Fig. 35.1 Anatomy of the tympanic membrane. Reproduced from Baloh, Robert W., Honrubia, Vicente, et al., Baloh and Honrubia's Clinical Neurophysiology of the Vestibular System (4 ed.), 2011, Oxford University Press.
Ear, nose, and throat surgery: overview
Ear, nose, and throat surgery: in clinic
Ear, nose, and throat surgery: in the emergency department
Otolaryngology/head and neck surgery, or ear, nose, and throat (ENT) surgery as it is commonly known, is an incredibly diverse specialty. At least 50% of ENT is clinic based reflecting the large medical component of the specialty. Medical school ENT rotations are typically short which means you have to be particularly proactive.
These patients usually present to the ED.
Again, these patients usually present to the ED or are admitted directly onto the ENT ward. As well as seeing patients with acute tonsillitis, consolidate your learning with observing an elective tonsillectomy.
If your ENT department has a head and neck service, it is best to spend time in the head and neck clinic to see a large volume of patients at different stages of their disease. Otherwise the neck lump clinic will provide an ideal opportunity to practise palpating thyroid and neck masses.
Commonly referred to the ENT emergency clinic by the GP, these patients may require aural microsuction under a microscope, allowing you to view the ear under high magnification.
Due to the unpredictable timing, you may not be exposed to an airway emergency during your attachment.
Commonly performed in clinic, on the ward, or in ED to look for abnormalities with the internal nose, post-nasal space, pharynx, and larynx.
This is performed by audiologists in the audiometry department to assess hearing.
Aim to see the common operations for each of the main subspecialties of ENT: tonsillectomy, adenoidectomy, myringotomy and grommet insertion, functional endoscopic sinus surgery, septoplasty, myringoplasty, thyroidectomy, tracheostomy, and neck dissections.
Inflammation or infection of the external ear. Risk factors for this condition include swimmers, psoriasis, and diabetes. On examination there may be associated cellulitis of the pinna, a narrowed and oedematous external auditory canal (EAC), with foul smelling discharge and debris. Management includes advice on keeping the ears dry (i.e. no swimming), and regular aural toileting and antibiotic steroid ear drops. Aural microsuction is the mainstay of treatment. If the EAC is narrow, a pope wick can be inserted to reduce swelling. In diabetic patients it is important to exclude malignant otitis externa where classically there are granulations on the floor of the EAC. Treatment is with systemic and topical antibiotics.
A full cranial nerve exam should be performed, in order to determine if there are any other neurological signs and if the seventh nerve palsy is an upper or lower motor neuron lesion. In a lower motor neuron lesion, the entire ipsilateral face is affected, while in an upper motor neuron lesion, the forehead is spared. The ears should be examined and a neck examination should be performed to exclude any neck lumps. Causes of a lower motor neuron lesion include Bell’s palsy, viral infections, cholesteatoma, cerebellopontine angle tumours, trauma, and malignancies of the parotid gland. When a cause for a lower motor neuron seventh nerve lesion cannot be found, it is termed Bell’s palsy. The majority of Bell’s palsy patients make a full recovery. This is managed with a course of oral prednisolone. Corneal ulceration can occur if there is incomplete eye closure so the patient should be given eye drops/ointment and advised to tape their eyelid closed at night. The presence of painful vesicles over the ear canal, on the tongue, and palate may suggest Ramsay Hunt syndrome, which is causes by herpes zoster infection. Aciclovir and prednisolone are the usual treatments.
A patient with a fractured injury must be examined to exclude a head injury, another facial bone fracture, CSF leak, or septal haematoma. Otherwise they are usually seen in the ENT emergency clinic after 5–7 days once swelling has reduced. If the nose is deviated, and the patient is unhappy with their appearance, a manipulation under anaesthesia may be performed within 14 days of the injury, and certainly by 21 days at the latest.
An infection of the middle ear, which affects all ages but is very common in children. Often there will be history of a recent UTRI, followed by otalgia and fever. Discharge suggests a perforated ear drum. Management consists of analgesia. Antibiotics are not routinely indicated but may be beneficial if symptoms persist after 2 days, if there is systemic upset, or a particularly bulging tympanic membrane. (See Fig. 35.1.)
