINICAL
PHOTOGRAPH
Introductory Answer
question
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Competency Answer
question(s)
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Advanced Answer
question(s)
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problem and would like you to come
urgently.
Introductory Answer
question
What is your
• Bilateral choanal atresia,
differential
diagnosis? • Nasal mass (glioma, encephalocele,
meningoencephalocele, nasolacrimal
duct tumours etc)
• Piriform aperture stenosis
• Severe neonatal rhinitis
Competency Answer
question(s)
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request an ECHO to rule out cardiac
abnormalities, Ultrasound scan of
kidneys to rule out renal problems.
Later, slit lamp examination of eyes
(coloboma) as well as OAEs and ABR
• Treatment – surgery ASAP to create and
maintain patent posterior choanae. Can
be done endonasally under direct vision
by using a 120 degrees rigid Hopkins rod
in the mouth. The alternative is the
trans-palatine approach, which involves
removal the posterior part of the vomer.
A soft tube splint for up to 6 weeks is
necessary.
Advanced Answer
question(s)
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1.8 RETROPHARYNGEAL ABSCESS
Introductory Answer
question
Competency Answer
question(s)
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patient? • History – Blunt trauma, foreign body
ingestion, URTI, tuberculosis contact,
DH/allergy.
• Examination – Effort and efficacy of
breathing noting stertor/stridor and
administration of high flow humidified
oxygen by parent. Careful oral
assessment for parapharyngeal &
retropharyngeal swelling. Associated
neurology or chest signs.
• Investigation – cross-sectional imaging if
symptoms do not settle within 24 hours
of IV antibiotics or evidence of frank
collection. Allows planning of route of
drainage and identification of
complications.
• Treatment – analgesia and IV antibiotics.
Manage sepsis with paediatrician.
Drainage if signs of airway compromise
or no response to antibiotics. Liaise with
senior anaesthetist for naso-tracheal
intubation following gaseous induction
taking care not to rupture collection.
Oro-tracheal intubation over a rigid
endoscope may be required. Trans-oral
drainage is ideal first line route. Monitor
for signs of recurrence of complications.
Advanced Answer
question(s)
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collection cervical incision at hyoid level retracting
extending into the SCM laterally and rotating larynx and
thorax? pharynx medially following ligation of
middle thyroid vein.
• Collections above T4 will drain through a
trans-cervical incision. Those below will
require discussion with a paediatric
surgeon regarding need for trans-
thoracic drainage.
• Repeat imaging is essential to ensure
resolution and management with a
paediatrician in a level 2 or 3
environment.
Introductory Answer
question
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5. Chronic laryngitis
Competency Answer
question(s)
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method of most units).
• Adjuvant therapy may include alpha-
interferon for aggressive disease.
Cidofovir, a cytosine nucleoside
analogue, has been topically intra-
operatively but concerns have been
raised about carcinogenic potential.
• Tracheostomy is sometimes employed in
children whose disease presents a risk of
airway loss, but should be regarded as a
last resort as a tracheostomy has
precipitate distal airway involvement of
papillomata.
Advanced Answer
question(s)
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oropharyngeal cancer, the vaccine may
be given to boys in the future.
CLINICAL
PHOTOGRAPH
Introductory Answer
question
Competency Answer
question(s)
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how you manage cartilage of the root of helix. 25-50% are
this. bilateral and associated with Syndromes
e.g. Branchio-oto-renal (BOR) syndrome.
Describe the
surgical • Acute infections treated with directed
techniques used antibiotics or I+D if abscess.
to electively treat • Elective assessment of EAC for
this condition connecting pits suggesting first branchial
arch anomaly. Inspect contralateral ear
and neck for second arch cyst/sinus.
• Consider renal tract us/s for BOR
syndrome if pre-auricular sinus and one
of the following:
1. FH of hearing loss, renal anomaly or BOR
syndrome
2. A second dysmorphic feature
3. Maternal gestational diabetes
• Non-infected pits typically remain un-
infected and do not require further
assessment or surgery.
• The 3 techniques include:
1. Simple sinusectomy
2. Wide local excision by a supra-auricular
approach
3. ‘Inside-out’ technique
• Sinsuectomy involves elliptical skin
incision around the punctum and
excision of tract using probe +/-
methylene blue. 20-40% risk of
recurrence
• Wide local excision (Emery) includes an
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elliptical incision extended in a curvilear
fashion above the pinna. An en-bloc
specimen is removed with a cuff of
perichondrium from helical root and
tissue removed to the depth of the
temporalis fascia remaining posterior to
the temporal artery to minimise injury to
the facial nerve branches. 5% risk of
recurrence.
• The inside-out technique (Jensma)
combines the wide-local incision
approach and surgical magnification with
opening of the tract to follow each
branch of the sinus.
Advanced Answer
question(s)
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1.11 MICROTIA
CLINICAL
PHOTOGRAPH
Introductory Answer
question
Competency Answer
question(s)
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how would you dysfunction. It is important to determine the
manage them? status of the other ear and the presence of
other abnormalities, for example is the
patient syndromic (Golderhar, CHARGE). For
rehabilitation of hearing loss, consider a trial
of bone conduction hearing aid on soft band
and later BAHA
Cosmetic issues –surgical reconstruction or
prosthesis. Only a few centres achieve good
results with surgery, which involves multiple
staged procedures. Bone anchored
prosthesis is probably the preferred option.
Advanced Answer
question(s)
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1.12 OTITIS MEDIA WITH EFFUSION (GLUE EAR)
SCENARIO GP referral
(no clinical Please could you see this 4 year old girl
photograph) whose parents have concerns about her
hearing.
Introductory Answer
question
Competency Answer
question(s)
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membrane probably indicates a recent URTI.
Watch and wait (at least 3months).
Medications: No evidence that
decongestants, antibiotics or antihistamines
What are the non- are beneficial. Steroids may be helpful but
surgical options has significant side effects.
for treating glue
Autoinflation such as with the Otovent
ear?
balloon has been shown to improve effusions
over a 2 week to 3 month period but
evidence for longer term benefit is lacking.
Bearing in mind the complications associated
with ventilation tube insertion, many
clinicians consider autoinflation techniques
particularly useful in cases of unilateral
middle ear effusions.
Hearing aids should also be considered.
Adherence to the 2008 NICE guidelines are
often required.
Advanced Answer
question(s)
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1.13 BRANCHIAL CLEFT SINUS
Introductory Answer
question
Competency Answer
question(s)
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during quiescence. Type 1 sinus is EAC
duplication and approached through
parotidectomy incision with facial nerve
monitoring. Type 2 sinus traced between
internal/external carotid above CN12 into
tonsil in older children via step-ladder
incision.
Advanced Answer
question(s)
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1.14 DROOLING
Introductory Answer
question
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Competency Answer
question(s)
Which groups of
patients have Chronic drooling: Cerebral palsy, syndromic
drooling? (e.g. Trisomy-21), children on anti-
convulsants.
Acute drooling: foreign body, infections e.g.
epiglotitis, tonsilitis, gingivitis.
How would you
manage this
child? Management should be guided by the cause
and severity of drooling and an appreciation
of the psychosocial impact. Management of a
drooling child is challenging and requires a
multi-disciplinary approach. Involve the
community paediatrician, paediatric
neurologist, dentist, physiotherapist etc.
Severity may be graded by the presence of
peri-oral skin maceration and the number of
clothes changes per day for the soiling.
Investigation includes MDT assessment of
head control, dental malocclusion and
swallowing dysfunction. Assess for causes of
hypersecretion eg dental carries and causes
of incomplete lip seal eg macroglossia.
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Conservative: sitting positions, changing food
texture, oromotor exercises, cognitive
behavioural therapy
Medical: Hyoscine, glycopyrolate
Botulinum toxin injection. This is normally
available at tertiary paediatric units. Can be
injected under ultrasound guidance and can
be repeated. Effect wears off after 3 - 4
months.
Surgery: tonsillectomy, salivary gland
surgery.
Advanced Answer
question(s)
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1.15 LARYNGOMALACIA
Introductory Answer
question
Competency Answer
question(s)
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patient? impact on feeding, choking, apnoea, and
cyanosis. Birth history as well as number and
When would you
duration intubations. Neuromuscular
perform direct
disorders.
laryngoscopy?
Examination – effort and efficacy of
ventilation including nasal flare, tracheal tug,
chest recession. Phase and type of noise:
pharyngeal stertor improved with jaw thrust
or laryngotracheal stridor. Nasal cold spatula
testing. Oral examination – cleft palate and
glossoptosis. Neck – mass. Top to toe exam
for cutaneous haemangioma.
Fa
t P Co
Advanced Answer
question(s)
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noted. What is fixed narrowing which may result from a
the significance of complete tracheal ring.
this and how
Any possibility of extrinsic compression
would you
should be investigated with CT thorax which
manage this
in young infants may be performed by ‘feed
child?
and wrap’ techniques or in older children may
require sedation using local protocol eg oral
chloral hydrate +/- rectal paraldehyde. Rarely
infants may decompensate with sedatives
and may need imaging under general
anaesthetic with intubation.
Vascular compression due to complete rings
include double aortic arch causing
posterolateral compression of the distal
trachea, right aortic arch with left
ligamentum arteriosum. Incomplete rings
may be caused by aberrant innominate artery
compression of the anterior wall of the upper
trachea. Compression may also be caused by
anomalous left or right pulmonary artery
(pulmonary artery sling).
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1.16 DOWN SYNDROME
SCENARIO
(clinical
photograph)
Introductory Answer
question
Competency Answer
question(s)
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come to see you disorders pertaining to the Ear, Nose,
as an ENT Throat and Neck.
surgeon?
• Ears: Small low set pinnae, Ear canal
stenosis, Conductive hearing loss, Wax
impaction, Otitis Media with Effusion
(OME) (decreased immunity, hypotonic
palate, Eustachian tube dysfunction),
Cholesteatoma, Ossicular abnormalities
(deformed stapes, thickened malleus),
Up to 80% facial nerve dehiscence (wide
angle 2nd genu), Sensorineural hearing
loss in 21% of patients under 20 years
of age, 55% of patients over 20 years
(labyrinthine hypoplasia, small bony
island LSCC)
• Nose: Structure (cosmesis) and
function, Flat, Nasal congestion
(increased URTI), drooling, Small narrow
nasopharynx (OME), Sinus hypoplasia
(increased sinonasal disease),
hypotonicity of pharynx
• Throat (inc Airway): macroglossia,
Obstructive Sleep Apnoea, no lip seal,
drooling, subglottic narrowing,
recurrent croup (reduced
immunity/immature T and B cell
function), smaller endotracheal tube
needed
• Neck: Atlantoaxial instability (10%); this
is relevant to Tonsillectomy, Ear
Surgery. Pre-op x-ray neck +/-
neurology opinion may be needed.
Patients should be operated in the
neutral position.
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Advanced Answer
question(s)
1.17 HAEMANGIOMAS
Introductory Answer
question
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stenosis (primary or acquired), subglottic
web/cyst and foreign body
Competency Answer
question(s)
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potential heart failure, hypoglycaemia,
bronchospasm and hypotension are
possible side effects.
Advanced Answer
question(s)
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Introductory Answer
question
Competency Answer
question(s)
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• Microcystic oral disease may present
with acute infection and bleeding
Management is led by whether the disease is
microcystic and macrocystic, whether it
impacts or will impact on function and
whether a staged approach is appropriate.
MR imaging can provide a radiological
diagnosis and stage the disease.
Only 5% of such lesions spontaneously
involve. The two treatment options are
1. Intra-lesional sclerotherapy – no
consensus on best therapy. Requires
ultrasound guided aspiration and
injection under GA with acute
inflammatory response needing to be
covered with anti-inflammatories or
occasionally elective intubation.
