ENT

AN INTRODUCTION
AND PRACTICAL GUIDE
This page intentionally left blank
 ENT
AN INTRODUCTION
AND PRACTICAL GUIDE

EDITED BY
James Russell Tysome MA PhD FRCS (ORL-HNS)
Senior Clinical Fellow in Neurotology and Skull Base Surgery
Cambridge University Hospitals NHS Foundation Trust

AND
Rahul Govind Kanegaonkar FRCS (ORL-HNS)
Consultant ENT Surgeon
Medway NHS Foundation Trust
Guy’s and St Thomas’ NHS Foundation Trust
First published in Great Britain in 2012 by
Hodder Arnold, an imprint of Hodder Education, Hodder and Stoughton Ltd,
a division of Hachette UK
338 Euston Road, London NW1 3BH

http://www.hodderarnold.com

© 2012 Hodder & Stoughton Ltd

All rights reserved. Apart from any use permitted under UK copyright law, this
publication may only be reproduced, stored or transmitted, in any form, or by any
means with prior permission in writing of the publishers or in the case of reprographic
production in accordance with the terms of licences issued by the Copyright Licensing
Agency. In the United Kingdom such licences are issued by the Copyright Licensing
Agency: Saffron House, 6–10 Kirby Street, London EC1N 8TS.

Hachette UK’s policy is to use papers that are natural, renewable and recyclable
products and made from wood grown in sustainable forests. The logging and
manufacturing processes are expected to conform to the environmental regulations
of the country of origin.

Whilst the advice and information in this book are believed to be true and accurate at
the date of going to press, neither the author[s] nor the publisher can accept any legal
responsibility or liability for any errors or omissions that may be made. In particular,
(but without limiting the generality of the preceding disclaimer) every effort has been
made to check drug dosages; however it is still possible that errors have been missed.
Furthermore, dosage schedules are constantly being revised and new side-effects
recognized. For these reasons the reader is strongly urged to consult the drug
companies’ printed instructions, and their websites, before administering any of
the drugs recommended in this book.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging-in-Publication Data

A catalog record for this book is available from the Library of Congress

ISBN-13 978-1-444-14908-1

1 2 3 4 5 6 7 8 9 10

Commissioning Editor: Francesca Naish

Production Controller: Joanna Walker
Cover Design: Helen Townson
Project management provided by Naughton Project Management

Typeset in 10/12 pt Minion Regular by Datapage

Printed and bound in Spain by Graphycems

What do you think about this book? Or any other Hodder Arnold title?
Please visit our website: www.hodderarnold.com
 Dedication
This book is dedicated to Dipalee, Amee and Deven
and to Laura, George and Henry
This page intentionally left blank
 CONTENTS
Contributors 8
Foreword 9
Preface 10
Introduction 11

1 Clinical anatomy 12
2 ENT examination 29
3 Common ENT pathology 37
4 Epistaxis 50
5 Audiology 59
6 Tonsillectomy 68
7 Adenoidectomy 72
8 Grommet insertion 75
9 Septoplasty 78
10 Septorhinoplasty 84
11 Turbinate surgery 87
12 Antral washout 90
13 Endoscopic sinus surgery 92
14 Nasal polypectomy 96
15 Tympanoplasty 98
16 Mastoidectomy 104
17 Stapedectomy 111
18 Bone-anchored hearing aid 115
19 Panendoscopy 118
20 Direct- and micro-laryngoscopy 119
21 Pharyngoscopy 121
22 Rigid oesophagoscopy 124
23 Examination of the postnasal space (PNS) 125
24 Rigid bronchoscopy 126
25 Submandibular gland excision 128
26 Hemi- and total thyroidectomy 131
27 Superficial parotidectomy 134
28 Tracheostomy 138
29 Voice 145
30 Airway management 149
31 Radiology 152
32 Management of neck lumps 157
33 Vertigo and dizziness 161

Index 169
 CONTRIBUTORS
Mr Ketan Desai FRCS
Associate Specialist in Otorhinolaryngology
Royal Sussex County Hospital, Brighton

Mr Neil Donnelly MSc (Hons) FRCS (ORL-HNS)

Consultant Otoneurological and Skull Base Surgeon
Cambridge University Hospitals NHS Foundation Trust

Dr Dipalee Vijay Durve MRCPCH FRCR

Consultant Radiologist
Guy’s and St Thomas’ NHS Foundation Trust

Mr Steven Frampton MA MRCS DOHNS

ENT Specialist Trainee Registrar
Wessex Region

Mr Jonathan Hughes MRCS DOHNS

Specialist Registrar in Otolaryngology
North Thames rotation/Royal National Throat Nose and Ear Hospital

Mr Ram Moorthy FRCS (ORL-HNS)

Consultant ENT Surgeon
Heatherwood and Wexham Park Hospitals NHS Foundation Trust
and Honorary Consultant ENT Surgeon, Northwick Park Hospital

Ms Joanne Rimmer FRCS (ORL-HNS)

Specialist Registrar in Otolaryngology
North Thames rotation/Royal National Throat Nose and Ear Hospital

Mr Francis Vaz FRCS (ORL-HNS)

Consultant ENT/Head and Neck Surgeon
University College London Hospital

8
FOREWORD
The ‘Introduction to ENT’ course has now become an established and
must attend course for the novice ENT practitioner. The synergistic blend
of didactic teaching and practical skills training has allowed many junior
trainees to raise the standard of care they deliver to their ENT patients.

The course manual is now a ‘Bible’ for juniors in nursing and medicine
caring for patients on the wards, clinics or in emergency room. The Royal
College of Surgeons has endorsed this course in the past and it continues
to maintain a high standard of post graduate training. I would strongly
recommend this course to any trainee embarking on a career in ENT.

Khalid Ghufoor

Otolaryngology Tutor
Raven Department of Education
The Royal College of Surgeons of England

9
 PREFACE
This book has been written for trainees in otorhinolaryngology and to
update general practitioners. Common and significant pathology that
might present itself is described. Included also are relevant supporting
specialties such as audiology and radiology. A significant proportion
of this text has been devoted to common surgical procedures, their
indications and operative techniques, as well as the management of their
complications. We do hope that the text will facilitate and encourage junior
trainees to embark on a career in this diverse and rewarding specialty.

Writing this book would not have been possible had it not been for the
encouragement of our many friends and colleagues, and the unfaltering
support of our families.

We would, however, like to make a special mention of some extraordinary

and gifted tutors without whom we may not have initiated the popular
‘Introduction to ENT’ course nor written the course manual from which
this text originates. Ghassan Alusi, Alec Fitzgerald O’Connor, Khalid
Ghufoor, Govind Kanegaonkar, Robert Tranter and the late Roger
Parker instilled in us a passion for teaching, nurtured our curiosity for
all things medical and encouraged us to undertake the research that has
served us so well.

10
INTRODUCTION
Otorhinolaryngology (ENT) is a diverse and challenging specialty which is
poorly represented on the busy Medical School curriculum. Although an
estimated 20% of cases seen in primary care are ENT-related, many general
practitioners have little or no direct clinical training in this field.

This book has evolved from the Introduction to ENT course manual which
has served so many of us so well. Over 1200 doctors have attended this
course and its Essential Guide partner over the last eight years.

This book covers both common and the life-threatening emergencies

that may present in primary care. It not only describes the common
management pathways for conditions, but also lists possible complications
of procedures and their treatment and provides a basis for referral if there
is doubt.

The updated colour illustrations concisely depict relevant clinical anatomy

without unduly simplifying the topic in question.

I am certain this text will prove to be as, if not more, popular and relevant
to general practitioners than the Introduction to ENT text from which it is
derived.

Dr Junaid Bajwa
June 2011

11
 1 CLINICAL ANATOMY

THE EAR
The ear is divided into three separate but related Scaphoid fossa
subunits. The outer ear consists of the pinna and
external auditory canal bounded medially by the Helix Trianglar
fossa
lateral surface of the tympanic membrane. The
middle ear contains the ossicular chain, which
Auricular
spans the middle ear cleft and allows acoustic tubercle
energy to be transferred from the tympanic Cymba conchae
membrane to the oval window and hence the Antihelix Tragus
cochlea of the inner ear.
Antitragus
Conchal bowl
This elaborate mechanism has evolved to overcome Intertragic notch
the loss of acoustic energy that occurs when
transferring sound from one medium to another Lobule
(impedance mismatch), in this case from air
to fluid.
Figure 1.1. Surface landmarks of the pinna.
❚❘ The outer ear

The pinna consists largely of elastic cartilage over of the first and second branchial arches on either
which the skin is tightly adherent (Figure 1.1). The side of the first pharyngeal groove. These fuse and
cartilage is dependent on the overlying perichon- rotate to produce an elaborate but surprisingly con-
drium for its nutritional support; hence separation sistent structure. Failure of fusion may result in an
of this layer from the cartilage by a haematoma, accessory auricle or preauricular sinus, while failure
abscess or inflammation secondary to piercing may of development of the antihelix (from the fourth
result in cartilage necrosis resulting in permanent hillock) in a protruding (‘bat’) ear.
deformity (cauliflower ear). The lobule, in contrast,
is a fibro-fatty skin tag. The external auditory canal is a tortuous pas-
sage that directs and redistributes sound from the
The pinna develops from six mesodermal conden- conchal bowl to the tympanic membrane. The skin
sations, the hillocks of His, during the sixth week of of the lateral third of the external auditory canal is
embryological development. Three arise from each thick, contains ceruminous glands, is hair-bearing

12 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

and tightly adherent to the underlying fibrocar- during maturation. This produces an escalator
tilage. The skin of the medial two-thirds is thin, mechanism that allows debris to be directed out
hairless, tightly bound to underlying bone and of the canal. Disruption of this mechanism may
exquisitely sensitive. result in debris accumulation, recurrent infec-
tions (otitis externa) or erosion of the ear canal,
The sensory nerve supply of the canal is provided as seen in keratitis obturans.
by the auriculotemporal and greater auricular
nerves. There are minor contributions from The tympanic membrane is continuous with the
the facial nerve (hence vesicles arise on the posterior wall of the ear canal and consists of
posterolateral surface of the canal in Ramsay three layers: laterally, a squamous epithelial layer; a
Hunt syndrome) and Arnold’s nerve, a branch middle layer of collagen fibres; and a medial surface
of the vagus nerve (provoking the cough reflex lined with respiratory epithelium continuous with
when stimulated with a cotton bud or during the middle ear.
microsuction). The squamous epithelium of the
tympanic membrane and ear canal is unique and The tympanic membrane is divided into the pars
deserves a special mention. The superficial layer tensa and pars flaccida, or attic (Figure 1.2). They
of keratin of the skin of the ear is shed laterally are structurally and functionally different.

Scutum
Pars flaccida

Chorda tympani Lateral process of

malleus
Long process of incus
Handle of malleus

Pars tensa
Umbo
Eustachian tube
Round window niche Light reflex
Promontory

Figure 1.2. Right tympanic membrane.

The collagen fibres of the middle layer of the pars pars tensa accounts for 55 mm2. Unlike the pars
tensa are arranged as lateral radial fibres and medial flaccida, the pars tensa buckles when presented
circumferential fibres that distort the membrane. with sound, conducting acoustic energy to the os-
As a result, the pars tensa ‘billows’ laterally from the sicular chain. Interestingly, high-frequency sounds
malleus. In contrast, the collagen fibres of the pars preferentially distort the posterior half of the
flaccida are randomly scattered and this section is tympanic membrane, while low-frequency sounds
relatively flat. distort the anterior half.

Whilst the surface area of the tympanic mem- The handle and lateral process of the malleus are
brane of an adult is approximately 80 mm2, the embedded within the tympanic membrane and

Clinical anatomy 13
are clearly visible on otoscopy. The long process ❚❘ The middle ear
of the incus is also commonly seen, although the
heads of the ossicles are hidden behind the scutum The middle ear is an irregular, air-filled space
superiorly. that communicates with the nasopharynx via the

Body of malleus Lateral semicircular

canal

Body of incus
Handle of malleus Horizontal portion of
the facial nerve
Long process of incus

Tympanic membrane Oval window

Basal turn of the cochlea

Eustachian tube

Figure 1.3. Coronal section of the ossicles in the middle ear.

Eustachian tube (Figure 1.3). Chewing, swallowing of the footplate in otosclerosis prevents sound
and yawning result in untwisting of the tube, allow- conduction to the inner ear, resulting in a conduc-
ing air to pass into the middle ear cleft. In children, tive hearing loss.
Eustachian tube dysfunction is common and may
result in negative middle ear pressure, recurrent
otitis media or middle ear effusions. ❚❘ The inner ear
The middle ear mechanisms that improve sound The inner ear consists of the cochlea and peripheral
transfer include: vestibular apparatus (Figure 1.4).

● The relative ratios of the areas of the tympanic The cochlea is a 2¾-turn snail shell that houses the
membrane to stapes footplate (17:1). organ of Corti. Acoustic energy causes buckling
● The relative lengths of the handle of malleus to of the basilar membrane, with deflection maximal
the long process of incus (1.3:1). at a frequency-specific region of the cochlea. This
● The natural resonance of the outer and results in depolarization of the inner hair cells in
middle ears. this region, with information relayed centrally via
● The phase difference between the oval and the cochlear nerve. The cochlea is tonotopic, with
round windows. high-frequency sounds detected at the basal turn
● The buckling effect of the tympanic membrane. of the cochlea, while low-frequency sounds are
detected at the apex.

Acoustic energy is conducted by the middle ear The peripheral vestibular system is responsible for
ossicles and transferred to the cochlea through detecting static, linear and angular head move-
the stapes footplate at the oval window. Fixation ments. While the semicircular canals are responsible

14 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 Ampulla
Macula

Cupula striola

otoconia
gel
Superior reticular membrane
semicircular supporting cells
canal Vestibular ganglion
Neural firing rate
Head Posterior
Utricle
rotation semicircular
Saccule Facial nerve
canal

Head tilt
Cochlear
nerve
Horizontal
Head semicircular
Ampulla
rotation canal

Cochlea gravitational
force
Clinical anatomy 15

Figure 1.4. The inner ear. Angular acceleration is detected by the ampullae of the semicircular canals, while linear acceleration and static head tilt
are detected by the maculae of the utricle and saccule.
for detecting head rotation, the saccule and utricle gelatinous mass, the cupula, which is deflected dur-
are responsible for detecting static head tilt and ing rotational head movements.
linear acceleration head tilt. This is achieved by two
similar, but functionally different sensory receptor The sensory neuroepithelium, responsible for de-
systems (Figure 1.4). tecting linear acceleration, is limited to specific re-
gions, the maculae. Whilst the macula of the saccule
The semicircular canals are oriented in orthogonal is oriented principally to detect linear acceleration
planes to one another and organized into func- and head tilt in the vertical plane, the macula of the
tional pairs: the two horizontal semicircular canals; utricle detects linear acceleration and head tilt in
the superior canal and the contralateral posterior the horizontal plane. The hair cells of the maculae
canal; and the posterior canal and the contralateral are arranged in an elaborate manner and project
superior canal. into a fibro-calcareous sheet, the otoconial mem-
brane. As this membrane has a greater specific grav-
The sensory neuroepithelium of the semicircular ity than the surrounding endolymph, head tilt and
canals is limited to a dilated segment of the bony linear movement result in the otoconial membrane
and membranous labyrinth, the ampulla. A crest moving relative to the underlying hair cells. The
perpendicular to the long axis of each canal bears shearing force produced causes depolarization of
a mound of connective tissue from which proj- the underlying hair cells with conduction centrally
ect a layer of hair cells. Their cilia insert into a via the vestibular nerve.

THE FACIAL NERVE

The facial nerve (CN VII) has a long and tortuous (horizontal portion) within the medial wall of the
course through the temporal bone before exiting middle ear and then inferiorly (vertical segment)
the skull base at the stylomastoid foramen and within the temporal bone to exit the skull base at
passing into the parotid gland (Figure 1.5). Disease the stylomastoid foramen. During its descent it
processes affecting the inner ear, middle ear, skull gives off the chorda tympani nerve, which passes
base or parotid gland may result in facial nerve forward and upward entering the middle ear. An
paralysis. additional motor branch supplies the stapedius
muscle.
The facial nerve arises from the pons and passes
laterally as two nerves: facial motor and nervus Having left the skull base, the facial nerve gives
intermedius. These enter the internal auditory off branches to the rudimentary muscles of the
canal where they combine to form the facial pinna and a small branch to the external auditory
nerve. The nerve passes laterally (meatal seg- canal. It then continues forward, lying in the
ment), then anteriorly (labyrinthine section) and tympanomastoid groove to enter the parotid
within the bony wall of the middle ear under- gland, where it divides into superior and inferior
goes a posterior deflection (the first genu) where divisions before terminating in its five motor
the geniculate ganglion is found and the greater branches (Figure 1.6). Additional branches
petrosal nerve given off (this enters the middle supply the posterior belly of digastric and
cranial fossa). The facial nerve passes posteriorly stylohyoid muscles.

16 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 SUPERIOR Motor nucleus
“Bill’s” bar
Superior salivary nucleus
(parasympathetic)
VII SVN
ANTERIOR POSTERIOR Tractus soliarius
(taste)
Internal auditory
CN IVN Simple sensory
canal
Falciform
crest I
Singular Geniculate II
nerve ganglion
INFERIOR Greater
petrosal n.

(b)
60°

Intracranial segment 24 mm
I – Meatal segment, 10 mm III
II – Labyrinthine segment, 5 mm. Dome of the lateral
The narrowest portion, 0.7 mm semicircular canal
Malleus
III– Tympanic (horizontal) segment, 10 mm
IV – Mastoid (vertical) segment – 14 mm 30°

Chorda tympani
nerve
Cutaneous fibres
accompany auricular IV
fibres of vagus
Clinical anatomy 17

Stylomastoid
foramen
(a)

Figure 1.5. The intratemporal course of the facial nerve (a), relative positions of the facial, cochlear and vestibular nerves within the internal auditory
canal. (VII = facial nerve, SNV = superior vestibular nerve, IVN = inferior vestibular nerve)
 Temporal

Zygomatic

Buccal

Marginal mandibular

Cervical

Figure 1.6. External branches of the facial nerve.

THE NOSE
The principal function of the nose is respiration, The upper aero-digestive tract is divided into the
secondary functions include: nasal cavity, oral cavity, oropharynx, larynx and
hypopharynx (Figure 1.8).
● Warming of inspired air.
● Humidification of inspired air.
❚❘ The nasal cavities
● Filtering of large particulate matter by coarse
hairs (the vibrisiae) in the nasal vestibule.
The nasal cavities are partitioned in the midline by
● Mucus production, trapping and ciliary
the nasal septum, which consists of both fibrocarti-
clearance of particulate matter.
lage and bone (Figure 1.9).
● Immune protection.
● Olfaction. As with the cartilage of the pinna, the cartilage of
● Drainage/aeration of the middle ear cleft via the the septum is dependent on the overlying adher-
Eustachian tube. ent perichondrium for its nutritional support.
● Drainage/aeration of the paranasal sinuses. Separation of this layer by haematoma or abscess
● Drainage for the nasolacrimal duct. may result in cartilage necrosis and a saddle nose
● Prevention of lung alveolar collapse via the cosmetic deformity.
nasal cycle.
● Voice modification. The venous drainage of the nose and mid-face
● Pheromone detection via the Vomero-nasal communicates with the cavernous sinus of the
organ of Jacobsen. middle cranial fossa via the ophthalmic veins,
deep facial vein and pterygoid plexus. As a
❚❘ Nasal skeleton result, an infection in this territory may spread
intracranially, resulting in cavernous sinus
The external nasal skeleton consists of bone in the thrombosis and death.
upper third (the nasal bones) and cartilage in
the lower two-thirds. External nasal landmarks are In contrast to the smooth surface of the nasal
illustrated in Figure 1.7. septum, the lateral wall is thrown into folds by three

18 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 Glabella Glabella

Nasion Nasal bone

Dorsum hinion
Frontal process
of maxilla Septum
Supratip Upper lateral
cartilage
Tip
Lower
lateral
cartilage
Collumnella

Figure 1.7. Nasal landmarks and external nasal skeleton.

Nasal cavity
Sphenoid sinus

Adenoidal pad
Tonsil of Gërlach
Hard palate
NASOPHARYNX

Tongue
Palatine tonsil
Lingual tonsil
OROPHARYNX
Vallecula
Hyoid bone
Epiglottis
Vocal cord HYPOPHARYNX
Thyroid cartilage
Cricoid cartilage
Cricoid cartilage
Cervical oesphagus

Thyroid isthmus

Figure 1.8. Sagittal section through the head and neck. Note the hard palate lies at C1, the hyoid bone at
C3 and the cricoid cartilage at C6.

Clinical anatomy 19
 Perpendicular
plate of ethmoid

Septal cartilage
Vomer

Crest

Palatine bone

Figure 1.9. The skeleton of the nasal septum.

bony projections: the inferior, middle and superior The olfactory mucosa is limited to the roof and
turbinates (Figure 1.10). These vascular structures superior surface of the lateral wall of the nasal cavity
become engorged ipsilaterally, increasing airway (Figure 1.10). Olfactants, once dissolved in mucus,
resistance and reducing airflow, while those of the combine with olfactory binding proteins, which in
contralateral cavity contract. This normal alternat- turn bind to specific olfactory bipolar cells. Their
ing physiological process, the nasal cycle, may be axons converge to produce 12−20 olfactory bundles,
more noticeable in patients with a septal deviation which relay information superiorly to secondary
or in those with rhinitis. neurones within the olfactory bulbs that lie over the
cribiform fossae of the anterior cranial fossa.
The nasal cavity has an enormously rich blood
supply, which originates from both the internal and The paranasal sinuses are paired, air-filled spaces
external carotid arteries (Figure 1.11). As a result, that communicate with the nasal cavity via ostia
epistaxis may result in considerable blood loss, located on the lateral nasal wall (Figure 1.12).
resulting in death. In cases of intractable posterior Development of the paranasal sinuses occurs at
nasal bleeding, the sphenopalatine artery may be different ages, although the frontal sinuses may not
endoscopically ligated by raising a mucoperiosteal develop in a minority of patients.
flap on the lateral nasal wall. Bleeding from the
ethmoidal vessels requires a periorbital incision and Mucus produced by the respiratory epithelium
identification of these vessels as they pass from the within the paranasal sinuses does not drain entirely
orbital cavity into the nasal cavity in the fronto- by gravity. In the maxillary sinus, for example,
ethmoidal suture. cilliary activity results in a spiral flow that directs
mucus up and medially to the ostium high on the
medial wall.

20 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 Olfactory mucosa

Superior turbinate

Middle turbinate

Inferior turbinate

Eustachian tube cushion

Figure 1.10. The lateral surface of the nasal cavity.

Anterior ethmoidal artery (I)

Posterior ethmoidal artery (I)

Sphenopalatine artery (E)

Little’s area

Superior labial artery (E) Greater palatine artery (E)

Figure 1.11. Arterial blood supply to the nose. The nose has a rich blood supply, supplied by both internal
(I) and external (E) carotid arteries.

Clinical anatomy 21
 Posterior ethmoid ostia
Sphenoid sinus ostium
Anterior ethmoid ostia

Maxillary sinus ostia

Nasolacrimal duct

Sphenopalatine artery

Figure 1.12. The lateral wall of the nasal cavity. (The turbinates have been removed in order to allow visual-
ization of the ostia of the paranasal sinuses.)

The anterior and posterior ethmoidal air cells The osteomeatal complex represents a region
are separated from the orbital contents by the through which the paranasal sinuses drain
lamina papyracea, a thin plate of bone derived (Figure 1.13). Obstruction may lead to acute or
from the ethmoid bone. Infection within these chronic sinusitis; hence opening this area is pivotal
paranasal sinuses may extend laterally, resulting when surgically treating sinus disease.
in a subperiosteal abscess or orbital abscess, with
eventual loss of vision. Extension posteriorly via
the ophthalmic veins may result in cavernous sinus
thrombosis and death.

Frontal sinus

Anterior ethmoid sinus

Lamina papyracea
Middle turbinate
Osteomeatal complex
Maxillary sinus
Inferior turbinate

Septal cartilage

Figure 1.13. Coronal section of the paranasal sinuses.

22 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

ORAL CAVITY
The oral cavity is bounded anteriorly by the The sensory nerve supply to the surface of the
lips, posteriorly by the anterior tonsillar pillars, tongue reflects its embryological development, the
inferiorly by the tongue base and superiorly by the anterior two-thirds supplied by the mandibular
hard and soft palates (Figure 1.14). division of the trigeminal nerve via the lingual
nerve, the posterior third by the glossopharyngeal
The surface of the tongue is coarse, consisting of and superior laryngeal nerves.
filliform and fungiform papillae.
The chorda tympani nerve, whose fibres hitchhike
The tongue is derived from mesoderm from the with the lingual nerve, supplies taste sensation to
third and fourth branchial arches. the anterior two-thirds of the tongue. Sweet, sour,

Posterior tonsillar pillar

Hard palate (palatopharyngeus)
Soft palate

Uvula Anterior tonsillar pillar

Tonsil (palatoglossus)

Sulcus terminalis
Retromolar region

Figure 1.14. The oral cavity. The sulcus terminalis consists of the circumvallate papillae and represents the
V-shaped junction of the anterior two-thirds and posterior third of the tongue. The foramen caecum, from which
the thyroid gland originates, lies at the apex of the ‘V’.

bitter and saltiness are detected by the fungiform The tongue consists of a considerable mass of
papillae scattered along the superior margin of the striated muscle separated in the midline by a fibrous
tongue, and the filiform papillae. membrane. Both intrinsic muscles (contained
entirely within the tongue) and extrinsic muscles
The circumvallate papillae form an inverted ‘V’ that (inserted into bone) are supplied by the hypoglossal
separates the anterior and posterior two-thirds of nerve, except for the palatoglossus (supplied by the
the tongue. The foramen caecum lies at the apex pharyngeal plexus). A unilateral hypoglossal nerve
of this ‘V’ and represents the embryological site of palsy results in deviation of the tongue towards the
origin of the thyroid gland. Rarely, due to failure of side of the weakness.
migration, a lingual thyroid may present as a mass
at this site.

Clinical anatomy 23
The floor of the mouth is separated from the airway emergency and requires urgent interven-
neck by the mylohyoid muscle. The muscle fans tion to extract the affected tooth and drain
out from the lateral border of the hyoid bone to the abscess.
insert into the medial surface of the mandible as
far back as the second molar tooth. A dental root The hyoid bone lies at the level of the third cervi-
infection that is anterior to this may result in an cal vertebra. The larynx is suspended from this
abscess forming in the floor of the mouth (Lud- C-shaped bone and hence rises with the laryngeal
wig’s angina). This is a potentially life-threatening skeleton during swallowing.

THE PHARYNX
The pharynx essentially consists of a fibrous cup, between its superior border and the skull base.
the pharyngobasilar fascia enclosed within a further Stylopharyngeus and the glossopharyngeal and
three stacked muscular cups: the superior, middle lingual nerves pass below the constrictor.
and inferior constrictors. The muscle fibres of the
The middle constrictor arises from the greater horn of
constrictors sweep posteriorly and medially to meet
the hyoid bone, its fibres sweeping to enclose the supe-
in a midline posterior raphe. The pharyngeal plexus
rior constrictor, and passing as low as the vocal cords.
provides the motor supply to the musculature of
the pharynx, except for stylopharyngeus, which is The inferior constrictor consists of two striated
supplied by the glossopharyngeal nerve. muscles, the thyropharyngeus and cricopharyngeus.
A potential area of weakness lies between the two
The superior constrictor arises from the medial muscles posteriorly: Killian’s dehiscence. A poste-
pterygoid plate, hamulus, pterygomandibluar rior pulsion divertivulum may form a pharyngeal
raphe and mandible. The Eustachian tube passes pouch within which food and debris may lodge.

THE NASOPHARYNX
The postnasal space, or nasopharynx, communi- and swallowing to allow air to pass into the middle
cates with the middle ear cleft via the Eustachian ear cleft to maintain atmospheric pressure within
tube (Figure 1.15). This tube opens during yawning the middle ear. This mechanism depends on

Adenoid

Fossa of Rossenmüller

Eustachian tube cushion Posterior margin

of septum
Lateral nasal wall
Eustachian tube orifice To oropharynx
Soft palate

Figure 1.15. Endoscopic view of the right postnasal space.

24 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

normal soft palate musculature and hence a cleft of Rossenmüller. An enlarged adenoidal pad may
palate is associated with chronic Eustachian tube result in obstructive sleep apnoea, requiring
dysfunction. surgical removal.
Blockage of the Eustachian tube may result in a
middle ear effusion. This can be unilateral if due to
a nasopharyngeal carcinoma arising from the fossa

THE LARYNX

The principal function of the larynx is as a The arytenoid cartilages are pyramidal structures
protective sphincter preventing aspiration of from which the vocal cords project forward and
ingested material (Figure 1.16). Phonation is a medially. Abduction (lateral movement) of the
secondary function. The three single cartilages cords is dependent on the posterior cricoarytenoid
of the larynx are the epiglottic, thyroid and muscle, hence this is described as the most impor-
cricoid cartilages. The three paired cartilages of tant muscle of the larynx. Additional instrinsic and
the larynx are the arytenoid, corniculate and extrinsic muscles provide adduction and variable
cuneiform cartilages. cord tension.