Fig. 35.1 Anatomy of the tympanic membrane. Reproduced from Baloh, Robert W., Honrubia, Vicente, et al., Baloh and Honrubia's Clinical Neurophysiology of the Vestibular System (4 ed.), 2011, Oxford University Press.
This is a hallucination of movement and needs to be differentiated from other symptoms such as lightheadedness and unsteadiness. It is important to probe about the character of the symptom and any triggers. Vertigo can be due to central or peripheral causes. Central vertigo is caused from an insult to brainstem vestibular nuclei that can result from CVA, MS, and tumours. The majority of vertigo is a result of peripheral causes.
Most neck lumps in children will be benign, but in adults a neck lump is considered malignant until proven otherwise. Red flag symptoms for head and neck malignancy are important to recognize and include a short duration of presentation with an enlarging lump, associated unilateral otalgia or nasal obstruction, dysphonia, dysphagia, and weight loss. These symptoms should raise the suspicion of either malignant lymphadenopathy or a primary malignancy. Ask about risk factors for malignancy. Weight loss and night sweats may suggest lymphoma. A recent URTI suggests reactive lymph nodes. A benign diagnosis is more likely for a neck lump with a longer history and without red flag symptoms. Clinic investigations include a full ENT examination, flexible nasoendoscopy, and blood tests. FNAC of the lesion may be performed to diagnose the neck lump. Imaging includes US, CT, or MRI of the neck. A CT chest or CXR can be used to exclude a second primary or distant metastasis. Panendoscopy is indicated if these investigations do not yield a diagnosis.
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The biggest risk factors for developing head and neck cancers are smoking tobacco and drinking alcohol. If these risk factors are combined, then there is a synergistic 
in the likelihood of developing cancer. About 75% of head and neck cancers are related to tobacco and alcohol. Smaller risk factors include a positive FHx, previous radiotherapy, exposure to wood dust (paranasal sinus cancers), nickel, and asbestos. Infection with HPV subtypes 16 and 18 is now recognised as an important risk factor, and is responsible for the dramatic increase in oropharyngeal cancers.
This is the standard hearing test performed by audiologists in a soundproof booth to determine the hearing sensitivities to tones with a set frequency (pure tones). The aim is to detect the extent of hearing loss. Frequencies vary from low pitches to high pitches. A button is pressed by the patient when they can hear the sound being played through the microphone, and the sound intensity is 
until it is no longer heard. The results are plotted on a chart, providing information on the severity of hearing loss, and whether the hearing loss is conductive, sensorineural, or mixed. The hearing test requires the cooperation of the individual, so it cannot be used on children under the age of 3.
Permits the rapid assessment of masses arising from the neck, thyroid gland, and salivary glands without the risks of radiation or contrast. It gives important information on whether a lesion is cystic or solid. When performed by an experienced operator in conjunction with FNAC it has high sensitivity and specificity for diagnosis. US scanning is limited by the skill of the operator, and is inappropriate for deeper structures.
The ability to define soft tissue makes MRI the gold standard for diagnosing vestibular schwannomas. It is important in evaluating the extent of head and neck tumours, and to look for any vascular involvement. Contraindicated in patients with metallic implants and cochlear implants.
Nosebleeds are very common and most cases are self-limiting. In more severe cases, blood loss has the potential to be significant necessitating prompt treatment. Causes are divided into local (e.g. idiopathic, nose picking, trauma, infection, tumours) and systemic (e.g. anticoagulation, hypertension, coagulopathy). The commonest site of bleeding is Little’s area, (the Kiesselbach’s) plexus of branches of the internal and external carotid arteries located at the anterior nasal septum. Less commonly, the source of bleeding is the posterior septum from Woodruff’s plexus. Remember that anterior epistaxis is more common but posterior epistaxis can be more more serious. All patients requiring admission need a FBC and clotting screen and severe cases require a group and save. Interventions start with basic first aid (applying firm pressure and ice to the nose) and progressing in a stepwise manner to cauterization (silver nitrate sticks), anterior nasal packing (with tampons or bismuth iodine paraffin paste impregnated ribbon gauze), posterior nasal packing with a Foley catheter, electrocautery, ligation of artery, and embolization.