2. Open excision – aim to debulk
macrocystic disease. Oral, pharyngeal or
laryngeal disease may be treated with
surface coblation.
Advanced Answer
question(s)
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Giguere Classification
Give an example • Macrocystic – cystic spaces at least 2cm
of a sclerosant or more
used for intra- • Microcystic – cystic spaces less than 2cm
lesional • Mixed
sclerotherpy and
All sclerosants work by the same principle of
give alternatives.
provoking an inflammatory thus causing
fibrosis and obliterating cystic spaces
OK-432, ( Picibanil )
• Inactive strain of Group A Streptococcus
pyogenes. Unique challenge is highly
variable availability.
• This is not licensed in the UK.
Doxycycline
• 10mg/ml by ultrasound guided injection
under GA. Maximum suggested dose of
100mg for term children 12months and
200mg if >12months. Unique side-effects
include possible hypoglycaemia and
macrolide hypersensitivity.
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1.19 THYROGLOSSAL DUCT CYST
Clinical
photograph
Introductory Answer
question
Competency Answer
question(s)
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Explain how the obliteration of the developmental tract
embryology of that the thyroid tissue makes from its
thyroglossal duct origin at the foramen caecum of the
cyst informs the tongue (junction of the anterior 2/3 and
operative posterior 1/3).
management.
• Complete excision of the TGDC should
include the descending tract from the
tongue base across the midline of the
hyoid bone. This forms the embryological
basis of the Sistrunk procedure.
• Thyroid tissue within the TGDC may
represent the only functioning thyroid
tissue. This may be established by pre-
operative cervical us/s to minimise the
risk of removing the only functioning
thyroid tissue.
Advanced Answer
question(s)
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1.20 LINGUAL THYROID
CLINICAL
PHOTOGRAPH
Introductory Answer
question
Competency Answer
question(s)
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could you swelling and establish the presence of
perform to functioning thyroid tissue elsewhere. In
confirm the 75% cases the ectopic thyroid tissue
diagnosis? represents the only functioning thyroid
tissue in the body.
• Most ectopic tissue is asymptomatic but
How would you
may increase in size and become
manage this
symptomatic during puberty and
patient?
pregnancy. It is four times more common
in females. They may bleed, and
malignant transformation has been
reported.
• In symptomatic older patients unfit for
complete resection partial trans-oral
ablation is suggested. Radioactive iodine
ablation has also been used.
• In younger patients with a consequently
greater risk of malignant transformation
complete resection is advised. If possible
trans-orally or otherwise by trans-cervical
pharyngostomy and a covering
tracheostomy. Post-operative T4
replacement may be given to suppress
ectopic thyroid tissue recurrence.
Advanced Answer
question(s)
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1.21 CONGENITAL MIDLINE NASAL MASS
SCENARIO
(clinical
photograph)
Introductory Answer
question
Competency Answer
question(s)
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manage this crying or straining. Previous meningitis.
patient? Vaccination history.
• Examination – nasal endoscopic
examination. Furstenberg sign -
compression of the ipsilateral jugular
vein leads to an increase in size of the
mass.
• Investigation – combined CT and MR
imaging to determine the presence and
nature of intra-cranial extension.
• Treatment – early planned surgery is
advised due to risk of meningitis in the
presence of cyst infection and intra-
cranial tract extension.
Advanced Answer
question(s)
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1.22 CLEFT LIP AND PALATE
CLINICAL PHOTO
Introductory Answer
question
Competency Answer
question(s)
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involve the soft palate.
• Veau classification of palatal cleft:
Class 1 – isolated soft palate
Class 2 – isolated hard palate
Class 3 - unilateral CLAP
Class 4 – bilateral CLAP
• Management requires a multidisciplinary
approach including speech and language
therapist, orthodontist, facial plastic and
cleft surgeon.
• Infancy – cleft lip repair once 10weeks or
10 pounds, to aid oral feeding
• Toddler – cleft palate repair at 10months
to aid phonation
• Late childhood – alveolar bone grafting at
12years +/- dental implant
• Early adulthood – midfacial advancement
and rhinoplasty options.
Advanced Answer
question(s)
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velopharyngeal insufficiency (VPI)
• Children with suspected submucosal cleft
are best assessed prior to adenoidectomy
by the cleft MDT. Alternatively suction
diathermy adenoidectomy may be
undertaken leaving a band of tissue
against which the soft palate may
approximate to minimise the risk of
permanent VPI.
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Introductory Answer
question
Competency Answer
question(s)
Advanced Answer
question(s)
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differs from middle ear.
primary acquired 2. Epithelial cells present in the amniotic
cholesteatoma. fluid may enter the middle ear cleft and
subsequently grow into a cholesteatoma.
Theories for acquired cholesteatoma include:
1. Immigration
2. Retraction
3. hyperplasia due to chronic inflammation
4. Metaplasian due to vit deficiency
5. Implantation
For further details see Persaud et al 2007 “An
evidence-based review of the
aetiopathogenic theories of congenital
and acquired cholesteatoma.” Journal
Laryngology Otology. 121 (11):1013-
1019.
Clinical
photograph
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Introductory Answer
question
Competency Answer
question(s)
Advanced Answer
question(s)
- 74 -
various subtypes? • Type 4 is inherited in an autosomal
recessive fashion.
• Type 1/3 – heterozygous
haploinsufficiency from PAX3 mutation
• Type 2 – MITF mutation.
• Type 4 – homozygous mutation in EDN3
(endothelin 3) or endothelin receptor B
(EDNRB).
1.25 RANULA
SCENARIO
(clinical
photograph)
Introductory Answer
question
- 75 -
diagnosis? • Dermoid cyst
• Supra-hyoid thyroglossal duct cyst
• Ectopic thyroid
Competency Answer
question(s)
Advanced Answer
question(s)
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• The risk of ranula formation may be
minimised by resecting the sublingual
gland when repositioning Wharton’s
duct.
Introductory Answer
question
- 77 -
clinical swelling in level II of the neck of a child.
photograph.
Competency Answer
question(s)
- 78 -
going to do? – If serology positive (10%)– Discharge
And what do you – If negative and lump same or bigger – List
do at the next for excision
appointment? – If negative and lump smaller - Discharge
Advanced Answer
question(s)
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1.27 TRAUMATIC PERFORATION OF TYMPANIC MEMBRANE AND
NON-ACCIDENTAL INJURY (NAI)
Introductory Answer
question
- 80 -
• Non-accidental injury (NAI)
Competency Answer
question(s)
- 81 -
• A quiet child who refuses to speak, or the
so called “frozen watchfulness” in a post-
lingual child are also signs to be aware of.
Advanced Answer
question(s)
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can sometimes be missed.
• It is important to make sure that the
clinical needs of the child are met and
not overshadowed by the child
protection concerns. In this case consider
topical antibiotics and aural toilet to
remove crusts.
Introductory Answer
question
Competency Answer
question(s)
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manage this when, volume and has the bottle been
patient? recovered. Alkali results in a deeper
liquefactive necrosis than the coagulative
necrosis of acids.
• Examination – Evidence of airway
compromise and staging of injury.
Inspect for signs of NAI eg injury out of
keeping with a child of that age.
• Investigations – In conjunction with a
paediatrician blood taken for
paracetamol and salicylate levels.
• Treatment – If airway compromise
present child will likely need to be
intubated in theatre. If not emergent an
upper endoscopy should be carried out
within 48hrs to stage extent and depth of
injury. Any ulcerative processes require
prophylactic antibiotics, PPI +/-
corticosteroids. Nasogastric tube
insertion and parenteral nutrition should
be considered.
• Follow-up – be observant for
complications including bleeding,
perforation/sepsis and stricture
formation.
Advanced Answer
question(s)
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protection authority. I would ensure that
the child remains in a place of safety until
this is achieved and that the nursing staff
are aware of these concerns.
• I would take a full social history and
consider the need to protect any siblings
at home from abuse.
• Consider the need for support and
protection of other family members
within a multi-agency team framework.
Introductory Answer
question
- 85 -
• Idiopathic epistaxis
• Digital trauma
• Allergic rhinitis
• Bleeding disorder
• Pyogenic granuloma
• Juvenile nasopharyngeal angiofibroma
(JNA)
Competency Answer
question(s)
- 86 -
Advanced Answer
question(s)
- 87 -
1.30 AIRWAY FOREIGN BODY
Introductory Answer
question
What is going
• Based on the history and clinical
through your presentation, this is an emergency
mind and what situation with a possible foreign body in
would you do? the aerodigestive tract
Competency Answer
question(s)
- 88 -
Ok. Here is the • I would check for stridor, stertor,
chest xray. drooling, dysphagia and dyspnoea
Describe what you • Then I would consider requesting a chest
see. x-ray
• This is a portable erect AP chest x-ray
showing a radiolucent object resembling
a coin in the upper aerodigestive tract
• I would also like to see a lateral view to
assess if the FB is in the oesophagus,
airway or in-between (intra-thoracic)
• Inform the senior anaesthetist and
What will you do paediatrician. Consider informing the
next? senior emergency theatre coordinator
about the case and to identify
appropriate surgical instruments
required (e.g. forceps, rigid endoscopes,
paediatric tracehoestomy tubes etc.)
• Do the above but ask for the senior
anaesthetist, A&E consultant to be
present.
• Consider transferring the child to Majors
or Resus.
• Consider giving the child some Heliox
(Mixture of helium and oxygen. The
composition has a lower density than
room air, thus making breathing easier in
cases or airway obstruction.)
• This child needs to go to theatre to have
this foreign body removed.
• Speak to the family and seek informed,
signed consent.
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• If you had informed the other health-
care professionals earlier, transfer to
theatre may be more expeditious.
Advanced Answer
question(s)
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1.31 SLEEP DISORDERED BREATHING IN A CHILD
Introductory Answer
question
Competency Answer
question(s)
- 91 -
When would you restless sleep, frequent awaking.
refer a child for 2. Diurnal: hyperactive, poor concentration,
respiratory swallowing issues, mouth breathing.
investigations
Full ENT Examination (syndromic, nasal
such as obstruction, mouth breathing, large tongue,
polysomnography adenoidal face, OME).
or to a tertiary
Investigations (consider overnight pulse
paediatric centre?
oximetry or full sleep study if child is
syndromic or failure to thrive is present.
• Diagnosis of OSA is unclear
• Age under 2 yrs
• Weight under 15kg
• Down
• Cerebral palsy
• Hypotonia/Neuromuscular disorders
• Craniofacial abnormalities
• Mucopolysaccharidosis
• Obesity
• Significant co-morbidity
• Residual symptoms after adequate
adenotonsillectomy
Advanced Answer
question(s)
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referral centre? o PEEP may be required in a HDU setting.
- 93 -
Rhinology and Facial Plastics
2.1 ANOSMIA
Introductory Answer
question
- 94 -
Competency Answer
question(s)
Advanced Answer
question(s)
- 95 -
different in a A malingerer will score approximately 0-5/40.
malingerer?
Introductory Answer
question
Competency Answer
question(s)
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• Investigations – Tau protein analysis of
>0.5ml of fluid to confirm diagnosis; if
positive and atraumatic - localise source
of leak by CT of skull-base to include
temporal bone. (Tegmen or petrous apex
leak with fluid filling middle ear and
tracking down the Eustachian tube can
present with rhinorrhoea). Also T2
weighted MRI (where CSF signal is high).
Pre-operative intra-thecal fluorosceine
may be used to further localise.
• Treatment – advise to seek medical
attention if develop signs of meningeal
irritation. If following head injury – head
up bed rest, laxatives for 1/52. Surgery
and lumbar drain if not settling. If
atraumatic then surgical repair following
localisation by endoscopic or open
technique with neurosurgeon.
Advanced Answer
question(s)
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failure.