Interarytenoid bar Posterior

pharyngeal wall
Right arytenoid

Cricoid cartilage Left pyriform

fossa
Right vocal cord
Laryngeal inlet
Quadrangular
membrane

Epiglottis Left vallecula

Median lLingual tonsil

glossoepiglottic
fold

Figure 1.16. Endoscopic view of the larynx.

The motor supply of the muscles of the larynx The cricoid is a signet ring-shaped structure
is derived from the recurrent laryngeal nerves. which supports the arytenoid cartilages. As the
An ipsilateral palsy results in hoarseness, while only complete ring of cartilage in the airway,
a bilateral palsy results in stridor and airway trauma may cause oedema and obstruction of the
obstruction. central lumen.

Clinical anatomy 25
 The Pouiseille-Hagan formula describes airflow
through the lumen of a tube.
r
Reducing the lumen of a tube by half causes the
PB l PA flow to fall to 1/16th of the original. Therefore,
trauma to the cricoid cartilage and oedema partially
Flow (L/min) = (PA−PB) × v × r × π
4
l 8 narrowing the lumen may result in a dramatic
PA = pressure A reduction in airflow.
PB = pressure B
v = viscosity
l = length
r = radius

THE MAJOR SALIVARY GLANDS

Whilst minor salivary glands are scattered within Saliva produced by the parotid gland drains via
the oral cavity, saliva is predominantly pro- Stenson’s duct. The duct is approximately 5 cm in
duced by three paired major salivary glands: the length and lies superficial to the masseter muscle.
parotid, submandibular and sublingual glands At the anterior border of this muscle it pierces the
(Figure 1.17). fibres of buccinator to enter the oral cavity opposite
the upper 2nd molar tooth.

The facial nerve passes into and divides within the

substance of the parotid gland to separate it into
superficial and deep portions. Hence, an abscess
or malignant lesion within the parotid gland may
result in facial paralysis.

In addition, the retromandibular vein passes

Parotid
gland through the anterior portion of the gland and is a
useful radiological marker for defining the superfi-
Submandibular cial and deep portions of the gland.
Sublingual
gland
gland
The submandibular gland is a mixed serous and
mucous salivary gland and forms the majority of
saliva production at rest. Its superficial portion
fills the space between the mandible and mylo-
Figure 1.17. The major salivary glands of the head hyoid muscle, while its deep part lies between the
and neck. mylohyoid and hyoglossus. The gland drains into
the floor of the oral cavity via Wharton’s duct, the
The parotid gland is a large, serous salivary gland papilla lying adjacent to the lingual frenulum. The
enclosed by an extension of the investing layer of duct may become obstructed by a calculus, which
deep fascia of the neck. This parotid fascia is unfor- causes painful enlargement of the gland.
giving and inflammation of the gland may result in
severe pain. The sublingual glands lie anterior to hyoglossus in
the sublingual fossa of the mandible. These mucus
glands drain via multiple openings into the sub-
mandibular duct and sublingual fold in the floor of
the oral cavity.

26 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

CERVICAL LYMPH NODES
The neck is divided into six levels. These describe Level 5 – Posterior triangle: lateral border of
groups of lymph nodes. Their landmarks are: sternocleidomastoid (SCM), superior border of
clavicle, medial border of trapezius.
Level 1 – Submental and submandibular triangles,
Level 6 – Paratracheal lymph nodes medial to
bounded by the midline, digastric and the
the carotid.
mandible.
Level 2 – Anterior triangle including sternocleido- These levels allow description of the various
mastoid from skull base to the inferior border types of neck dissection that are performed when
of hyoid. managing malignant disease (Figure 1.18). For
Level 3 – Anterior triangle including sternocleido- example, a modified radical neck dissection involves
mastoid from inferior border of hyoid to inferior removal of levels 1−5.
border of cricoid.
Level 4 – Anterior triangle including sternoclei-
domastoid from inferior border of cricoid to
superior border of clavicle.

Preauricular node

Postaural node

Upper, middle
and lower cervical
nodes II
Sublingual node I
Posterior triangle
Submandibular node III

Supraclavicular V
Anterior triangle node IV
node

Figure 1.18. Lymph nodes groups and the triangles of the neck.

SENSORY DISTRIBUTION OF THE FACE

The sensory nerve supply of the face is derived from a pattern of vesicular eruption consistent with the
branches of the trigeminal nerve (Figure 1.19). distribution of that division.
Herpes zoster reactivation (shingles) will result in

Clinical anatomy 27
 Supraorbital

Supratrochlear
OPHTHALMIC DIVISION

External nasal lacrimal

Zygomaticotemporal
MAXILLARY DIVISION Zygomaticofacial
Infraorbital

Auriculotemporal
Buccal
MANDIBULAR DIVISION

Mental

Figure 1.19. Sensory distribution of the face.

28 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 2 ENT EXAMINATION

A thorough clinical examination is essential in the chapter provides a systematic and thorough, step-
diagnosis and management of any patient. This wise guide for clinicians assessing patients.

OTOSCOPY
Ensure that both you and the patient are seated comfortably into the ear and place it onto the
comfortably and at the same level. otoscope.

Examine the pinna, postaural region and Gently pull the pinna upwards and backwards to
adjacent scalp for scars, discharge, swelling straighten the ear canal (backwards in children).
and any skin lesions or defects (Figure 2.1). Infection or inflammation may cause this
Choose the largest speculum that will fit manoeuvre to be painful.

Site of endaural
incision

Site of postaural
incision

Figure 2.1. Examination of the pinna and postaural region. The pinna is pulled up and back and the tragus
pushed forward in order to straighten the external auditory canal during otoscopy.

ENT examination 29
Hold the otoscope like a pen and rest your small membrane (Figure 2.2). Adjust your position and
digit on the patient’s zygomatic arch. Any unex- the otoscope to view all of the tympanic
pected head movement will now push the speculum membrane in a systematic manner. The ear
away from the ear, preventing trauma. Use the light cannot be judged to be normal until all areas of
to observe the direction of the ear canal and the the tympanic membrane are viewed: the handle
tympanic membrane. The eardrum is better visual- of malleus, pars tensa, pars flaccida (or attic) and
ized by using the left hand for the left ear and the anterior recess. If the view of the tympanic
right hand for the right ear. Insert the speculum membrane is obscured by the presence of wax,
gently into the meatus, pushing the tragus forward. this must be removed. If the patient has undergone
This further straightens the ear canal. mastoid surgery where the posterior ear canal wall
has been removed, methodically inspect all parts
Inspect the entrance of the canal as you insert of the cavity and tympanic membrane or drum
the speculum. Pass the tip through the hairs of remnant by adjusting your position. The normal
the canal but no further. Looking through the appearance of a mastoid cavity varies, practice and
otoscope, examine the ear canal and tympanic experience will allow you to recognize pathology.

Scutum
PARS FLACCIDA

Chorda tympani Lateral process of

malleus
Long process of incus
Handle of malleus
PARS TENSA
Umbo
Eustachian tube
Round window niche Light reflex
Promontory

Anterior recess

Figure 2.2. Examination of the right pinna. The scutum (‘shield’) is a thin plate of bone that obscures the view
of the heads of the malleus and incus. It may be eroded by cholesteatoma and hence this area must always
be inspected.

RINNE’S AND WEBER’S TUNING FORK TESTING

Although there have been various reports regarding the also useful as a quick bedside test for checking that the
reliability of tuning fork tests (1), they are simple, quick patient has not suffered a dead ear following surgery.
and invaluable aids in the diagnosis of hearing loss (2).
Tuning fork tests can be used to confirm audiometric Traditionally, a 512 Hz tuning fork is used for
findings, especially if the hearing test does not seem testing. Low-frequency tuning forks provide
to be congruent with the clinical findings. They are greater vibrotactile stimulation (which can be

30 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

misinterpreted as an audible signal by the patient), If Rinne’s test is +ve on the left and −ve on the right,
while high-frequency tuning forks have a higher and Weber’s test lateralizes to the right side, this sug-
rate of decay (i.e., the tone does not last long after gests a conductive hearing loss in the right ear.
the tuning fork has been struck). There is evidence
to suggest, however, that a 256 Hz tuning fork is If Rinne’s test is −ve on the right and +ve on the
more reliable than a 512 Hz tuning fork (3,4). left, and Weber’s test lateralizes to the left side, this
suggests a right sensorineural hearing loss in the
The commonest tuning fork tests performed are the right ear.
Rinne’s and Weber’s tests. They must be performed
in conjunction in order to diagnose a conductive or
sensorineural hearing loss.
❚❘ Anterior rhinoscopy

The head mirror is often approached with some

❚❘ Rinne’s test trepidation by the junior ENT surgeon, who may
feel self-conscious as the mirror can be cumber-
A 512 Hz tuning fork is struck on the elbow. It is es- some. Many departments use headlights as an
sential that the examiner checks that they can hear alternative.
the tuning fork as this also serves as a comparative
test of hearing. The tuning fork is presented to the A right-handed examiner should position the Bull’s
patient with the prongs of the fork held vertically lamp over the patient’s left shoulder at head height
and in line with the ear canal. The patient is asked and wear the head mirror over their right eye. The
if they can hear a sound. The tuning fork is held by lamp light can be directed onto the head mirror and
the ear for a few moments before its base is firmly the beam focused onto the patient.
pressed against the mastoid process behind the ear.
The patient is asked, ‘Is it louder in front or when I Examine the profile of the nose, looking for
place it on your head?’ external deviation of the nasal dorsum. Check for
bruising, swelling, signs of infection, nasal discharge
As air conduction (AC) is better that bone conduc- and scars.
tion (BC) in a normal hearing ear, the tuning fork
is heard louder in front of the ear than when placed Gently raise the tip of the nose to allow you to
behind the ear (i.e., AC > BC). This is described as examine the vestibule of the nose and the antero-
Rinne +ve; if bone conduction is greater than air inferior end of the nasal septum.
conduction, this is Rinne –ve.
The Thudichum speculum is held in the non-
❚❘ Weber’s test dominant hand (i.e., the left if the examiner is
right-handed), leaving the dominant hand free to
A 512 Hz tuning fork is struck on the elbow and use any instruments.
firmly placed on the patient’s forehead. The patient
is asked, ‘Is the sound louder in your left ear, right Hold the metal loop on your index finger with the
ear, or somewhere in the middle?’ finger pointing towards you and the prongs away
from you.
As the hearing in both ears should be the same, in a
normal subject the sound heard will be ‘in the middle’. Swing your middle finger to one side of the Thu-
dichum and your ring finger to the other. You can
❚❘ Interpretation now squeeze the Thudichum and use the prongs
to open the nares to examine the nasal cavity. This
In order to diagnose a conductive or sensorineural provides a view of the nasal septum, inferior tur-
hearing loss, both Rinne’s and Weber’s tests must be binate and head of the middle turbinate. A flexible
performed (Figure 2.3). nasolaryngoscope or a rigid endoscope is required

ENT examination 31
 Rinne’s test Weber’s test

(a) AC > BC AC > BC Interpretation: Normal

+ve +ve

Interpretation: Right
(b) BC > AC AC > BC conductive hearing loss
−ve +ve

Interpretation: Right
(c) BC > AC AC > BC sensorineural hearing loss
–ve +ve

Figure 2.3. Interpretation of tuning fork tests.

in order to assess the middle meatus, posterior nasal the external auditory canal. Warn the patient
cavity and postnasal space. that they will hear a loud hissing noise and
may experience temporary dizziness following
In children, especially if a foreign body is suspected, the procedure.
it is often kinder simply to lift the tip of the nose
rather than use a Thudichum speculum. Alterna- Position the patient supine (or sitting in a chair)
tively, an otoscope provides an excellent view. with the head turned to the opposite side. With the
microscope illuminating the ear, take this opportu-
Nasal patency is assessed by placing a metal specu- nity to study the pinna, canal opening and sur-
lum under the nose. Misting or condensation on the rounding skin for scars or sinuses.
metal surface during expiration provides a measure
of nasal patency. Adjust the eye pieces and start with the lowest
magnification. Use the largest speculum that will
❚❘ Ear microsuction comfortably enter the external auditory canal. Hold
the speculum between the index finger and thumb,
Explain to the patient that microsuction is re- place the middle finger into the conchal bowl and
quired in order to remove debris and wax from gently pull the pinna posteriorly. This will open

32 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

and straighten the ear canal. If the ear canal is nar- The nasoendoscope may be used with or without a
row, use a smaller speculum or ask the patient to sheath, depending on local decontamination proto-
open their mouth (this manoeuvre often increases cols. Clean the tip of the scope with an alcohol wipe
the antero-posterior diameter of the canal as the to prevent condensation and apply a thin film of
condyl of the mandible is related to the anterior lubricant gel to the distal 5 cm of the nasoendoscope.
canal wall). Ensure the gel does not cover the tip of the scope
as this will occlude your view. The patient’s saliva
Assess the canal wall and contents. Remember that provides an effective alternative.
the hairy outer third of the canal is relatively insen-
sitive but the thin inner skin is exquisitely sensi- Ask the patient to breathe through their mouth
tive. Any contact with the speculum or suction will and, holding the end of the scope between the
produce a great deal of discomfort. index finger and thumb, place the tip of the nasoen-
doscope into the nasal cavity. Ensure full control
Using a wide bore sucker, begin by removing debris of the scope by placing the middle finger on the
within the lateral hairy portion of the canal. Aim tip of the patient’s nose. If a patient were to fall
to touch only the debris and not the canal skin. Try forward, the nasoendoscope will not be driven into
to remove all the debris, especially in cases of otitis the nasal cavity.
externa where debris will result in ongoing infec-
tion if not removed. A wax hook may be used as an Insert the scope into the nostril and pass it along
alternative method for wax removal. the floor of the nose with the inferior turbinate
laterally and septum medially. Posteriorly, the Eu-
If the debris or wax is too hard or the procedure too stachian tube orifice and postnasal space will come
uncomfortable for the patient, a course of sodium into view (see Chapter 1, Figure 1.2). If the septum
bicarbonate ear drops (two drops three times a day is deviated and the scope cannot be easily advanced,
for two weeks) will be required before a further at- try to pass it between the inferior and middle tur-
tempt at wax removal is made. binates (laterally) and the septum (medially). If this
is too uncomfortable for the patient, the other nasal
If the tympanic membrane is obscured, micro- cavity may be used.
suction along the anterior canal wall until the
tympanic membrane is visible (the tympanic mem- With the postnasal space in view, ask the patient to
brane is continuous with the posterior canal wall breathe in through their nose. This opens the inlet
and can be damaged if microsuction follows the into the oropharynx. Use the control toggle to flex
posterior canal wall). the distal end of the scope inferiorly and gently
advance.
If there is trauma to the ear canal or if bleeding
occurs, prescribe a short course of antibiotic ear
The uvula and soft palate will slide away and the
drops, warning the patient of the risk of ototoxicity.
base of tongue and larynx will come into view (see
Chapter 1, Figure 1.14).
❚❘ Flexible nasolaryngoscopy
Adopt a system to ensure that all aspects of this
Explain the procedure to the patient and ask the region are examined. The following is a guide:
patient which side of their nose is the easier to tongue base, valleculae, epiglottis (lingual and
breathe through, selecting this side for examina- laryngeal surfaces), supraglottis, interarytenoid bar,
tion. Spray the chosen side with local anaesthetic vocal cords (appearance and mobility), subglottis,
or insert a cotton wool pledget soaked in local pyriform fossae and posterior pharyngeal wall. The
anaesthetic. Patients often describe numbness of the larynx may be difficult to view in those patients
upper lip or back of their tongue, which can be used with an infantile epiglottis or prominent tongue
as a guide to the level of anaesthesia. base. Where this is encountered, ask the patient to

ENT examination 33
point their chin up to the ceiling to draw the tongue ❚❘ Rigid nasoendoscopy
base forward and bring the larynx into view. To
assess the pyriform fossae, ask the patient to blow Rigid endoscopy of the nasal cavity requires a
their cheeks out while you pinch their nose. If secre- systematic examination involving three passes with
tions obscure your view, ask the patient to swallow. either a 0° or 30° scope (Figure 2.4).

Remove the scope gently and supply patients with The first pass provides an overall view of the
tissues to use after completing the examination. anterior nasal cavity, the septum and the floor

1st

2nd

3rd

Figure 2.4. Rigid endoscopy. The first pass of the endoscope should pass along the floor of the nose, the
second is into the middle meatus and the third into the superior meatus and olfactory niche.

of the nasal cavity to the posterior choana. The Using the head mirror or headlight, begin by exam-
Eustachian tube cushion, orifice and the fossa of ining the lips and face of the patient. Note any scars
Rossenmüller, and adenoidal pad must also be or petechiae.
examined.
It is important to be systematic (Figure 2.5).
The second is into the middle meatus and allows Use two tongue depressors. Begin by asking the
identification of the uncinate process, middle patient to open their mouth and insert one tongue
meatal ostium and ethmoidal bulla. The third depressor onto the buccal surface of each cheek and
examines the superior meatus and olfactory niche; ask the patient to clench their teeth. Gently pulling
the sphenoid ostium may be identified during laterally, withdraw the blades examining the buccal
this pass. mucosa, gingivae, teeth, parotid duct orifices and
buccal sulci. Anteriorly, draw the blades superiorly
to examine beneath the upper lip and repeat with
❚❘ Examination of the oral cavity the lower lip.

Ensure that both you and the patient are seated Ask the patient to open their mouth and study the
comfortably, at the same level. superior surface of the tongue. With the tongue

34 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

(a) (b) (c)

Parotid duct
opening

(d) (e) (f)

Retromolar Frenulum
region
Papilla of the
Lateral border submandibular
of the tongue duct

(g)

Uvula
Posterior
pharyngeal wall

Figure 2.5. Examination of the oral cavity. A systematic approach must be used to assess the oral cavity fully.

pointing superiorly, examine the floor of the mouth Palpate the tongue including the tongue base.
and inferior surface of the tongue. The openings of Submucosal tumours in these structures can often
the submandibular ducts are found just lateral to be palpated before they are seen. Where the history
the frenulum of the tongue. is suggestive of an abnormality of the submandibu-
lar gland or duct, bimanual palpation should be
Using both tongue blades again, examine the retro- used.
molar regions and lateral borders of the tongue.

Ask the patient to keep their tongue in their mouth ❚❘ Examination of the neck and
and keep breathing. Gently depress the anterior facial nerve function
half of the tongue, avoiding the posterior third as
this can make patients gag. Examine both tonsils, Inspect the general appearance of the patient,
comparing their relative size. Inspect the orophar- noting any facial scars or asymmetry of facial tone
ynx, including uvula and movements of the soft at rest. Ensure adequate exposure of the patient
palate. Ask the patient to look up to the ceiling and by removing neck ties and unfasten the upper
examine the hard palate. shirt buttons so that both clavicles are visualized.

ENT examination 35
Inspect the neck, noting scars, sinuses, masses or The most commonly used grading system is the
tattoos (these were previously used to mark radio- House-Brackmann facial grading system. Note
therapy fields). that there is complete eye closure in a grade 3 and
incomplete eye closure in a grade 4 facial palsy.
Stand behind the subject and sequentially palpate
the same lymph node levels on both sides of the Grade 1 − Normal.
neck simultaneously (Figure 2.5). It is important Grade 2 − Slight weakness with good eye closure
to be systematic. Start with the submental then with minimal effort, good forehead movement
submandibular triangles (level 1), followed by the and slight asymmetry of the mouth.
jugulodigastric and jugular lymph nodes (levels 2, Grade 3 − Symmetry and normal tone at rest with
3, 4) by palpating along the anterior border of each obvious weakness, although complete eye closure
sternocleidomastoid muscle and the paratracheal and asymmetrical mouth movement with effort.
region. Examine the posterior triangle nodes. Grade 4 − Incomplete eye closure, no movement
Working posteriorly, palpate the parotid gland, of the forehead, but symmetry and normal tone
postaural and occipital lymph nodes. at rest.
Grade 5 − Asymmetry at rest with barely percep-
Once again, palpate the laryngeal skeleton and tible movement of the mouth and incomplete
thyroid gland from behind. Note the site, size and eye closure.
appearance of any mass and whether it is tethered Grade 6 − No movement.
to the skin or underlying muscles. Assess whether
the mass moves with swallowing (give the patient a When faced with a true lower motor neuron palsy,
glass of water to drink) or tongue protrusion. Aus- look for a cause by examining the remaining cranial
cultate for a bruit and, in the case of a thyroid mass nerves, perform otoscopy to exclude middle ear
with retrosternal extension, percuss from superior pathology and palpate the parotid glands. Audiology
to inferior along the sternum. is required with tympanometry, a pure tone audio-
gram and occasionally stapedial reflexes.
❚❘ Examination of facial nerve
function REFERENCES
1 Burkey JM, Lippy WH, Schuring AG, Rizer FM
Sitting level with the patient, examine their general (1998). Clinical utility of the 512-Hz Rinne
appearance and for any scars or masses. tuning fork test. Am J Otol 19: 59−62.
2 Behn A, Westerberg BD, Zhang H, et al (2007).
Ask the patient to raise their eyebrows and compare
Accuracy of the Weber and Rinne tuning fork
both sides. Remember that there is crossover in the
tests in evaluation of children with otitis media
innervation of this region so that a patient is still
with effusion. J Otolaryngol 36: 197−202.
able to wrinkle their forehead in a unilateral upper
3 Browning GG, Swan IR (1988). Sensitivity and
motor neuron palsy.
specificity of Rinne tuning fork test. BMJ 297:
1381−2.
Ask the patient to shut their eyes tightly, flare their
4 Browning GG, Swan IR, Chew KK (1989).
nostrils, blow out their cheeks and bare their teeth.
Clinical role of informal tests of hearing.
Where facial weakness is observed, blinking repeat-
J Laryngol Otol 103: 7−11.
edly may reveal synkinesis where reinnervation has
occurred along incorrect pathways; contraction
of obicularis oris may result in contraction of the
angle of the mouth.

All patients must have their facial weakness

graded so that any changes can be monitored.

36 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 3 COMMON ENT
PATHOLOGY

OTITIS EXTERNA
Otitis externa is inflammation of the external commonly caused by S. aureus infection of a hair
auditory canal. It is common, extremely painful follicle in the ear canal and is exquisitely painful.
and often precipitated by irritants such as cotton Incision and drainage are often required, together
buds. There may be an infective component, com- with topical antibiotics.
monly bacterial, such as Pseudomonas aeruginosa,
Staphylococcus aureus and Proteus, or less frequently An important differential diagnosis of otitis externa
fungal, such as Aspergillus species or Candida albi- is malignant otitis externa, which is a necrotizing
cans. The external auditory canal is often swollen osteomyelitis of the ear canal and lateral skull
and filled with debris, that requires microsuction. base, which occurs more frequently in diabetics
Treatment is with one week of ear drops contain- and immunocompromised patients. Pseudomonas
ing a combination of steroid and antibiotic. Fungal aeruginosa is the most common cause and the
infections require a 3−4-week course of anti-fungal typical otoscopic appearance is granulation tissue
drops. An ear swab is useful in directing antibiotic or exposed bone on the floor of the ear canal. As the
selection where the infection does not resolve with infection spreads through the skull base, the lower
the initial treatment. cranial nerves (CN VII−XII) are affected. The diag-
nosis is usually made on computerized tomography
When the external ear canal is very swollen, a (CT) scan and the treatment is a prolonged (six-
wick is inserted to splint the meatus open to allow week) course of intravenous antibiotics followed
penetration of the topical treatment. This should by further oral antibiotics, regular microsuction,
be removed as the swelling decreases, usually after topical antibiotic−steroid ear drops, good glycaemic
48 hours. The infection may progress to involve control and analgesia. Sometimes a biopsy is needed
the pinna and peri-auricular soft tissues (cellulitis), to exclude malignancy and determine microbiologi-
necessitating hospital admission for intravenous cal sensitivities. Radioisotope scans (e.g., gallium) or
antibiotics. Sometimes the infection is localized magnetic resonance imaging (MRI) can be used to
and a small abscess, or furuncle, can form. This is assess the response to treatment.

IMPACTED WAX

Ear wax is composed of secretions from sebaceous impacted in 10% of children, 5% of healthy adults
and apocrine glands in the lateral third of the ear and nearly 60% of the elderly (1). Although often
canal mixed with dead squamous cells. It becomes asymptomatic, it may cause a significant conductive

Common ENT pathology 37

hearing loss and discomfort. Impacted wax needs to syringing. In otolaryngology departments, wax is
be removed to facilitate examination of the tympan- removed under the microscope using a Zoellner
ic membrane. In primary care, removal is facilitated sucker, wax hook, Jobson-Horne probe or crocodile
by the use of ceruminolytic agents (2) or ear syring- forceps. Care should be taken to avoid trauma to
ing. Syringing is, however, contraindicated in those the ear canal. The use of cotton buds by the patient
who have a tympanic membrane perforation or who should be discouraged as this impacts the wax and
have developed otitis externa following previous traumatises the ear canal causing otitis externa.

ACUTE OTITIS MEDIA (AOM)

Inflammation of middle ear mucosa mainly af- be treated by insertion of grommets or long-term
fects young children as part of an upper respira- antibiotics.
tory tract infection. Causative organisms in-
clude viruses and bacteria, such as Streptococcus Rare but potentially serious complications of AOM
pneumoniae, Haemophilus influenza and Moraxella (and more commonly of acute mastoiditis − see
catarrhalis. Patients present with general symptoms below) can be classified anatomically into three
of irritability, pyrexia and nausea, with ENT groups:
symptoms of otalgia and hearing loss. Examina-
tion reveals a bulging erythematous tympanic 1 Intratemporal − Tympanic membrane perfora-
membrane, which may perforate and discharge tion, facial nerve palsy (particularly if the tym-
pus. Initial treatment is supportive, with simple panic segment of facial nerve is dehiscent) and
analgesia or antipyretics. If symptoms persist, acute mastoiditis with mastoid abscess.
oral antibiotics such as amoxicillin or clarithro- 2 Intracranial − Meningitis, brain abscess,
mycin are indicated (3). Frequent episodes of encephalitis and sigmoid sinus thrombosis.
AOM (more than four episodes over six months) 3 Systemic − Septicaemia, septic arthritis and
require ENT referral. Recurrent otitis media may endocarditis.

OTITIS MEDIA WITH EFFUSION (OME) (GLUE EAR)

Persistent otitis media with bilateral effusions hearing aids rather than grommet surgery if they
(OME) is the most common cause of hearing loss have OME. Children with cleft palate can be offered
in children. The typical audiological finding is a grommets as an alternative to hearing aids.
mild to moderate conductive hearing loss, associ-
ated with a flat (type B) tympanogram. Bilateral Adults with persistent unilateral OME should
grommet insertion is indicated (4) where effu- undergo examination of the postnasal space under
sions persist for over three months associated with general anaesthesia, with a biopsy taken from the
a hearing level in the better hearing ear of 25−30 fossa of Rosenmüller, immediately posterior to the
dB HL or worse, averaged at 0.5, 1, 2 and 4 kHz. Eustachian tube orifice, to exclude the possibility of
Children with Down’s syndrome should be offered a nasopharyngeal tumour.

ACUTE MASTOIDITIS
Acute mastoiditis is an inflammatory process complication of acute otitis media. Patients are
affecting the mastoid air cells; it occurs most generally unwell, with spiking temperatures. There
commonly in children. It is an uncommon is a post-auricular abscess with lateral and anterior

38 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

displacement of the pinna and tenderness over the anatomy, particularly where there is failure to
mastoid bone. The majority of cases respond to improve after 48 hours or the suspicion of compli-
medical treatment with intravenous antibiotics, cations demands surgical intervention (see above);
analgesia and hydration (5). A contrast-enhanced commonly, cortical mastoidectomy and grommet
CT scan is used to exclude a brain abscess, lat- insertion with placement of a corrugated drain
eral sinus thrombosis and assess temporal bone within the post-auricular wound.

PINNA HAEMATOMA
Blunt trauma to the pinna may result in a sub- the scar will be least visible, ideally along the
periosteal haematoma. Since the cartilage gains rim of the conchal bowl, under the helical rim
its nutrient supply from the overlying perichon- or approached from the cranial surface of the
drium, an untreated pinna haematoma results pinna (with a small window of cartilage excised).
in cartilage necrosis and permanent deformity – ‘Through-and-through’ sutures can be placed to
‘cauliflower ear’. Needle aspiration of a pinna secure silastic splints or dental rolls, to achieve
haematoma followed by a compression bandage more reliable pressure and prevent haematoma
is rarely effective. A small incision through the recurrence under the head bandage. All patients
overlying skin under local anaesthetic allows should receive co-amoxiclav or an equivalent anti-
continued drainage and is a more definitive treat- biotic to prevent perichondritis and be reviewed
ment (6). The incision should be placed where after 7 days for suture removal.