Tonsillitis is a very common condition. The condition presents with sore throat, pain and difficulty in swallowing, fever, tonsillar swelling and exudate, and earache. (See Fig. 35.2.) It is usually bacterial in origin but can occur after a viral infection. Patients who have difficulty swallowing enough fluids or severe pain usually require admission. Treatment consists of regular analgesia, oral or IV fluids, and penicillin antibiotics (ampicillin is not given due to a potential type IV hypersensitivity reaction, a pruritic maculopapular rash, in patients with glandular fever). Tonsillitis can be complicated with a peritonsillar abscess (quinsy) which presents as a swelling of the soft tissue between the tonsil and pharyngeal constrictor with uvular deviation. Incision and drainage or aspiration using a wide-bore needle and IV antibiotics is required.
Fig. 35.2 Anatomy of the tonsils and throat. Reproduced from Blausen.com staff (2014). ‘Medical gallery of Blausen Medical 2014’. WikiJournal of Medicine 1 (2). Free to use under CC BY 3.0 license.
Airway emergencies are uncommon, but potentially life-threatening when they occur. Senior help is mandatory and management should be joint with anaesthetics and in children, the paediatric team. Stridor is an important sign that you need to witness. It is caused by a narrowed airway, and is a late alarm sign for airway obstruction. Acquired causes include croup, epiglottis, supraglottitis, foreign body, trauma, or a deep neck space infection. The priority is to decide whether intervention is needed to secure the airway and this is based on careful assessment of the patient to look for any respiratory distress. In children, it is important not to cause further distress, so that means do not examine their throat, no cannulas, and no radiographs. Medical management involves high-flow oxygen, nebulized adrenaline (epinephrine), IV steroids, and antibiotics if the cause is infective. Definitive airway interventions begin with endotracheal intubation, and if this fails a cricothyroidotomy or tracheostomy is indicated.
Airway assessment
• Look for drooling, cyanosis, intercostal recession, assessor muscle usage, respiratory rate, nasal flaring, oxygen saturation, and fever.
• Listen for stridor, cough, voice, and difficulty in finishing full sentences.
Wheeze is heard on expiration and due to turbulent bronchiolar flow. Stridor is high pitched and suggests a degree of obstruction at/below the larynx. It can be inspiratory, expiratory, or biphasic.
This is an ENT emergency managed jointly with ophthalmology and paediatrics. It is a complication of acute ethmoidal sinusitis and affects young children. It presents with redness, pain, and swelling (Fig. 35.3). It is important to examine for proptosis, a change in visual acuity, colour vision, diplopia, reduced eye movements, and a relative afferent pupil defect (RAPD) as there is a risk of blindness. The condition needs to be managed promptly with IV broad-spectrum antibiotics. A sinus and orbit CT should be performed. If a subperiosteal or intraorbital abscess is present, urgent surgery to decompress the orbit is mandated.
Fig. 35.3 Orbital cellulitis. Reproduced with permission from the MSD Manual Consumer Version (Known as the Merck Manual in the US and Canada and the MSD Manual in the rest of the world), edited by Robert Porter. Copyright (2018) by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co, Inc, Kenilworth, NJ. Available at http://www.msdmanuals.com/consumer. Accessed (03/01/18).
You may be asked the reasons for performing this very common operation. There are three main indications: recurrent acute tonsillitis, suspicion of tonsillar malignancy, and obstructive sleep apnoea due to enlarged tonsils. The operation involves bluntly dissecting the tonsil along with its capsule away from the adjacent pharyngeal musculature, working from the upper tonsillar pole, towards the tongue base. The blood supply of the tonsils enters via the lower tonsillar pole, so this is tied to avoid haemorrhage. Many different methods can be used including coblation, electrocautery, and laser but the commonest method which also has the lowest incidence of postoperative haemorrhage is cold steel dissection.
The main complications are infection and haemorrhage which may be primary (occurring in the first 24 hours) or secondary (occurring 5–10 days after surgery). A post-tonsillectomy bleed is an ENT emergency requiring IV resuscitation and antibiotics. A return to theatre may be needed to arrest the bleed.
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Scottish Intercollegiate Guidelines Network (SIGN) guidelines for tonsillectomy for tonsillitis—patients should meet these criteria:
• Sore throats are caused by acute tonsillitis.