SCENARIO GP referral:
(and IMAGING) Please could you kindly see this 42 year old
lady with a history of recurrent episodes of
sinusitis, occurring 4 times each winter,
requiring antibiotics on each occasion and
which is now causing her significant
symptoms. A CT scan was organised and here
is a section.
Introductory Answer
question
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substance of the maxillary sinus. There is
a large expansive mass within the right
side of the nose leading to extensive
bony remodelling. There appears to be
an extension of the lesion into the right
orbit with a possible mucocele.
Competency Answer
question(s)
- 99 -
Do you know of NB. In addition there are 6 minor criteria
any classification (asthma, unilateral predominance, bone
of fungal erosion on radiography, fungal culture,
sinusitis? charcot leiden crystals, eosinophilia). In
practice, you may also add MRI scan findings
to this list owing to the well described
ferromagnetic properties of fungi. Some of
these criteria are only diagnosed
postoperatively however, hence their
limitations for clinical diagnosis.
Classification
• Invasive (acute, such as mucormycosis vs
chronic)
• Non-invasive (fungal ball, Allegic fungal
rhinosinusitis)
OR
• Fungal Ball – non-invasive, usually
Aspergillus, typically unilateral maxillary
sinus, may have unilateral
proptosis/facial hypesthesia, Histo – Y-
shaped hyphae, endoscopic removal
• Allergic – fungal infection (Aspergillus,
molds) leading to antigen for allergic
response, rhinorrhoea/nasal congestion,
RAST for fungus/molds, no invasion,
endoscopic debridement, topical steroids
+/- antifungals
• Acute Invasive (Mucormycosis) – rapidly
invades bone/soft tissue
(necrosis)/vessels (thombus/infacts),
Aspergillus/Mucor/Rhizopus,
immunocompromised (DM, chemo, HIV,
bone marrow transplant), 50% mortality
- 100 -
with CNS/cavernous sinus involvement,
Histo – T-shaped hyphae, Surgical
debridement and Amphotericin B
Chronic Invasive – Rare, indolent invasion of
soft tissues (but otherwise similar to acute),
surgical debridement and long term
Amphotericin B and Itraconazole for 1 year
Advanced Answer
question(s)
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2.4 HEREDITARY HAEMORRHAGIC TELANGECTASIA (HHT)
SCENARIO
(clinical
photographs of
tongue and face
of the same
patient)
Introductory Answer
question
- 102 -
diagnosis. • Capillary malformation-AVM syndrome
• CREST syndrome
• Hereditary benign telangiectasia
• Bleeding disorders (ie. Von Willebrand
disease)
Diagnosis is based on 4 criteria:
• Epistaxis (spontaneous and recurrent)
• Telangiectasias (lips, oral cavity, fingers,
nasal septum)
• Internal Lesions (GI telangiectasia,
pulmonary/hepatic/brain AVMs)
• Family History (first degree relative with
HHT)
>2 – Definite
>1 – Possible
0-1 - Unlikely
Competency Answer
question(s)
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What is HHT? • HHT is a genetic disorder of the blood
vessel wall, characterized by abnormal
blood vessel unable to contract.
• Autosomal dominant (5 genetic types)
Tell me about the
genetics of HHT. • HHT1 (Chromosome 9q33-34)
• HHT2 (Chromosome 12q11-14)
• HHT3 (Chromosome 5q31 (unidentified
gene))
• HHT4 (Chromosome 7p14 (unidentified
gene))
• HHT and juvenile polyposis – MADH4
How would you (Chromosome 18q21)
manage this • HHT1 – pulmonary and cerebral AVMs
patient? higher than HHT2 and oral/nasal mucosal
telangectasias present earlier.
• HHT2 – Hepatic AVMs higher than in HHT1
• Take great care when examining such
patients in clinic as even rigid
nasendoscopy can trigger a significant
epistaxis. Avoid unnecessary
instrumentation where possible.
Figure 2.4a.Nasal
mucosa of a HHT • Epistaxis is most common presentation,
patient followed by bleeds anywhere in the GI
tract, AVMs (pulmonary, liver,
intracranial). Telangiectasia on finger tips.
History:
• spontaneous recurrent epistaxis. FH.
Frequency of blood transfusions to assess
severity.
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Examination:
What are the • Oral mucosal telangectasia
treatment options
• Nasal mucosal telangectasia
for a HHT patient
presenting with • Conjunctival or retinal telangectasia
recurrent chronic
troublesome • Focal neurology in brain AVM
epistaxis. • Tachypnoea/cyanosis/clubbing/pulmonary
bruit in pulmonary AVM
• Jaundice/hepatosplenomegaly/right upper
quadrant bruit or thrill
• Signs of anaemia
Figure 2.4b. Clots • nasal, oral and digital examination.
in the nose of a
Investigations:
HHT patient
• FBC, Clotting
• ABGs – low pO2 in right-to-left shunt
• Imaging – CXR then CT or Transthoracic
contrast echocardiogram (pulmonary
AVM), MRI or CT (Brain AVM), MRI (Spinal
AVM), Doppler ultrasound
• Diagnose by FH, muco-cutaneous
telangiectasia and screen for visceral AVM
so genetic testing will identify causative
gene in the proband in 80% of cases.
Family risk may be assessed by linkage
analysis.
Acute Treatment
• Avoid traumatic packing in acute episodes.
Kaltostat soaked in adrenaline or
dissolvable nasopore is preferred to
abrasive merocel. Transanexnic acid is
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helpful in prevent fibrinolysis.
Chronic Treatment
• Medical Treatment: Coagulation therapy
is often the quickest way to stop epistaxis,
but there is some controversy as to the
best way to do this. Many experts believe
that laser coagulation therapy (KTP laser)
is preferable to electric and chemical
cautery because it causes less damage to
the inside of the nose. However, some
experts have reported good success with
bipolar electric cautery. Regardless of the
method used, it is important to have
coagulation therapy by someone who has
expertise in treatment of HHT patients.
Most patients who undergo coagulation
therapy see significant improvement for a
period of time, but it usually needs to be
repeated periodically.
• Sprays and ointments containing
oestrogen, bevacizumab (Avastin), and
tranexamic acid have been used in small
numbers of patients and are currently
being studied in clinical trials.
• Several small research studies have
suggested that various oral therapies can
help some patients for whom the local
therapies (i.e. home moisturizing care and
laser therapy) have not been successful.
Oral contraceptive pills have been used
the most, and while they do seem to help
some patients, they have significant side
effects. Drugs that affect either the
formation of clots or vasculature are being
investigated (i.e., estrogens, tamoxifen, n-
- 106 -
acetylcysteine, bevzcizumab (Avastin), and
others) to examine the effectiveness and
safety of these drugs.
• Surgical Treatment: Septodermoplasty,
Youngs Procedure and KTP laser are
surgical treatment options, but are usually
only considered when epistaxis is severe,
significantly affecting quality of life and
coagulation therapy has repeatedly failed
to help. Septodermoplasty replaces the
thin lining of the nose with a split skin
graft. It can significantly reduce or stop
haemorrhages, often for two or more
years. Daily care of the nose is required
after septodermoplasty to keep the nose
moist and clean. In Youngs procedure, the
nostrils are surgically closed with local skin
flaps. This therapy is quite effective but
the downside is that taste and smell are
affected.
• Embolization: This procedure blocks an
artery which, in most cases, stops severe
epistaxes that have been unresponsive to
other treatments. This procedure is
usually only effective for 6-8 weeks as
collateral vessels enlarge and lead to
recurrence. This therapy for the nose
should be used only on an emergency
basis until more durable therapies can be
started.
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Advanced Answer
question(s)
- 108 -
2.5 ANTROCHOANAL POLYP
CLINICAL
PHOTOGRAPH
Introductory Answer
question
- 110 -
Competency Answer
question(s)
Advanced Answer
question(s)
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mucosa into the nose
• Mucopolysaccharide changes lead to
polyp formation
2.6 SARCOIDOSIS
Introductory Answer
question
- 112 -
Competency Answer
question(s)
- 113 -
• Renal dysfunction
• Splenomaegaly
• Arrhythmias
• Lytic or sclerotic bone lesions
• Neuropathy
Advanced Answer
question(s)
- 114 -
palsy
• Diagnostic rigid laryngoscopy +/- biopsy
• Surgical excision of obstructing
supraglottic lesions
Introductory Answer
question
- 115 -
• Nasendoscopy
Competency Answer
question(s)
- 116 -
Advanced Answer
question(s)
2.8 OLFACTION
- 117 -
Introductory Answer
question
Competency Answer
question(s)
- 118 -
How would you Smell Tests
investigate
• UPSIT (University of Pennsylvania Smell
hyposmia?
Identification Test)
Uses microencapsulated odours which are
released by scratching standardised odour-
impregnated test booklets (some smells
‘Americanised’)
• Sniffin’ Sticks
Pen-like odour dispensing devices which are
used to assess olfactory threshold,
discrimination and identification.
• Combined Olfactory Test
The test consists of an odour recognition test
of nine odours (i.e. coffee, engine oil, etc),
where an odour in a bottle is chosen from a
list of four possible odours in a forced choice
manner. This is followed by a threshold test
using a series of three-fold dilutions of 1-
butanol. The mean of the two scores is the
combined olfactory score.
• Smell Diskettes
Reusable diskettes as applicators of 8
different odorants (coffee, vanilla, smoke,
peach, pineapple, rose, coconut, vinegar).
Using a questionnaire with illustrations, the
test was designed as a triple forced multiple
choice test resulting in a score of 0 to 8
• Threshold (Doty) Bottles
• Olfactometers
Cross-sectional Radiology
• CT – exclude paranasal sinus disease,
- 119 -
trauma
• MRI – intracranial pathology
Blood Tests
• Thyroid Function Tests
• ACE/ANCA
• Zinc
Advanced Answer
question(s)
- 120 -
2.9 SEPTAL PERFORATION and SEPTAL BUTTON
CLINICAL
PHOTOGRAPH
Introductory Answer
question
- 121 -
Competency Answer
question(s)
Advanced Answer
question(s)
- 122 -
perforation of the septum may lead to
rhinolalia aperta.
CLINICAL
PHOTOGRAPH
Introductory Answer
question
- 123 -
Competency Answer
question(s)
Advanced Answer
question(s)
- 124 -
photograph) epistaxis.
Introductory Answer
question
Competency Answer
question(s)
- 125 -
obligatory.
• Treatment – Guided by underlying
diagnosis. WG/sarcoidosis managed in
conjunction with rheumatologists etc.
Basic hygiene with decrusting and nasal
douching +/- antibiotics guided by swabs.
Septal button as first line management of
symptomatic perforation.
Advanced Answer
question(s)
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2.12 SYSTEMIC WEGENER’S GRANULOMATOSIS
(GRANULOMATOSIS POLYANGIITIS, GPA)
Introductory Answer
question
Competency Answer
question(s)
Background
Tell me about
• Unknown aetiology – possibly
Wegner’s
autoimmune
Granulomatosis?
• Idiopathic necrotising granulomatous
vasculitis
• Multinucleated giant cells which may
affect upper and lower respiratory tracts
- 127 -
and may also cause necrotising
glomerulonephritis
• Affects upper and lower respiratory
tracts
• Causes glomerulonephritis
• Limited – no renal involvement
Systemic – renal involvement
Symptoms
• Haemoptysis, cough, dyspnoea
• Haematuria
• Fever, night sweats
• Arthralgia/myalgia
• Cutaneous lesions
Signs
• Epistaxis, nasal obstruction,
rhinosinusitis, septal
ulceration/perforation
• Subglottic stenosis
• Uveitis
• Hearing loss (CHL/SNHL)
Investigations
• cANCA and PR3 (86% specific)
• Biopsy (lung – highest yield, renal – if
glomerulonephritis, nasal – poor yield)
Prognosis very poor if left untreated
- 128 -
Advanced Answer
question(s)
- 129 -
Introductory Answer
question
Describe what
• Coronal and sagital sections showing loss
you see? of mucosal surfaces necessary to
humidify inhaled air
• This may result in empty nose syndrome
and atrophic rhinitis
Competency Answer
question(s)
- 130 -
How would you normal nasal structures is universal in
manage this these patients, and the symptoms of
patient? atrophic rhinitis coupled with a
cavernous nasal airway lacking
identifiable turbinate tissue has been
termed the empty nose syndrome.