PERICHONDRITIS AND PINNA CELLULITIS

Inflammation of the perichondrium (perichon- should be sought in order to exclude relapsing
dritis) can result in a permanent deformity of perichondritis.
the pinna. It commonly occurs as a result of
bacterial infection following trauma to the pinna Perichondritis and pinna cellulitis require a combi-
from a piercing, insect bite or skin abrasion, nation of intravenous and oral antibiotics as carti-
although can also be secondary to otis externa. lage compromise can lead to marked disfigurement
The pinna is swollen, erythematous and extremely of the pinna. Piercings in the affected ear should be
tender. Previous episodes of perichondritis or removed. Rarely, surgery is required to drain a col-
inflammation of other cartilaginous structures lection or debride necrotic soft tissue (7).

SUDDEN SENSORINEURAL HEARING LOSS (SSHL)

This is a unilateral or bilateral subjective deteriora- viral and vascular insults to the inner ear and rup-
tion in hearing, which develops over seconds to ture of the cochlear membrane. Approximately 60%
hours and on objective testing is confirmed to be of patients improve with or without intervention
sensorineural in nature. A conductive hearing loss and evidence for any particular treatment is mixed.
should first be excluded by careful examination of Treatment options include prednisolone (oral or in-
the ear, tuning fork tests and a pure tone audio- jected into the middle ear) (9), aspirin, betashistine
gram. In 88% of cases, no obvious cause is found, (10), acyclovir and inhaled carbogen (oxygen mixed
but a careful history and examination should with 5% CO2) (11). Unilateral loss may be managed
consider potential infective, auto-immune, vascular, in the outpatient setting, but those with bilateral
traumatic, neoplastic and neurological causes (8). loss require admission for investigation (blood tests
Competing theories for idiopathic cases include to exclude autoimmune causes and MRI scanning).

Common ENT pathology 39

FACIAL NERVE PALSY
There are a wide variety of causes for a facial nerve in order to protect the cornea. If the eye becomes
palsy. Lower motor neurone lesions are distin- painful or red an urgent ophthalmic opinion should
guished from upper motor neurone lesions by the be sought.
absence of forehead movement (forehead move-
ment is spared in upper motor neurone lesions as a Approximately 60% of patients with an idiopathic
result of the bilateral upper motor neurone distri- palsy recover to House Brackmann grade 1 or 2.
bution supplying this area). All patients must have A further 12% suffer a recurrence on the same or
their degree of facial weakness recorded using the contralateral side.
House Brackmann scale.
❚❘ Ramsay Hunt syndrome
Lower motor neurone pathology can occur any-
where along the path of the affected nerve. An This condition is caused by herpes zoster. The facial
assessment of the cranial nerves, ear, parotid gland, palsy is accompanied by painful vesicles on the pinna
oral cavity and neck examination is mandatory. or external auditory canal, and occasionally the soft
palate. Onset is rapid and the 8th nerve may become
Causes include Bell’s palsy, Ramsay Hunt Syn- involved with concurrent hearing loss and vertigo.
drome, malignant otits externa, ear or parotid Treatment is similar to that of Bell’s palsy (14,15).
surgery, middle ear disease temporal bone fracture
and iatrogenic trauma. ❚❘ Acute suppurative otitis media
(ASOM)
❚❘ Bells palsy
An acute otitis media may result in a facial nerve
This syndrome of facial paralysis is a diagnosis of palsy, typically if the bony canal of the facial nerve
exclusion. Although described as idiopathic, there is is dehiscent within the middle ear cleft. Treatment
evidence to suggest the palsy occurs due to herpes includes intravenous antibiotics, oral steroids and
reactivation. A thorough history and examination are nasal decongestants. CT of the temporal bone may
required. An MRI is only indicated if this is a recur- be of value in order to exclude chrinoc supporative
rent palsy or if the palsy fails to recover (12). oititis media (CSOM). A myringotomy may be con-
sidered appropriate if there is no clinical improve-
Initial treatment is with oral prednisolone (1 mg ment following 24–48 hours of medical treatment.
per kg, typically 60 mg for an adult) for seven days.
Although there is inconclusive evidence to support ❚❘ Trauma
the use of antivirals, acyclovir (800 mg five times a
day for 10 days) is also often prescribed (13). Any Every patient undergoing middle ear surgery must
patient with a facial nerve palsy who is unable to have their facial nerve function recorded pre- and
close their eye (House-Brackmann grade 4–6) must post-operatively. Iatrogenic damage may require
use artificial tears and tape their eye closed at night surgical re-exploration and nerve repair.

FOREIGN BODIES–EAR
Foreign bodies within the external ear canal the only chance. If the foreign body cannot be re-
commonly affect children and may be difficult to moved, a short general anaesthetic in the following
remove. Children will need to be held by a parent few days is indicated to allow removal. The excep-
or nurse, and the first attempt at removal is often tion are batteries, which are corrosive and must be

40 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

removed that day. Objects can be removed under to objects that can be grasped. Insects should be
the microscope using a wax hook, microsuction drowned using olive oil prior to removal. Do not
or irrigation (Figure 3.1). The use of crocodile attempt to flush out tablets, seeds or nuts (organic
forceps can result in medial displacement of the materials) as these swell and become more difficult
foreign bodies and their use should be restricted to remove.

Wax
hook

Bead

Figure 3.1. Removal of a bead from the external auditory canal.

TYMPANIC MEMBRANE TRAUMA

Pressure changes or direct trauma can dam- more common when there is an accompanying
age the external auditory canal and tympanic temporal bone fracture.
membrane. On otoscopy, the tympanic mem-
brane is often obscured by blood. Tuning fork Treatment is generally conservative. Patients are reas-
tests and audiograms are used to assess hear- sured and advised to keep the ear dry and have an
ing. Hearing loss may be conductive due to outpatient follow-up at six weeks, where spontaneous
blood in the middle or external ear or ossicular healing of tympanic membrane is usually confirmed.
discontinuity. Sensorineural hearing loss is An audiogram documents return of hearing to normal.

TEMPORAL BONE FRACTURES

The temporal bone contains many vital structures, sparing has been shown to be more predictive of
including the facial nerve, cochlea, labyrinth, ossi- complications (16). Initially, advanced trauma
cles, internal carotid artery, jugular vein and sigmoid life support (ATLS) management takes priority
sinus. Temporal bone fractures are traditionally as temporal bone fractures can be associated with
classified as longitudinal, transverse and oblique, in significant head injury. Clinical signs include blood
relation to the petrous ridge of the temporal bone. in the ear canal, haemotympanum and Battle’s
The usefulness of this classification system has been sign (post-auricular bruising). Of more concern
questioned and a newer system categorizing injuries are sensorineural hearing loss, vertigo, facial nerve
on CT as otic-capsule violating and otic-capsule injury and cerebral spinal fluid (CSF) otorrhoea.

Common ENT pathology 41

Facial nerve function immediately after injury must paralysis is suggestive of nerve transection and
be documented. CT scanning is helpful in excluding may require surgical exploration. However, most
intracranial injury, identifying damage to important traumatic facial nerve palsies are delayed in onset,
intra-temporal structures and classifying the type secondary to fracture-related nerve oedema and are
of fracture. Immediate-onset severe facial nerve treated conservatively with steroids.

FOREIGN BODIES–NOSE
Foreign bodies in the nose should be removed as wax hook allow removal in most cases. A useful
soon as possible as there is a theoretical risk of additional removal technique is the ‘parent’s kiss’,
aspiration (Figure 3.2). As with foreign bodies in whereby the parent blows air into the mouth of
the ear, children need to be held by a parent the child while occluding the contralateral nostril
or nurse, often with a blanket wrapped around (17). If these manoeuvres are unsuccessful, a short
the body and arms. A headlight, suction and general anaesthetic is required for removal.

Wax hook

Figure 3.2. Removal of a foreign body from the nasal cavity.

NASAL TRAUMA
Nasal trauma may result in a deviated bridge. A patient should be recalled 5–7 days post injury and
patient who has sustained a nasal injury, with sus- the nasal bridge reassessed.
pected deviation of the nasal bones should be first
assessed for other injuries (ATLS protocol). If the nasal bones are deviated, and the patient
desires it, the nose can be manipulated under local
The nose should be examined to exclude a septal or general anaesthesia (18). It is essential that this is
haematoma and any epistaxis managed. Swelling performed within 14 days of the initial injury as the
over the nose may prevent an accurate assess- bridge may become fixed, making simple manipula-
ment of the position of the nasal bones. Hence, the tion impossible. Risks include epistaxis, periorbital

42 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

bruising and septal haematoma. Patients should be prior to the injury. The nose will remain unstable
warned that the aim is to straighten the bony bridge until the bones have re-healed and so further injury
and that their nose may appear different to that should be avoided.

SEPTAL HAEMATOMA / ABSCESS

Septal haematomas can rapidly develop following made and a corrugated drain sutured in place (a trou-
nasal trauma or after septal surgery. A haematoma ser drain may be required with a ‘leg’ on either side of
can become secondarily infected resulting in an ab- the septal cartilage). Antibiotic treatment is required
scess. Patients describe nasal obstruction and pain. following abscess drainage and a pus swab sent to mi-
Examination usually reveals bilateral septal swell- crobiology. A septal haematoma or abscess should be
ing, which is compressible on palpation. Pus may be seen within a few hours and operated on within a day,
seen lying on the surface of the septum. as prolonged devascularisation of the cartilage results
in its re-absorption resulting in nasal deformity (19).
Patients require formal incision and drainage under In addition, infection may extend intracranially via
general anaesthetic. A hemitransfixtion incision is the ophthalmic veins to involve the cavernous sinus.

ACUTE SINUSITIS
Acute sinusitis is generally managed in primary care worse on bending forward. Patients may be referred
with oral antibiotics and nasal decongestants. It if there are concerns regarding complications of si-
commonly occurs following an acute upper respira- nusitis such as periorbital cellulitis. Fungal sinusitis
tory tract infection and presents with purulent nasal should be considered when assessing patients who
discharge, nasal obstruction and facial pain that is are immuno-compromised.

PERIORBITAL CELLULITIS
Periorbital cellulitis is an ENT emergency and and it is worth seeking paediatric and ophthalmo-
patients may become blind within a matter of hours. logical consultations early. Patients with periorbital
A subperiosteal abscess may arise due to spread of cellulitis or a potential intraorbital collection should
infection from the ethmoidal air cells laterally into be discussed promptly with a senior so that they can
the orbital cavity. Patients often describe a recent be reviewed or their management discussed.
upper respiratory tract infection. These patients must
be discussed promptly with a senior colleague so that An urgent CT scan of the paranasal sinuses is
they can be reviewed or their management discussed. essential. For young children preparations may be
made to perform the scan under general anaes-
thetic, proceeding to surgery if the imaging reveals
The eyelids may be swollen with associated che- a collection. Children should receive appropriate
mosis, and there may be proptosis of the eye. It is analgesia, intravenous antibiotics (normally a 3rd
important to assess red colour vision, in particular, generation cephalosporin) and, if there is evidence
and this may be performed using an Ishihara chart. of sinusitis, paediatric nasal decongestant.
Visual acuity and eye movements, also require regu-
lar monitoring. Restricted eye movement or pain on Surgical decompression of a subperiosteal
eye movement is often associated with an abscess. abscess is performed endoscopically or via a
Given that the condition predominantly occurs in Lynch-Howarth incision. A drain is required if an
children, such an examination can be challenging open approach is used.

Common ENT pathology 43

TONSILLITIS
Tonsillitis is most commonly bacterial, caused by must undergo flexible nasolaryngoscopy. In such
Streptococci, Staphylococci or Haemophilus influ- cases, these patients should be given steroids
enza. Viral infections also occur, most commonly (either 8 mg dexamethasone IV or hydrocortisone
the Epstein-Barr virus (EBV), which is the cause 200 mg IV), discussed with a senior colleague
of infectious mononucleosis or glandular fever. and closely monitored in an ENT airway obser-
Patients have a painful throat with odynophagia vation bed or in a high dependency or critical
(pain on swallowing) and sometimes referred care unit. If, conversely, a patient complains of
otalgia. They are treated in primary care with a severe sore throat and has tonsils with normal
phenoxymethylpenicillin (Penicillin V), or a mac- appearances, immediate nasolaryngoscopy should
rolide if they are penicillin-allergic. Ampicillin, be performed to assess whether the diagnosis is
Amoxicillin and Co-Amoxiclav should be avoided supraglottitis.
as these can precipitate a severe scarring rash in
patients with EBV. Inpatient treatment is normally required for no
more than 24–48 hours and patients are discharged
If patients are unable to swallow fluids, they should with analgesia and oral antibiotics. A short course
be admitted to hospital for re-hydration and intra- of steroids may be useful in patients with glandular
venous antibiotics. Bloods are sent for a full blood fever, who should also be advised to refrain from al-
count, electrolytes, liver function tests, C reactive cohol for two months while the liver recovers from
protein, and the locally-agreed test for EBV. the acute injury. They should also be advised to
avoid contact sport as EBV-induced hepatospleno-
Intravenous benzylpenicillin is required and oral megaly can put them at risk of internal bleeding
soluble paracetamol, codeine and a non-steroidal from any abdominal injury. If patients meet the
anti-inflammatory for analgesia. Tonsillar criteria for tonsillectomy (see tonsillectomy section)
enlargement may cause airway obstruction, and this can be considered after the inflammation has
if there is any suggestion of compromise patients settled – an ‘interval’ tonsillectomy.

PERITONSILLAR ABSCESS
Also known as a quinsy, a peritonsillar abscess is a and 10 or 20 mL syringe is used (1 cm of the tip of
collection of pus that develops between the tonsil- the needle sheath can be cut off and the remain-
lar capsule and the surrounding superior constric- der of the sheath replaced on the needle to act as
tor muscle. This condition mainly occurs in young a guard preventing over-insertion). The needle is
adults, either spontaneously or as a result of acute pointed towards the back of the mouth (rather than
tonsillitis. drifting laterally), and the area of maximal fluctu-
ance aspirated (or on an arc between a third of the
On examination, the patient has trismus (an in- way, and half way from the base of the uvula to the
ability to fully open the mouth), and the uvula last upper molar).
is pushed away from the midline by the swelling
under the soft palate. If large, a quinsy may cause Incision and drainage can be performed in the same
airway compromise. location using a no.11 blade with tape wrapped
around the blade to expose only the distal 1 cm.
The soft palate is first sprayed with local anaes- The incision can be opened by the use of Tilley’s
thetic, and the collection aspirated to confirm the dressing forceps, and a Yankauer sucker can be used
presence of pus. A 19G white needle on a luer-lock to remove the purulent material.

44 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

Patients are usually admitted and treated as for se- antibiotic therapy although patients are usually
vere tonsillitis with intravenous antibiotics, although managed with benzylpenicillin and metronidazole.
where symptoms completely resolve after drainage,
outpatient antibiotic therapy may be sufficient. It is
helpful to send a sample to microbiology to guide

SUPRAGLOTTITIS
Supraglottitis is inflammation of the soft tissues ITU or a high dependency unit but the milder cases
immediately above the vocal cords. It is normally may be observed in an easily-visible ‘airway’ bed on
caused by Haemophilus influenzae, Streptococcus an ENT ward.
pneumoniae or Streptococcus pyogenes. Patients
usually complain of a short history of a sore throat Adrenaline nebulisers (1 mL of 1:1000, or diluted
with rapid hoarseness and dysphagia. This may be in 4 mL of normal saline) are effective in reducing
sufficiently severe to prevent them from swallowing some of the mucosal swelling. Heliox (Helium/oxy-
their saliva. gen) provides relief as this low density gas increases
flow. Patients should be cannulated and given
These patients must be assessed as a priority as the intravenous dexamethasone 8 mg or hydrocortisone
airway can rapidly deteriorate. Shortness of breath, 200 mg to help reduce mucosal oedema, although
tachypnoea or stridor are worrying features and a this only works fully after a few hours. Intravenous
senior ENT and anaesthetic input should always 3rd generation cephalosporins are normally the
be sought. Flexible nasolaryngoscopy should be antibiotic of choice. These patients may need inter-
performed with caution where significant airway vention to secure their airway such as intubation,
obstruction is present. Depending on the severity of tracheostomy under local anaesthesia, or emergency
the airway compromise patients may be nursed in cricothyroidotomy.

EPIGLOTTITIS
Severe inflammation of the epiglottis in children is should not be examined nor cannulated. A Senior
fortunately now rare as a result of the Haemophylus anaesthetist and ENT surgeon must be called. The
influenzae Type B vaccine (20, 21). patient is taken to theatre in order to secure the
airway by intubation, although an emergency tra-
Children present with stridor; drooling is common, cheostomy may occasionally be required. Patients
and ‘sitting upright’ (in the ‘sniffing the morning are kept intubated and treated with intravenous an-
air’ position) to maximize the available airway. tibiotics until a leak around the cuff of the endotra-
cheal tube is observed, an indication of decreased
Any potential stimulant can send them into airway swelling.
complete airway obstruction. These children

SMOKE INHALATION
Patients who have been exposed to dense smoke are hospital in a high dependency setting. Singeing of
often admitted under chest physicians. The upper the nasal hair and soot on the nasal or oral mu-
airway must not be neglected. The effects of smoke cosa and voice change indicate smoke inhalation.
injury on the larynx can develop over several hours Nasolaryngoscopy should be performed to visual-
and these patients should be closely monitored in ize the larynx and this may need to be repeated if

Common ENT pathology 45

symptoms deteriorate. Steroids can be useful in opment of marked laryngeal inflammation may
reducing mucosal oedema. These patients should be prevent intubation and necessitate a tracheostomy
discussed with a senior promptly, because devel- to secure the airway.

PARAPHARYNGEAL ABSCESS
An abscess may form within the parapharyngeal with limitation of movement, and may have trismus.
space. This is an inverted pyramidal space bounded There will be a palpable swelling in the upper neck
superiorly by the skull base, medially the pharynx, near the angle of the jaw, with medialisation of
posteriorly by the prevertebral muscles, laterally by the oropharynx. History and examination find-
the mandible and parotid fascia, with its apex at the ings should help to identify the initial source of the
greater cornu of the hyoid bone. infection and antibiotics (normally a cephalosporin
and metronidazole) should be commenced intrave-
Infection may arise from a dental or pharyngeal nously. Patients require a contrast enhanced CT scan
source (commonly tonsil). The carotid sheath runs to confirm the presence of a collection and to plan
through the parapharyngeal space and therefore, potential surgical drainage (these include an external
infections in this area can lead to thrombosis of the neck approach, or via a transoral route following
great vessels or airway compromise (22). Patients excision of the tonsil). Patients should, therefore, re-
report throat discomfort, unilateral neck swelling main starved until discussed with a senior colleague.

RETROPHARYNGEAL ABSCESS
In the absence of a penetrating foreign body, a examination. A full blood count with inflammatory
retropharyngeal abscess normally occurs in chil- markers and a lateral soft tissue neck radiograph
dren and results from necrotic degeneration of a will help confirm the diagnosis, but a CT scan of
retropharyngeal lymph node. In adults they can the neck with contrast is required.
rarely result from the spread of spinal tuberculosis
(22). Patients present with stridor, neck stiffness, In some situations, a tracheostomy is first performed
pain, and dysphagia. Protrusion of the posterior under local anaesthetic in order to secure the airway,
pharyngeal wall can be seen on nasendoscopic before the abscess is drained via a per-oral route.

FOREIGN BODIES (UPPER AERO-DIGESTIVE TRACT)

Oral cavity − Foreign bodies are usually easily foreign body. However, a lateral soft tissue
visible on examination with a headlight. It is x-ray is indicated, although some fish bones
also possible to palpate the floor of the mouth, are not radio-opaque (23). Foreign bodies can
tongue and other structures to identify a foreign be carefully removed per-orally using Magill
body. The foreign body can be carefully removed forceps.
per-orally with conventional instruments. Hypopharynx/oesophagus − Foreign bodies rang-
Oropharynx – Foreign bodies, typically fish bones, ing from meat or fish bones, soft food bolus to
may not be readily visible. Careful examination batteries and coins can obstruct in this region.
of the tonsils, posterior pharyngeal wall, tongue Patients will complain of a foreign body sensa-
base and valleculae is essential, using both the tion, pain, dysphagia or drooling. If the foreign
headlight and flexible nasoendoscope. Visual body is above the cricopharyngeus, patients can
examination is typically sufficient to exclude a reliably locate the site of impaction (24).

46 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

The most common sites of oesophageal obstruction perforation and subsequent complications,
are at the: including parapharyngeal or mediastinal
abscess, which can be fatal.
● Cricopharyngeus.
● Arch of aorta.
Larynx/Trachea − A foreign body in the larynx
● Tracheal bifurcation.
or trachea can cause stridor, voice change, chok-
● Gastro-oesophageal junction.
ing, cyanosis, difficulty breathing, tachypnoea
The hypopharynx can be examined with the flexible and pneumonia. In an emergency, where total or
nasoendoscope looking carefully in the pyrifom partial obstruction causes compromise, a back
fossae and post-cricoid region. Pooling of saliva in slap or abdominal thrust (Heimlich manoeuvre)
the hypopharynx is suggestive of an oesophageal is employed (27).
foreign body.
In stable patients suspected of having inhaled a
If the foreign body is not easily visualized in the foreign body, further investigation is mandatory. In
hypopharynx or oesophagus a soft tissue neck film young children, the distinction between ingestion
or chest film (anterior posterior (AP) and lateral) is and inhalation is often blurred and they should
required. Where a fish bone is difficult to locate CT undergo both chest PA inspiration and expiration
is more accurate (25, 26). views and abdominal films. A senior opinion is
sought regarding the need for formal endoscopy,
If the bolus contains no bony or sharp material, which is highly likely.
these can be initially managed with fizzy drinks or
pineapple juice. Buscopan or diazepam can relieve Most inhaled foreign bodies enter the trachea and
any spasm and allow the bolus to pass into the stom- then lodge in the right main bronchus.
ach. If a soft bolus is in the lower oesophagus, then a
flexible oesophagogastroduodenoscopy (OGD) is a Foreign bodies at the laryngeal inlet can be
safer option to push the bolus into the stomach. removed using an anaesthetic laryngoscope and
Magill forceps. Foreign bodies in the trachea
If the foreign body is a bone, sharp fragment or and main bronchus require formal tracheo-
non-organic, especially a battery, then removal bronchoscopy.
is required urgently to avoid oesophageal

LEAKAGE OR LOSS OF TRACHEOESOPHAGEAL

VOICE PROSTHESIS
The speech and language therapist or ENT special- in water) while carefully looking at the valve and
ist nurse usually undertakes the routine manage- stoma with a headlight.
ment of the voice prosthesis in patients who have
undergone laryngectomy. It is important, however, Central leakage through the voice prosthesis is the
that all ENT doctors are able to manage a leaking most common. This signifies damage to the valve
voice prosthesis or inadvertent dislodgement. by Candida colonization or inadvertent dam-
age during cleaning of the voice prosthesis. The
In all cases of leakage the patient should be advised problem is resolved by fitting a new voice prosthe-
to remain nil by mouth until after appropriate sis by an appropriately trained healthcare profes-
assessment to minimize aspiration. To assess the sional. If no one is available, the patient is kept
leakage ask the patient to swallow a small sip of nil by mouth and a fine bore feeding tube can be
coloured fluid (e.g., coloured cordial or food dye passed through the lumen of the voice prosthesis

Common ENT pathology 47

or a nasogastric tube placed for feeding until a management of acute mastoiditis in children.
new voice prosthesis can be fitted. If this becomes Int J Pediatr Otorhinolaryngol 72: 629−34.
a recurrent problem, then consideration can be 6 Jones SEM, Mahendran S (2004). Interventions
given to fitting a more expensive, anti-fungal for acute auricular haematoma. Systematic
voice prosthesis (28, 29). Reviews 2: CD004166.
7 Davidi E, Paz A, Duchman H, Luntz M,
Peripheral leakage around the voice prosthesis Potasman I (2011). Perichondritis of the
is less common and potentially more difficult to auricle: analysis of 114 cases. Isr Med Assoc J 13:
resolve. Leakage is caused by the tracheoesophageal 21–4.
puncture (TEP) becoming larger than the voice 8 O’Malley MR, Haynes DS (2008). Sud-
prosthesis. This can be related to tumour recurrence den Hearing Loss. Otolaryngol Clin N Am 41:
or infection, which must be excluded. A number of 633–49.
techniques are available to the appropriately trained 9 Wei BPC, Mubiru S, O’Leary S (2006).
individual, including fitting a larger voice prosthesis, Steroids for idiopathic sudden sensorineural
allowing the TEP to shrink and using a smaller voice hearing loss. Cochrane Database of Systematic
prosthesis or even removing the voice prosthesis and Reviews 1: CD003998. DOI: 10.1002/14651858.
allowing the TEP to close. If no one suitable is avail- CD003998.pub2.
able, the patient is kept nil by mouth and a fine bore 10 Agarwal L, Pothier DD (2009). Vasodilators and
feeding tube can be passed through the lumen of vasoactive substances for idiopathic sudden
the voice prosthesis or a nasogastric tube placed for sensorineural hearing loss. Cochrane Database
feeding until they can be appropriately managed. of Systematic Reviews 4: CD003422. DOI:
10.1002/14651858.CD003422.pub4.
If a patient inadvertently dislodges the voice pros- 11 Bennett MH, Kertesz T, Perleth M, Yeung P
thesis, most are taught to pass a dilator, 14Fr Jacques (2007). Hyperbaric oxygen for idiopathic sud-
or Foley catheter to keep the TEP patent or to attend den sensorineural hearing loss and tinnitus.
hospital for the same. If the voice prosthesis is not Cochrane Database of Systematic Reviews 1:
located, then it is prudent to pass a nasoendoscope CD004739. DOI: 10.1002/14651858.CD004739.
via the stoma to ensure that the voice prosthesis has pub3.
not been inhaled. A new voice prosthesis can be fitted 12 Danner CJ (2008). Facial Nerve Paralysis. Oto-
by an appropriately trained healthcare professional. laryngol Clin N Am 41: 619–32.
13 Sullivan FM, Swan IR, Donnan PT et al (2009).
A randomised controlled trial of the use of aci-
REFERENCES clovir and/or prednisolone for the early treat-
1 McCarter DF, Courtney AU, Pollart SM (2007). ment of Bell’s palsy: the BELLS study. Health
Cerumen impaction. Am Fam Physician 2007; Technol Assess 13(47): iii–iv, ix–xi 1–130.
75:1523–8. 14 Uscategui T, Doree C, Chamberlain IJ, Burton
2 Burton MJ, Doree C (2009). Ear drops for the MJ (2008). Antiviral therapy for Ramsay Hunt
removal of ear wax. Cochrane Database of syndrome (herpes zoster oticus with facial pal-
Systematic Reviews 1: CD004326. sy) in adults. Cochrane Database of Systematic
3 SIGN. Diagnosis and management of child- Reviews 4: CD006851. DOI: 10.1002/14651858.
hood otitis media in primary care. Available at: CD006851.pub2.
www .sign.ac.uk/guidelines/fulltext/66/index. 15 Uscategui T, Doree C, Chamberlain IJ, Bur-
html. ton MJ (2008). Corticosteroids as adjuvant
4 NICE. Surgical management of children with to antiviral treatment in Ramsay Hunt syn-
otitis media with effusion (OME). Available at: drome (herpes zoster oticus with facial palsy)
guidance.nice.org.uk/CG60. in adults. Cochrane Database of Systematic
5 Geva A, Oestreicher-Kedem Y, Fishman G, Reviews 3: CD006852. DOI: 10.1002/14651858.
Landsberg R, DeRowe A (2008). Conservative CD006852.pub2.

48 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

16 Little SC, Kesser BW (2006). Radiographic clas- 24 Connolly AAP, Birchall M, Walsh-Waring
sification of temporal bone fractures: clinical GP, Moore-Gillon V (1992). Ingested foreign
predictability using a new system. Arch Otolar- bodies: patient-guided localization is a useful
yngol Head Neck Surg 132: 1300−4. clinical tool. Clinical Otolaryngology and Allied
17 Purohit N, Ray S, Wilson T, Chawla OP (2008). Sciences 17(6): 520−24.
The ‘parent’s kiss’: an effective way to remove 25 Lue AJ, Fang WD, Manolidis S (2000)
paediatric nasal foreign bodies. Ann R Coll Surg Use of plain radiography and computed
Engl 90: 420−22. tomography to identify fish bone foreign
18 Chadha NK, Repanos C, Carswell AJ (2009). bodies. Otolaryngology Head and Neck
Local anaesthesia for manipulation of nasal Surgery 123(4): 435−38.
fractures: systematic review. J Laryngol Otol 26 Shrime MG, Johnson PE, Stewart MG (2007).
123: 830–6. Cost-effective diagnosis of ingested foreign
19 Ketcham AS, Han JK (2010). Complications bodies. The Laryngoscope 117(5): 785−93.
and management of septoplasty. Otolaryngol 27 UK Resuscitation Council (2010). Adult
Clin North Am 43: 897–904. Basic Life Support. Resucitation Guidelines:
20 Guardiani E, Bliss M, Harley E (2010). 25−6.
Supraglottitis in the era following widespread 28 Leder SB, Acton LM, Kmiecik J, et al (2005).
immunisation against Haemophilus influenzae Voice restoration with the advantage
type B: evolving principle in diagnosis and tracheoesophageal voice prosthesis. Otolaryn-
management. Laryngoscope 120: 2183–8. gol Head Neck Surg 133(5): 681−84.
21 Sobol SE, Zapata S (2008). Epiglottitis and 29 Soolsma J, van den Brekel MW, Ackerstaff
Croup. Otolaryngol Clin N Am 41: 551–66. AH, et al (2008). Long-term results of Provox
22 Vieira F, Allen SM, Stocks RM, Thompson JW ActiValve, solving the problem of frequent
(2008). Deep neck infection. Otolaryngol Clin candida- and ‘underpressure’- related voice
N Am 41: 459–83. prosthesis replacements. Laryngoscope 118(2):
23 Ell SR, Parker AJ (1992). The radio-opacity of 252−57.
fishbones. Clinical Otolaryngology and Allied
Sciences 17(6): 514−16.