• Attacks of sore throat are disabling and prevent normal functioning.
• Seven or more episodes of sore throat in the past year or five or more episodes in the past 2 years or three or more in the past 3 years.
Grommets are tiny tubes inserted into the tympanic membrane in order to drain away fluids and improve ventilation of the middle ear. The procedure is mainly indicated for treating otitis media with effusion (glue ear) lasting >3 months and recurrent acute otitis media. Grommets are inserted using a microscope under either local anaesthetic or GA. A binocular microscope is used for the procedure. A radial cut (myringotomy) is usually made in the inferior-anterior quadrant. Crocodile forceps are used to place the grommet in the incision.
Most microscopes will have a teaching arm allowing you to see what the surgeon is seeing, and this makes it ideal for you ask the surgeon to point out the features of the ear drum. Ask the surgeon before the operation to set up the teaching microscope. Make sure you can identify the different parts of the ear drum, including the umbo, handle of the malleus, incus, and the cone of light. Complications of grommets include otorrhoea which may need antibiotic treatment, scarring, and perforation of the ear drum after the grommet has fallen out.
Performed to treat thyroid carcinoma, a goitre affecting breathing or swallowing, or for hyperthyroidism refractory to medical treatment. Performed increasingly in ENT departments with head and neck units, this is a golden opportunity to assist and to learn about neck anatomy at the same time. Try to see the patient preoperatively to examine their neck. Look out for the important structures as the operation progresses. A good way to remember them is to follow the dissection and work from superficial to deep, starting from the skin, platysma, and the strap muscles which are divided to reveal the trachea, cricoid, and thyroid lobes. The inferior and middle thyroid veins are ligated and divided. The inferior and superior poles are mobilized, and the superior thyroid artery and vein is ligated and divided. You will notice the surgeon concentrating on identifying the recurrent laryngeal nerve which is found in the tracheoesophageal groove. This is essential to prevent iatrogenic damage 
vocal cord palsy and hoarse voice. Nerve monitoring devices are increasingly being used to assist with identification. The thyroid is dissected free from the trachea. Complications include recurrent laryngeal or external laryngeal nerve palsy, hypocalcaemia, an airway emergency secondary to haematoma or tracheomalacia, and recurrence.
Head and neck cancer operations are increasingly being concentrated in regional head and neck centres. If there is limited opportunity for theatre, a neck dissection is a good operation to see in terms of appreciating the anatomy of the neck and the surgical management of head and neck cancer. A neck dissection may be performed: prophylactically for malignancy, therapeutically to treat cancer with lymph node spread, or for obtaining lymph node biopsies (e.g. for lymphoma). The operation involves surgical removal of all or selected lymph nodes on one or both sides of the neck. The sternocleidomastoid, accessory nerve, and internal jugular vein may also be removed.
Know the reasons for performing this procedure. They are to secure an obstructed upper airway, to establish an airway in patients with surgery to the head and neck, to facilitate weaning from ventilatory support, to assist removal of respiratory secretions, and to protect the airway from aspiration in patient with a poor cough reflex. It is usually performed under GA and requires excellent teamwork between the surgeon and anaesthetist. A horizontal incision is made midway between the cricoid and sternal notch. Ask your surgeon to demonstrate these landmarks before the operation. The strap muscles are divided in the midline, and the thyroid isthmus is usually divided. A hole is made in the trachea by removing the anterior part of the third and fourth tracheal rings. A tracheostomy tube is inserted, and once the cuff is inflated it is secured. Complications include infection, bleeding, recurrent laryngeal nerve injury, subcutaneous emphysema, pneumothorax, tube displacement, aspiration, and tracheal stenosis.
Your priority during your ENT placement is to practise how to take an ENT history and to perform an ENT examination on real patients. Your GP attachment will also feature a lot of ENT patients.
You will find there is a wide range of different presentations in ENT. As with all histories you start with an open question: ‘Can you please start from the beginning and tell me what the problem is?’ You can then focus your closed questions based on whether the problem is related to the ear, nose, or throat.
• Ear review: ask about which is the affected side, any hearing loss, earache, and ear discharge. Dizziness is a common presentation so differentiate between true vertigo, lightheadedness, and peripheral imbalance.