• Managing this condition is challenging
and the evidence base for most
treatment modalities remains low.
• Recommended conservative
management does not differ significantly
from atrophic rhinitis and includes a
combination nasal lavage, lubricant drops
and topical corticosteroids.
• Surgical intervention for ENS aims to
increase nasal airway resistance by
narrowing the nasal valve region or to
reconstruct the resected turbinate.
Advanced Answer
question(s)
- 131 -
normalization of nasal patency and in
restoration of mucociliary clearance at up
to 6 years follow-up.
Introductory Answer
question
Competency Answer
question(s)
- 132 -
a 6 months homogenous lesion in the left frontal
history of nasal sinus, extending into the left orbit. There
congestion and is bony erosion over the supraorbital rim.
headache. She The globe appears to be displaced
had endoscopic downwards compared to the opposite
sinus surgery side. There is a rim of thin bone at the
several years ago bottom of the lesion. There is evidence of
for chronic previous sinus surgery as the anterior
rhinosinusitis with ethmoid cells have been excised.
polyps, and had
• This is likely a frontal mucocele,
been on topical
secondary to scarring/ stenosis of the
treatment since.
frontal sinus outflow tract. Pressure
Describe what
effect of the mucocele causes bony
you see in this
erosion and remodelling. There may even
scan.
be reversible palsy of the trochlear nerve
supplying superior oblique muscle,
resulting in diplopia and difficulty walking
down stairs.
• She will require surgery to drain the
mucocele. This can be undertaken as an
What do you external approach (e.g. Lynch-Howarth
think has incision) or endoscopically (e.g. Draf IIb,
happened to this III). Prophylactic antibiotics remains
patient? contentious and should be withheld if the
How would you patient is asymptomatic Consider
manage this referring the patient to a rhinologist. A
patient? MRI scan may be required to determine
the entent of the mucocele and there
should be discussion with the
ophthalmologist to discuss
reconstruction of the defect on the outer
table, if necessary
- 133 -
Advanced Answer
question(s)
- 134 -
and occasional epistaxis.
What is your
• Benign: Simple inflammatory polyps
differential (e.g large antrochoanal polyp),
diagnosis? inverted papilloma, angiofibroma,
granulomatous lesion, tuberculous
• Malignant (primary or secondary):
squamous cell carcinoma,
adenocarcinoma, met from kidney or
elsewhere in the body)
• The history should concentrate on
How would you
sinonasal symptoms: rhinorhoea,
assess this obstruction, pain, pressure, epistaxis,
patient? reduction in sense of smell, excessive
itching and sneezing. Visual
disturbance and previous sinus
surgery as well as significant past
medical history are also relevant.
• Full ENT Examination including
endoscopy of the nasal and
nasopharyngeal regions.
Competency Answer
question(s)
Describe what
• This is an endoscopic view of the right
you see. nasal cavity; the septum is on the
right and the middle turbinate is on
- 135 -
the left.
• There is a fleshy/polypoidal mass
originating from the lateral wall,
blocking the middle meatus. It does
How would you
not appear to be vascular and the
investigate this surface appears to be lined with
patient? squamous epithelium.
- 136 -
Caldwell - Luc and/or septotomy
could also be undertaken to improve
exposure to facilitate resection. The
site of origin may be identified on CT
scans (an area suggestive of osteitis)
and should be drilled to prevent
recurrence.
• Follow-up: You would recommend
long-term review for recurrence. The
European position paper suggest 3
years follow-up.
Advanced Answer
question(s)
What
• Krause system
classification
• Yes, the literature states that the
system do you
incidence of synchronous and
know for
metachronous carcinoma to be
inverted approximately 5-10 percent.
papilloma? However, it should be remembered
that this data is based in a review of
Is there tertiary departments and the
malignant incidence could be biased.
potential with • The evidence for using radiotherapy
inverted in the primary treatment of inverted
papilloma? papilloma. The issue of radiotherapy
in extensive disease following surgical
What is the role resection remains contentious. This
of radiotherapy decision is predicated on the severity
in treating of metaplasia and dysplasia in the
inverted histological samples, and should be
- 137 -
papilloma? duly discussed in a multidisciplinary
setting.
Introductory Answer
question
What is going
• Atrophic rhinitis would be my main
through your concern
mind with the
above history? • I would also be thinking of
granulomatous diseases such as
Why is he having Wegeners, sarcoidosis, syphilis, leprosy
and TB.
choking
episodes? • Crust from the nose obstructing the
larynx
- 138 -
Competency Answer
question(s)
Advanced Answer
question(s)
- 139 -
atrophic rhinitis? • Resorption of bulla and uncinate
• poorly defined OMC
• Hypoplastic maxilla
• Erosion of lat nasal wall and atrophy of
turbinates.
Introductory Answer
question
What do you
• The history is typical of someone with
think is the cause potential cavernous sinus thrombosis.
for her
symptoms?
- 140 -
Competency Answer
question(s)
Advanced Answer
question(s)
What is the
- 141 -
treatment?
GP Referral:
SCENARIO
FOLLOWED BY A Dear Dr, Please could you see this gentleman
CLINICAL with a forehead lump which appears to be
PHOTOGRAPH increasing in size over the last 48 hours. The
lump is associated with a swinging pyrexia and
nasal discharge. He has a history of
rhinosinusitis.
Introductory Answer
question
Based on the
• I would be considering an infective or
history given and neoplastic process.
the appearance of
- 142 -
the lump, what is • For example, frontal sinusitis, Pott’s
your differential puffy tumour, benign sinus tumour such
diagnosis? as a polyp, primary malignancy or
metastatic disease.
Competency Answer
question(s)
- 143 -
sinus surgery (FESS)].
• Direct incision may lead to fistulation and
frontal sinus surgery may be hazardous.
• Frontal sinus trephine may represent an
effective compromise.
• Bony sequestra occasionally require open
debridement.
• When there are co-existing intracranial
complications (30% of cases) treatment is
best decided by a multi-professional
team involving surgeons, radiologist and
microbiologist.
Advanced Answer
question(s)
- 144 -
2.19 ALLERGIC RHINITIS
CLINICAL
PHOTOGRAPH
Introductory Answer
question
Describe what
• Clinical photograph of the right nostril
you see in the showing enlarged inferior turbinate and
- 145 -
photograph watery rhinorrhoea
• This may represent rhinitis (allergic or
infective) or CSF rhinorrhoea
Competency Answer
question(s)
- 146 -
Advanced Answer
question(s)
- 147 -
Leucotrienes antagonists + H1 blocker not as
good as intranasal corticosteroids.
CLINICAL
PHOTOGRAPH
Introductory Answer
question
What is the
• The patient will develop rhinitis
problem medicamentosa
associated with
long term usage
of the nasal drops
shown in the
- 148 -
photo?
Competency Answer
question(s)
- 149 -
Advanced Answer
question(s)
- 150 -
2.21 DISORDER OF SCARRING
CLINICAL
PHOTOGRAPH
Introductory Answer
question
Describe what
• A keloid scar because the scar tissue
you see in the extends beyond the incision
photographs
• A hypertrohic scar because the scar
tissue is confined to the site of the
- 151 -
incision
Competency Answer
question(s)
- 152 -
Advanced Answer
question(s)
- 153 -
2.22 SEPTORHINOPLASTY
CLINICAL
PHOTOGRAPHS
Introductory Answer
question
Talk me through
This patient appear to have a left sided
the assessment of deviated nasal pyramid with a dorsal hump;
the nose for the nose also appear to be long although the
septorhinoplasty nasolabial angle is about 90 degrees. I would
with reference to assess further in terms of:
the patient seen Horizontal Thirds
in the
• Upper – trichion to glabella
- 154 -
photographs. • Middle – glabella to sub-nasale
• Lower – sub-nasale to menton
Vertical Fifths
• Width of nose = width of eyes = width of
lateral canthus to ear
Lines and angles
Tell me about the
lines and angles • Frankfort horizontal line = Superior
point of auditory canal to most inferior
relevant to
point of infra-orbital rim; this is
septorhinoplasty important for clinical photograph before
and after surgery
• Facial line is a vertical line from the
glabella perpendicular through Frankfort
horizontal and ideally should touch the
anterior chin; hence indicating if there is
excessive protrusion or retraction of the
chin.
• Nasofrontal Angle = 115-130 degrees
(angle defined by glabella-nasion line
intersecting nasion-tip line)
• Nasofacial Angle = 30-40 degrees
(angle defined by glabella-pagonion line
intersecting tip-pagonion line)
• Nasomental Angle =120-132 degrees
(angle defined by nasion-tip line
intersecting tip-pagonion line)
• Nasolabial Angle = 90-110 degrees
(95-110 for females)
• Columullar show 2-4mm on profile
view
- 155 -
• Nasal Projection - Goode’s Method: ratio
of (nasal tip to alar line) to (nasion to
nasal tip line); normal is 0.55-0.60
Competency Answer
question(s)
- 156 -
Advanced Answer
question(s)
- 157 -
• revision surgery
• good tool for training
CLINICAL
PHOTOGRAPHS
- 158 -
Introductory Answer
question
Describe the
• Saddle nose deformity
abnormality
present in the
photographs
Competency Answer
question(s)
- 159 -
Advanced Answer
question(s)
CLINICAL
PHOTOGRAPH
- 160 -
Introductory Answer
question
Competency Answer
question(s)
- 161 -
necessary
• It may be necessary to have any
psychological assessments complete
before proceeding with surgery. There
may be need to apply for commissioners
for funding; so explain that surgery
should not be rushed. Furthermore, the
nasal reconstruction required by this
patient is complex and will require time
to plan or even refer on to a more
experienced facial plastics colleague.
Advanced Answer
question(s)
- 162 -
2.25 ALAR BASAL CELL CARCINOMA
CLINICAL
PHOTOGRAPH
Introductory Answer
question
- 163 -
Competency Answer
question(s)
- 164 -
subunit) and inverting it such that the
outer skin becomes the inner lining of the
defect. This effectively doubles the size of
the outer (lateral) defect which can then
be reconstructed as above.
- Middle layer: usually cartilage either
from septum or ear.
• Alternatively a composite graft such as
from the pinna can be used for two of
the layers. Also, if the middle and inner
linings have been taken care of, a
forehead flap can be used if the skin
defect is larger than can be
accommodated by a local nasal or facial
flap.
Advanced Answer
question(s)
- 165 -
2.26 PINNAPLASTY
Introductory Answer
question
- 166 -
than 90 degrees and this suggests a
protruding ear.
Competency Answer
question(s)
- 167 -
• Complications – bleeding/infection/scar,
telephone ear, over or under-correction,
late failure, hypertrophic/keloid scar,
tattooing of skin, extrusion of suture
material.
• Explore concerns of the child and parents
e.g. bullying.self awareness.
Advanced Answer
question(s)
- 168 -
2.27 RHOMBOID FLAP
Introductory Answer
question
- 169 -
Competency Answer
question(s)
- 170 -
An easy way to remember how to draw it
quickly is illustrated in the diagram below.
- 171 -
Advanced Answer
question(s)
2.28 RHINOPHYMA
CLINICAL
PHOTOGRAPH
Introductory Answer
question
- 172 -
• There is evidence of scars suggesting
previous surgical intervention.
• Also be aware that other cutaneous
malignancies e.g. SCC/ BCC could be
concealed underneath.