Common ENT pathology 49

 4 EPISTAXIS

This common ENT emergency has been estimated cases (1). Patients may present in the acute setting
to affect 7−14% of the population, although or be seen on an elective basis in the outpatient
ENT specialists see only approximately 6% of all clinic with recurrent episodes of epistaxis.

ANATOMY
Multiple branches of both the internal and external common area to bleed is Little’s area the anterior
carotid arteries supply the nose, through multiple septum, also known as Kiesselbach’s plexus
anastamoses. The internal carotid artery, via the (Figure 4.1) (3).
ophthalmic artery, supplies the roof of the nasal
cavity by the anterior and posterior ethmoidal Although Woodruff ’s plexus has been described
arteries. The external carotid artery supplies the as a common site of posterior bleeding (4)
nasal cavity via the sphenopalatine, greater palatine (a venous plexus located inferior to the
and superior labial arteries (2). posterior end of the inferior turbinate), it is
now accepted that even posterior bleeds are
Most epistaxes arise from septal vessels rather more likely to be septal than from the lateral
than those of the lateral wall of the nose. The most nasal wall (5).

AETIOLOGY
Epistaxis can be classified into primary (idiopathic) angiofibroma) or malignant (sinonasal tumours),
or secondary (6). Around 80% of epistaxes are id- neoplastic or environmental (e.g., airborne par-
iopathic. Causative factors can be divided into local ticulate matter) (7).
and systemic (Table 4.1).
Systemic causes include: hypertension, antiplatelet
The most commonly identified local cause of or anticoagulant drugs (e.g., aspirin, clopidogrel,
epistaxis is trauma − digital, surgical or acciden- warfarin, heparin), haematological disorders
tal. Other local causes include infection, inflam- such as haemophilia, leukaemia, thrombocyto-
mation, foreign body, endocrine (e.g., during penia and hereditary haemorrhagic telangectasia
pregnancy), benign (e.g., juvenile nasopharyngeal (HHT).

50 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 Anterior ethmoidal artery (I)

Posterior ethmoidal artery (I)

Sphenopalatine artery (E)

Little’s area

Superior labial artery (E) Greater palatine artery (E)

Figure 4.1. Arterial blood supply to the nose. The nose has a rich blood supply, supplied by both internal
(I) and external (E) carotid arteries. Little’s area, or Kiesselbach’s plexus, represents a confluence of these
vessels.

Table 4.1. Local and systemic causes of epistaxis.

Local Systemic Disorders

Trauma Hypertension
Infection (e.g., upper respiratory tract infection Drugs (e.g., aspirin, warfarin)
(URTI), acute sinusitis)
Foreign body Haematological disorders:
Myelomas
Leukaemia
Haemophilia
Hepatic disorders
Chemical irritants Genetic conditions (e.g., hereditary haemorrhagic
telangectasia (HHT)

Neoplastic disorders
Benign/malignant neoplasm
Juvenile angiofibroma

Epistaxis 51
HISTORY
In the elective outpatient setting this can be taken factors including recent trauma or surgery. If
at leisure; in an acute bleed it is often taken while trauma is involved, significant head injury must be
treatment is being initiated. Important points excluded. In the past medical history, key factors
about the bleeding itself include onset, duration, include hypertension, coagulopathies and HHT.
side (may often start on one side then appear to Relevant drugs include antihypertensives, aspirin,
become bilateral due to overflow), whether anterior warfarin and heparin. Social history is important as
(running out of the nose) or posterior (swallowing it may determine whether a patient is safe to be dis-
blood), or both, with profuse bleeding; previous charged after a potentially heavy bleed. Frail elderly
episodes and any treatment given; precipitating patients living alone may not be.

MANAGEMENT
Never underestimate this ENT emergency. Always coagulation screens are not indicated in the
begin with the Airway, Breathing, Circulation absence of relevant risk factors (8). Check heart
(ABC) algorithm: rate and blood pressure and resuscitate with
fluids and/or blood as required. Remember that
Airway – If compromised, assess the oropharynx young patients may maintain a normal pulse
and suction any clots. rate and blood pressure until in severe shock.
Breathing Estimate blood loss and instigate simple first aid
Circulation – Ensure wide-bore intravenous access measures with firm compression of both nostrils,
and send blood for a full blood count and group head tilted forward, and apply ice to the back of
and save (G&S) in all but minor cases; routine the patient’s neck.

EXAMINATION
In the outpatient clinic, or if the acute bleed vessel. If no obvious bleeding point is seen and the
has settled, this can be done thoroughly. In the situation permits, complete the examination using
acute situation it may not be possible to examine a rigid Hopkins rod endoscope to evaluate the nasal
the patient fully, depending on the degree cavities and postnasal space.
of bleeding.
In emergency situations, wear gloves, an eye shield
If you are able to do so, begin with anterior rhinos- and an apron or gown. Suction is usually required
copy using a Thudichum’s speculum and headlight. during examination and treatment. Other equip-
This allows inspection of the anterior septum and ment needs to be available to allow further manage-
in particular Little’s area, a likely site of the bleeding ment as detailed below.

TREATMENT
It is important to correct hypertension and over- packs avoided in these cases if possible as they
anticoagulation. Medical or haematological input cause further trauma to the nasal mucosa with
may be required in difficult cases. Thrombocyto- inevitable re-bleeding on pack removal. Absorb-
penia is corrected with platelet transfusion and able packs, such as oxidized cellulose or gelatine

52 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

sponge soaked in adrenaline or tranexamic acid, are is controlled and the INR back in the therapeutic
a useful alternative. There is little to be gained from range. The use of low-dose diazepam has been
stopping aspirin therapy as the half-life of platelets advocated in the past, particularly in anxious hy-
is seven days, but if a warfarinized patient has an pertensive patients, but there is little evidence for its
elevated international normalized ratio (INR), then use and controlling the epistaxis is more effective in
withholding warfarin is advisable until the bleeding reducing both blood pressure and anxiety (9).

CAUTERY
Cautery aims to identify and seal the bleeding chlorhexidine dihydrochloride, 0.5% neomycin
vessel. This allows control of the epistaxis, avoids sulphate) is applied to the cauterized area twice
packing and in many cases allows the patient to be daily for 1−2 weeks. An alternative, such as chlor-
discharged after a period of observation. As most amphenicol ointment, should be used in patients
bleeding vessels arise in Little’s area, cautery is with peanut allergy, as Naseptin contains arachis
often possible with anterior rhinoscopy and a silver (peanut) oil.
nitrate cautery stick.
If an obvious vessel or bleeding point is not seen
After identifying the bleeding vessel, apply topical anteriorly, it may be possible to examine more pos-
anaesthesia, ideally combined with a vasocon- teriorly with a rigid endoscope, again after topical
strictor to keep the field as dry as possible (e.g., anaesthesia/vasoconstriction. While the use of silver
co-phenylcaine – 5% lidocaine with 0.5% phenyl- nitrate cautery is possible for posterior epistaxis, it
ephrine). This can be applied directly to the vessel is more difficult to be precise and avoid touching
on cotton wool. Silver nitrate cautery of the vessel other parts of the nose with the stick (10). If avail-
is then performed directly; if it is an ‘end-on’ ves- able, bipolar electrocautery is more practical for
sel, it can be helpful to cauterize around it before use with an endoscope, allowing diathermy of the
touching the vessel itself. Naseptin cream (0.1% specific bleeding point (11).

ANTERIOR NASAL PACKING

If the epistaxis is not controlled with simple back, not upwards. Once in place, sponges need to
measures, then packing is required. In the first be expanded with a little water; newer devices may
instance this is anterior nasal packing, which is have a concealed balloon that requires inflation.
most commonly performed with a nasal tampon
(Figure 4.2). Various packs are available, from Unilateral packing of the bleeding side may be
simple sponges such as Merocel™ to newer, self- sufficient. However, the expanded pack may push
lubricating, hydrocolloid-covered packs such as the septum across without providing adequate
Rapid Rhino™. compression. If bleeding does continue, insert a
contralateral pack.
The insertion technique is the same for all nasal
packs. Elevate the nasal tip with one hand and firm- Anterior packing may also be performed with a
ly push the pack in along the floor of the nose with long length of ribbon gauze soaked in bismuth
the other. It is preferable to support the back of the iodoform paraffin paste (BIPP). This is layered
patient’s head to facilitate complete insertion in one into the nose, along its whole length, using Tilley
smooth movement. Ensure that the pack is inserted dressing forceps (Figure 4.3). This is not a pleasant
parallel to the palate as the nasal cavity runs straight experience for the patient, whose head will need

Epistaxis 53
 Expanded
Merocel pack
in place

Figure 4.3. BIPP packing of the nasal cavity.

Figure 4.2. Insertion of a Merocel nasal tampon.

to be supported during the packing, but it can be a observation and pack removal after 24 hours
very effective way of providing more compression if stable. However, local protocols will be in
than nasal tampons. place and some patients may be discharged
with their pack(s) in situ, to return for
It is standard practice in most departments to follow-up and pack removal in the outpatient
admit patients once they have been packed for department (12).

POSTERIOR NASAL PACKING

If bleeding continues despite adequate anterior with 5–10 mL of water (not saline as this can
nasal packing, the next step is a posterior pack. corrode the balloon), the catheter is gently pulled
There are various commercial balloon devices into the posterior choana. The catheter is clipped
designed for this (Figure 4.4). Although not li- to prevent deflation of the balloon and to hold
censed, in some situations a female Foley catheter it in place; an umbilical clip or a simple artery
can be used (size 12 or 14 French). The catheter clip can be used. An anterior BIPP pack is placed
is passed along the the floor of the nose until the round the catheter. It is essential to ensure that
tip is seen behind the soft palate. Once inflated the catheter or umbilical clip does not rest on the

54 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

Figure 4.4. Position of an inflated epistaxis balloon.

nares as they can rapidly cause pressure necrosis stimulation) and cardiac (including myocardial
of the alar rim with subsequent notching. Gauze infarction) (13).
or cotton wool can be used to protect the alar
margin. Packs, either anterior or posterior, are left in for
24 hours and no longer than 48 hours. If the patient
Other complications reported with posterior nasal has any risk factors for endocarditis or has required
packing have been respiratory (such as obstructive repacking, oral antibiotic cover (e.g., amoxicillin) is
sleep apnoea), vagal (from nasopharyngeal given while packs are in place.

SURGICAL INTERVENTION
If bleeding remains uncontrolled, or if the patient Septoplasty may be required if there is significant
bleeds again after removal of their pack, an deviation or a large septal spur; this may have
examination under anaesthetic is required with a prevented adequate packing initially. If an obvious
view to cautery or vessel ligation as indicated, or bleeding point is seen, it can be cauterized with
rarely more formal posterior nasal packing. bipolar diathermy.

VESSEL LIGATION
Endoscopic sphenopalatine artery (SPA) ligation is is required (14). The SPA is the major blood supply to
now commonly employed as the primary surgical the posterior aspect of the nasal cavity and may have
procedure for epistaxis when operative intervention multiple branches that require ligating individually.

Epistaxis 55
Transantral maxillary artery ligation, via a Caldwell the anterior and posterior ethmoid arteries can
Luc approach, has become less popular with the be ligated. This is performed via an external
advent of the endoscopic SPA technique, which is approach using a modified Lynch-Howarth
much less invasive. incision.

If SPA or maxillary artery ligation fails to If bleeding continues despite these measures, then
control bleeding, or in cases of traumatic the external carotid artery may be ligated in the
epistaxis (with possible ethmoid fracture), neck (15).

EMBOLIZATION
Some centres will have access to radiological em- bleeding vessel before particulate embolization can
bolization. This may be employed if other mea- be performed. Patients are warned of the risk of
sures have failed or if general anaesthesia has to be stroke and skin and palate necrosis (16).
avoided due to significant comorbidities. Patients
must be actively bleeding for this procedure to be See Figure 4.5 for a basic treatment algorithm for
effective, as angiography is required to identify the epistaxis.

HEREDITARY HAEMORRHAGIC TELANGECTASIA

This autosomal dominant condition warrants specific treatment as above. Such cases may require
specific mention, as its most common symptom is discussion with a specialist centre.
nosebleeds. Patients are well educated and will often
not seek medical treatment unless the bleeding
becomes severe or protracted. Cautery, standard KEY POINTS:
packing and surgical ligation of vessels should be
avoided if at all possible. If packing is required, an 1 Epistaxis is a common problem that is
absorbable pack such as a gelatine sponge soaked in potentially life-threatening; resuscitation
adrenaline is the most appropriate method, as the may be required.
nasal mucosa in these patients is very fragile and 2 Visualization and cautery of the
will be further traumatized by pack insertion and bleeding point are often successful, as
subsequent removal. If formal packing is required, most primary epistaxis arises from the
it should ideally be removed in theatre under gen- anterior septum.
eral anaesthetic, when KTP or an argon laser can be 3 Anterior and/or posterior nasal pack-
used to target the individual lesions, or more defini- ing may be required to control profuse
tive treatment such as septodermoplasty or even bleeding.
nasal closure can be performed (17). Vessel ligation 4 Recalcitrant cases will require timely
and embolization tend to provide only a tempo- operative intervention.
rary solution, but may allow time to arrange more

56 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 EPISTAXIS

No active Active
bleeding bleeding

Haemodynamically Haemodynamically
stable unstable

Examination
and cautery

No further Bleeding Anterior nasal pack

bleeding persists and rescucitate

No further Bleeding
bleeding persists
Consider discharge
if small volume and
blood loss,
Repack with
otherwise admit for
posterior
observation
pack,
Admit, resuscitate
resuscitate,
FBC, G&S, Bleeding
Coag if persists
indicated,
observe
Admit,
resuscitate,
FBC, G&S,
Coag if
indicated,
plan for
theatre

Figure 4.5. A treatment algorithm for epistaxis.

REFERENCES 3 Mackenzie D (1914). Little’s area or the Locus

1 McGarry GW (7th edition 2008). Epistaxis. Kiesselbachi. Journal of Laryngology 1: 21−2.
In: Scott-Brown’s Otorhinolaryngology Head 4 Woodruff GH (1949). Cardiovascular epistaxis
and Neck Surgery Volume 2 Part 13. Hodder and the naso-nasopharyngeal plexus. Laryngo-
Arnold, London. scope 15: 1238−47.
2 Janfaza P, Montgomery WM, Salman SD 5 Chiu TW, Shaw-Dunn J, McGarry GW (1998).
(2001). In: Surgical Anatomy of the Head Woodruff ’s nasopharyngeal plexus: how
and Neck (pp. 283−4). Lippincott Williams & important is it in posterior epistaxis? Clinical
Wilkins, Philadelphia. Otolaryngology 23: 272−9.

Epistaxis 57
 6 Melia L, McGarry GW (2011). Epistaxis: update pack need admission? A retrospective study
on management. Current Opinion in Otolaryn- of 116 patients managed in accident and
gology Head and Neck Surgery 19: 30−5. emergency with a peer-reviewed protocol.
7 Bray D, Monnery P, Toma AG (2004). Airborne Journal of Laryngology and Otology 121:
environmental pollutant concentration and 222−7.
hospital epistaxis presentation: a 5-year review. 13 Rotenberg B, Tam S (2010). Respiratory
Clinical Otolaryngology 29: 655−8. complications from nasal packing: systematic
8 Shakeel M, Trinidade A, Iddamalgoda T, et al review. Journal of Otolaryngology Head and
(2010). Routine clotting screen has no role in Neck Surgery 39: 606−14.
the management of epistaxis: reiterating the 14 Douglas R, Wormald P (2007). Update on
point. European Archives of Otorhinolaryngol- epistaxis. Current Opinion in Otolaryngology
ogy 267: 1641−4. Head and Neck Surgery 15: 180−3.
9 Thong JF, Lo S, Houghton R, Moore-Gillon 15 Srinivasan V, Sherman IW, O’Sullivan G (2000).
V (2007). A prospective comparative study to Surgical management of intractable epistaxis:
examine the effects of oral diazepam on blood an audit of results. Journal of Laryngology and
pressure and anxiety levels in patients with Otology 114: 697−700.
acute epistaxis. Journal of Laryngology and 16 Sadri M, Midwinter K, Ahmed A, Parker A
Otology 121: 124−9. (2006). Assessment of safety and efficacy of
10 Webb CJ, Beer H (2004). Posterior nasal cau- arterial embolization in the management
tery with silver nitrate. Journal of Laryngology of intractable epistaxis. European Archives of
and Otology 118: 713−14. Otorhinolaryngology 263: 560−6.
11 Ahmed A, Woolford TJ (2003). Endoscopic 17 Lund VJ, Howard DJ (1999). A treatment
bipolar diathermy in the management of epi- algorithm for the management of epistaxis
staxis: an effective and cost-efficient treatment. in hereditary haemorrhagic telangectasia.
Clinical Otolaryngology 28: 273−5. American Journal of Rhinology 13: 319−22.
12 Van Wyk FC, Massey S, Worley G, Brady S
(2007). Do all epistaxis patients with a nasal

58 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 5 AUDIOLOGY

The principal function of audiological testing is to be measured. This response may be the test subject
establish hearing thresholds accurately and to performing a specific task to indicate hearing a
determine whether there is any impairment. If sound stimulus (behavioural response) or the
impairment is detected, testing is used to establish measurement of a physical property of the sys-
the site, type (conductive, sensorineural or mixed) tem (objective response). Objective tests do not
and severity of the hearing loss (Figure 5.1). require the active cooperation of a subject and are
not a true measure of hearing, which is a subjec-
Tests of hearing are divided into behavioural and tive sensation. They do, however, allow for certain
objective. When presented with sound, each aspect inferences to be made regarding a subject’s ability
of the auditory pathway responds in a way that can to hear.

–10

0
NORMAL
10

20

30 MILD
HEARING LEVEL (dB)

40

50
MODERATE
60

70

80 SEVERE

90

100
PROFOUND
110

120
125 250 500 1000 2000 4000 8000
Frequency (Hz)

Figure 5.1. Levels of hearing loss.

Audiology 59
BEHAVIOURAL AUDIOMETRY
❚❘ Pure tone audiometry Pure tone audiometry is performed in accordance
with the British Society of Audiology’s recommended
Indication procedures (1). Testing is ideally carried out in a
customized acoustic booth to minimize background
● To establish hearing thresholds noise. Frequency-specific sound stimuli are first deliv-
ered via headphones to test air conduction thresholds.
Pure tone audiometry is used to provide threshold Patients are instructed to indicate (by pressing a
information and to identify the presence and mag- button) when they hear a tone, however faint. Testing
nitude of any hearing loss. Thresholds are usually begins with the better hearing ear and frequencies
measured both for air conduction (via headphones) (250−8000 Hz) are tested in a specified order. Stimuli
and for bone conduction (via a bone vibrator). The are initially presented at 30 dB above expected thresh-
information provided by pure tone audiometry old. This is then increased in 20 dB steps until heard.
may be plotted graphically as an audiogram. The The stimulus is then lowered in 10 dB steps until no
audiogram represents hearing sensitivity (dB HL) longer heard and raised in 5 dB steps until a threshold
across a discrete frequency spectrum (125−8000 becomes evident. There must be a minimum of two
Hz). A wide variety of symbols are used to denote responses at that level. The threshold is marked on
the findings (Figure 5.2). the audiogram with the appropriate symbol. Bone
conduction thresholds are undertaken with a bone
O right air conduction thresholds vibrator placed on the mastoid process of the ear with
the worst air conduction thresholds. It is only possible
X left air conduction thresholds
to test frequencies between 250 and 4000 Hz. The
Δ unmasked bone conduction maximum output of the bone vibrator is approxi-
[ right bone conduction thresholds mately 70 dB; stimulation beyond these levels may
result in the vibrations being felt rather than heard.
] left bone conduction thresholds

threshold poorer at that level, but Air conduction thresholds represent the sensitivity
cannot be determined because of
of the hearing mechanism as a whole (conductive,
limited output of the audiometer
sensorineural and central components), whereas
Figure 5.2. Symbols commonly used in pure tone bone conduction thresholds represent the sensitivity
audiometry. of the hearing mechanism from the cochlear on-
wards. Any difference between the two thresholds is
referred to as an air−bone gap (ABG). An ABG is at-
The reason for using a hearing level scale rather tributed to a problem in the conduction mechanism
than sound pressure level (SPL) scale reflects the and hence referred to as a conductive hearing loss.
fact that the threshold of hearing as measured
in SPL is not the same across all frequencies. For In reality, sound through bone conduction reaches
example, less energy is required to detect a 1000 the cochlea in three ways:
Hz sound at threshold (7.5 dB SPL) than at 125 Hz
(47.5 dB SPL); the resulting audiogram would be 1 Sound escapes to the external ear canal and is
particularly difficult to interpret. The dB HL scale subsequently transferred to the cochlea through
is a scale of human hearing where 0 dB HL reflects the normal middle ear mechanism.
the threshold of hearing of an otologically normal 2 Vibrations travel directly through the middle ear
individual irrespective of its frequency. It is against ossicles and then to the cochlea.
this normal hearing population that an individual’s 3 Vibrations reach the cochlea directly through
hearing is compared. the skull.

60 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

If there is an external or middle ear pathology A bone vibrator, on the other hand, will vibrate
resulting in a conductive hearing loss, sound will be the entire skull regardless of where it is placed,
poorly transmitted by the first two routes, resulting with sound energy being transmitted to both
in poorer bone conduction thresholds than expect- cochleas with no attenuation (0 dB). It therefore
ed. This effect is greatest at 2 kHz and explains the corresponds to the hearing cochlea, regardless of
Carhart notch seen in otosclerosis. It also explains the side tested (Figure 5.3b). For this reason, it is
why correcting a conductive hearing loss can result the sensitivity of the better hearing cochlea that
in an apparent improvement in the bone conduc- determines whether masking is required, not the
tion thresholds. better hearing ear.

As discussed above, pure tone audiometry presents Three particular rules are employed to help deter-
sound to one ear at a time, and the response mea- mine whether masking is needed (2).
sured. However, in certain conditions it is not pos-
sible to be certain that the intended (test) ear is the
one actually responding. In some cases the non-test
❚❘ Rules of Masking
ear can pick up the sound just as well or better, a
Rule 1: When testing air conduction, if the thresh-
phenomenon known as cross-hearing (Figure 5.3).
old between the two ears differs by 40 dB or
For example, when the hearing acuity of the ears
more at any frequency, the worse ear becomes
is very different it is possible that when testing the
the test ear and the better ear is masked.
worse ear, the better ear detects the test signal more
Rule 2: When testing bone conduction, if the not
easily. In this situation special techniques (masking)
masked bone conduction threshold at any
are employed to ‘exclude’ the non-test ear.
frequency is better than the worse ear air
conduction threshold by 10 dB or more, the
worse ear by air conduction becomes the test
(a) (b)
ear and the better ear is masked. This provides
ear-specific masked bone conduction thresholds.
–40 dB Rule 3: When testing air conduction, if rule 1 has
not been applied (i.e., inter-aural AC difference
less than 40 dB), but the not masked bone
conduction threshold is better by 40 dB, then
the not masked air conduction is attributed to
the worse ear. The worse ear becomes the test ear
and the better ear is masked.
Figure 5.3. Transcranial attenuation through air (a)
and bone conduction (b). Interpretation of an audiogram

● Air and bone conduction thresholds equal to or

better than 20 dB are considered to be within
In order to understand cross-hearing it is normal limits (Audiogram 5.4a). Beyond 20 dB,
necessary to understand how sound travels to the degree of hearing loss is classified as mild,
the cochlea during audiological testing using the moderate, severe or profound (Figure 5.4a−d).
headphones and the bone vibrator. When a sound ● With a pure conductive hearing loss, the ear-
is presented via headphones to one ear, part of it specific masked bone conduction threshold is
escapes and vibrates the skull. This sound energy normal while there is a gap of more than 10 dB
is transmitted via bone conduction to the cochlea between the air and bone conduction thresholds
of the opposite side and is attenuated (loses sound (Audiogram 5.4b). This gap is known as the
energy) by approximately 40 dB (Figure 5.3a). air−bone gap (ABG).

Audiology 61
 (a) –20 (b) –20
–10 –10
0 0
10 10

Hearing Level (dBISO)

Hearing Level (dBISO)
20 20
30 30
40 40
50 50
60 60
70 70
80 80
90 90
100 100
110 110
120 120
125 250 500 1000 2000 4000 8000 125 250 500 1000 2000 4000 8000
Frequency (Hz) Frequency (Hz)

(c) –20 (d) –20

–10 –10
0 0
10 10
Hearing Level (dBISO)

Hearing Level (dBISO)

20 20
30 30
40 40
50 50
60 60
70 70
80 80
90 90
100 100
110 110
120 120
125 250 500 1000 2000 4000 8000 125 250 500 1000 2000 4000 8000
Frequency (Hz) Frequency (Hz)

Figure 5.4. (a) Normal hearing. (b) Left conductive hearing loss. (c) Left sensorineural hearing loss. (d) Right
mixed hearing loss.

● With a pure sensorineural hearing loss, both the and there is an ABG greater than 10 dB (Audio-
ear-specific air and the bone conduction thresh- gram 5.4d).
olds are worse than 20 dB, but there is no ABG ● Asymmetry in thresholds is considered
(Audiogram 5.4c). significant if there is more than 10 dB
● In a mixed hearing loss, the ear-specific bone difference between the ears at two adjacent
conduction thresholds are worse than 20 dB frequencies.

SPEECH AUDIOMETRY
Indications: ● To confirm conductive or sensorineural
hearing loss.
● Functional hearing assessment (speech or word
discrimination). ● Investigation of non-organic hearing loss.

62 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

In speech audiometry, the patient is asked to phenomenon known as rollover may be observed
repeat pre-recorded words (i.e., the Arthur (line 4, Figure 5.5).
Boothroyd word list) presented via a free field,
headphones or bone conductor at various Speech audiometry supplies useful information
intensity levels. The speech audiogram graphi- regarding a patient’s hearing handicap and can guide
cally displays the percentage of correct responses management. An example of this is in the manage-
as a function of the sound pressure level that ment of otosclerosis. When considering stapedec-
the words were presented at (Figure 5.5). One tomy, a patient with an ODS of less than 70% must
of the variables measured is the optimum be counselled that their perceived benefit may not
discrimination score (ODS). This is 100% in be as good as that of someone with a score of over
patients with normal hearing (line 1, Figure 5.5) 70%, even if the ABG is successfully closed. An
and in patients with pure conductive hear- optimum discrimination score of less than 50% is
ing losses, although a conductive loss requires regarded as being not socially useful, which can have
higher intensity levels (line 2, Figure 5.5). In implications in the management of individuals with
sensorineural hearing losses, ODS is usually vestibular schwannoma. If optimally aided ODS in
less than 100% regardless of the sound inten- the better hearing ear is less than 50%, then an in-
sity (line 3, Figure 5.5). With neural losses, a dividual meets the criteria for cochlear implantation.

100 30
2
Normal 1

Number of phonemes correctly repeated

Conductive
hearing hearing loss
80 24

60 18
3
Score %

40 16
Sensorineural
hearing loss
4
20 12

Rollover
0 0
0 10 20 30 40 50 60 70 80 90 100 110
Relative speech level dB

Figure 5.5. Speech audiogram.

OBJECTIVE AUDIOMETRY
❚❘ Tympanometry Tympanometry is not a test of hearing but is used
in conjunction with pure tone audiometry to help
Indications determine the nature of any hearing loss.