• Nose review: ask about nasal discharge (rhinorrhoea), pain, nosebleeds (epistaxis), obstruction, loss of smell (anosmia), itching, sneezing.
• Throat and neck review: inquire about pain in the throat, mouth, neck, ears, change in voice (dysphonia), difficulty in swallowing (dysphagia) or painful swallowing (odynophagia), shortness of breath (dyspnoea), stridor, neck lumps, weight loss, night sweats, and reflux symptoms.
• Thyroid review: ascertain the patient’s thyroid status. For hyperthyroidism, ask about weight loss, heat intolerance, depression, agitation, anxiety, infrequent menstruation (oligomenorrhoea), weakness, tremor, palpitations, and diarrhoea. For hypothyroidism, ask about weight gain, cold intolerance, depression, memory impairment, heavy menstruation (menorrhagia), constipation, and hoarseness.
• Systems review: ask about the relevant ENT area not covered in the PC.
As well as the general enquiry about past medical problems you need to ask specifically about any previous ENT surgery and problems with the ENT.
Many ENT problems will have a positive FHx. For ear presentations, ask about a FHx of hearing problems. For neck lumps, check if there is a FHx of thyroid disease/surgery.
Ask about current medications and allergies. Use of ototoxic drugs (e.g. gentamicin, cisplatin) is important in hearing loss.
Smoking and alcohol are synergistic risk factors for head and neck malignancy. What is their profession? Anosmia in a chef will have a significant impact on quality of life. Carpenters are exposed to hardwood dust which the risk of some head and neck cancers.
Although ENT placements are typically short, ENT cases commonly feature in surgical exams. The good thing is that this is almost always a neck examination, and this may be on an actor with no signs, or on a patient from the head and neck clinic. Therefore, make sure you spend sufficient time in clinic so that you are able to slickly perform a neck examination and to demonstrate any signs.
This is the most likely case to appear in surgical OSCEs. An ENT department will have no shortage in supplying patients with neck lumps to your OSCE.
• Position the patient and expose the neck to the clavicles. The patient’s chair is often placed with its back on a wall and the patient may be wearing a scarf. Ensure that you move the chair forwards so you have enough room to examine from behind and ask the patient to remove any clothing that obstructs the view of the neck!
• Ensure hand hygiene, gain consent, and ask the patient if they have any pain in their neck.
• Inspect the neck from front and side. Look for any masses, scars, asymmetry, or skin changes.
• Assess the patient’s voice (recurrent laryngeal nerve function) by asking the patient to count from one to ten.
• Ask the patient to take a sip of water, hold, and swallow when asked. Any thyroid mass will move upwards on swallowing.
• Look inside the mouth, then ask the patient to stick out their tongue. Look for any midline masses that move on protrusion such as a thyroglossal cyst.
• Stand behind the patient to palpate their neck using the pulp of your fingers. Work up the midline from the suprasternal notch along the trachea and larynx (level 6 nodes). Palpate the thyroid gland. Palpate the submental and submandibular area (level 1) and then palpate inferiorly along the sternocleidomastoid (levels 2, 3, and 4). Palpate the supraclavicular and infraclavicular area, and then move superiorly along the posterior edge of the sternocleidomastoid and the posterior triangle (level 5). Palpate the occipital, post- and pre-auricular nodes, and the parotid gland. You may be taught to palpate the neck in a different order but the important thing is not to miss out on any areas.
• Use a system to describe any lump you find. Comment on the site, size, shape, surface, consistency, tenderness, transillumination, pulsatility, and attachment to underlying structures.
• For a parotid or submandibular mass, perform bimanual palpation.
Students are often unsure whether they should perform a full thyroid examination when examining the neck in OSCEs. Usually you will be clearly instructed to examine the thyroid gland. However, if you are only asked to examine a patient’s neck, and you suspect a midline lump, then you should suspect a thyroid mass. Ask the examiner if you can proceed to examine the thyroid status.
Neck anatomy
The neck is divided into two triangles which are used to describe the site of a neck lump (see Fig. 35.4):
• Anterior triangle: bound anteriorly by the midline of the neck, superiorly by the inferior border of the mandible, and posteriorly by the anterior border of the sternocleidomastoid.