Competency Answer
question(s)
Advanced Answer
question(s)
- 173 -
How would you • Consider referring this patient to the
manage a patient Dermatologist
with • Consider referring to a clinical
rhinophyma? psychologist for support
• Varied treatment options but the
principles are paring down the bulky
tissue to either allow re-epithelialisation
or split-skin grafting.
• A variety of lasers have been used e.g.
Nd:YAG, Er:YAG, Argon, carbon dioxide in
a resurfacing mode (Sharplan 4 - 7 mm
spot at 20 - 40W or continuous 10 - 20 W
using a defocused 2 - 3mm beam).
• Debulking can also be done using the
microdebrider and FloSeal™ applied
topically for haemostasis.
- 174 -
- 175 -
2.29 LOWER LIP SCC AND KARAPANDZIC FLAP
CLINICAL
PHOTOGRAPH
Introductory Answer
question
Competency Answer
question(s)
- 176 -
back as SCC. • Skin MDT
What would you
• MOH surgery or excision with at least
do? 4mm margins
How would you • Reconstruction ladder
treat this lesion
surgically and
reconstruct the
defect?
Advanced Answer
question(s)
- 177 -
2.30 Z-PLASTY
CLINICAL
PHOTOGRAPH
Introductory Answer
question
- 178 -
Competency Answer
question(s)
Show me how
you would do a Z-
plasty
By how much is
the scar
lengthened?
- 179 -
Note that the direction of the scar and the
length of the scar increase depending on the
angles used; the rule is every 15 degrees there
is an increase in length of 25 percent (so 30
degress/25 %; 45 degrees/50% ; 60
degrees/75% etc)
Advanced Answer
question(s)
- 180 -
CHAPTER 3
CLINICAL IMAGES
Introductory Answer
question
- 181 -
you see. sternocleidomastoid muscle.
Competency Answer
question(s)
Advanced Answer
question(s)
- 182 -
spillage. Given • Continue with the operation. There is no
that the evidence that any intra-operative
pathology is manoeuvre decreases the risk of
benign, is this recurrence. Most surgeons would cover
occurrence the breached tumour surface with a swab
significant? and wash the surrounding surgical site
with copious amounts of saline. If the
breach is small or limited to the tumour
What would you capsule, some surgeons even repair it to
do in the event of prevent actual spillage of neoplastic
tumour spillage? tissue into the surrounding wound. The
parotid bed is again washed out at the
end of the operation.
• Importantly, the case should be
discussed at the Head and Neck MDT to
decide if post-operative radiotherapy is
warranted.
• These patients will require long-term
follow-up.
- 183 -
3.2 NECK LUMP
Introductory Answer
question
• Branchial cyst
- 184 -
the FNA aspirate for
a brachial cyst?
Competency Answer
question(s)
Describe the
images you see.
CT scans in axial,
coronal and saggital
planes respectively.
There is a low
intensity mass on
the left side of the
neck (Level 2/3),
beneath the
sternocleidomastoid
muscle. The mass
appears to be well
defined and there is
no evidence of
- 185 -
lymphadenopathy.
Advanced Answer
question(s)
- 186 -
3.3 HOARSE VOICE
Introductory Answer
question
Competency Answer
question(s)
- 187 -
microlaryngoscopy and excision biopsy of
the lesions using cold steel or a
microdebrider. Care must be taken to
avoid webbing in the region of the
anterior commissure.
• In cases of frequent reoccurrences, I
would consider further surgical
debridement along with adjuvant therapy
such as intra-lesional cidofovir or antiviral
agents eg ribavirin.
• The histology is likely to show HPV
subtypes HPV 6 or 11 (the latter is more
aggressive).
Advanced Answer
question(s)
- 188 -
Introductory Answer
question
Competency Answer
question(s)
- 189 -
case? ultrasound-guided Fine Needle Aspiration
for Cytology (FNAC).
• I will also request a staging MRI scan of
the head and neck as well as a CT scan of
chest and upper-abdomen
• If a primary is obvious on examination, I
will proceed to doing a pharyngo-
laryngo-oesphagoscopy with a view to
obtaining a tissue diagnosis from the
primary and also rule out synchronous
primary disease within the upper-
aerodigestive tract.
• If no primary disease is detected, I will
request a half-body CT-PET scan to look
for a source particularly within the
oropharynx and then perform
panendoscopy with bilateral
tonsillectomies and targeted biopsies of
any site of increased activity seen on the
scan.
Advanced Answer
question(s)
- 190 -
• There is no evidence to suggest that
combined modality treatment (unless
evident ECS) or mucosal irradiation
increases either overall survival or loco-
regional control.
Clinical
photographs
- 191 -
Introductory Answer
question
Competency Answer
question(s)
- 192 -
i) Surgery followed by chemoradiotherapy
(CRT) /RT alone (if chemotherapy is
contra-indicated i.e age > 70 years/poor
renal function)
ii) CRT followed by ipsilateral neck
dissection.
• Surgical options include:
a) ipsilateral selective neck dissection
followed by chemoradiotherapy
b) traditional lip split mandibulotomy with
wide excision plus free flap
reconstruction with bilateral selective
neck dissection
c) transoral laser/robotic-assisted resection of
primary disease plus bilateral selective
neck dissection.
Advanced Answer
question(s)
- 193 -
Options could include RT in combination
with Cetuximab (instead of standard CRT)
or de-intensification of RT dose.
CLINICAL
PHOTOGRAPH
Introductory Answer
question
This is an
• There is a fleshy lesion in the posterior
endoscopic view part of the nose consistent with either a
of the nose of a benign process (such as adenoid
55 year old hypertrophy) or a malignant lesion (such
Chinese man as a nasopharyngeal carcinoma)
complaining of • Considering the patient is from Asia, I
- 194 -
nasal blockage, would be very concerned that this is a
hearing loss and possible nasopharyngeal carcinoma.
epistaxis.
Describe what
you see and tell
me the most
likely diagnosis.
Competency Answer
question(s)
- 195 -
• Consider PET
Advanced Answer
question(s)
What treatment
modality would • In adult cases: Concurrent cisplatin or
the MDT decide 5FU with RT
to use? • In Paediatric cases: Neoadjuvant chemo
followed RT (IMRT if possible to avoid
cord damage).
- 196 -
3.7 LARYNGEAL CARCINOMA AND NECK DISSECTION
CLINICAL
PHOTOGRAPHS
Introductory Answer
question
- 197 -
Competency Answer
question(s)
- 198 -
2. levels II-IV for larynx and hypopharynx
3. levels II-V usually for skin tumours eg
melanoma
4. level VI – for thyroid cancer
• Extended neck dissection
Advanced Answer
question(s)
- 199 -
Introductory Answer
question
Competency Answer
question(s)
- 200 -
investigations lymphoma, may prefer trucut core biopsy
would you as FNAC often not sufficient yield to
arrange? make diagnosis of lymphoma.
Advanced Answer
question(s)
- 201 -
identified: ChemoRXT or surgery.
- 202 -
Introductory Answer
question
Competency Answer
question(s)
- 203 -
incarcerated.
• The condition is mostly asymptomatic
but when candidal overgrowth occurs it
may lead to burning tongue syndrome (or
Glossodynia).
• The condition may be treated with
brushing and or tongue scraping. Diet
changes i.e. more roughage, less caffeine
etc.
• Surgery is reserved for unresponsive
cases; Electrodessication, CO2 laser,
scissors.
Advanced Answer
question(s)
- 204 -
3.10 BENIGN PAROTID LESION
Introductory Answer
question
Competency Answer
question(s)
- 205 -
patient? loss, medical comorbidities (dehydration,
diabetes, sarcoid).
• Examination: swelling – firm or soft;
location – clench teeth (parotid or
masseter); intraoral examination (Deep
lobe; also Stensens and Whartons ducts,
stones); neck nodes; FNE of upper
aerodigestive tract (UADT).
• Investigation – Ultrasound plus FNAC,
MRI scan.
- 206 -
purposes.
- May need facial reanimation techniques
(CNVII grafting or repair if known to be
transected, otherwise static or dynamic
reanimation methods).
Advanced Answer
question(s)
- 207 -
3.11 MALIGNANT PAROTID LESION
CLINICAL
PHOTOGRAPH
Introductory Answer
question
- 208 -
Competency Answer
question(s)
What clinical
features are you • Pain, rapid growth, fixed to surrounding
aware of which structures, nerve involvement or neck
suggests parotid metastasis.
gland
malignancy?
- 209 -
picture? neck dissection is indicated for high-stage
and clinically high-grade disease such as
high-grade adenocarcinoma, carcinoma
ex-pleomorphic adenoma, squamous cell
carcinoma, high-grade mucoepidermoid
and undifferentiated carcinoma.
The following factors are indications for post
operative radiotherapy:
• microscopic residual disease.
• adenoid cystic tumours.
• aggressive undifferentiated tumours.
• large tumours "4cm rule".
Advanced Answer
question(s)
- 210 -
3.12 VOCAL CORD DYSPLASIA/EARLY GLOTTIC SCC
Introductory Answer
question
Competency Answer
question(s)
- 211 -
differential laryngopharyngeal reflux, benign growths
diagnosis? (nodule, polyp, cyst, sulcus, papillomata).
• malignant: dysplasia; malignant lesion
(SCC).
- 212 -
voice are equal for small T1a lesions.
Advanced Answer
question(s)
- 213 -
3.13 HPV AND OROPHARYNGEAL LESION
CLINICAL
PHOTOGRAPHS
Introductory Answer
question
- 214 -
Competency Answer
question(s)
- 215 -
• Immunohistochemistry for P16, a
surrogate marker,, is cheaper 100%
Sensitive, 79% specific.
• 7% discordant rate between PCR and P16
Advanced Answer
question(s)
- 216 -
3.14 FACIAL PAIN
Introductory Answer
question
Competency Answer
question(s)
- 217 -
(visual, limb or face dysaesthesia, mood
change). Aura precedes pain by 10-60
mins. Throbbing unilateral pain that
spreads. Photophobia, phonophobia and
nausea may last 4-72 hours. Patients are
often pain free between attacks.
Treatment: Antiemetics, Analgesics,
Ergotamine – can abort impending
attack, Sumatriptan (5-HT1 agonist) given
subcutaneously can abort attack,
Prevention by avoiding precipitants, or
trial use of beta blocker, pizotifen or
methysergide.
• Cluster headaches occur 1-8 times/day,
each attack lasts 15 mins – 3 hours and
may go on for 3-12 weeks. Patients can
be symptom-free for up to 1.5 years. The
deep throbbing severe headache often
wakes the patient up. The headache is
associated with parasympathetic
overdrive such as nasal congestion,
injected conjunctiva and ptosis and may
be confused with allergic rhinitis.
Exercise with increased sympathetic
activity (eg pacing up and down) is
helpful in relieving symptoms, other
forms of treatment includes oxygen
therapy (cerebral vasoconstriction),
ergotamine, sphenopalatine ganglion LA
block.
• Tension headache is usually a dull aching
pain which may be unilateral or bilateral.
There are associated with specific trigger
points in muscles such as
sternocleidomastoid, trapezius,
temporalis and pterygoids. Tension
- 218 -
headache is linked to stress and
therefore relaxation is therapeutic.
• Trigeminal neuralgia is a sharp short
stabbing pain in the distribution of one or
more of the three branches of the
trigeminal nerve. The pain occurs in
response to innocuous stimuli. It is due
to local demyelination of trigeminal root
entry zone. This may be caused by
compression by a small vein or artery in
posterior cranial fossa. Treatment
includes carbamazepine, gabapentin
alcohol/Glycerin/Radiofrequency
ablation to the trigeminal ganglion.
Surgical decompression of vascular loop
via a posterior fossa craniotomy is rarely
required.