● In conjunction with audiometry to characterize Tympanometry measures the compliance of the

hearing loss. middle ear system. Factors influencing middle ear
● To document normal middle ear compliance. compliance include the integrity and mobility of

Audiology 63
the tympanic membrane and ossicular chain, the tympanic membrane as a function of the change
presence of fluid and middle ear pressure. Tym- in pressure in the external ear canal. Tympano-
panometry is therefore used clinically to provide grams are most commonly described according
information regarding the state of the tympanic to the Jerger system of classification (3). There are
membrane, ossicular chain, middle ear cleft and three types.
Eustachian tube function.
Type A − Demonstrates a well-defined peak
compliance of between +100 and −150 daPa
The test involves placing a small probe in the ear (Figure 5.6a). It signifies normal middle
canal to form an airtight seal. The probe contains a ear pressure.
sound generator, microphone and pump, all Type B − Demonstrating no obvious peak across
connected to a tympanometer. A sound stimulus is the pressure range (Figure 5.6b). Interpretation
passed down the ear canal to the tympanic mem- depends on the measured ear canal volume.
brane. The stimulus used is a 226 Hz probe tone This should be less than 1 cm3 in a child and less
unless testing infants less than four months old, for than 1.5 cm3 in an adult. If the ear canal volume
whom a 1 kHz stimulus is used. A proportion of is normal, the flat trace is likely to represent a
the sound energy is transmitted through the middle middle ear effusion. If the ear canal volume is
ear apparatus and the rest is reflected. The probe increased, then the finding is likely to represent a
microphone records reflected sound energy. The tympanic membrane perforation or presence of
more compliant the middle ear system, the less ener- a patent grommet.
gy reflected. Because the compliance of the tympanic Type C − Demonstrates a well-defined compliance
membrane is maximal when the pressure between its peak at less than −150 daPa (Figure 5.6c). This
two sides is equal, it is possible to measure the middle most commonly signifies Eustachian tube dys-
ear pressure by altering the pressure in the external function or a partial middle ear effusion.
ear canal via the pump channel in the ear probe.
Tympanometry does not provide information
The test generates a tympanogram. This is a about hearing and inferences must be made in
graphical representation of the compliance of the conjunction with information from other tests.

Ytm 226 Hz ml
ml ml 1.5
1.5 1.5
1.0
1.0 1.0

0.5
0.5 0.5

0.0 0.0 0.0

–400 –200 0 +200 –400 –200 0 +200 –400 –200 0 +200

600/200 daPa/s daPa 600/200 daPa/s daPa 600/200 daPa/s daPa
Earcanal volume: 1.1 Earcanal volume: 0.5
(a) Type A (b) Type B (c) Type C

Figure 5.6. Tympanometry. (a) Normal peak. (b) No peak. (c) Negative peak.

64 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

AUDITORY EVOKED POTENTIALS
Indications potential (AP). Common clinical uses include
frequency-specific estimation of hearing thresh-
● To establish likely hearing thresholds. olds in the very young or difficult to test and
● To identify cochlear or retro-cochlear pathology. the determination of endolymphatic hydrops in
Menière’s disease.
Auditory evoked potentials (AEP) describe the elec- 2 Auditory brainstem responses (ABR) − The
trical activity within the cochlea and along the audi- auditory brainstem response is a series of
tory pathway in response to auditory stimulation. five waves occurring within 10 ms of a sound
The test involves a sound stimulus being presented stimulus (Figure 5.7). Each wave is attributed
to the test ear. This results in electrical activity within to a different part of the auditory pathway from
the auditory pathway. Scalp electrodes detect this and distal auditory nerve to inferior colliculus. ABR
other non-auditory activity. The electrodes pass in- has a number of clinical uses, principally the
formation to an amplifier, which amplifies and filters estimation of hearing thresholds using wave
differences between pairs of electrodes. The stimulus V. Because the ABR is present from birth it is a
is presented repeatedly and the recordings averaged. useful hearing screening tool for neonates. The
The process of amplification, filtering and averaging precise latency of each waveform has previously
results in evoked potential (signal) being separated been exploited to detect pathology affecting the
from non-auditory electrical activity (noise). cochlear nerve, in particular as a screening test
for vestibular schwannomas. In this condition
Four types of AEP are in common clinical usage: there can be a delay in the latency of wave V. This
has now been largely superseded by contrast-
1 Electrocochleography − This measures electri- enhanced magnetic resonance imaging (MRI).
cal activity within the cochlea and first-order 3 Auditory steady state responses (ASSR) − This
cochlear nerve fibres in response to sound. The is a test that uses frequency-specific stimuli
electrocochleogram (ECochG) records three modulated with respect to amplitude and fre-
potentials: the cochlear microphonic (CM), quency. Higher modulation rates generate AEP
the summating potential (SP) and the action derived from the brainstem. Auditory steady state

Wave I
Wave V

Wave III
Wave IV
Wave II

Wave V latency

Wave I–V latency

1 ms

Figure 5.7. Auditory brainstem response.

Audiology 65
 responses (ASSR) analysis is based on the fact (CAEP). They span the transition from
that related electrical activity coincides with the obligatory to cognitive responses. They can be
stimulus repetition rate and relies on statistical generated using frequency stimuli. The accurate
detection algorithms. The test can be used as in correspondence with true frequency-specific
automated assessment of auditory thresholds. hearing thresholds make this a useful test in
4 Cortical auditory evoked potentials (CAEP) − medico-legal assessment of hearing for com-
Evoked potentials occurring beyond 50 ms are pensation cases and for diagnosis in suspected
referred to as cortical auditory evoked potentials non-organic hearing loss.

OTOACOUSTIC EMISSIONS
Indications effusion). If OAE are genuinely absent, no infer-
ence as to the degree of loss can be made, which can
● Hearing screening. range from mild (zone of uncertainty) to profound.
Additionally, robust OAE may be found in individ-
Otoacoustic emissions (OAE) represent sound uals with auditory neuropathy spectrum disorder
energy generated by the contraction and expansion who may have a profound hearing loss.
of outer hair cells in the cochlear. These echoes can
be measured by sensitive microphones placed in
the ear canal. OAE are classified into two groups: KEY POINTS:
spontaneous (only present in 50% of population)
and evoked. Evoked OAE are emissions generated ● Ensure testing equipment is maintained
in response to a sound stimulus and are present in and meets the appropriate National
the majority of individuals with hearing thresholds Physical Laboratory calibration
better that 40 dB HL. In fact, OAE are present in schedule.
99% of individuals with thresholds better than 20 ● Expertise is required for both the test-
dB and always absent with thresholds over 40 dB. ing and interpretation of results.
Between 20 and 40 dB there is a zone of uncertainty. ● Ensure that appropriate ear-specific
For this reason they have been widely adopted as a information is obtained. Have masking
hearing screening tool (4). rules been applied?
● No single test provides all the answers.
Clinically, two main types of evoked OAE are used: ● Beware of discrepancies. Where out-
transient evoked OAE (TEOAE) and distortion comes of tests are unexpected and do
product OAE (DPOAE). The test involves placing not fit with observed auditory function,
a small insert in the ear canal, which contains a check that the equipment is functioning
sound generator and microphone and is attached to normally and that the test subject is
an OAE machine. A stimulus is generated and any performing the test appropriately.
ensuing emission measured. The test is performed
in a quiet environment. In addition to being able to
infer hearing thresholds of better than 40 dB HL,
these tests provide frequency-specific information ✱ RECOMMENDED READING
in the speech frequencies (500−4000 Hz). ● Browning GG (2nd edition 1998). Clinical
Otology & Audiology. Butterworth-Heinemann,
Absent evoked OAE do not necessarily reflect a London.
cochlear hearing loss and can arise if the ear canal is ● Graham J, Baguley D (2009). Ballantyne’s
blocked or if there is middle ear pathology (i.e., an Deafness. Wiley-Blackwell, Chichester.

66 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

● Katz J, Medwetsky L, Buckard RF, Hood LJ (6th 2 British Society of Audiology (1986). Recom-
edition 2010). Handbook of Clinical Audiology. mendations procedures for masking in pure
Lippincott Williams & Wilkins. tone threshold audiometry. British Journal of
Audiology 20: 307−14.
3 Jerger J (1970). Clinical experience with
REFERENCES impedance audiometry. Arch Otolaryngol 92:
1 British Society of Audiology (1981). Recom- 311−24.
mended procedures for pure-tone audiometry 4 Rea PA, Gibson WP (2003). Evidence for surviv-
using a manually operated instrument. British ing outer hair cell function in congenitally deaf
Journal of Audiology 15: 213−16. ears. Laryngoscope 113: 2030−4.

Audiology 67
 6 TONSILLECTOMY

Indications ● To access a parapharyngeal abscess.

● Rarely, to access an elongated styloid process in
● Recurrent acute tonsillitis. the management of Eagle’s syndrome.
● Two or more episodes of quinsy.
● Obstructive sleep apnoea. Recurrent acute tonsillitis remains the commonest
● Possible malignancy (e.g., unilateral tonsillar indication for tonsillectomy. The frequency and
enlargement or ulceration of the tonsil surface). severity of episodes required to list a patient
● In cases of the occult primary (i.e., a for this procedure varies from unit to unit.
metastatic deposit in a neck node), Whilst the Scottish Intercollegiate Guidelines
tonsillectomy may be indicated in order to Network (SIGN) recommendations are helpful
exclude this as a site for the primary in (suggesting patients who suffer five or more
conjunction with a panendoscopy. episodes of tonsillitis per annum benefit from
● As part of a uvulopalatopharyngoplasty this procedure) a decision must be made on a
performed for the treatment of snoring. case-by-case basis (1, 2).

PREOPERATIVE REVIEW
The vascularity of the tonsillar tissue increases signifi- true tonsillitis in the preceding 28 days even if anti-
cantly during an episode of tonsillitis. Many surgeons biotics have been prescribed, as intra-operative haem-
will postpone surgery if the patient has experienced orrhage is increased if tonsillectomy is performed.

OPERATIVE PROCEDURE
Once anaesthetized and the airway secured with an midline by sweeping the tongue base with digital
endotracheal tube (ET), a shoulder bolster is placed manipulation. Draffin rods are used to support and
under the patient and the neck extended. The lift the gag. The head must remain supported on the
patient’s eyes must be taped closed. A headlight is operating table.
worn by the surgeon and the patient draped.
Secretions are cleared from the oral cavity using
The operation is performed from the head of the suction (Figure 6.1a).
operating table. A Boyle-Davis mouth gag with an
appropriately sized blade is inserted and the mouth In order to remove the right tonsil, Dennis-Brown
gently opened. The tongue is positioned in the or Luc’s forceps are held in the surgeon’s left hand

68 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 Tongue blade

Tonsil
Anterior pillar
Grasping forceps Gutter

Soft palate Soft palate

(a)
(b)

Diathermy forceps

Gutter

(c) (d)

Clip on
lower pole

(e)

Figure 6.1. Bipolar tonsillectomy.

Tonsillectomy 69
and the superior pole of the right tonsil is gently then trimmed. The tonsillar fossa is packed with
grasped and pulled medially (Figure 6.1b). This, in a tonsil swab while dissection is performed on the
most cases, produces a visible gutter in the anterior opposite side.
tonsillar pillar, which marks the lateral limit of the
tonsil. The mucosa is incised using McIndoe scissors Haemostasis is achieved using bipolar diathermy or
or cauterized with bipolar forceps (Figure 6.3c). The further ties. Once haemostasis has been achieved,
scissors can then be gently inserted into the incision the gag is relaxed for 30 seconds and the mouth
and opened to develop the plane between the tonsil reopened. The fossae are inspected for bleeding
and the superior constrictor muscle fibres. At this and dealt with accordingly. Gentle use of the sucker
stage, the forceps are repositioned with the superior to remove blood from the base of the tongue and
blade within this developed plane and the inferior under the soft palate is accompanied by the passage
blade over the medial surface of the tonsil. of a Jacques suction catheter through the nose to
remove a potential ‘coroner’s’ clot from the
A Gwyn-Evans dissector or bipolar diathermy for- postnasal space. If not removed, this clot may fall
ceps may be used to separate the muscle fibres from into and obstruct the airway, to be retrieved only
the white capsule of the tonsil, which should gradu- later by the coroner. Suction is attached and the
ally peel away. Bleeding is inevitable during this catheter gently withdrawn.
part of the procedure but identifying the tonsillar
capsule early and staying within the correct plane The Boyle-Davis gag is relaxed and carefully re-
will minimize its extent. Continued traction with moved. The endotracheal tube may on occasion
the forceps is the key to a clean and brisk dissection herniate into the tongue blade and hence the patient
(Figure 6.1d). may be inadvertently extubated. This will result in a
significant airway compromise and must be avoided.
As the dissection proceeds, a small ‘stalk’ of tissue
tethers the tonsil at its inferior pole. This usually A survey of the teeth must be performed to
bears a significant feeding arterial vessel (the ton- document any dental trauma (or loss which will
sillar branch of the ascending pharyngeal artery) require retrieval of the tooth). The jaw must also
which requires clipping with a curved Negus clip be assessed to exclude a temporo-mandibular joint
and tying with silk (Figure 6.1e). The clip is then dislocation. It is also essential to confirm that all the
slowly removed as the tie is thrown and the tie tonsil swabs have been removed.

POSTOPERATIVE REVIEW AND FOLLOW-UP

Patients undergoing tonsillectomy alone do not It is essential that patients eat and drink normally
require follow-up unless tissue has been sent as this reduces not only the likelihood of infection
for histology. Whilst tonsillectomy is routinely but also subsequent secondary bleeding.
performed as a day case procedure, those with
obstructive sleep apnoea require overnight
observations as an inpatient.
Patients will complain of odonophagia and
otalgia, and require regular analgesia for the
first postoperative week.

POST-TONSILLECTOMY HAEMORRHAGE
This is a potentially life-threatening emergency assessed in the Emergency Department. Assess-
and should be managed as such. Patients must be ment should include the ABC algorithm with early

70 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

cannulation using wide-bore cannulae. Blood must application of a tie. However, the tissue is generally
be taken for a full blood count, clotting screen and friable in these situations, laying a strip of Surgi-
group and save. cel within the tonsillar fossa and over-sewing the
anterior and posterior pillars together with a heavy
If the bleeding has spontaneously stopped, patients stitch may be required.
are admitted for observation.
REFERENCES
If bleeding persists behind a tonsillar clot, this
1 Management of sore throat and indications for
should be removed with a Yankauer sucker or
tonsillectomy, a national clinical guideline (April
Magill’s forceps. A tonsil swab or ribbon gauze
2010). Scottish Intercollegiate Guidelines Net-
soaked in 1:5000 adrenaline can be held over the
work, Guideline 117.
bleeding point and may achieve haemostasis.
2 Lowe D, Van der Meulen J, Cromwell D et al
(2007). Key messages from the National
If these measures fail, the patient is transferred
Prospective Tonsillectomy Audit. Laryngoscope
to theatre for emergency surgical arrest of the
117(4): 717−24.
haemorrhage. This can be achieved by diathermy or

Tonsillectomy 71
 7 ADENOIDECTOMY

Indications the Eustachian tube orifice causing Eustachian

tube dysfunction, or a biofilm may extend
● Obstructive sleep apnoea. from the adenoidal pad onto the Eustachian
● In conjunction with grommet insertion (an tube cushion).
enlarged adenoidal pad may encroach onto

PREOPERATIVE REVIEW
One must always be cautious when it comes to oper- tendency and discuss this with a senior colleague if
ating on small children (<15 kg or <3 years of age) as necessary. There is an increase in the vascularity of
they have a smaller circulating blood volume and a the adenoidal pad following an upper aero-digestive
preoperative group and save sample may be required. tract infection and many surgeons will postpone
One should exclude a personal or familial bleeding surgery if there has been a recent episode.

OPERATIVE TECHNIQUE
Two techniques are commonly used for ● Exclude a pulsatile adenoidal pad (this may actu-
adenoidectomy. ally be an angiofibroma, in which case adenoid-
ectomy is ill advised).
❚❘ Adenoidal curettage ● Exclude the presence of a cleft palate or sub-
mucous cleft (an adenoidectomy may result in
Once intubated, a shoulder roll is placed under the a nasal voice and nasal regurgitation, and is a
patient to extend the neck. A headlight is required. contraindication for curette adenoidectomy).
The patient is draped, a Boyle-Davis gag inserted ● To exclude a choanal atresia.
and the mouth opened. Once secured with Draffin ● To sweep the adenoidal pad into the midline.
rods, care should be taken to avoid damage to the
teeth and lips and kinking of the endotracheal tube. An adenoidal curette is passed into the postnasal
A finger is inserted into the postnasal space to: space and the adenoidal pad curetted with firm but
gentle pressure. The postnasal space is packed with
● Confirm the presence of an enlarged swabs to achieve haemostasis (several swab changes
adenoidal pad. may be required).

72 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

Haemostasis is confirmed by tilting the head for- oral cavity and used to assess the adenoidal pad. If
ward and inspecting for any bleeding. Further brisk enlarged, suction diathermy is used to cauterize the
bleeding requires repacking of the postnasal space. surface of the pad.
Occasionally, suction diathermy or adrenaline-
soaked packs may be required. The stem of the suction diathermy is angled to
allow access to the adenoidal pad. Great care is
❚❘ Suction diathermy taken to avoid injury to the surrounding struc-
tures, including the Eustachian tube cushions.
This technique has recently gained popularity Adequate clearance is gained when both choanae
(Figure 7.1)(1, 2). Evidence suggests that are clearly visible and the posterior pharyngeal
suction diathermy adenoidectomy results in less wall has a smooth contour. The Draffin rods
intra-operative blood loss, less remnant adenoidal are removed and the head tilted forward to
tissue and less postoperative nasal regurgitation allow inspection of the oropharynx for evidence
of food (3). of bleeding.

Once anaesthetized, the patient is placed supine and Complications

a shoulder roll inserted in order to extend the neck.
A Boyle-Davis mouth gag is inserted and supported ● Bleeding.
with Draffin rods. Jacques catheters are passed ● Infection.
through each nostril and the distal ends are drawn ● Grisel’s syndrome – atlanto-axial sublux-
out of the oral cavity. Gentle traction is used to ation due to ligamentous laxity as a result of
elevate the soft palate. A mirror is inserted into the infection.

Posterior margin of
nasal septum
Tongue blade

Anterior pillar
Left tonsil Right tonsil
Adenoidal pad
Mirror

Suction diathermy

Suction catheter Suction catheter

Figure 7.1. Suction diathermy of the adenoidal tissue.

Adenoidectomy 73
POSTOPERATIVE REVIEW
Patients may develop minor neck stiffness and
regular analgesia should be taken for up to a week. REFERENCES
1 Hartley BE, Papsin BC, Albert DM (1998).
Prophylactic oral antibiotics may also be prescribed.
If torticollis occurs, this may indicate Grisel’s syn- Suction diathermy adenoidectomy. Clin
drome and the patient should return to hospital. Otolaryngol Allied Sci 23: 308−9.
2 Lo S, Rowe-Jones J (2006). How we do it:
There is a risk of bleeding for the week following transoral suction diathermy adenoid ablation
surgery, and relative isolation from other children under direct vision using a 45 degree endoscope.
reduces the risk of viral transmission and the de- Clin Otolaryngol 31: 440−42.
3 Suction Diathermy Adenoidectomy (December
velopment of secondary haemorrhage. In children
this requires one week off school. Should bleeding 2009). NICE guidance IPG328. www.nice.org.uk/
occur, the patient should attend the Emergency nicemedia/live/12127/46633/46633.pdf.
Department immediately.

74 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 8 GROMMET INSERTION

Grommets are tubes placed in the tympanic mem- Current National Institute for Health and Clini-
brane to ventilate the middle ear space. cal Excellence (NICE) guidelines (CG60 February
2008) recommend direct surgical intervention for
Indications otitis media with effusion (OME) in children up to
the age of 12 years who demonstrate a hearing loss
● Persistent bilateral middle ear effusions resulting due to a persistent middle ear effusion lasting three
in >30 dB HL bilateral conductive hearing loss in months or more (1). However, patients must be
two or more frequencies for at least three months. treated on a case-by-case basis, taking into account
● Recurrent acute otitis media. their educational progress and speech development.
● In adults, a unilateral middle ear effusion (com- Grommet insertion is not currently recommended
bined with a postnasal space examination and for children with Down’s syndrome, who are man-
biopsy). aged with hearing aids.
● Significant tympanic membrane retraction.
● Menière’s disease.

PATIENT INFORMATION AND CONSENT

The rationale for grommet insertion and alternative 18 months in the paediatric age group. In 30% of
treatment with hearing aids should be discussed. children, middle ear effusions recur once the grom-
Grommets remain in place for an average of mets have extruded.

OPERATIVE PROCEDURE
In children and most adults this procedure is per- non-dominant hand and the microscope focused
formed under general anaesthetic. to provide a clear image of the tympanic mem-
brane (Figure 8.1a). Any wax is removed using
The anaesthetized patient is positioned supine a Jobson-Horne probe, crocodile forceps or a
and the head rotated away from the operator, who Zoellner sucker. Care must be taken not to trau-
is seated. A perforated ear drape is placed over matize the canal mucosa. If bleeding does occur, a
the ear. The largest aural speculum that comfort- cotton wool pledget soaked in 1:10 000 adrenaline
ably fits in the canal is used. This is held with the provides haemostasis.

Grommet insertion 75
 (a) Promontory (b) (c)
Malleus

Long process
of incus
Line of
Round incision
window Myringotome
niche

(d) (e) (f)

Middle
ear effusion

Sucker

(g) (h) (i)

Grommet
in place
Curved needle
Crocodile forceps

Figure 8.1. Grommet insertion.

The anteroinferior quadrant is identified and a needle is usually required to push the grommet into
myringotome used to make a radial incision from place (Figure 8.1h).
the umbo towards the annulus (Figure 8.1b). As the
incision is performed, a note is made of the pres- A grommet inadvertently pushed into the middle
ence of an effusion and its appearance (Figure 8.1c). ear may be retrieved by a senior colleague.
This is removed gently with suction using a fine end
attached to a Zoellner sucker. The use of topical ear drops immediately following
grommet insertion has gained popularity and may
reduce the incidence of grommet blockage (2).
Forceps are used to grasp the grommet at either its
rim or heel (Figure 8.1e, f). Once firmly grasped, Complications
the long axis of the grommet should be in line with
the long axis of the forceps (Figure 8.1g). ● Recurrent ear infections, occasionally requiring
removal of the grommet.
The grommet is advanced such that its toe is ● Persistent perforation (1−2%); patients may
inserted into the myringotomy incision. Gentle require a myringoplasty in order to close the
pressure applied at the heel of the grommet with a perforation (3).

76 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

POSTOPERATIVE REVIEW AND FOLLOW-UP
Many surgeons advise that the ears are kept abso- 2 Arya AK, Rea PA, Robinson PJ (2004).
lutely dry for at least 2 weeks after the procedure. The use of perioperative Sofradex eardrops
Patients may be allowed to swim with grommets in in preventing tympanostomy tube blockage:
place several weeks after insertion, unless they suffer a prospective double-blinded randomized-
recurrent ear infections. controlled trial. Clin Otolaryngol Allied
Sci 29: 598−601.
Patients are reviewed after 12 weeks with repeat 3 Lous J, Burton MJ, Felding JU, et al (2005).
audiometry. Grommets (ventilation tubes) for hearing loss
associated with otitis media with effusion in
children. Cochrane Database Syst Rev 25(1):
REFERENCES CD001801.
1 Surgical management of children with otitis
media with effusion (OME) (February 2008).
NICE clinical guidance CG60. Available at:
guidance.nice.org.uk/CG60.

Grommet insertion 77
 9 SEPTOPLASTY

Nasal obstruction due to a deviated nasal septum with nasal obstruction due to septal devia-
was previously corrected by submucous resection tion alone have an excellent outcome (3). If the
(SMR). This involved excising much of the septal obstruction is mainly due to mucosal disease
cartilage and bone at the expense of maintaining (e.g., allergic rhinitis), then results are often less
nasal support. This procedure has given way to satisfactory (4).
septoplasty, which involves resection of as little ● Cosmetic correction of a deviated nose as part
septal cartilage and bone as possible (Figure 9.1), of a septorhinoplasty. If there is severe deviation
and aims to reposition it instead (1). This retains of the mid- and lower thirds of the nose, such
septal support and reduces the risk of postoperative as in the ‘twisted nose’, then an extracorporeal
septal perforation (2). septoplasty technique may be required (5).
● Access for endoscopic sinonasal or skull base
Indications procedures.
● In the management of epistaxis where a deviated
● Nasal obstruction secondary to a deviated nasal septum prevents adequate nasal packing.
septum. Patient selection is paramount. Those ● To obtain septal cartilage for use as an autograft.

Perpendicular
plate of ethmoid

Septal cartilage
Vomer

Crest

Palatine bone

Figure 9.1. The skeleton of the nasal septum.

78 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

OPERATIVE PROCEDURE
An appropriately informed, consented and of the quadrilateral cartilage at the septocolumel-
anaesthetized patient is positioned supine, head lar junction (hemitransfixion incison) or approxi-
up, with a head ring for support. Topical nasal mately 0.5 cm behind the mucocutaneous junction
preparations such as Moffett’s solution (a variable (Killian’s incision) (Figure 9.4). It is often easier to
mixture of cocaine, adrenaline, normal saline find the correct plane of dissection using a Killian’s
and sodium bicarbonate) (6) or co-phenylcaine incision, but it is difficult to address caudal septal
spray (5% lidocaine, 0.5% phenylephrine) may be deviations through this incision. The incision is
instilled into the nose to improve the surgical field. usually made on the left, but in certain cases (e.g.,
The patient’s eyes are taped closed or lubricating caudal septal dislocation to the right) the surgeon
ointment instilled. The surgeon wears a headlight, may elect to make the incision on the right.
although the procedure may be performed
endoscopically (7). It is important to find the correct plane for dis-
section; this is subperichondrial, between the
Skin preparation is not routinely used. The patient cartilage and the perichondrium. It is easy to be
is draped with a head towel and the whole nose misled and dissect the plane between perichon-
exposed. The nasal cavities and septal deviation are drium and mucosa. The perichondrium has a pale
assessed using a Killian’s or Cottle’s nasal speculum. pink appearance due to its blood supply, whereas
It is important to identify the side and site of the septal cartilage has a shiny white/pale blue co-
deviation and relate this to the patient’s obstructive lour. If a hemitransfixion incision has been made,
symptoms (Figure 9.2). sharp pointed scissors are helpful initially as the
mucopericondrium is tethered anteriorly due to
“McGilligan’s fibres”. The short nasal speculum
may be pressed firmly into the incision against the
Columnella cartilage to assist dissection.
Middle turbinate
A Freer’s elevator is inserted between the cartilage
and mucoperichondrium and the mucoperichon-
Enlarged inferior drial flap raised carefully along the full length of
turbinate Deviated septum
the septum (Figure 9.5). It is often easier to elevate
the flap superiorly first, where it is less adherent,
and continue inferiorly and posteriorly with gentle
Figure 9.2. Septal deviation to the left. sweeping movements.

Care must be taken not to tear the flap, which can

A short nasal speculum is held with one blade on be particularly difficult over spurs or fracture lines.
either side of the caudal edge of the quadrilateral Another area of difficulty is at the junction of the
cartilage, and both sides of the septum infiltrated septal cartilage and maxillary crest inferiorly, as
with 2% lidocaine with 1:80 000 adrenaline using a the mucoperiosteum overlying the latter is more
dental syringe (Figure 9.3a−b). The mucoperichon- tightly adherent than the mucoperichondrium is
drium should blanche following infiltration. to the quadrilateral cartilage, and the two are not
in continuity. It is helpful to raise the mucoperi-
A no. 15 scalpel blade is used to incise the muco- ostium posteriorly over the vomer first, and then
perichondrium down to cartilage (Figure 9.3c–d). continue the dissection anteriorly with a hockey
This incision can be placed along the caudal edge stick dissector.

Septoplasty 79
 (a) (b)

Infiltration of
the septum

Incision

(c) (d)

Freer’s
elevation

Exposed
cartilage
Mucoperichondrial
flap

(e) (f)

Transcartilaginous
incision

(g)

Improved nasal patency

Figure 9.3. (a−g). Infiltration of the leading edge provides haemostasis (a), before an incision is made (b).
A Freer’s elevator is commonly used to dissect perichondrium from the septal cartilage. Once the mucoperi-
chondrial flap has been raised, a vertical incision is made through the septal cartilage (d). A Freer’s elevator is
passed through the incision and the mucoperichondrium separated from the cartilage on the contralateral side
(e). Turbinectomy scissors may be use to excise the cartilaginous deflection (f). The mucoperichondrial flap is
separated from the cartilage and an inferior strut, shaded area, may be excised to improve nasal patency (g).

80 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 Hemitransfixtion icision

Killian’s incision

Figure 9.4. Incisions for a septoplasty. A hemitransfixtion incision is made along the anterior (leading) edge
of the septum, whilst a Killian’s incision is made 0.5 cm posterior to the mucocutaneous junction.

Figure 9.5. Elevation of the flap is performed with a Freer’s elevator. Care must be taken to avoid a flap tear.