• Posterior triangle: formed anteriorly by the posterior edge of the sternocleidomastoid, inferiorly by the clavicle, and posteriorly by the anterior edge of trapezius muscle.
Fig. 35.4 Triangles of the neck. Reproduced with permission from Ellis H. and Mahadevan V., Clinical Anatomy, Thirteenth Edition, Wiley-Blackwell, Oxford, UK, Copyright © 2013.
In addition to the full neck examination, the thyroid examination also includes the following points:
• Inspect the patent’s skin and look for any restlessness.
• Examine the hands for sweatiness, thyroid acropachy, palmar erythema, and tremor.
• Feel the pulse to look for AF or tachycardia.
• Inspect the eyes for lid retraction, exophthalmos, lid lag, chemosis, and loss of hair from the outer third of the eyebrows.
• Inspect the neck and ask the patient to swallow.
• Ask the patient to cough and count to ten.
• Palpate the thyroid gland while asking the patient to swallow water and then to protrude their tongue. Feel the thyroid lobes and isthmus gland, and then palpate the neck for any lymphadenopathy.
• Percuss over the upper sternum to detect any retrosternal extension.
• Auscultate over the thyroid to listen for any bruit.
• Ask the patient to stand up with their arms folded (proximal myopathy).
• Look for pretibial myxoedema and assess the ankle reflexes.
This can be practised during both your ENT and GP attachments. The important thing is to become familiar with handling the otoscope. Common pitfalls include holding the otoscope with the wrong hand, or pushing the otoscope too far into the EAC, thereby causing pain. Hold the otoscope with the right hand when examining the right ear and vice versa.
• Ask if there is a better hearing ear and start with that ear.
• Check if there is any pain in the ears.
• Inspect the post- and pre-auricular area, mastoid, pinna, and external auditory meatus. Look for any scars, discharge, sinuses, or inflammation. Scars behind the pinna are particularly hard to miss.
• Use the otoscope to examine the EAC while pulling the pinna upwards and backwards in order to straighten out the EAC. Look for any inflammation, wax, debris, or polyps. It is easy to cause pain by pushing the speculum of the otoscope too far into the ear canal. Prevent this by steadying your hand holding the otoscope with your little finger on the patient’s cheek.
• Examine all four quadrants of the tympanic membrane. Look at the ossicles and comment on whether the tympanic membrane is intact, perforated, or retracted. What colour is the drum?
• Repeat this with the worse hearing ear.
• You would then perform tuning fork tests: Rinne and Weber tests (Table 35.1).
Table 35.1 Rinne vs Weber test results
| Weber without lateralization | Weber lateralizes left | Weber lateralizes right | |
| Rinne both ears AC >BC | Normal | Right sensorineural loss | Left sensorineural loss |
| Rinne left BC >AC | Left conductive hearing loss | Combined loss: left conductive and sensorineural loss | |
| Rinne right BC >AC | Combined loss: right conductive and sensorineural loss | Right conductive hearing loss | |
| Rinne both ears BC >AC | Conductive loss in both ears | Combined loss in right ear and conductive loss in left | Combined loss: right conductive and sensorineural loss |
AC, air conduction; BC, bone conduction.
Make sure you ask your ENT registrar/consultant to first demonstrate how to perform tuning fork tests, and then practise on patients with both normal and abnormal hearing. Tuning forks are found in the ENT clinic. Always request a 512 Hz tuning fork, and practise striking it on your elbow or knee to make it vibrate.
Place the vibrating fork end on the patient’s forehead, vertex, or chin. Ask the patient if they can hear it loudest in the right, left, or in the middle. In a person with normal hearing, the sound is loudest in the middle. Sensorineural hearing loss results in the sound lateralizing to the unaffected ear. In conductive hearing loss, the sound lateralizes to the affected ear.
The vibrating fork is first placed behind the ear against the mastoid process to test bone conduction. The fork is then held in front of the ear, in line with the external auditory meatus, to test air conduction. Ask the patient which was the loudest sound. This is repeated for the other ear. The test assesses air conduction against bone conduction. A normal result occurs when air conduction is louder than bone conduction, and unintuitively this is known as a positive Rinne test. An abnormal result is known as a negative Rinne test and occurs when bone conduction is louder than air conduction.