Advanced Answer
question(s)
- 219 -
3.15 PHARYNGEAL POUCH
Introductory Answer
question
Competency Answer
question(s)
- 220 -
evidence of reflux,
clinical
examination was
unremarkable. • Water soluble contrast, or Barium
What is your swallow.
differential
diagnosis?
• Barium swallow image demonstrating a
pharyngeal pouch. There is no evidence
How would you
of a filling defect within the pouch or
investigate this
aspiration on this image. A full series of
patient?
images would be required for
confirmation.
Describe what you
see.
- 221 -
patient? anaesthetic opinion is needed to ensure
that they are medically fit for a general
anaesthetic. Endoscopic stapling is now
an established technique in the UK. NICE
guidance (2003) also recommend that
sub-specialisation within ENT
departments should occur for this
procedure.
• A recent literature review (Leong et al.,
2012) of outcomes from UK departments
reported that 92.3% (540 out of 585)
were successfully stapled. Forty-five
(7.7%) procedures were abandoned
intra-operatively. The most common
reason was difficulty assessing a small
pouch. The majority of patients (92%)
had resumed oral intake by the second
post-operative day. Most patients (87%)
were discharged by the second post-
operative day. Outcomes were good with
over 90% reporting resolved or
significantly improved symptoms.
Advanced Answer
question(s)
- 222 -
• The most feared complication following
this procedure is perforation. The UK
review (Leong et al., 2012) reported an
overall perforation rate of 4.8% The
patient needs to be regularly monitored
for retrosternal pain, tachypnoea,
tachycardia, pyrexia and odynophagia.
- 223 -
3.16 PARAPHARYNGEAL MASS
Introductory Answer
question
- 224 -
of the cartilage of the Eustachian tube.
Assuming that this
is a • Schwannoma
parapharyngeal
• Paraganglioma
space tumour
arising from the • Neurofibroma
post-styloid
compartment,
what would be
your differentials?
Competency Answer
question(s)
- 225 -
Advanced Answer
question(s)
• Parotid space
• Masticater space
- 226 -
• retropharyngeal space
• peri-vertebral space
CLINICAL
PHOTOGRAPH
- 227 -
Introductory Answer
question
Competency Answer
question(s)
- 228 -
patient? • Hypoglossal canal: schwannoma,
meningioma, metastasis, spread of
nasopharyngeal carcinoma, large glomus
jugulare (grown into the hypoglossal
canal)
• Central causes: vascular e.g. thrombosis
of the vertebral artery, motor neurone
disease, syringobulbia
Advanced Answer
question(s)
- 229 -
3.18 CERVICAL MYCOBACTERIAL LYMPHADENITIS (SCROFULA)
Introductory Answer
question
- 230 -
• So my differential diagnosis would be:
1. infections, including Tuberculous
mycobacteria
2. Non-tuberculous (atypical) mycobacteria
(NTM)
3. Metastatic SCC or NPC
4. Papillary thyroid carcinoma
5. Lymphoma
Competency Answer
question(s)
Advanced Answer
question(s)
- 231 -
Multi-drug therapy for mycobacteria
tuberculosis infection (this may include
Tell How would pyrazinamide, isoniazid, ethambutol,
you treat this rifampicin and streptomycin (‘PIERS’).
patient? Note that during therapy new or existing
cervical nodes may enlarge but this is not
indicative of failure as it is only transient.
• In the case of non-tuberculous
mycobacteria: Surgical excision.
Introductory Answer
question
- 232 -
of his symptoms? • In view of the antibiotic, I would consider
Pseudomembranous Colitis.
• MRSA is also a possibility
Competency Answer
question(s)
Advanced Answer
question(s)
- 233 -
3.20 REINKE’s OEDEMA
Introductory Answer
question
What is going
• The history suggests Reinke’s oedema of
through your the vocal folds.
mind?
• I would also be thinking of a neoplastic
process since she is a smoker.
Competency Answer
question(s)
- 234 -
Draw a cross
section of the
vocal fold
showing the
various layers
and Reinke’s
space
Advanced Answer
question(s)
- 235 -
3.21 RADIOTHERAPY AND SIDE EFFECTS
CLINICAL
PHOTOGRAPH
Introductory Answer
question
Describe the
• Clinical photograph of the neck showing
clinical photo. erythema anteriorly in the region of the
larynx.
• The may represent radiotherapy changes
or thyroiditis
Competency Answer
question(s)
- 236 -
of radiotherapy • Skin: erythema; desquamation; tanning;
loss of hair follicles; sweat/sebaceous
gland dysfuntion
• GI: Loss of taste; salivary dysfunction;
mucositis; N+D+V
• Bone marrow suppression
• Lung pneumonitis
Long term:
• Neck: fibrosis
• Jaw: fibrosis, reduced mouth opening
• Lymphatic: Lymphoedema
• Wounds: delayed healing
• Skin: telangectasias, ulceration leading to
ORN
• Salivary: xerostomia (amifostine through
treatment, pilocarpine after); dental
disease
• CNS: transient radiation myelopathy;
transverse myelitis (Lhermittes)
• Endocrine: hypothyroisim, GH deficiency
• Eye: cataracts, retinitis, keratitis(dry eye)
• Ears: OME; SNHL
• 2nd malignancy
- 237 -
Advanced Answer
question(s)
SCENARIO
(followed by a
clinical
photograph)
- 238 -
Introductory Answer
question
Competency Answer
question(s)
- 239 -
with a free flap such as radial forearm,
anterior thigh or rectus abdominis if bulk
is needed. Work up usually involves
OPG, MRI oral cavity and neck, CT chest
as well as EUA and biopsy.
Advanced Answer
question(s)
- 240 -
lesion then a neck dissection should be
done as it allows for histopathological
staging.
• Otherwise RT to primary lesion and neck
• Regional recurrence of pathological N0
neck is 1.9 percent.
- 241 -
Introductory Answer
question
Describe what
• A fleshy polypoidal lesion of the right
you see and tell hemilarynx. It is difficult to see where it is
me your attached.
differientials.
• This may represent a polyp or vocal
process granuloma. Other less likely
differientials includes SCC, TB,
hsitoplasmosis, coccidiomycos,
blastomycosis, Wegeners, syphilis,
leprosy, Crohns
Competency Answer
question(s)
- 242 -
Advanced Answer
question(s)
- 243 -
3.24 PARAPHARYNGEAL SPACE ABSCESS
CLINICAL
PHOTOGRAPH
Introductory Answer
question
- 244 -
• The most likely diagnosis is a
parapharyngeal abscess (DD branchial
cyst).
Competency Answer
question(s)
- 245 -
mandible, lat pterygoid
Advanced Answer
question(s)
- 246 -
3.25 GOITRE
CLINICAL
PHOTOGRAPH
Introductory Answer
question
What is the
• This is an axial CT scan through the neck
abnormality at the level of the trachea showing a
shown in the huge goitre
image
• At the level shown there is no
compromise to the tracheal airway.
Competency Answer
question(s)
- 247 -
causes a goitre? subgroups as shown below:
• Physiological: Puberty, increased
metabolic demand pregnancy
• Autoimmune: Graves’ disease,
Hashimoto’s thyroiditis
• Thyroiditis: Subacute granulomatous/de
Quervain’s, subacute lymphocytic, silent
Riedel’s thyroiditis, acute infective
(transient)
• Granulomatous diseases: Sarcoidosis,
tuberculosis, Iodine deficiency, Idiopathic
- 248 -
Advanced Answer
question(s)
- 249 -
3.26 NASOLABIAL CYST
CLINICAL IMAGE
Introductory Answer
question
What is the
• Axial CT soft tissue window image
abnormality in this showing a lesion consistent with a
CT scan? nasolabial cyst (also known as a
Klestadt’s cyst, Non-odontogenic cyst,
epithelial inclusion cyst, fissural cyst).
• Less typical differentials include a
neoplastic lesion (minor salivary gland
tumour); skin appendage lesion,
developmental abnormalities,
odontogenic lesion.
- 250 -
Competency Answer
question(s)
Advanced Answer
question(s)
- 251 -
4.27 FREY’S SYNDROME AND BOTOX
CLINICAL
PHOTOGRAPHS
Introductory Answer
question
The patient is
• Starch-iodine test for Frey’s syndrome
awake and asked
• There is a small positive reaction near the
- 252 -
to eat a few right ear lobe suggestive of gustatory
grapes after the sweating.
white material is
applied. What
test is shown in
the diagram?
Competency Answer
question(s)
How is the
condition • Aluminium based deodorant
treated?
• Topical glycopyrrolate
• Botox injection
• Neuronectomy (Jacobson’s nerve section
in the middle ear)
- 253 -
Botox therapy? the gold standard treatment for Frey’s
syndrome. Botox is a protease exotoxin,
which works by blocking the release of
acetylcholine from the cholinergic nerve
end plates leading to inactivity of the
glands or muscle innervated.
Advanced Answer
question(s)
- 254 -
3.28 GIANT PLEXIFORM NEUROFIBROMA OF SCALP
CLINICAL
PHOTOGRAPH
Introductory Answer
question
Describe what
• Clinical photograph of a massive lesion
you see in the on the head of a patient most likely to be
photograph benign or a benign tumour that has
become malignant
• Such lesion is consistent with
neurofibroma, most likely plexiform
neurofibroma (involving multiple
peripheriphal nerves) rather than the
dermal type which affects on one
peripheral nerve.
- 255 -
Competency Answer
question(s)
- 256 -
• The scalp is then prepared for the split-
thickness skin graft by checking for any
breach in the periosteal layer. Any
denuded bony area is saucerised with a
cutting bur to create a vascular bed so
that the overlying split skin graft will
remain viable.
• Two separate large split-thickness skin
grafts are harvested from the thigh and
carefully prepared to cover the entire
surgical defect on the scalp.
• The skin grafts are carefully placed on the
scalp, trimmed and secured with clips to
the free skin edge; the two skin grafts
were joined using 4.0 vicryl rapide .
• Gelonet gauze is then applied over the
split skin graft followed by copious
amounts of chloramphenicol ointment .
• Finally blue gauze, mefix adhesive
dressing and a head hooded cap are
added sequentially to further enhance
the pressure dressing over the split-
thickness skin graft.
Advanced Answer
question(s)
Do plexiform • Yes
neurofibromas
• Yes, a parotid tumour weighting 2.5kg
have malignant (reported in ENTNews from Doncaster
potential? ENT Team)
- 257 -
The weight of the
resected
plexiform
neurofibroma was
exactly 3.4576
Kgs. Do you know
the weight of the
largest head and
neck lesion
previously
resected in the
UK?
RESECTED
SPECIMEN
- 258 -
CHAPTER 4
Introductory Answer
question
Competency Answer
question(s)
- 259 -
proceed? compliance; water exposure and cotton
bud use; previous ear disease or surgery.
• Examination – Careful otomicroscopy
with microsuction plus take a swab for
culture.
• Investigations – Swab and Pure Tone
Audiogram (PTA) initially. Consider high
resolution CT (HRCT) temporal bones if
suspicious of Necrotising OE (NOE).
• Treatment – Meticulous aural toilet with
regular microsuction is the mainstay of
treatment. Topical antibiotic drops such
as Ciprofloxacin, Sofradex or Gentisone is
the primary treatment, guided by culture
sensitivities. Oral or IV antibiotics are
reserved for cases of NOE.
- 260 -
medicine white cell scan. HBA1C can
delineate poor diabetic control.
• Long term, high dose IV antibiotics are
required, plus very regular aural toilet.
Meticulous diabetic control is essential.
• Surgical debridement of necrotic bone
may be indicated, but is not routine.
• Hyperbaric Oxygen treatment may have a
role, and is currently undergoing trials.