It is sometimes necessary to elevate a complete con- deviations only, and is avoided if possible to reduce
tralateral mucoperichondrial flap, in which case the the risk of septal perforation.
plane can be followed over the caudal edge of the
quadrilateral cartilage onto the right side and dis- The procedure from this point will be determined
sected as above. This is usually necessary in severe by the extent of the deviation. If the quadrilateral

Septoplasty 81
cartilage is fixed laterally by a deviated bony septum, PPE, nasal bones and upper lateral cartilages.
the osseochondral junction may be incised to release The cartilage and bone should not be completely
it posteriorly. The area of deviation may be amenable separated at this point to avoid dorsal collapse. It
to resection, in which case the quadrilateral cartilage is advisable to leave at least 1 cm dorsal and caudal
is fully incised at an appropriate point (often the struts of septal cartilage for support, although in
most deviated part), and then a partial contralateral practice one should aim to leave much more carti-
flap is elevated via the transcartilaginous incision lage in place if feasible. Bony spurs inferiorly may be
(Figure 5.2e–f) to allow removal of the intervening resected using a fishtail gouge. Septal cartilage may
piece of cartilage or bone. Through-cutting forceps be incised or scored in order to help repositioning,
(e.g., Jansen Middleton forceps) should be used and various cutting and suturing techniques have
when removing the bony septum in order to avoid been described, particularly to address the most
twisting the perpendicular plate of the ethmoid difficult problem of caudal deviation (8, 9).
(PPE), as there is a theoretical risk of skull base frac-
ture at the cribriform plate and an ensuing CSF leak. Once the deviation has been corrected, the incision
is closed with an absorbable suture. The same suture
When removing quadrilateral cartilage, it is vital to can be used to ‘quilt’ the septum with through-and-
understand the major areas of support that should through mattress sutures. This reduces the risk of
not be resected. The most important is the keystone septal haematoma formation by closing the dead
area; this is the junction of the quadrilateral cartilage, space. Nasal packing is not routinely inserted.

POSTOPERATIVE REVIEW
The patient can be discharged after observation
according to the hospital’s day surgery protocol. REFERENCES
1 Fettman N, Sanford T, Sindwani R (2009).
Discharge medication may include analgesia and
nasal douches. Patients are advised to take 10−14 Surgical management of the deviated septum:
days off work, avoid nose-blowing for one week, techniques in septoplasty. Otolaryngologic
sneeze with their mouth open if possible and avoid Clinics of North America 42: 241−52, viii.
2 Goode RL, Smith LF (2nd edition 2001). Nasal
heavy lifting or strenuous exercise for two weeks.
Patients may be followed up at three months. septoplasty and submucous resection. In: Atlas
of Head & Neck Surgery – Otolaryngology
(pp. 462−4). Lippincott Williams & Wilkins,
Complications Philadelphia.
3 Moore M, Eccles R (2011). Objective evidence
● Bleeding – Some oozing is normal but heavy epi- for the efficacy of surgical management of
staxis requires return to hospital and may warrant the deviated septum as treatment for
nasal packing. If a septal haematoma develops, it chronic nasal obstruction: a systematic
will require draining and nasal packing. review. Clinical Otolaryngology doi:
● Infection. 10.1111/j.1749-4486.2011.02279.x [epub
● Ongoing symptoms – Either related to persistent ahead of print].
or recurrent deviation as septal cartilage has 4 Karatzanis AD, Fragiadakis G, Moshandrea J,
‘memory’, or to concurrent mucosal disease. et al (2009). Septoplasty outcome in patients
● Septal perforation − Usually asymptomatic, but with and without allergic rhinitis. Rhinology 47:
may cause crusting, bleeding or whistling. 444−9.
● Cosmetic change – Significant collapse (saddle 5 Gubisch W (2005). Extracorporeal septoplasty
nose) is rare, but subtle changes are probably for the markedly deviated nasal septum. Archives
under-recognised by patients and surgeons. of Facial Plastic Surgery 7: 218−26.

82 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

6 Benjamin E, Wong DKK, Choa D (2004). 8 Jang YJ, Yeo NK, Wang JH (2009). Cutting and
‘Moffett’s’ solution: a review of the evidence and suture technique of the caudal septal cartilage
scientific basis for the topical preparation of the for the management of caudal septal deviation.
nose. Clinical Otolaryngology 29: 582−7. Archives of Otolaryngology Head and Neck
7 Paradis J, Rotenberg BW (2011). Open versus Surgery 135: 1256−60.
endoscopic septoplasty: a single-blinded, 9 Kenyon GS, Kalan A, Jones NS (2002).
randomized, controlled trial. Journal of Columelloplasty: a new suture technique to
Otolaryngology Head and Neck Surgery 40 correct caudal septal cartilage dislocation.
(Suppl. 1): S28−S33. Clinical Otolaryngology 27: 188−91.

Septoplasty 83
 10 SEPTORHINOPLASTY

There are numerous techniques involved in rhino- mid- and lower thirds of the nose, such as in the
plasty surgery, which are beyond the scope of this ‘twisted nose’, then an extracorporeal septoplasty
book. Briefly, it can be divided into the endonasal technique may be required (2).
(closed) approach and the external (open) approach ● Functional − To correct nasal obstruction that
(1). The endonasal approach is discussed here. would not be successfully managed by simple
septoplasty alone.
Indications

● Cosmetic correction of a deviated nose and

septum. If there is severe deviation of the

PREOPERATIVE REVIEW
Patient selection in rhinoplasty is paramount; preoperative photographs are required in lateral,
their expectations must be realistic. Standard frontal, oblique, bird’s eye and basal views.

OPERATIVE PROCEDURE
An appropriately informed, consented and anaes- The septum is infiltrated with 2% lidocaine
thetized patient is positioned supine, head up, with with 1:80 000 adrenaline as for a septoplasty
a head ring for support. Topical nasal preparations (Chapter 9). Infiltration is continued superiorly
such as Moffett’s solution (a variable mixture of in the nasal vestibules along the lines of inter-
cocaine, adrenaline, normal saline and sodium bicar- cartilaginous incisions (Figure 10.1) and into
bonate) (6) or co-phenylcaine spray (5% lidocaine, the soft tissue overlying the dorsum of the nose,
0.5% phenylephrine) may be instilled into the nose particularly at the incision sites for external lateral
to improve the surgical field. The patient’s eyes are osteotomies. The nasal hairs are trimmed with
taped closed or lubricating ointment is instilled. A short curved scissors.
headlight is worn, although overhead operating lights
may be used, particularly in the external approach. Septoplasty is performed using a left hemitransfix-
ion incision as described in Chapter 9. Once this
Skin preparation is used around the nose. The is completed, bilateral intercartilaginous incisions
patient is draped with a head towel so that the are made between the upper and lower lateral
whole face is exposed. cartilages. The groove between the cartilages is

84 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 Upper lateral cartilage Line of an intercartilaginous
incision
Lower lateral cartilage

Nasal speculum

Figure 10.1. Intercartilaginous incision.

best displayed using an alar retractor with external

pressure from the surgeon’s middle finger. Care is
taken not to incise the cartilages themselves. On
the left the incision is continued caudally into the
hemitransfixion incision. The hemitransfixion
incision is extended to complete a full transfixion
incision (through-and-through), although this
does not need to extend completely to the base of
the columella.

The dorsal and lateral nasal skin and soft tissue

envelope is then degloved with a no. 15 scalpel
blade or curved scissors, taking care not to button-
hole the skin by staying on cartilage and bone. The Figure 10.2. An osteotome may be used to remove
skin is freed sufficiently to allow visualization of the a dorsal hump once the overlying soft tissue enve-
nasal dorsum with an Aufricht’s retractor and the lope has been lifted. The line of the osteotomy is
scissors to pass freely from one side of the nose to illustrated.
the other. Release the procerus muscle at the nasion
using a periosteal elevator.
ensure its position and to prevent buttonholing the
If there is a dorsal hump, it can be removed with a skin. External lateral osteotomies are performed
6−8 mm osteotome, taking care not to buttonhole using a 2 mm osteotome via small stab incisions
the skin at either side (Figure 10.2). The dorsum is made with a no. 11 scalpel blade. The line of the
then rasped smooth. osteotomy is ‘scratched’ onto the bone before being
‘postage-stamped’ where multiple small osteoto-
Bilateral medial osteotomies are performed inter- mies are made along the lines shown in Figure 10.3.
nally, using a 4−6 mm osteotome placed through The assistant stabilizes the patient’s head while the
the intercartilaginous incision. The osteotome is surgeon employs the mallet. Firm digital pressure is
positioned perpendicular to the bone at the caudal used to reposition the bones appropriately.
end of the nasal bone, just lateral to the septum
(3). The line of the osteotomy is shown in Figure In more complex cases, tip work or grafts may be
10.3. The assistant gently taps with a mallet, while required; these are often better undertaken via an
the surgeon’s palpates the edge of the osteotome to external approach.

Septorhinoplasty 85
 The incisions are closed with an absorbable
suture. The same suture is used to ‘quilt’ the
septum with through-and-through mattress
sutures to reduce the risk of septal haema-
toma formation by closing the dead space, as
for standard septoplasty. Steristrips are applied
over the dorsum and to support the tip, and a
triangular plaster of Paris is placed. Nasal packing
is not routinely inserted.

Figure 10.3. Medial and lateral osteotomy.

POSTOPERATIVE REVIEW
The patient can be discharged with analgesia after ● Septal perforation − Usually asymptomatic, but
observation according to the hospital’s day surgery may cause crusting, bleeding or whistling.
protocol. Patients are advised to have two weeks ● Ongoing cosmetic concerns – Patients should
off work and to avoid heavy lifting or strenuous be advised of a 5−10% revision rate following
exercise, avoid nose-blowing for one week, and primary rhinoplasty surgery.
sneeze with their mouth open if possible. They are
warned to expect periorbital bruising and swelling.
Initial follow-up is after 5−7 days for removal of the
plaster, after which patients can begin to douche REFERENCES
the nose. 1 Gillman GS (2008). Basic rhinoplasty.
In: Operative Otolaryngology Head and
Neck Surgery (pp. 806−10). Saunders,
Complications
Philadelphia.
2 Senyuva C, Yücel A, Aydin Y, et al (1997).
● Bleeding – Some oozing is normal but heavy
Extracorporeal septoplasty combined with
epistaxis requires return to hospital and may
open rhinoplasty. Aesthetic Plastic Surgery 21:
warrant nasal packing. If a septal haematoma
233−39.
develops, it will require draining and packing.
3 Calhoun KC (2nd edition 2001). Osteotomies. In:
● Infection.
Atlas of Head & Neck Surgery – Otolaryngology
● Ongoing obstructive symptoms – Either related to
(pp. 468−9). Lippincott Williams & Wilkins,
persistent/recurrent deviation as septal cartilage
Philadelphia.
has ‘memory’, or to concurrent mucosal disease.

86 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 11 TURBINATE SURGERY

Indications

● Nasal obstruction secondary to inferior turbinate

hypertrophy refractory to medical treatment.

OPERATIVE PROCEDURE
There is an ever-increasing number of methods surgeon, or a rigid Hopkins rod used for endoscopic
used to reduce inferior turbinate tissue and a recent techniques. The patient’s eyes are taped closed. Skin
Cochrane Review found no high-quality evidence preparation is not routinely used. The patient is
for any technique (1). All are performed on an draped with a head towel.
appropriately informed, consented and anaesthe-
tized patient, positioned supine with a head ring for
❚❘ Out-fracture of the inferior
support, slightly head up. Topical nasal preparations
such as Moffett’s solution (a variable mixture of turbinate
cocaine, adrenaline and sodium bicarbonate) (6) or
co-phenylcaine spray (5% lidocaine, 0.5% phenyl- A Hill’s elevator is used first to in-fracture the
ephrine) may be instilled into the nose to improve inferior turbinate (IT) and then out-fracture it
the surgical field. A headlight may be worn by the (lateralize) (Figure 11.1).

❚❘ Submucous diathermy to the

inferior turbinate
An insulated Thudichum’s speculum is used to allow
visualization of the IT. A monopolar diathermy
Abbey needle is inserted into the inferior turbinate
soft tissue, medial to the bone, along its full length. It
is activated while being slowly withdrawn, cauteriz-
ing the erectile soft tissue. This is usually performed
three times, superiorly, inferiorly and at the mid-
point of the turbinate (Figure 11.2a and b).

A similar technique may be employed using two

Figure 11.1. Out-fracture of the inferior turbinate. passes of a radiofrequency probe (2).

Turbinate surgery 87
 (a) (b)

Figure 11.2. Submucous diathermy of the right inferior turbinate.

❚❘ Submucosal out-fracture of the turbinectomy scissors are used to trim its inferome-
inferior turbinate (SMOFIT) dial aspect (Figure 11.3).

The anterior end of the IT is infiltrated with 2% A small dressing (e.g., ribbon gauze soaked in
lidocaine with 1:80 000 adrenaline using a dental adrenaline, or a piece of non-adhesive gauze) may
syringe. The IT is in-fractured as above, and a small be left in the nose during the recovery period. If
stab incision is then made in the anterior end over there is significant bleeding, a nasal tampon may
the turbinate bone. A Freer’s elevator is used to el- be required, in which case the patient is kept in
evate the soft tissue off the turbinate bone along its overnight and the pack removed the following
full length. As it is withdrawn, the Freer’s elevator morning.
is used to out-fracture the bone at multiple points
along its length.

❚❘ Inferior turbinoplasty

There are multiple methods and instruments used

to reduce the IT soft tissue. Following a SMOFIT
(as above), a small Tilley Henkel forceps can be
used to remove pieces of bone and soft tissue. This
can be done endoscopically for more controlled
reduction. A laser may be used, and a turbinoplasty
microdebrider attachment is also available, which is
inserted through a stab incision as above and allows
powered removal of IT bone and soft tissue (3).

❚❘ Turbinectomy

This may be performed using a headlight or Figure 11.3. Turbinectomy. Care must be taken to
endoscope. The IT is in-fractured as above, then avoid damage to the nasolacrimal duct.

88 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

POSTOPERATIVE REVIEW
Any small pack may be removed after 1−2 hours. hence the newer turbinoplasty procedures do not
The patient can be discharged after observation remove turbinate mucosa.
according to the hospital’s day surgery protocol. ● Ongoing/recurrent symptoms – Any benefit may
Discharge medication includes analgesia and nasal be temporary and ongoing medical treatment of
douches; regular intranasal treatment for rhinitis rhinitis may be required postoperatively.
should be recommenced after a few days. Patients
are advised to take one week off work, avoid nose-
blowing for one week, sneeze with their mouth REFERENCES
open if possible and avoid heavy lifting or strenuous 1 Jose J, Coatesworth AP (2010). Inferior turbi-
exercise for two weeks. Follow-up may be arranged. nate surgery for nasal obstruction in allergic
rhinitis after failed medical management.
Cochrane Database of Systematic Reviews 8:
Complications
CD005235.
2 Cavaliere M, Mottola G, Iemma M (2005).
● Bleeding – This may be profuse and patients
should be warned of the potential need for a Comparison of the effectiveness and safety of
blood transfusion. The risk is higher with turbi- radiofrequency turbinoplasty and traditional
nectomy than the turbinoplasty procedures. surgical technique in the treatment of inferior
● Nasal crusting – Turbinectomy leaves a large raw turbinate hypertrophy. Otolaryngology Head and
area, unlike turbinoplasty; diathermy can also Neck Surgery 133: 972−8.
3 Lee DH, Kim EH (2010). Microdebrider-assisted
cause crusting.
● Adhesions – Between the IT and septum. versus laser-assisted turbinate reduction: com-
● Empty nose syndrome – Excessive removal of IT parison of improvement in nasal airway accord-
tissue causes worsening symptoms of obstruc- ing to type of turbinate hypertrophy. Ear Nose
tion due to loss of sensation of nasal airflow, and Throat Journal 89: 541−5.

Turbinate surgery 89
 12 ANTRAL WASHOUT

This procedure is rarely performed as it has been Indications

almost completely superseded by endoscopic sinus
surgery (1). It is now generally reserved for the sick ● Acute maxillary sinusitis unresponsive to medi-
patient unfit for formal endoscopic sinus surgery cal treatment.
in whom the maxillary sinus is thought to harbour ● To provide diagnostic cultures.
infection and when cultures are required. This
procedure can be performed under local anaesthetic
on the intensive care unit if necessary.

OPERATIVE PROCEDURE
An appropriately informed, consented and anaesthe-
tized patient (where possible) should be positioned
head up with a head ring for support. If the patient
is sedated or under general anaesthesia, topical nasal
preparations such as Moffett’s solution (a variable
mixture of cocaine, adrenaline and sodium bicar-
bonate) or co-phenylcaine spray (5% lidocaine,
0.5% phenylephrine) may be instilled into the nose
Maxillary sinus
to improve the surgical field. If the patient is awake,
2% lidocaine with 1:80 000 adrenaline may be Inferior turbinate
infiltrated into the lateral nasal wall adjacent to the
inferior turbinate (IT). A headlight is worn and the
nasal cavity examined using a nasal speculum.

The IT is in-fractured (medialized) using a Hill’s Sheathed trocar

or Freer’s elevator and a sheathed antral washout
trocar is passed into the nasal cavity. The trocar is
inserted beneath the IT, approximately 1.5−2 cm Figure 12.1. Antral washout. Once in-fractured,
posterior to its anterior attachment (to avoid dam- a sheathed trocar is inserted beneath the inferior
age to the nasolacrimal duct). The trocar is aimed turbinate. Gentle force is used to direct the tip of
laterally, in the direction of the ipsilateral tragus the trocar towards the external auditory canal of the
(Figure 12.1). ipsilateral ear.

90 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

The needle is gently advanced while the eye is held ● Subcutaneous emphysema due to misplacement
open by an assistant (a misplaced trocar may enter of the trocar superficial to the antrum.
the orbital cavity). A ‘give’ is often felt as the trocar ● Orbital injury due to misplacement of trocar;
enters the antrum. this technique is contraindicated in patients
with a hypoplastic maxillary sinus as this risk
Once in place, the trocar is withdrawn, leaving the is increased.
sheath in situ. The maxillary sinus may be irrigated
with a 20 mL syringe of saline. Fluid can then be
aspirated to provide a sample for culture. Irrigation REFERENCES
is continued until the aspirate is clear. It is essential 1 Lazar RH, Mitchell RB (2nd edition 2001).
to watch the patient’s eye carefully during irrigation Intranasal antrostomy through the inferior
to ensure the sheath is not within the orbit. meatus. In: Atlas of Head & Neck Surgery –
Otolaryngology (pp. 916−17). Lippincott
Nasal packing is not routinely required. Williams & Wilkins, Philadelphia.

Complications

● Bleeding.
● Nasolacrimal duct injury.

Antral washout 91
 13 ENDOSCOPIC SINUS
SURGERY

Also referred to as functional endoscopic sinus ● Recurrent acute sinusitis.

surgery (FESS), the aim of endoscopic sinus sur- ● Complications of acute sinusitis that have failed
gery (ESS) is to improve the drainage and function medical management.
of the paranasal sinuses. Mucosal stripping is to ● Sinus mucocoeles.
be avoided and the natural sinus ostia are opened ● Sinonasal tumour excision.
whenever possible. There are a number of ● Endoscopic dacrocystorhinostomy (DCR).
extended applications for ESS, including those ● Orbital or optic nerve decompression.
listed below (1). ● Endoscopic repair of CSF leak.
● Transphenoidal approach to the pituitary/ante-
rior skull base lesions.
Indications

● Chronic rhinosinusitis with or without nasal pol-

yps, refractory to maximum medical treatment.

PREOPERATIVE REVIEW
A CT scan of the sinuses is mandatory and should the extent of disease, any previous surgery or bony
be available at the time of surgery. This must be loss and any anatomical variants (1).
reviewed preoperatively by the surgeon to evaluate

OPERATIVE PROCEDURE
An appropriately informed, consented and anaes- of any orbital bleeding, and the eye to be balloted,
thetized patient should be positioned supine with while observing the lateral nasal wall for any evi-
a head ring for support, slightly head up. Topical dence of movement (suggesting a dehiscent lamina
nasal preparations such as Moffett’s solution (a papyracea). Skin preparation is not routinely used.
variable mixture of cocaine, adrenaline and sodium The patient is draped with a head towel.
bicarbonate) or co-phenylcaine spray (5% lido-
caine, 0.5% phenylephrine) are instilled into the A 0° rigid Hopkins rod endoscope is used to inspect
nose to improve the surgical field. The patient’s eyes the nasal cavities bilaterally using the three-pass
are not taped or covered, but lubricating ointment technique (see Chapter 2). The first pass is along the
is instilled. This allows immediate identification floor of the nose to the postnasal space, assessing

92 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

the inferior meatus (Figure 13.1). The second is into The uncinate process is palpated with the Freer’s
the middle meatus, and the third into the superior elevator (Figure 13.4).
meatus and olfactory niche; the sphenoid ostium
may be identified during this pass. Important land- A Freer’s elevator or a sickle knife is used to
marks to note are the septum, inferior and middle perform an uncinectomy and expose the natural
turbinates and the posterior choana (Figure 13.2). ostium of the maxillary sinus. Incise along the
anterior attachment of the uncinate process from
superior to inferior (Figure 13.5). Care should be
Middle turbinate taken not to enter the orbit with this incision.
Middle meatus

Nasal Middle turbinate

septum
Inferior turbinate Middle meatus

Floor of
nasal cavity
Freer's elevator
Inferior turbinate
Figure 13.1. First pass along the floor of the nose
(left nasal cavity).
Figure 13.3. Gentle mediatization of the middle tur-
binate to access to the middle meatus.
Middle turbinate

Middle meatus
Middle turbinate

Uncinate process
Nasal
septum

Inferior turbinate

Nasal septum

Figure 13.2. The second pass allows access to the

middle meatus.
Figure 13.4. Palpation of the uncinate process with
At this point, it is often helpful to insert adren- a Freer’s elevator.
aline-soaked neuropatties or ribbon gauze into
the middle meatus, using a Freer’s elevator for Middle turbinate
accurate positioning. This provides further de-
congestion and vasoconstriction to improve the
surgical field.

The middle turbinate should not be forcefully

medialized as this risks skull base fracture with Nasal septum
CSF leak. It can be gently moved out of the way of
instruments, but if very large and obstructing, then
a wedge can be removed from the anterior end with
a through-cutting punch, whilst preserving the ma- Figure 13.5. Incision along the anterior attachment
jority as an anatomical landmark (Figure 13.3). of the uncinate process.

Endoscopic sinus surgery 93

The uncinate process will become apparent as
a sickle-shaped thin sheet of bone with a free
Middle
posterior edge. Small scissors may be used to turbinate
cut through the remaining superior and inferior
attachments of the uncinate process, or straight
Blakesley-Wilde forceps can be used directly to Nasal septum Ethmoid bulla
remove it with a twisting motion to avoid tearing
the mucosa (Figure 13.6).
Nasal sucker
Inferior
turbinate

Middle turbinate
Figure 13.7. Opening of the ethmoid bulla.

The anterior ethmoids are opened with a curette

or Blakesley-Wilde forceps, as may the posterior
ethmoids if indicated (Figure 13.8). Appropriately
Nasal septum trained and experienced surgeons may perform
Blakesley-Wilde
forceps
sphenoid sinus and frontal recess surgery, as required.

Figure 13.6. Removal of the uncinate process.

Opened anterior
ethmoid air cells

The uncinate process may also be removed using a

retrograde technique with backbiting forceps placed Nasal Curette
septum
behind the free posterior edge of the uncinate
process. This is thought to reduce the risk of orbital
penetration (2). Inferior turbinate

Once the uncinectomy is complete, the natural

maxillary ostium should be visible and the ethmoid
bulla will also now be in view (Figure 13.7). Figure 13.8. Opening of the anterior ethmoids.

A curved sucker may be passed into the sinus to If bleeding is minimal, then no packing is required.
remove any mucus or pus. The antrostomy may be Depending on the surgeon’s preference and the
widened if necessary using a backbiting forceps. The amount of bleeding, packing may be inserted in
bulla can be opened using straight or 45°-angled the form of adrenaline-soaked ribbon gauze, non-
Blakesley-Wilde forceps or a sucker as illustrated in adhesive gauze, nasal tampon or newer absorbable
Figure 13.7. packing materials.

POSTOPERATIVE REVIEW
If nasal packing is inserted, it can be removed in tal’s day surgery protocol, or may require overnight
recovery, on the ward or the next morning, depend- admission. Discharge medication can include an-
ing on the amount of oozing. The patient may be algesia, oral and/or topical nasal steroids and nasal
discharged after observation according to the hospi- douches. Antibiotics may be given, often depending

94 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

on an intraoperative finding of infection. Patients polyps) it is important to make patients aware
are advised to avoid nose-blowing for one week, that ESS may not be a cure for the underlying
sneeze with their mouth open if possible and have disease process and that symptoms can recur.
10−14 days off work while avoiding heavy lifting or Patients are therefore advised to continue long-
strenuous exercise during this period. If follow-up term treatment with intranasal steroids and
is planned, this should be after two weeks to allow douche after surgery.
for outpatient decrusting of the nasal cavities. ● Orbital injury or bleeding – Occurs in approxi-
mately 0.2% of cases (3).
● CSF leak – Occurs in approximately 0.06% of
Complications cases (3).

● Bleeding − Some oozing is normal but heavy

epistaxis requires return to hospital and may REFERENCES
warrant nasal packing or rarely return to theatre. 1 Wormald P-J (2005). Endoscopic Sinus Surgery:
Perioperative haemorrhage occurs in approxi- Anatomy, Three-Dimensional Reconstruction,
mately 5% of cases, with significant postopera- and Surgical Technique. Thieme Medical Pub-
tive bleeding in less than 1% (3). lishers, New York.
● Infection. 2 Schaitkin BM (2008). Maxillary sinus:
● Nasal crusting – Minimized with regular douch- the endoscopic approach. In: Operative
ing and early outpatient review. Otolaryngology Head and Neck Surgery
● Adhesions – Usually between the middle tur- (pp. 53−4). Saunders, Philadelphia.
binate and the lateral nasal wall, but can occur 3 Hopkins C, Browne JP, Slack R, et al (2006).
between the inferior turbinate and the septum if Complication of surgery for nasal polyposis and
traumatized during surgery. chronic rhinosinusitis: the results of a national
● Recurrent symptoms – In certain cases (e.g., audit in England and Wales. Laryngoscope
chronic rhinosinusitis with or without nasal 116: 1494−9.

Endoscopic sinus surgery 95

 14 NASAL POLYPECTOMY

Indications
● Histological identification in cases of unilateral
● Nasal polyposis causing obstructive symptoms polyps.
despite maximum medical management.

PREOPERATIVE REVIEW
As nasal polypectomy is now invariably performed ous surgery or bony loss and anatomical variants.
as an endoscopic procedure, a CT scan of the Nasal polypectomy is commonly combined with
sinuses is mandatory. This must be available at the endoscopic sinus surgery (ESS), as there is evidence
time of surgery and reviewed preoperatively by the that even limited ESS can reduce revision rates over
surgeon to evaluate the extent of disease, any previ- a five-year period (1).

OPERATIVE PROCEDURE
An appropriately informed, consented and anaes- or neurosurgical patties soaked in adrenaline are
thetized patient is positioned supine with a head inserted bilaterally for vasoconstriction.
ring for support, slightly head up. Topical nasal
preparations such as Moffett’s solution (a variable Various methods are available, but the two most
mixture of cocaine, adrenaline and sodium bicar- commonly used are:
bonate) or co-phenylcaine spray (5% lidocaine, 1 Direct removal with grasping instruments such as
0.5% phenylephrine) are instilled into the nose to Tilley Henkels or Blakesley-Wilde forceps; 45°-
improve the surgical field. The patient’s eyes are angled forceps may be useful for more complete
not taped or covered, but lubricating ointment is clearance superiorly. Care must be taken not to
instilled to allow immediate identification of any exert too much force when removing tissue; gentle
orbital bleeding. Skin preparation is not routinely pressure or a twisting motion should be sufficient.
used. The patient is draped with a head towel. 2 Powered instrumentation in the form of a micro-
debrider. This instrument consists of an oscil-
A 0° rigid Hopkins rod endoscope is used to inspect lating cutting blade within a sheath, attached to
the nasal cavities. Representative biopsies are irrigation and suction. Care must be taken to en-
taken from both sides, particularly if a microde- sure that the tip of the instrument can be seen at
brider is to be used. Short pieces of ribbon gauze all times to avoid damage to adjacent structures.

96 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

Ideally all polyps are removed. If bleeding is mini- packing may be inserted in the form of adrenaline-
mal, then no packing is required. Depending on the soaked ribbon gauze, non-adhesive gauze, nasal
surgeon’s preference and the amount of bleeding, tampon or newer absorbable packing materials.

POSTOPERATIVE REVIEW
If nasal packing is inserted, it can be removed in the underlying disease process and that polyps
recovery, on the ward or the next morning depend- tend to recur. They are therefore advised to
ing on the degree of oozing. The patient may be continue long-term treatment with intranasal
discharged after observation according to the hospi- steroids and douche after surgery.
tal’s day surgery protocol, or may require overnight ● Persistent anosmia – Surgical polypectomy does
admission. Discharge medication can include an- not guarantee the return of a sense of smell and
algesia, oral and/or topical nasal steroids and nasal may even reduce it.
douches. Antibiotics may be given, depending on ● Orbital injury or bleeding – Unlikely in the
the intraoperative finding of infection. Patients are absence of formal ESS but the lamina papyracea
advised to take 10−14 days off work and to avoid may be dehiscent in nasal polyposis.
heavy lifting or strenuous exercise during this ● CSF leak – Unlikely in the absence of formal ESS
period. They should avoid nose-blowing for one but polyps removal in the region of the olfactory
week and sneeze with their mouth open if possible. niche may damage the cribriform plate.

Complications
REFERENCE
● Bleeding − Some oozing is normal but heavy
1 Hopkins C, Slack R, Lund V, et al (2009).
epistaxis requires return to hospital and may
Long-term outcomes from the English national
warrant nasal packing or rarely return to theatre.
comparative audit of surgery for nasal polyposis
● Infection.
and chronic rhinosinusitis. Laryngoscope 119:
● Recurrent polyps – It is important to make
2459−65.
patients aware that polypectomy is not a cure for

Nasal polypectomy 97
 15 TYMPANOPLASTY

DEFINITION
Tympanoplasty is the term used for the surgical intact and mobile ossicular chain. This procedure is
eradication of middle ear disease and the restoration synonymous with the term myringoplasty.
of middle ear function, including the reconstruc-
tion of the tympanic membrane and ossicular chain Type III tympanoplasty describes the reconstruc-
(ossiculoplasty). tion performed when the incus and malleus have
been removed or eroded by disease. The tym-
Historically, Wullstein described five types of panic membrane is reconstructed to lie on the
tympanoplasty (1): stapes head to create a columella effect or myrin-
gostapedopexy. The same principle is applied
Type 1 Myringoplasty – Closure of a tympanic with some ossiculoplasty procedures where the
membrane perforation. stapes superstructure or footplate is in contact
Type 2 Reconstruction of the tympanic mem- with the reconstructed tympanic membrane via
brane over the malleus remnant and long a prosthesis.
process of incus.
Type 3 Reconstruction of the tympanic mem-
brane over the head of the stapes. Indications
Type 4 Reconstruction of the tympanic
membrane over the round window. ● Recurrent ear infection.
Type 5 Reconstruction of the tympanic ● Hearing loss.
membrane over an artificial fenestration ● To ‘waterproof ’ the ear.
in the basal turn of the cochlea.
Type 6 Reconstruction of the tympanic mem- The main indications for tympanoplasty are chronic
brane over an artificial fenestration in the secretory otitis media, either mucosal (tympanic
horizontal semicircular canal. membrane perforation) or with cholesteatoma, and
the surgical management of pars tensa retraction
Only two of these remain relevant today. pockets (Figure 15.1). These conditions often result
in ear discharge (otorrhoea), conductive hearing loss
Type I tympanoplasty describes the reconstruction and the social inconvenience of being unable to get
of the tympanic membrane in the presence of an the ear wet.

98 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

PRE-OPERATIVE ASSESSMENT
❚❘ History Table 15.1. Sade classification (2).

Establish the nature of the symptoms and the Grade Description

impact these have on the patients; quality of 1 Mild retraction of pars tensa
life; this will help when counseling them. Does
2 Retraction touching the incus or stapes
the ear discharge? How often? Is it painful?
Is there any subjective hearing loss? Is there any 3 Retraction touching the promontory
associated vertigo or tinnitus? What about Tympanic membrane adherent to the
4
the other ear? Is there any other relevant ENT promontory
history?

❚❘ Investigations
❚❘ Examination Pure tone audiometry, including air conduction
and appropriately masked bone conduction, is an
Document the position (central or marginal) essential part of the assessment and should be
and size of the perforation. Is there an associated performed within three months of surgery.
cholesteatoma? Describe the status of the
middle ear (dry or infected). Is it possible to Imaging of the temporal bone is not usually
comment on the state of the ossicular chain? required for a simple perforation. If there is choles-
If there is a pars tensa retraction pocket, it is teatoma and a concurrent mastoidectomy proce-
helpful to use the descriptive Sade classification dure is planned, a high resolution fine-cut CT scan
(See Table 15.1). Document the state of the of the temporal bones is recommended to act as a
contralateral ear. ‘roadmap’ for surgery.

MYRINGOPLASTY
❚❘ Aims of surgery Complications

The principal aims of surgery are to provide the ● Scar (potential for poor cosmesis).
patient with an intact tympanic membrane resulting ● Bleeding.
in a safe and dry ear that hears as well as possible. ● Infection.
● Graft failure (personal audit will determine this
risk – 10−30%).
❚❘ Alternatives to surgery ● Chorda tympani injury with taste disturbance
(usually temporary).
In addition to discussing surgery, it is important to ● Ear numbness (particularly with a post-auricular
advise patients of the alternatives available to them. incision).
In the case of a central perforation, these include ● Hearing loss (dead ear <1%).
observation coupled with water precautions, par- ● Tinnitus (rare).
ticularly if there are few symptoms and the impact ● Vertigo (rare).
on lifestyle is minimal. A trial of a hearing aid is an ● Facial nerve palsy (usually temporary and
option if hearing loss is the primary symptom. rare).

Tympanoplasty 99
OPERATIVE PROCEDURE
Preoperatively, it is important to ensure the ● Side − correct side?
patient is adequately marked, has an up-to-date ● Spikes (facial nerve monitor).
audiogram and still has the perforation ● Straps − is the patient secured to the table?
(Figure 15.1a).

Do not assume that the anaesthetist is familiar with ❚❘ Procedure steps

the type of surgery planned. In particular, discuss
the need for intraoperative hypotension to reduce Injection of local anaesthetic
bleeding and lack of paralysis to enable facial nerve
monitoring. The use of a local anaesthetic such as 2% xylociane
with 1:80 000 adrenaline is used to aid vasocon-
The patient is placed supine, with their head on striction. The procedure can be performed under
a head ring, rotated away from the operative ear. local anaesthetic, but general anaesthesia is more
A small amount of hair removal may be required. common. The ear canal skin is infiltrated with local
We recommend the use of a facial nerve monitor anaesthetic providing hydrodissection, making it
as if it is used for all otological cases (other than easier to dissect and less likely to bleed. The site of
insertion of a grommet), then the entire theatre any intended external incision is then infiltrated.
team become familiar with how to set it up and
there is no ambiguity as to whether it is required Remove margins of the perforation
for a particular procedure. It is also useful in the
event of any unexpected pathology. Strapping the With the perforation clearly in view a gently curved
patient to the table is helpful and allows them needle can be used to make a series of tiny perfora-
to be rotated during surgery, which can improve tions around it (Figure 15.1b). It is helpful to start
visualization of middle ear structures. A useful inferiorly and work superiorly to prevent bleeding
check list prior to scrubbing up is to consider from the edge obscuring the view. The small per-
three S’s: forations are joined together and, the inner ring

Margin
Curved needle
of perforation

(b)
(a)
Figure 15.1. (b) Freshening the edge of the
Figure 15.1. (a) Tympanic membrane perforation. perforation.

100 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 Crocodile forceps Incision for
tympanomeatal flap

(c) (d)

Figure 15.1. (c) Freshening edge of perforation. Figure 15.1. (d) Tympanomeatal flap incision.

of tissue can be gently pulled away using crocodile Tapes passed through the ear canal and out via the
or cupped forceps leaving a freshened and slightly re-entry incision can be used to retract the pinna
larger perforation (Figure 15.1c). and lateral meatal skin out of the field of view.
● Pre-auricular (endaural) − an incision is made
Incision just anterior to the anterior helix of the pinna and
runs inferiorly between the helix and tragus. It is
There are three standard approaches for performing continued into the roof of the EAC. A limb can be
otological procedures. The choice usually comes extended down the posterior wall of the EAC. The
down to surgeon preference. Adequate exposure of meatal skin lateral to this limb can then be elevated
the entire perforation is essential and will influence laterally over the bony margin of the ear canal. A
which approach is used. It may also be necessary to two-prong retractor is then used to give exposure.
perform a limited canalplasty to remove any bone
obscuring the view of the perforation, particularly Tympanomeatal flap
if there is an anterior canal wall overhang obscuring
an anterior perforation. Whatever approach is used, it is usually neces-
● Permeatal − if the external auditory canal (EAC) sary to elevate a tympanomeatal flap, except in
permits a view of the entire perforation and is the cases of very small perforations, where a fat or
wide enough to accommodate a large speculum, facial graft can be ‘tucked’ through the perfora-
this approach can be used for both small and tion. A posteriorly placed bucket handle incision
large perforations. It is helpful to use as wide is made, extending from the 12 o’clock position
a speculum as the EAC will allow. This can be of the tympanic membrane (TM) (adjacent to the
secured with a clear plastic drape. lateral process of the handle of malleus) to beyond
● Post-auricular − a curved incision is made the 6 o’clock position. Microscissors are required
approximately 1 cm behind the post-auricular for the thicker meatal skin of the superior EAC.
crease through the skin and subcutaneous tissue The flap is elevated using an elevator such as a
onto the temporalis fascia in its upper half. A Rosen ring until the annulus is reached. A fine
semicircular incision is made through the perios- elevator such as a Hugh’s is used to elevate the
teum just posterior to the bony EAC. The skin of annulus and enter the middle ear. By entering the
the posterior EAC is then elevated prior to making middle ear posteroinferiorly, injury to the chorda
a re-entry incision into the EAC (Figure 15.1d). tympani is minimized. Once the TM is reflected

Tympanoplasty 101
anteriorly, it should be possible to see the medial have a very high success rate for repair of both small
surface of the anterior extent of the perforation. and large perforations, and are resilient to retraction
For a larger perforation, it is helpful to elevate without adversely affecting hearing outcomes (3).
the TM off the handle of malleus. An ophthalmic
keratome knife is extremely useful for dividing the
adherent fibres attaching the TM to the umbo. Graft sizing

A helpful technique is to cut a paper template to

Check the ossicular chain accurately size the perforation or region of tympanic
membrane that requires reconstruction. If using fascia,
Visually inspect the ossicles, in particular the incu- the graft will need to be bigger than the template. If
dostapedial joint (ISJ). Gently palpate the malleus using a composite island graft, the cartilage can be
handle and observe the movement of the malleus trimmed to the size of the perforation, while retaining
and incus (limited if there is attic fixation), confirm a perichondrial apron to aid with graft placement.
the integrity of the ISJ and mobility of the stapes
footplate.
Graft placement

Graft harvest The graft is placed beneath the tympanic membrane

in an underlay fashion (Figure 15.1e) and manipu-
The two commonest graft materials used are lated such that the entire TM defect is sealed (Figure
temporalis fascia and a composite cartilage perichon- 15.1f). The graft should lie flat against the undersur-
drium graft. Temporalis fascia is simply harvested via face of the TM. Surface tension is usually adequate
a post- or pre-auricular incision. To enable it to be to keep the graft in place, but additional support can
easier to manipulate, it is scraped flat and left to dry. be obtained by placing small GelfoamTM or Spon-
Cartilage can be harvested from the concha cymba, gostanTM pieces in the middle ear. The tympanome-
concha cavum or fossa triangularis if using a post- atal flap is then relocated in its original position.
auricular incision or from the tragus if performing
a permeatal or end-aural approach. The composite
perichondrium cartilage graft technique uses a single Ear packing
shield or island-shaped graft that remains attached
to its perichondrium to reconstruct part or all of The surface of the tympanic membrane is gently
the tympanic membrane. Cartilage composite grafts covered to protect it and allow epithelium to grow

Incudostapedial joint
Chorda tympani
Curved needle
Temporalis fascia graft

(e)

Figure 15.1. (e) Underlay graft.

102 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 over the graft. The dressing used is dependent on the
preference of the surgeon. This can be done with a
thin strip of clear silastic, small pieces of BIPP ribbon
gauze or with gel foam blocks. The external auditory
Graft in place canal is then filled with further short strips of BIPP
ribbon gauze (or similar) or a Pope wick in order to
keep the meatal skin in place and prevent blunting of
the angle between the TM and ear canal.
Curved needle
Closure

(f ) The wounds are closed in layers, preferably with an

absorbable suture such as 4/0 Vicryl or Monocryl.
Figure 15.1. (f) Graft positioning.
A head bandage may or may not be required (four
hours is usually adequate).

POSTOPERATIVE REVIEW
Postoperatively, it is good practice to document the Advise the patient to keep the ear dry until after
facial nerve function and confirm that there is still review. Postoperative follow-up is usually 2−4
hearing in the operated ear by performing a Weber weeks after surgery, at which time the dressings are
test. The majority of myringoplasty cases can be removed from the ear.
performed as day surgery, particularly if performed
permeatally.

REFERENCES
KEY POINTS: 1 Wullstein H (1956). Theory and practice of
tympanoplasty. Laryngoscope 66: 1976−93.
● Audiometry − Ensure the patient has an 2 Sade J, Berco E (1976). Atelectasis and secretory
up-to-date, ear-specific, appropriately otis media. American Journal of Otolaryngology
masked audiogram prior to surgery. 85(Suppl. 25): 66−72.
● CT scan − A high-resolution temporal 3 Dornhoffer J (2003). Cartilage tympanoplasty:
bone CT scan provides a useful indications, techniques and outcomes in a 1000
‘roadmap’ for mastoid surgery. patient series. Laryngoscope 113(11): 1844−56.
● Facial nerve monitor − Make it a routine
part of your practice.
● Correct side.
● Optimal access and visualization. The
local anaesthetic, hypotensive general
anaesthetic, surgical approach and
ability to manoeuvre the operating
table combine to provide the best
surgical conditions.

Tympanoplasty 103
 16 MASTOIDECTOMY

Mastoidectomy is the surgical removal of all or part (CSOM) and, most commonly, CSOM with
of the petromastoid portion of the temporal bone. cholesteatoma.
The degree of removal depends on the condition ● For access − The mastoid component of the
being addressed. temporal bone acts as a conduit for a number
of surgical procedures, including hearing im-
plantation surgery (cochlear and middle ear),
Indications endolymphatic sac surgery, labyrinth surgery
(posterior or superior semicircular canal
● For pathology − Removal of disease within occlusion and osseous labyrinthectomy) and
the mastoid air cells or from the middle translabyrinthine approaches to the internal
ear, including acute mastoiditis, malignancy, auditory canal and cerebellopontine angle
mucosal chronic secretory otitis media (vestibular schwannoma surgery).

CHOLESTEATOMA SURGERY
Cholesteatoma is keratinizing squamous epithelium production and pressure necrosis can result in
(skin cells) within the middle ear space. They tend the destruction of bony structures, including the
to gradually enlarge. The combination of enzyme ossicles and otic capsule.

ASSESSMENT
❚❘ History ❚❘ Examination
Cholesteatomas present with a painless Document the origin of the cholesteatoma. Does it
discharging ear (often with an unpleasant originate in the attic, from a marginal perforation
odour) and an associated hearing loss. Less or pars tensa retraction pocket? Describe the status
commonly, they can present with one of the of the middle ear (dry or infected?), including the
more serious complications of CSOM with state of the ossicular chain. Document the state of
cholesteatoma, including meningitis, acute the contralateral ear.
mastoiditis, facial nerve palsy and vertigo
secondary to a lateral semicircular canal fistula. ❚❘ Investigations
As with any otological procedure, the condition
of the contralateral ear is an important Pure tone audiometry, including air conduction
consideration. and appropriately masked bone conduction, is an

104 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

essential part of the assessment and should be ● The course of the facial nerve and whether this is
performed within three months of surgery. dehiscent.
● Whether there is erosion of the otic capsule.
An axial high-resolution fine-cut CT scan of the ● The state of the ossicles.
temporal bones with coronal reconstructions is an A number of different mastoidectomy techniques
important component of management. This is can be employed in the treatment of cholesteatoma
not performed for diagnostic purposes, which is (Figure 16.1a). These include:
clinical, but serves as a ‘roadmap’ for planning
surgery to determine: ● Combined approach tympanoplasty (CAT), also
known as a canal wall up mastoidectomy (Figure
● The extent of cholesteatoma (often unreliable). 16.1b).
● Whether the sigmoid sinus is dominant or ● Atticotomy or small cavity mastoidectomy, also
situated anteriorly. known as front-to-back mastoidectomy.
● The level of the middle fossa dura and whether ● Modified radical mastoidectomy, also known as a
this is dehiscent. canal wall down mastoidectomy (Figure 16.1c).

(a) (b)
Malleus
Malleus
Cholesteatoma Malleus
Promontory

Tegmen
Promontory
Facial nerve
Stapes
Lateral semicircular
canal Round window
Site of posterior
tympanotomy
Chorda tympani
nerve
Stapes Round window

Malleus TM remnant

Tegmen
Promontory
Facial nerve
Stapes
Lateral semicircular canal
Round window

Sinodural angle
Sigmoid sinus

(c)

Figure 16.1. (a−c) Surgical options for cholesteatoma (a) include combined approach tympanoplasty (b) or
modified radical mastoidectomy (c).

Mastoidectomy 105
A good otologist should be trained in all three tailored to the specific disease and requirements of
techniques so that the procedure performed can be the patient.

AIMS OF SURGERY
The principal aims of surgery are to provide the its ability and to eradicate the risks associated with
patient with a safe, dry ear that hears to the best of untreated cholesteatoma.

ALTERNATIVES TO SURGERY
When discussing surgery, it is important to advise ● Infection.
patients of the alternatives available to them. In the ● Residual or recurrent disease (up to 25% with
case of cholesteatoma, surgery is the only means of CAT, hence the need for second-look surgery).
eradicating the disease and the associated complica- ● Facial nerve injury (<1%).
tions. Observation is an option in selected cases, in ● Chorda tympani injury with taste
particular, in patients who are symptom-free, too disturbance (usually temporary even if
unfit for surgery or who decline surgery. the chorda is divided).
● Ear numbness (particularly with post-auricular
Cholesteatoma in an only hearing ear is not an
incision).
absolute contraindication to surgery, but it is
● Hearing loss (risk of dead ear up to 1%).
advisable that any procedure is undertaken by an
● Tinnitus (rare).
experienced otologist.
● Vertigo (rare).

❚❘ Complications
The risks of surgery include:
● Scar (potential for poor cosmesis).
● Bleeding.

OPERATION
Preoperatively, it is important to ensure the patient The patient is placed supine, with their head on a
is adequately marked and has an up-to-date audio- head ring, rotated away from the operative ear. A
gram. Review the CT scan and determine whether small amount of peri-auricular hair removal may
any complicating factors are anticipated. be required. Most otologists regard the use of a
facial nerve monitor for cholesteatoma surgery
Check the availability of any specialist equipment
as mandatory if the hospital is in possession of
with the scrub team. This may include an adequate
the device. Strapping the patient to the table is
selection of the preferred ossicular replacement pros-
extremely helpful and allows them to be rotated
theses, the availability of a KTP laser with appropri-
during surgery to improve visualization of
ately trained operator or a range of otoendoscopes.
difficult areas. Many surgeons mark the
Ensure that the anaesthetist is aware of the need for planned postaural incision and mastoid
intraoperative facial nerve monitoring and relative process (Figure 16.2a). A useful checklist prior
hypotension to reduce bleeding. to scrubbing up is to consider three S’s:

106 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

● Side − Correct side? time, the TM may be elevated off the handle of
● Spikes − Facial nerve monitor. malleus. An ophthalmic keratome knife is useful
● Straps − Is the patient secured to the table? for dividing the adherent fibres attaching the TM
to the umbo.
4 Check the ossicular chain − Visually inspect the
❚❘ Combined Approach ossicles and their relationship with the cholestea-
Tympanoplasty toma. If the ossicular chain is intact, a decision
regarding whether it will be possible to clear
Procedure steps disease adequately without disrupting it must be
made. With a more extensive cholesteatoma in-
1 Injection of local anaesthetic − The use of a volving the mesotympanum, it may be necessary
local anaesthetic such as 2% xylociane with to remove disease in order to get a view of the
1:80 000 adrenaline is used to infiltrate the canal incus and or stapes. In these cases, there is often
skin and the region of the post-auricular erosion of the long process of the incus. If the
incision (Figure 16.2b). incudostapedial joint is intact, it is divided with
2 Incision (post-auricular) − A curved incision is a joint knife and the incus carefully removed
made 1−2 cm behind the post-auricular crease without damaging the stapes superstructure. The
through skin and subcutaneous tissue onto neck of the malleus is then divided with malleus
temporalis fascia in its upper half (Figure 16.2c). nippers and the head of the malleus removed;
A horseshoe incision is made through the the handle of malleus can either be removed or
periosteum of the mastoid and a superiorly left in situ. Removal of the handle of malleus can
based subperiosteal flap raised (Figure 16.2d−e) make reconstruction simpler and reduce recur-
using a periosteal elevator (Figure 16.2f). The rent cholesteatoma.
skin of the posterior EAC is then elevated prior 5 Cortical mastoidectomy − Using a 5 or 6 mm
to making a re-entry incision into the EAC. cutting burr, the cortical bone is removed to
Tapes passed through the ear canal and out via make a cavity (Figure 16.2g−h), the superior
the re-entry incision are used to keep margin of which is the tegmen tympani,
the pinna and lateral meatal skin retracted. posterior margin the sigmoid sinus and anterior
This approach provides excellent exposure of the margin the bony wall of the external auditory
cortical bone of the mastoid and the root of the canal (Figure 16.2i). As bone is removed, air cells
zygomatic process. will come into view depending on the degree
3 Tympanomeatal flap and disease isolation − of sclerosis of the mastoid. It is important to
The goal is to isolate the middle ear compo- find the tegmen and sigmoid sinus and then
nent of the cholesteatoma, while preserving the skeletonize them (leave a thin layer of bone)
healthy remnant of the tympanic membrane. with a diamond burr. This ensures that optimal
As with a myringoplasty, a posteriorly placed access is achieved and that the surgeon does not
bucket handle incision is made, extending from become lost down a deep dark hole. The bone of
the 12 o’clock position of the TM (adjacent to the posterior canal is thinned while looking into
the lateral process of the handle of malleus) the cavity and down the EAC. Anterosuperiorly,
to beyond the 6 o’clock position. The superior the dissection continues forward with a smaller
aspect of the tympanomeatal flap incision is cutting burr into the root of the zygomatic
taken right up to the margin of cholesteatoma. process between the tegmen and bone of the
Microscissors are used to cut around the neck of superior EAC to provide access to the attic. With
the cholesteatoma. It may be necessary to divide progressive bone removal, the mastoid antrum
the chorda tympani cleanly if it is involved in the is encountered. With the mastoid antrum open,
disease. The resulting flap of posterior canal skin the bony bulge of the lateral semicircular canal
and tympanic membrane remnant is elevated comes into view, as does the lateral process of the
and reflected anteroinferiorly. At the same incus. Extreme caution is required as drilling on

Mastoidectomy 107
 (a)

Mastoid tip

Marker pen

(b) (c)

Mastoid tip

Postaural
incision

(d) Local anaesthetic (e)

infiltration

Ear canal
Superiorly
based palva
flap

(f)

Spine
of Henle

Tympanic
membrane
visible through
Temporalis muscle re-entry incision
Superiorly
based palva
flap reflected Periosteal
elevator

Figure 16.2. (a−f) Steps involved when performing a mastoidectomy via a postaural approach.

108 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 (g) (h)

Spine
of Henle
Air cells

Large Large
cutting burr cutting burr

(i)

Cholesteatoma sac

Air cells

Large cutting burr

Figure 16.2. (g−i) Steps involved when performing a mastoidectomy via a postaural approach.

an intact ossicular chain may result in a sensori- (Figure 16.1b) and is best performed with a
neural hearing loss. The dissection is continued small diamond burr. The first step is to find the
anteriorly until the anterior attic is accessible; mastoid segment of the facial nerve while drill-
this can otherwise be a common site for residual ing parallel to it with copious irrigation. Once
disease. Throughout the procedure, cholestea- located, it is possible to remove the bone lateral
toma and granulations may require piecemeal to the nerve in order to encounter the intra-
removal in order to maintain visualization. The osseous chorda. By removing the bone between
final cavity should be smooth and disease-free. the facial nerve and chorda tympani, the facial
6 Posterior tympanotomy − This refers to the recess is opened, providing a view of the stapes
removal of the triangle of bone between the (if present) and sinus tympani. In addition to
facial nerve, chorda tympani and fossa incudis the anterior attic, the sinus tympani is a frequent

Mastoidectomy 109
 site for residual cholesteatoma; a good posterior The head of the prosthesis lies against the un-
tympanotomy provides optimal visualization of dersurface of the cartilage checkerboard.
this tricky area, which can be supplemented with 9 Ear packing − The surface of the
angled otoscopes. reconstructed tympanic membrane is gen-
7 Tympanic membrane reconstruction − A com- tly covered with small pieces of BIPP ribbon
posite cartilage graft (cartilage and perichon- gauze. The ossiculopasty is inspected via the
drium) is an excellent material for this and has posterior tympanotomy to ensure that this re-
a high resilience to retraction without adversely mains in an optimal position prior to filling the
affecting hearing outcomes (1). Cartilage is external auditory canal with additional short
harvested from the concha cymba or concha strips of BIPP ribbon gauze.
cavum via the postauricular incision. The pos- 10 Closure − The post-auricular wound is closed
terior bony annulus and attic are smoothed off. in layers with absorbable sutures and a head
A tape passed through the canal and brought bandage with mastoid dressing is placed
out through the mastoid cavity can be used to overnight.
remove residual squames from the bony margin.
A paper template is prepared to size the attic and Postoperatively, the facial nerve function is
tympanic membrane reconstruction required. documented. A postoperative lower motor
This is done prior to harvesting the cartilage neurone palsy is extremely worrying and the
to ensure a large enough piece of cartilage is operating surgeon must be informed. While the
taken. Once harvested, the cartilage is shaped palsy may be due to the local anesthetic, if the
to the template (taking care to place the lateral nerve fails to recover, surgical exploration by the
aspect of the template on the cartilage) leaving operating surgeon and a second senior otologist
a peripheral apron of perichondrium surround- is required. Facial nerve reanastamosis may
ing the cartilage. The cartilage is scored down be attempted.
to perichondrium, twice horizontally and twice A Weber test or scratch test is also performed to
vertically. The result is nine separate pieces, confirm that there is still hearing in the operated
resembling a chessboard, that are attached to ear. While the majority of mastoidectomy cases
the perichondrium. This technique removes the require an overnight stay, they may be performed as
natural convexity of conchal cartilage and makes day case procedures.
the graft easier to manipulate in the ear. The
graft is placed in the middle ear in an underlay The patient is advised to keep their ear dry until
fashion with the perichondrium laterally. The after review. Postoperative follow-up is usually
perichondrium is placed over the bony meatal two weeks after surgery, at which time the dressings
wall lateral to the bony annulus, but medial to are removed. Postoperative antibiotics are not
the annular ligament and tympanomeatal flap usually necessary.
to anchor the graft and prevent medialization.
The cartilage should extend snugly to the bony
annulus but not overlap it.
REFERENCE
8 Ossiculoplasty − A partial or total ossicular
1 Dornhoffer J (2003). Cartilage tympanoplasty:
replacement prosthesis (typically titanium or
hydroxyapetite) is positioned to bridge the indications, techniques and outcomes in a 1,000
ossicular gap between the tympanic membrane patient series. Laryngoscope 113(11): 1844−56.
and stapes head or footplate respectively.

110 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 17 STAPEDECTOMY

Stapedectomy literally means the surgical removal (typically) and placed through a fenestration in
of the stapes bone. The term has come to refer to the stapes footplate (stapedotomy). This procedure
the operation in which the stapes superstructure is is used to correct the conductive hearing loss that
replaced by an artificial piston attached to the incus arises as a result of otosclerosis (Figure 17.1).

Artificial prosthesis

Figure 17.1. Stapedectomy typically involves removal of the stapes crura, fenestration of the footplate and
the insertion of an artificial piston.

Otosclerosis affects the bone of the otic capsule, ally, the stapes becomes fixed, resulting in reduced
leading to new bone formation around the edge transmission of sound to the cochlea and significant
of the oval window and stapes footplate. Eventu- conductive hearing loss.

ASSESSMENT

❚❘ History bilateral condition in patients with a family history

of hearing loss. Otosclerosis genes are transmitted
The typical presenting symptom of otosclerosis in an autosomal-dominant manner. However, due
is hearing loss. Less often there may be associated to variable penetrance and expression, it does not
tinnitus or vertigo. It is commonly (70%) a affect every generation.

Stapedectomy 111
❚❘ Examination higher frequencies become affected. There may be a
mixed conductive and sensorineural loss if there is
Tuning fork tests are useful to confirm clinically a additional cochlear otosclerosis. Characteristically, a
conductive hearing loss. It is necessary to docu- Carhart’s notch is seen where a dip in the bone con-
ment the state of both ears and exclude other duction occurs maximally at 2 kHz due to the loss
causes of conductive hearing loss (e.g., otitis media of the middle ear component of sound conduction
with effusion or a retraction pocket with ossicu- at this natural frequency of resonance of the ossicu-
lar erosion). In active disease, hypervascularity of lar chain.
the promontory may be seen as a pinkish blush
through the tympanic membrane. This is known as Tympanometry demonstrates a normal, type A
Schwartze’s sign. tympanogram confirming normal middle ear com-
pliance. Stapedial reflexes are typically absent on the
affected side.