Advanced Answer
question(s)
- 261 -
4.2 EXOSTOSES AND OSTEOMAS
Introductory Answer
question
- 262 -
• Skin conditions affecting the canal or
meatus i.e. eczema, psoriasis
• immunosuppression
Competency Answer
question(s)
- 263 -
and are usually unilateral. They are true
neoplasms consisting of cancellous bone.
Advanced Answer
question(s)
CLINICAL
PHOTOGRAPH
- 264 -
Introductory Answer
question
Competency Answer
question(s)
Advanced Answer
question(s)
- 265 -
and fixation of the ossicles resulting in a
conductive hearing loss and
sensorineural hearing loss can occur long
term, secondary to ototoxic toxins
secreted from the infecting organisms.
• The risks and complications of
Myringoplasty surgery should be
discussed, including hearing loss, taste
disturbance, graft failure, bleeding and
infection.
• This clinical picture may well represent a
complication of grommet insertion, in
view of the position of the perforation.
In this case, myringoplasty may be
complicated by recurrence of effusion,
and this should be addressed.
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Introductory Answer
question
Competency Answer
question(s)
- 267 -
retraction
Stage 2 – Retraction onto incudostapedial
joint
Stage 3 – Retraction onto promontory (lifts on
valsalva)
Stage 4 – Adherent to promontory
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- Regular valsalva manoeuvres
- Use of inflation devices such as Otovent
balloon.
- Nasal treatment if signs of
rhinitis/postnasal space oedema
- Grommet insertion in selected patients.
If symptomatic with recurrent
infection/discharge consider reinforcement
Tympanoplasty.
Advanced Answer
question(s)
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• The pars flaccida has some fibrous tissue
but it is not as well organised as the layer
in the pars tensa and this results in a lack
of rigidity.
CLINICAL
PHOTOGRAPH
Introductory Answer
question
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Competency Answer
question(s)
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cells into the cholesteatoma,
proliferation and the release of osteolytic
enzymes.
• Progressive expansion and infection of
the cholesteatoma can lead to
complications. These are subdivided into
otological complications, extra and
intracranial complications.
• Extra-cranial complications
- External abcesses
- Subperiosteal mastoid abscess
- Bezold Abscess (sternomastoid)
- Citelli Abscess (digastric)
- Lucs Abscess (temporalis)
• Intra-cranial Complications
- Meningitis
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- Extradural, Subdural abscesses
- Intracerebral abscess
- Cerebritis/encephalitis
- Lateral/sigmoid sinus thrombosis
- Hydrocephalus
Advanced Answer
question(s)
Describe this
Otoscopic view of the right tympanic
photograph
membrane should an intact drum with a
pearly white lesion in the anterior
superior quadrant. This is likely to
represent a congenital cholesteatoma as
it is the typical position to find such a
lesion.
What do
DWI is Diffusion Weighted Imaging. This
understand by
refers to Diffusion-weighted echo-planar
DWI? Magnetic Resonance Imaging. This can
be used as a pre-operative scanning
modality or as an alternative to second
look in combined approach
tympanoplasty patients. It can
distinguish between inflammatory tissue
and cholesteatoma, where other imaging
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modalities cannot.
4.6 OTOSCLEROSIS
Introductory Answer
question
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Competency Answer
question(s)
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variations in originally postulated by Belluci):
the footplate
Type I - stapes minimally fixed in oval
and what is
window
the surgical
significance Type 2 - thin footplate, resists perforation
of this? more than I
Type 3 - thick footplate
Type 4 - fixed to oval window, can only be
perforated by drilling.
Relevance relates to degree of ease of
stapedotomy and possibility of floating
stapes footplate.
Advanced Answer
question(s)
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examination, audiometry, CT scan if
persists, to check position of piston. May
not be related to stapedectomy. If
hearing deficit or fluctuant consider re-
exploration.
Introductory Answer
question
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Competency Answer
question(s)
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• Examination – Otoscopy for disease,
Cranial nerve examination in central
causes, Romberg and Unterberger tests
looking for proprioceptive and peripheral
vestibular signs, and Dix-Hallpike test for
BPPV. Hamalgi Head-thrust test to elicit
vestibulo-occular reflex (VOR)
abnormalities. Look carefully for
spontaneous and provoked nystagmus.
How would you Examination often normal unless there
treat a diagnosis are concurrent symptoms.
of Meniere’s
disease?
• Investigations –Hearing testing with
tuning fork tests and pure tone
audiogram. MRI of Internal Acoustic
Meati looking for vestibular schwannoma
indicated by unilateral hearing loss and
tinnitus. In equivocal cases or suspected
vestibulopathy, Video or
Electronystagmography (VNG, ENG) and
Caloric testing.
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above, intratympanic steroid has been
shown to provide some improvement.
• Endolymphatic sac decompression
surgery is effective in some.
• Ultimately, for those resistant or
debilitating cases, labyrinthectomy is
used. This can be either chemical via
intratympanic gentamycin or surgical.
• When Meniere’s is stable, vestibular
rehabilitation is very useful.
Advanced Answer
question(s)
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cochlea in response to auditory clicks via
air conduction. A probe is placed on or
near the tympanic membrane with a
reference electrode on the mastoid and
forehead. It can detect Endolymphatic
hydrops in Meniere’s by an increase in
the summation potential/Compound
Action Potential ratio.
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function.
2. Summation Potential (SP) - basilar
membrane ‘set point’.
3. Action Potential (AP) - reflects CN8.
CLINICAL
PHOTOGRAPH
Introductory Answer
question
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being done in the undergoing a particle repositioning
photograph. manoeuvre such as Epley.
Competency Answer
question(s)
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pathophysiology.
- Canalithiasis. Dislodged otoconia from
the saccule/utricle float freely in the
endolymph of the semicircular canal. The
inertial effect of their movement in the
fluid causes cupula displacement and
short-lived vertigo which resolves when
the otoconia come to rest.
- Cupulolithiasis. Loose otoconia become
adherent to the cupula causing
stimulation due to gravity on movement.
Treatment of BPPV following a positive Dix-
Hallpike test is with a particle repositioning
manoeuvre such as the Epley.
Advanced Answer
question(s)
How do these
types differ • Lateral canal BPPV elicits a horizontal
clinically? nystagmus on Dix-Hallpike test rather
than a torsional nystagmus. It may be
Geotropic (75%) or Ageotropic (25%).
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The supine roll test (patient supine with
head rolled to side) is an alternative to
Dix-Hallpike for this. Treatment requires
a Barbecue 360° roll manoeuvre.
• Superior canal BPPV is very rare due to
the position of the canal.
• Superior canal BPPV exhibits a
downbeating nystagmus on Dix-Hallpike
testing without a torsional element.
• All episodes of downbeating nystagmus
should be investigated as a central cause
for this is more common than a superior
canal BPPV.
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complaining of bleeding and hearing loss in
his left ear.
Introductory Answer
question
What is your There has clearly been some ear trauma here,
differential but it is important to determine if it is
diagnosis? simple blunt trauma or a bony fracture.
Competency Answer
question(s)
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carotid injury is suspected, or where the
fracture involves the foramen lacerum.
Advanced Answer
question(s)
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fractures are more often associated with
laceration through the tympanic
membrane and external canal fracture
therefore bleeding from the ear.
• Facial nerve injury is far more likely from
transverse fractures.
• Delayed nerve palsy may occur due to
oedema and ischaemia of the nerve.
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4.10 NOISE-INDUCED HEARING LOSS
Introductory Answer
question
- 289 -
Competency Answer
question(s)
Advanced Answer
question(s)
What is the • Outer hair cells and then inner hair cell
mechanism of loss via apoptotic and necrotic
noise induced mechanisms resulting from oxidative
hearing loss? stress and excito-toxicity
• Loss is potentiated by concomitant use of
How could you
ototoxic medication or genetic
develop a predisposition.
strategy to treat
• 4KHz may be preferentially degraded as
this condition?
the resonant frequency of the Organ of
Corti.
If the patient presents early enough <72hrs
empirical laboratory data suggest that there
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may be a role for drugs to prevent the
production of free radicals and the calcium
led apoptotic pathway via steroids and
calcineurin antagonists.
SCENARIO GP referral:
(Audiograms) A 55 year old patient is referred to the ENT
clinic from the direct access audiology service
with an asymmetric hearing loss
Introductory Answer
question
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Competency Answer
question(s)
Advanced Answer
question(s)
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Table 5.11a Tuning fork tests for sorting out the malingerer
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and simultaneously vibrating tuning fork
near EAC of same ear (not heard if not a
malingerer)
• Malingerer Response
– Will claim to hear sound as will assume
through bone conduction when it is
actually through air conduction
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Table 5.11b Voice tests for sorting out the malingerer (by Julian
Gaskin, FRCS (ORL-HNS).
Lombard • Principle
– Person will raise voice in speaking in
noisy environment
• Test
– Patient asked to read text aloud without
stopping
– Noise introduced into good ear (i.e.
Barany box)
– Patient’s voice will get louder
• Malingerer Response
– Will continue to read at even tone
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Erhardt test (loud • Principle
voice test)
– Occlusion of the EAC causes attenuation
of 30dB
• Test
– Good ear is occluded with a finger
– Sound projected into that ear
– Normally, the patient will be able to hear
the dampened sound
• Malingerer Response
– Denies hearing any sound at all, even
when sound increased
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4.12 DRUG-INDUCED HEARING LOSS
Introductory Answer
question
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Competency Answer
question(s)
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• It is important to exclude other causes of
sensorineural hearing loss in these
patients, and investigate accordingly.
• Amplification may be required to
improve the hearing. When profound or
total loss occurs, cochlea implantation
can be considered.
Advanced Answer
question(s)
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4.13 BONE ANCHORED HEARING AID (BAHA)
CLINICAL
PHOTOGRAPH
Introductory Answer
question
Competency Answer
question(s)
- 300 -
prescribed according to bone conduction
thresholds (e.g. <35dBHL Divino,
<45dBHL Intenso, <55dBHL Cordelle).
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to sparing of occipital nerve branches
during surgery.
Advanced Answer
question(s)
- 302 -
4.14 COCHLEAR IMPLANT
CLINICAL
PHOTOGRAPHS
Introductory Answer
question
- 303 -
Competency Answer
question(s)
- 304 -
Advanced Answer
question(s)
SCENARIO GP referral:
(no clinical Please could you see this 66 year old lady
photograph) with a long history of itchy ears, associated
with ear discharge and a reduction in hearing.
She has had a number of courses of
- 305 -
antibiotics which offer only temporary relief.
Introductory Answer
question
Competency Answer
question(s)
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can see TM). However do not assume
that this is the only problem there.
- Consider malignant OE – admit,
CT/MRI/WCC scan, iv antibiotics,
hyperbaric oxygen, debridement, DM
control
- May need biopsy to exclude SCC
Advanced Answer
question(s)
- 307 -
Surgery in OE:
For suction clearance under GA in children;
for biopsy of suspicious granulations in
ear canal to exclude SCC, or deeper lying
polyps arising from middle ear or attic;
consider bony and/or cartilaginous
meatoplasty if canal very narrow (in
some cases lining with a split skin graft
may be necessary); in malignant OE may
need surgical debridement if medical
therapies ineffective and/or
complications such as facial palsy exist.
Introductory Answer
question
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Other than a Pure • Magnetic Resonance Imaging of his
Tone Audiogram Internal Acoustic Meatus (MRI CPA/
(PTA), what single IAM). This is required to exclude a
investigation possible Cerebellopontine angle (CPA)
would you lesion in any patient who presents with
organise this unilateral or asymmetric audiological
patient? symptoms, such as unilateral tinnitus.
Competency Answer
question(s)
- 309 -
dominant condition presenting with
other intracranial and spinal lesions.
• There are two histological subtypes;
Antoni types A and B based on the
uniformity of the cells.
• They present classically with an
asymmetric sensorineural hearing loss,
unilateral tinnitus, vertigo and
vestibulopathy, and facial weakness.
Rarely they can present with central
signs.
Advanced Answer
question(s)
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investigating • Stapedial reflex decay – an inability to
modalities that maintain the stapedial reflex for 10
can be used for seconds in a sustained stimulus at 10dB
diagnosis (Historic HL.
examples
• Asymmetric caloric responses without
accepted)?
any symptoms of vertigo.
• Auditory Brainstem Response (ABR) –
abnormal wave V latancy between ears
or abnormal interaural wave I-V and III-V
latency difference.
SCENARIO GP referral:
(with a clinical Please could you kindly review this 69 year
photograph) old man who noticed a sudden weakness of
his face.
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Introductory Answer
question
Competency Answer
question(s)
- 312 -
- Transection with intact endoneurium:
Sunderland (2nd degree) and Seddon
(axonotmesis)
- Transection with intact perineurium:
Sunderland (3rd degree) and Seddon
(neurotmesis)
- Above + disruption of perineurium:
Sunderland (4th degree) and Seddon
(neurotmesis)
- Above + epineurium remains intact:
Sunderland (5th degree) and Seddon
(neurotmesis)
What
• Investigations: Audiogram; CT temporal
investigations
bones (either routinely or if abnormality
would you
on otoscopy); MRI neck/parotids if neck
undertake?
lump palpable; nerve conduction studies
(not universally available).
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Advanced Answer
question(s)
- 314 -
lifts, static slings.
• Dynamic – temporalis transfer, XII-VII
anastomosis.
CLINICAL
PHOTOGRAPH
Introductory Answer
question
- 315 -
Competency Answer
question(s)
Advanced Answer
question(s)
- 316 -
thickness advancement or rotation flap
from the adjacent occipital skin.
- 317 -
Introductory Answer
question
Competency Answer
question(s)
Advanced Answer
question(s)
- 318 -
lateral venous sinuses situated in the
jugular fossa. It ultimately drains into the
internal jugular vein passing through the
jugular foramen.
• At least half of cases are asymptomatic
and are diagnosed only on careful
otoscopy.
• Symptomatic cases may present with
conductive hearing loss, pulsatile tinnitus
or rarely with facial palsy or vertigo
secondary to erosion into the facial canal,
vestibular aqueduct or posterior
semicircular canal.
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4.20 GLOMUS TYMPANICUM
CLINICAL
PHOTOGRAPH
Introductory Answer
question
Competency Answer
question(s)
- 320 -
tumour? Tympanicum, Glomus Jugulare, Glomus
Vagale and Carotid Body Tumour.
• They are highly vascular tumours
supplied by the ascending pharyngeal
artery – a branch of the external carotid
artery.
• Glomus tympanicum presents with
pulsatile tinnitus and if extensive, may
present with the effects of local erosion
from the tumour. Other symptoms may
include otalgia, hearing loss, vertigo and
facial palsy.
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• 10% are multiple and are seen in Multiple
Endocrine Neoplasia (MEN) type 2
syndrome.
- 322 -
Advanced Answer
question(s)
Do they have a
malignant • YES, in general paraganglomias have a 3-
potential? 4 percent malignant potential. For
temporal bone glomus, the figure is
around 1 percent.
- 323 -
4.21 MENINGIOMA
Clinical
photograph
Introductory Answer
question
Competency Answer
question(s)
- 324 -
patients Size, unilateral vs bilateral, compression
on brainstem, operability
Surgeon factor :
Surgical teams available and preference
(i.e. retrosig vs translab)
Advanced Answer
question(s)
- 325 -
4.22 BELL’S PALSY
Introductory Answer
question
Competency Answer
question(s)
- 326 -
• Other grading systems such as
Sunderland (1st - 5th degree), Seddon,
Sunnybrook, Yanahigara, Sydney,
Nottingham etc.
What
investigations • Audiogram
would you • CT temporal bones
undertake for a
patient diagnosed • MRI neck
with Bell's palsy? • nerve conduction studies
Advanced Answer
question(s)
- 327 -
controlled trials shows significant benefit
from treating Bell's palsy with
corticosteroids.
- 328 -
4.23 CHRONIC OTITIS MEDIA ACTIVE MUCOSAL DISEASE
CLINICAL
PHOTOGRAPH
Introductory Answer
question
This patient is a
• Otoscopic view of the left ear with a large
49 year old central wet perforation with possible
engineer with erosion of the long process of the incus
chronic discharge as the stapes head is visible.
from ear nearly
• The history and clinical findings are
12 months. Tell suggestive of chronic otitis media of the
me what you see. active mucosal type, although there may
be an underlying cholesteatoma.
- 329 -
Competency Answer
question(s)
- 330 -
clarithromycin (500mg be for 7days).
Advanced Answer
question(s)
CLINICAL GRAPH
- 331 -
Introductory Answer
question
What is this
• This is a graph of a transient evoked
graph? otoacoustic emmission
Competency Answer
question(s)
- 332 -
Advanced Answer
question(s)
CLINICAL GRAPH
- 333 -
Introductory Answer
question
What is this
• The new format of otoacoustic
graph? emmissions (OAEs)
• It shows clear responses (Pass) because
the stimulus is good, the probe is stable
and at least 2 ‘signals’ are above 6dB
• In brief, 2 or more greens at the
frequency ‘traffic light’ indicate a pass.
Competency Answer
question(s)
- 334 -
Objective test for very young
Advanced Answer
question(s)
- 335 -
4.25 UNIVERSAL NEONATAL HEARING SCREENING
CLINICAL GRAPH
Introductory Answer
question
What do you
• Despite a good stimuli and satisfactory
think about the probe stability there is no clear responses
otoacoustic (Failed) (all reds at the frequency traffic
emission tracing? light)
- 336 -
• 1st wave England 2000
Competency Answer
question(s)
Advanced Answer
question(s)
- 337 -
• Behavioural thresholds vary from normal
to profound
• Speech perception worse than predicted
from PTA, especially in noisy
environment
Type 1-post synaptic ANSD
• Nerve neuropathy
• Dyssynchrony
• aplasia
Type 2-pre synaptic ANSD
• Inner hair cells
• Junction inner hair cell and auditory
nerve
- 338 -
4.26 AUDITORY BRAINSTEM RESPONSE
CLINICAL
PHOTOGRAPHS
- 339 -
Introductory Answer
question
What
• Diagnostic ABR (not automated ABR)
investigation is
being carried out
on this child?
Competency Answer
question(s)
Tell me about
this graph • There is a clear response at 35dB
• There is also a clear response 5dB above
(ie 40dB) but no clear response 5dB
below (ie 30dB)
• The ABR threshold is therefore 35 dB
- 340 -
Advanced Answer
question(s)
Explain what is a
clear response?
With regard to
Threshold assessment
the age of the
child what are the • Less than equal to 6 months: ABR
various threshold • Between 6 and 30 months: Visual
assessments Reinforcement Audiometry
available?
• 30 months and above: conditioned sound
field response (performance test), Pure
Tone Audiometry
- 341 -
4.27 PRESBYACUSSIS
CLINICAL
AUDIOGRAM
Introductory Answer
question
Describe this
• Bilateral sensorineural hearing loss
audiogram
• The pattern of hearing loss and the
speech discrimination is consistent with
neural presbyacusis.
Competency Answer
question(s)
- 342 -
presbyacusis? elderly individuals. Important problem as
elderly rely on hearing to counter deficits
in sight & reaction time. In addition to
decreased memory/concentration affects
speech recognition (worse in noisy
environments)
What is the
4 histopathological types
treatment?
• Sensory Epithelial atrophy with loss of
HCs/supporting cells in organ of Corti
(basal turn) possibly due to accumulation
of lipofuscin pigment. Good speech
discrimination
• Neural Atrophy of nerve cells in cochlea
and CNS pathways (?2100/35000
neurons lost/decade). Effects noted after
90% loss – i.e old age; Clinically
disproportionate loss in speech
recognition
• Metabolic Atropy of stria. Flat HL with
good speech recognition. 30-60 yrs
• Cochlear conductive Thickening and
stiffening of basilar membrane (good
speech discrimination)
- 343 -
Advanced Answer
question(s)
- 344 -
4.28 SUDDEN SENSORINEURAL HEARING LOSS
CLINICAL
AUDIOGRAMS
Introductory Answer
question
What is the
• Unilateral (left) sensorineural hearing
diagnosis? loss
• Normal hearing on the right, except 50
dB threshold dip at 8000Hz only
Competency Answer
question(s)
- 345 -
(3-12% acoustics present with SSNHL)
• Audiometry
If cause identified – treat otherwise
• Carbogen (5% CO2) – vasodilator.
• Increase blood flow (LMW dextrans,
anticoagulants) – no supportive evidence
• Steroids – systemic use supported by
studies. Intratympanic for
sever/profound
• Others (antivirals, diuretics, hyperbaric
oxygen)
• Note spontaneous recovery in 47-63
percent of cases
Negative prognostic Age <15 or >65;
Eleveted ESR, Verigo or abnormal ENG;
HL contralateral; Severe SSHL
Advanced Answer
question(s)
- 346 -
blood flow. Risk factors similar to cardiac
(hyperchol, low HDL,, high fibrinogen,
smoking)
• Intracochlear membrane rupture
• Immune mediated
4.29 TINNITUS
CLINICAL
PHOTOGRAPHS
- 347 -
Introductory Answer
question
This patient
• These clinical photographs show a
complains of a vascular malformation (rather than
pulsatile noise in haemangiomas) affecting the face and
her left ear. What therefore the cause for her tinnitus is
is the most likely likely to be vascular in origin, possibly
cause? arteriovenous malformation.
Competency Answer
question(s)
- 348 -
of sound arising within the head.
Is there any
• Masking therapy (eg white noise
effective maskers) appears to be effective
treatment for
• Tinnitus retraining therapy is also
subjective
effective but no more than direct
tinnitus? counseling.
• There are other treatments but their
effectiveness is controversial. However,
there is evidence for favourable
outcomes with benzodiazepines (eg
clonazepam or alprazolam),
antidepressants (eg amitriptyline, SSRI
and tricyclic) as well as dexamethasone,
but not for acupuncture, carbamazepine,
Ginkgo Biloba or gabapentin.
Advanced Answer
question(s)
- 349 -
Why do you think • Benzodiazepines enhance GABA effects
benzodiazepines and may be effective because one
may be effective proposed mechanism for tinnitus is the
in the treatment loss of GABAergic inhibitory neurons.
of subjective
tinnitus?
CLINICAL
PHOTOGRAPH
Introductory Answer
question
Describe the
• Lateral surface: inferior temporal line,
clinical anatomy spine of Henle, root of zygoma, tympanic
of the lateral
- 350 -
surface of the ring, tympanomastoid suture,
temporal bone tympanosquamous suture, TMJ,
shown here. mandibular condyle and fossa, masoid
bone
Competency Answer
question(s)
- 351 -
drilling the incudus may be visualised early by
temporal bone? utilizing the refractive index of water
(remember temporal bone drilling should
be sub-aquatic surgery).
Advanced Answer
question(s)
- 352 -
decompression endolymphatic sac.
surgery?
- 353 -
patient? impact on feeding, choking, apnoea, and
cyanosis. Birth history as well as number and
When would you
duration intubations. Neuromuscular
perform direct
disorders.
laryngoscopy?
Examination – effort and efficacy of
ventilation including nasal flare, tracheal tug,
chest recession. Phase and type of noise:
pharyngeal stertor improved with jaw thrust
or laryngotracheal stridor. Nasal cold spatula
testing. Oral examination – cleft palate and
glossoptosis. Neck – mass. Top to toe exam
for cutaneous haemangioma.
Fa
t P Co
Advanced Answer
question(s)
- 53 -