❚❘ Investigations Speech audiometry can be a useful investigation,

particularly in the presence of a mixed hearing loss.
Pure tone audiometry, including air conduction Maximum speech discrimination scores (SDS)
and appropriately masked bone conduction, is an of less than 70% may be associated with a poorer
essential part of the assessment. In early disease, a perceived benefit from surgery.
predominantly low-frequency conductive hearing
loss is found. With increased fixation of the stapes,

AIMS OF SURGERY
The principal aims of stapedectomy are to provide ability. The probability of improving the hearing to
the patient with an ear that hears to the best of its within 10 dB of the bone conduction is >90%.

ALTERNATIVES TO SURGERY
In addition to discussing surgery, it is Complications
important to advise patients of the alternatives
available to them. Many patients will elect for The risks of surgery include:
observation once the diagnosis has been made.
● Bleeding.
A trial of a hearing aid is a risk-free and effective
● Infection.
option that should be encouraged prior to electing
● Chorda tympani injury with taste disturbance.
for surgery.
● Dead ear or hearing loss (approximately 1%).
● Failure to close the air−bone gap within 10 dB
(approximately 5%).
● Late failure.
● Tinnitus.
● Vertigo.
● Facial nerve injury (rare).

112 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

OPERATION
The side to be operated on should be clearly marked annulus as it is often necessary to remove some
and the risks of the procedure explained. The ear of the bony annulus. The tympanomeatal flap is
must be dry, with no active infection. A recent (within raised, providing access to the posterior contents
three months) audiogram should also be present. of the mesotymanum and allowing the flap to
be hinged along the malleus and out of the way.
Check the availability of any specialist A view of the long process of incus, incudosta-
equipment with the scrub team. This includes pedial joint, stapedius tendon and stapes foot-
an adequate selection of the preferred stapedec- plate is required. If access is limited, a House
tomy prosthesis and, depending on the technique curette is used to remove the bone posterior
used, a KTP laser with an appropriately trained and superior to the stapes until the desired
operator. view is achieved (Figure 17.2a).
4 Check of the ossicular chain − Palpate the os-
As with other otological procedures, ensure the sicular chain with a needle. Confirm that the
anaesthetist is aware of the need for intraoperative stapes footplate is fixed and that the malleus
facial nerve monitoring and relative hypotension and incus are mobile.
to reduce bleeding. 5 Division of the incudostapedial joint (ISJ) − The
ISJ is divided with a joint knife or fine right-
The patient is placed supine, with their head on a angled hook. The joint can be clearly identified
head ring, rotated away from the operative ear. A by gently elevating the incus. Division of the joint
small sandbag is placed beneath the shoulders to should be in line with and away from the stape-
extend the neck as this makes it easier to access the dius tendon (Figure 17.2b).
posterosuperior region of the tympanic membrane. 6 Division of the stapedius tendon − The stape-
As with other ontological cases, facial nerve moni- dius tendon is divided with a laser, sharp sickle
toring and strapping the patient to the table can be knife or microscissors.
useful adjuncts. 7 Removal of stapes superstructure − The
posterior crus of the stapes is divided with
a laser or skeeter drill. The anterior crus
is divided by down-fracturing towards the
❚❘ Stapedectomy promontory.
8 Fenestration − A small fenestration (stapedot-
Procedure steps omy) is made in the stapes footplate using a
skeeter drill, laser or hand-held trephine. The
1 Injection of local anaesthetic − Local anaesthetic fenestration typically has a diameter of 0.8 or
(e.g., 2% xylociane with 1:80 000 adrenaline) is 0.7 mm to accommodate a 0.6 mm prosthesis
used to infiltrate the canal skin in order to thick- (Figure 17.2c).
en the tympanomeatal flap and reduce bleeding. 9 Prosthesis − A stapedectomy prosthesis is placed
It is common practice in many clinics to perform within the fenestration and secured around the
the entire procedure under local anaesthesia, long process of the incus. Small pieces of fat,
with a peri-auriclar block. harvested from the ear lobule, are placed around
2 Incision − Typically a permeatal or endaural the prosthesis to prevent leakage of perilymph. A
approach is used. vein graft may be placed over the fenestration to
3 Tympanomeatal flap − A posterior bucket handle perform the same task (Figure 17.2d).
incision is made, extending from the 12 o’clock 10 Ear packing − The tympanomeatal flap is
position of the TM to the 6 o’clock position. The replaced and the ear lightly packed with small
meatal incision should not be too close to the pieces of BIPP ribbon gauze.

Stapedectomy 113
POSTOPERATIVE REVIEW
The facial nerve function is documented and a The patient is given advice to keep their ear dry
Weber test is performed to confirm that there is still until after review. Postoperative follow-up is usually
hearing in the operated ear. The eyes are examined two weeks after surgery, at which time the dressings
and any nystagmus noted. While some stapedectomy are removed.
cases require an overnight stay, increasing numbers
are being performed as day case procedures.

(a) (b)
Malleus
Incudostapedial
joint separated
Malleus
Tympanic
Long prcess membrane
of incus reflected
anteriorly
Stapes
Stapes

Posterior canal wall

Posterior
canal wall

(c) (d)

Stapes footplate fenestrated

Stapes prosthesis

Figure 17.2. (a−d) Steps involved when performing a stapedectomy.

114 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 18 BONE-ANCHORED
HEARING AID
A bone-anchored hearing aid (BAHA) Indications
provides hearing rehabilitation through bone
conduction. The BAHA consists of a titanium ● Patients unable to wear a conventional hearing
implant, abutment and a sound processor. aid due to otitis externa, chronically discharging
The implant is placed surgically behind the ear ears, allergy to hearing aid moulds or congeni-
and forms a solid attachment to bone through tal malformation of the middle or external ear,
osseointegration. The sound processor is including canal and pinna atresia.
removable and facilitates sound conduction ● Unilateral complete sensorineural hearing loss.
through vibrations, which are transmitted via Placed behind the deaf ear, the BAHA facilitates
the abutment and implant complex through the the conduction of sound through the skull to the
skull to reach the cochlea. BAHA offers superior good ear. This prevents the head shadow effect
sound quality to a conventional bone conductor from the deaf side, although in general does not
hearing aid. improve directionality.

PREOPERATIVE REVIEW
Ensure that the patient has completed their audio- of a bone conductor worn on a headband. Mark the
logical assessment for BAHA, which includes a trial side on which the BAHA is to be placed.

OPERATIVE PROCEDURE
This is usually performed under general in order to ensure that the eventual position of the
anaesthetic. Ensure that at least two BAHA processor will not impinge on the ear and the arm
implants are available prior to starting (one spare). of glasses if worn. Draw around the dummy sound
The patient is positioned supine with the head processor in order to mark the skin flap, which is
facing 45° away from the surgeon. Shave the most commonly anteriorly based. Local anaesthe-
post-auricular area, prepare the skin and drape sia (2% xylocaine, 1:80 000 adrenaline) is instilled
(Figure 18.1a). (Figure 18.1c).

Mark the position of the implant 55 mm from the The skin flap may be raised manually (full thick-
external auditory meatus in the direction shown ness) or with a dermatome (split skin). Use a no. 15
(Figure 18.1b). Use the dummy sound processor scalpel blade to incise the skin alone (Figure 18.1d).

Bone-anchored hearing aid 115

 (a) Shaved area (b) (c)

55 mm

(d) (e) (f)

Full thickness
graft Periosteum Dummy processor

(g) Periosteum incision (h) (i) Countersink

(j) Dummy processor (k) (l) Flap sutured

Figure 18.1. (a) Post-auricular shave. (b) Marking implant position. (c) Incision. (d) Raising flap. (e) Excision
of subcutaneous fat. (f) Marking abutment site. (g) Periosteal incision. (h) Drilling guide hole. (i) Countersink.
(j) Placing abutment. (k) Incision for abutment. (l) Closure.

116 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

Carefully raise a full thickness skin flap, ensuring abutment as one unit (Figure 18.1i). A two-stage
that no fat is left on the flap and the hair follicles are technique may be used in children, where the
transected (Figure 18.1e). implant alone is initially placed under the skin and
an abutment screwed onto this three months later
Excise all subcutaneous fat down to, but preserving, after osseointegration has taken place. Mount the
the skull periosteum (Figure 18.1f). Angle the blade implant onto the drill using a no-touch technique.
at 45° to undermine fat under the skin edges in The implant is a self-tapping screw. Turn the irriga-
order to ensure that the implant and hearing aid are tion off and set the torque of the drill to 20 N/m2.
not in contact with the skin. It is essential that this is placed perpendicular to
the skull. Insert the implant into the hole and, after
Mark the implant position again using the dummy the first couple of turns, restart the irrigation. Do
hearing aid (Figure 18.1f). not stop the drill until the implant stops turning
(Figure 18.1j).
Make a cruciate incision in the periosteum and
elevate each corner (Figure 18.1g). Cut a hole in the overlying skin with a 4 mm
dermatological punch and make radial incisions in
Drill the hole for the implant, using the hand-held order to enable the abutment to pass through the
drill. Ensure that the irrigation is on and drill speed skin (Figure 18.1k).
high. Initially, drill a guide hole 3 mm deep per-
pendicular to the skull. Palpate the base of the hole Place the healing cap firmly onto the abutment and
carefully. If bone remains, redrill the hole to a depth suture the skin (Figure 18.1l). Place a non-adherent
of 4 mm (Figure 18.1h). dressing and foam under the healing cap for one
week. A head bandage compression dressing over-
One-stage implants are used in the majority night is optional.
of cases, consisting of the implant screw and

POSTOPERATIVE REVIEW AND FOLLOW-UP

Following observation according to the day sur- Complications
gery protocol, the patient can be discharged with
analgesia. Initial follow-up is at one week to remove ● Infection.
the healing cap and change the dressings. Further ● Bleeding or haematoma.
dressing changes may be performed by nursing ● Failure of skin graft.
staff. The patient is taught to care for their implant, ● Failure of implant.
which requires daily cleaning with a soft tooth-
brush. The hearing aid is fitted and programmed
after three months.

Bone-anchored hearing aid 117

 19 PANENDOSCOPY

Panendoscopy refers to the formal assessment of ● Laryngoscopy.

the upper aero-digestive tract using rigid endo- ● Rigid oesophagoscopy.
scopes. The term encompasses a number of distinct
procedures: On occasion, a rigid bronchoscopy may be required
● Examination of the postnasal space (PNS). to complete a formal assessment of the upper aero-
● Pharyngoscopy. digestive tract.

PREOPERATIVE REVIEW
All imaging must be reviewed. Patients at risk of opening and neck movement are assessed in the
cervical spine injury should undergo a cervical awake patient as this will impact on the ease of
spine x-ray. Loose teeth or dental crowns require the procedure.
extra precautions to prevent damage. Mouth

OPERATIVE PROCEDURE
The light source and carrier are checked to The eyes are taped closed and the head draped with
make certain they are functioning correctly. the nose and mouth exposed. The body is draped
An appropriate range of endoscopes, Hopkins leaving the neck exposed.
rods and a variety of biopsy forceps must
be available. In all cases, the neck is inspected for scars and the
neck palpated for masses and laryngeal crepitus.
The procedure is undertaken under general The oral cavity, tongue base and tonsils are also
anaesthetic and the patient placed supine on the palpated. For all procedures, except examination of
operating table. Either a pillow or head ring and the PNS, an appropriate mouth guard is placed to
shoulder roll are used to allow the neck to be protect the upper teeth. If the patient is edentulous
slightly flexed and the head extended to achieve a wet swab will suffice.
the ‘sniffing the morning air’ position. The
endotracheal or nasotracheal tube is secured, the Biopsies, if required, are taken distal to proximal in
former being secured on the left if the surgeon is order to ensure that bleeding does not obscure the
right hand-dominant. surgeon’s view.

118 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 20 DIRECT- AND
MICRO-LARYNGOSCOPY
Indications ● Investigation of an unknown cause for airway
symptoms.
● Laryngeal pathology (e.g., laryngeal carcinoma, ● Removal of a foreign body.
laryngeal polyp, cord oedema). ● Investigation and management of a patient with
● Investigation of a patient with an unknown a vocal cord palsy.
primary. ● Paediatric airway assessment.
● Investigation of a patient with dysphagia.

OPERATIVE PROCEDURE
The patient is intubated with a micro-laryngeal photographs taken. In paediatric patients, a probe
tube, which is of a standard length but smaller is used to assess mobility of the cords and the crico-
diameter to allow better visualization. arytenoid joints. Representative biopsies can be
taken from any lesions.
The mouth is held open with the non-dominant
hand. The laryngoscope is gently inserted and the The operating microscope can now be used if the
tongue followed until the oropharynx is reached, following procedures are undertaken:
with any secretions suctioned. ● A magnified view of the larynx is required to
allow accurate excision of a lesion or vocal
The endotracheal tube acts as a guide and can be
cord injection.
followed directly to the larynx. Inspect the lingual
● Both hands are required to perform the
and laryngeal surfaces of the epiglottis and the
procedure.
remainder to the supraglottis, including the aryte-
● Laser excision of a laryngeal lesion.
noids. Once the vocal cords, including the anterior
commissure, are visible, the laryngoscope handle
can be attached and the suspension arm fixed to the Complications
handle to support the laryngoscope when micro-
laryngoscopy is required. An anterior commisure ● Bleeding.
laryngoscope, which has a narrower cross-sectional ● Infection.
profile, may be required to allow assessment of the ● Damage to teeth, gums, lips and tongue.
anterior commisure. ● Hoarse voice.
● Sore throat.
A 0° Hopkins rod is passed through the lumen of ● Dysphagia.
the laryngoscope. Careful assessment is made of the ● Airway compromise, which may necessitate
supraglottis, glottis and subglottis and appropriate tracheostomy.

Direct- and micro-laryngoscopy 119

POSTOPERATIVE REVIEW
● If the patient is difficult to intubate and there is undertaken prior to transfer to recovery. If there
a high likelihood that the airway will be unstable is any concern, re-intubation and tracheostomy
on extubation, a tracheostomy should be may be required.
undertaken.
● If there is any concern that the airway may be Patients are advised to rest their voice for at least
compromised, then extubation is performed in 48 hours or talk normally with no shouting
theatre and assessment of the airway or whispering.

120 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 21 PHARYNGOSCOPY

Indications ● Identifying a synchronous tumour in a

patient with known malignancy of the upper
● Mass or ulcer of the oropharynx and aero-digestive tract.
hypopharynx. ● Removal of a foreign body.
● Investigation of a patient with an unknown ● Globus sensation, failing to respond to medical
primary. therapy or with features suggestive of malignancy
● Dysphagia. on history, examination or imaging.

OPERATIVE PROCEDURE
The non-dominant hand is used to gently open required at this point, as secretions will obscure
the mouth and the pharyngoscope inserted the surgical field. The tongue base, valleculae,
(Figure 21.1). The tongue will guide the surgeon tonsils, posterior and lateral pharyngeal walls are
inferiorly towards the oropharynx. Suction is carefully examined.

Figure 21.1. Insertion of the pharyngoscope.

Pharyngoscopy 121
The pharyngoscope is passed behind the endo- scope blindly. Wait patiently for the muscle to relax.
tracheal or nasotracheal tube in order to visualize Otherwise, the larynx may be gently lifted forward
the posterior pharyngeal wall, pyriform fossae and to allow identification of the lumen of the cervical
post-cricoid region. oesophagus. The tip of the scope is advanced gently
into the upper oesophagus. A 0° Hopkins rod can be
It is essential that the surgeon has a clear view at all passed through the lumen to take photographs of any
times. Never attempt to force the pharyngoscope as abnormality, prior to taking representative biopsies
this risks causing an oesophageal perforation (Figure using an appropriate biopsy forceps (Figure 21.3).
21.2). If this leads to mediastinitis, the mortality rate In patients with an unknown primary malignancy,
is 50%. At the cricopharyngeal bar, the lumen may biopsies of the tongue base and tonsils are usually
come to a blind end and the temptation is to push the taken if no obvious primary can be identified.

Figure 21.2. At the cripharyngeus, the scope is gently advanced in order to avoid tearing.

Figure 21.3. Suction is often required once the pharyngoscope is within the cervical oesophagus. Biopsy
forceps are required if a biopsy is to be taken.

122 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

At the end of the procedure, ensure haemostasis trauma, which must be documented in the
and remove the teeth guard, checking for any dental operation note.

POSTOPERATIVE REVIEW
If there is any concern of trauma to the upper Complications
oesophagus, a nasogastric tube should be passed
under direct vision during the procedure and the ● Bleeding.
patient kept nil by mouth. A contrast swallow ● Infection.
allows visualization of a potential perforation. If ● Damage to teeth, gums, lips or tongue.
the suspicion of perforation is low, the patient is ● Sore throat.
observed closely for pain radiating to the back, ● Dysphagia.
pyrexia, tachycardia or tachypnoea. If these do not ● Hoarse voice.
occur, the patient can commence sips of sterile ● Damage to pharyngeal mucosa, including
water, gradually building up to free fluids and a perforation.
soft diet prior to discharge home.

Pharyngoscopy 123
 22 RIGID
OESOPHAGOSCOPY
Rigid oesophagoscopy is performed in a similar Indications
manner to pharyngoscopy. Rigid oesophagoscopes
are typically available 25 cm or 40 cm in length, ● Similar to that for rigid pharyngoscopy.
which can reach the gastro-oesophageal junction.
It is important to ensure that suction and biopsy
forceps of an appropriate length are available.

OPERATIVE PROCEDURE
The procedure is similar to that for rigid distance from the incisors and document this in
pharyngoscopy. The oesophagoscope is the operation note. Representative biopsies are
manoeuvred into the post-cricoid region. The tip taken. Carefully assess the mucosa as the
of the oesophagoscope is gently lifted to allow oesophagoscope is removed and, if there is any
identification of the lumen of the oesophagus and suspicion of a mucosal tear or perforation, a
for the scope to be gently passed. Never force the nasogastric tube is passed under direct vision.
scope, especially if the lumen is not visible. Complete the procedure by removing the mouth
guard and checking the teeth.
If an abnormality is identified, use the etched
marks on the oesophagoscope to estimate the

POSTOPERATIVE REVIEW
Where there is no suspicion of trauma to the the radiologists. Obtain an urgent chest x-ray to
oesophagus, patients can eat and drink normally. exclude a pneumomediastinum indicative of a tear,
Otherwise, manage the patient as recommended for and inform a senior member of the team.
perforations after pharyngoscopy.

If a patient becomes pyrexic, tachycardic, tachy- Complications

pnoeic or has increasing retrosternal pain radiating
through to their back or dysphagia, always assume ● As for rigid pharyngoscopy, risk of mucosal tear
they have suffered an oesophageal tear. These and perforation. Patients should be made aware
patients must be kept nil by mouth. They require of the risk of requiring a nasogastric tube and
IV antibiotics (e.g., cefuroxime and metronidazole) close monitoring in hospital for a few days if a
and a nasogastric tube will need to be passed by perforation is suspected.

124 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 23 EXAMINATION OF THE
POSTNASAL SPACE
Indications ● Persistent unilateral middle ear effusion in
an adult.
● Mass or ulcer of the nasopharynx. ● Unexplained epistaxis.
● Investigation of patient with an unknown
primary.

OPERATIVE PROCEDURE
This procedure is usually undertaken last if it is is carefully examined. The fossa of Rosenmüller in
part of a panendoscopy, as any bleeding from the particular must be assessed as this may harbour a
nasopharynx due to instrumentation can track into malignancy. Biopsies are taken, if indicated, with
and obscure the view of the rest of the upper straight Blakesley-Wilde forceps. Adrenaline-
aero-digestive tract. soaked neuropatties or diathermy can be applied
if required for haemostasis.
The patient is placed supine on the operating
table and the head supported with a head ring.
A decongestant or topical anaesthetic with Complications
adrenaline is applied to the nose, usually in the
anaesthetic room. ● Bleeding/epistaxis.
● Infection.
A 0° Hopkins rod with an appropriate light source ● Otitis media with effusion secondary to inadvert-
is passed into the nasal cavity, and the nasopharynx ent damage to the Eustachian tube orifice.

Examination of the postnasal space 125

 24 RIGID BRONCHOSCOPY

Indications In many cases the proximal trachea can be assessed,

as described in Chapter 23, with a laryngoscope and
● Removal of foreign body from the trachea or 0° Hopkins rod.
main bronchi.
● Assessment of a tracheal lesion.

OPERATIVE PROCEDURE
Bronchoscopes are available in a number of sizes. (which minimizes the risk of damage to the vocal
Selection of an appropriately sized bronchoscope cord from the tip of the bronchoscope).
is essential for paediatric patients. Before the
patient is anaesthetized, ensure that the Once the bronchoscope is in the
bronchoscope is assembled correctly and that the proximal trachea, the anaesthetic circuit is
anaesthetic connectors are compatible. Confirm connected and the bronchoscope is advanced
that the light source is working and that the towards the carina. By gently turning the head
camera has been attached. Appropriate optical to the left, the bronchoscope can be advanced
forceps must be available if foreign body removal into the right main bronchus, and vice versa.
is required. Secretions can be removed using narrow suction
tubing, which can be advanced by an assistant or
Safe bronchoscopy requires good teamwork and scrub nurse.
communication between the surgeon and the
anaesthetist. When the patient is well oxygen- If a foreign body is visualized, it is vital that a
ated and the anaesthetist feels it is appropri- small volume of 1:10 000 adrenaline is instilled
ate, the endotracheal tube or laryngeal mask is via the suction tubing to reduce mucosal oedema
withdrawn and a mouth guard placed over the and allow vasoconstriction. This improves access
upper teeth. The anaesthetic laryngoscope is held and minimizes the risk of bleeding, which can
in the non-dominant hand and used to visualize make removal of the foreign body very challeng-
the larynx. The bronchoscope is held in the ing. Appropriate optical forceps are then used to
dominant hand and advanced until the larynx is remove the foreign body. The bronchoscope is
reached. The bronchoscope is rotated through 90o reinserted to ensure that there are no more for-
to facilitate passage through the glottic opening eign bodies and to assess for mucosal damage.

126 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

POSTOPERATIVE REVIEW
The patient is recovered in theatre to ensure that Complications
there are no breathing difficulties. If there has
been mucosal damage, then a chest x-ray (CXR) is These are similar to those for laryngoscopy. Others
performed to exclude a pneumothorax. include:
● Damage to the vocal cords by the
bronchoscope.
● Laryngospasm.
● Breathing difficulties due to airway oedema.
● Pneumothorax due to damage to of the mucosa
of the trachea or main bronchi.

Rigid bronchoscopy 127

 25 SUBMANDIBULAR
GLAND EXCISION
This is a common surgical procedure performed ● Benign tumours of the gland. If there is any
by both ENT surgeons and oral and maxillofacial suspicion of malignancy, then a level I neck dis-
surgeons for benign and malignant disease. section is more appropriate than simple excision
of the gland.
● Following open trauma to the gland, exploration
Indications
and removal may be necessary to avoid salivary
fistula formation.
● Recurrent submandibular gland sialadenitis.
● Drooling.
● Obstructive sialolithiasis.

PREOPERATIVE REVIEW
Mark the operative side and check the function ● Marginal mandibular nerve damage: transient
of the marginal mandibular, lingual and 5−30% (1−3); permanent <1% (1).
hypoglossal nerves ● Lingual nerve damage – 2−3% (1, 2, 3).
● Hypoglossal nerve damage.
● Salivary fistula.
Complications
● Scar.
● Recurrence (if surgery is for a tumour).
● Bleeding.
● Retained stone in stump of Wharton’s duct.
● Infection.

OPERATIVE PROCEDURE
Once intubated and transferred to the operating breadths below the lower border of the
table, position the patient supine on a head ring mandible, in order to avoid the marginal
and shoulder roll with a slight head-up tilt. The mandibular nerve (Figure 25.1a). The incision,
head is turned to the contralateral side. The skin ideally in a skin crease, runs forward from the
is appropriately prepared and draped to expose anterior edge of the sternocleidomastoid
the corner of the mouth, the angle and lower muscle and is approximately 5−7 cm in length
border of the jaw to the superior border of the (Figure 25.1b).
clavicle to the midline.
Make an incision through the skin, subcutaneous
Mark the lower border of the mandible and the tissue and platysma. The marginal mandibular nerve
site of the skin incision, which lies two finger can be damaged in the early stages of the procedure.

128 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 (a) (b)

(c) (d)

Facial Facial
vein artery

(e)

Lingual
nerve

Figure 25.1. (a−e) Submandibular gland excision.

The nerve does not have to be formerly identified, cervical fascia is incised inferior to the lower border
but knowledge of the relevant clinical anatomy is of the gland and elevated in an inferior to superior
important as the nerve lies deep to platysma but direction. The facial vein is ligated and divided close
superficial to the gland and the facial vein. to the inferior border of the gland and elevated
superiorly away from the gland (Figure 25.1c).
Stay close to the under-surface of platysma and
carefully observe for the nerve when elevating sub- Once the gland is exposed the facial artery is identi-
platysmal flaps. The superficial layer of the deep fied, ligated and divided. The gland is retracted and

Submandibular gland excision 129

dissected free of the underlying digastric muscle. especially in the small plexus near the ganglion.
The posterior border of the mylohyoid muscle is The duct is followed and ligated as distally as
identified and the muscle is retracted anteriorly to possible to complete the excision. Occasionally,
allow dissection of the deep aspect of the gland. the facial artery will need to be ligated again as it
courses over the mandible. The hypoglossal nerve
The gland is retracted posteroinferiorly and as dis- is identified during dissection of the deep aspect of
section proceeds, Wharton’s duct is exposed, which the gland (Figure 25.1e).
tents and exposes the lingual nerve and its ganglion
(Figure 25.1d). The lingual nerve is dissected off A drain may be inserted and the wound is closed
the duct, paying careful attention to haemostasis, in layers.

POSTOPERATIVE REVIEW
Examine the patient for nerve injury and haema- Non-absorbable skin sutures are removed after
toma. The drain can usually be removed in the seven days.
morning and the patient discharged home with
routine wound care advice.

REFERENCES
1 Preuss SF, Klussmann JP, Wittekindt C, et al
(2007). Submandibular gland excision: 15 years of
experience. J Oral Maxillofac Surg 65(5): 953−7.
2 Chua DY, Ko C, Lu KS (2010). Submandibular
mass excision in an Asian population: a 10-year
review. Ann Acad Med Singapore 39(1): 33−7.
3 Ichimura K, Nibu K, Tanaka T (1997). Nerve
paralysis after surgery in the submandibular
triangle: review of University of Tokyo Hospital
experience. Head Neck 19(1): 48−53.

130 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 26 HEMI- AND TOTAL
THYROIDECTOMY
Indications Complications

● Thyroid nodule or goitre. ● Bleeding.

– Suspicious (hemi-thyroidectomy) or ● Infection.
confirmed (total thyroidectomy) malignancy. ● Scar.
– Compressive symptoms. ● Hoarseness due to recurrent laryngeal
– Cosmesis. nerve injury.
● Thyrotoxicosis − A total thyroidectomy is ● Loss of the upper vocal range due to damage to
usually undertaken. superior laryngeal nerve injury, which is
especially important in singers.
● Breathing difficulties and rarely tracheostomy
if bilateral vocal cord palsy after total
thyroidectomy.
● Hypocalcaemia.

PREOPERATIVE REVIEW
It is essential that all patients undergo a vocal cord order to render them euthyroid to minimize the
check preoperatively to assess cord movement. risk of an intraoperative thyroid storm.
Review thyroid function tests and fine needle aspi-
ration cytology (FNAC) results. Thyrotoxic patients Ensure the correct side is marked in a
are managed jointly with the endocrinologists in hemi-thyroidectomy.

OPERATIVE PROCEDURE
The patient is placed supine on the operating table The incision passes through skin, subcutaneous
with a shoulder roll and head ring. The skin is pre- tissue and platysma (Figure 26.1). Sub-platysmal
pared and draped. flaps are elevated as far as the superior thyroid
notch superiorly and the supra-sternal notch
A horizontal skin crease collar incision is made inferiorly. The anterior jugular veins lie within the
approximately 1−2 finger breadths above the sternal sub-platysmal plane and may require ligation and
notch. Marking the incision prior to anaesthesia division. A Joll’s retractor or sutures are used to
helps identify an appropriate skin crease. retract the flaps out of the operative field.

Hemi- and total thyroidectomy 131

 skin

platysma
strap muscles
sternocleidomastoid

thyroid gland
trachea

internal jugular vein recurrent laryngeal nerve

oesophagus
common carotid artery

Figure 26.1. Axial section through the neck at the level of the thyroid isthmus. The vagus nerve is represented
by the asterisk.

The investing layer of deep fascia is incised and cricothyroid joint. Safe identification of the RLN
the strap muscles (sternothyroid and sternohyoid) can be made in several ways including:
lying in the midline will come into view. The strap ● The RLN runs within Beahr’s triangle, which is
muscles are separated in the midline. Sternothyroid formed by the common carotid, inferior thyroid
may occasionally need to be divided for large artery and the recurrent laryngeal nerve. The
goitres. This is performed as high as possible to RLN runs within Lore’s triangle, which is formed
preserve innervation from ansa hypoglossi. by the trachea, the carotid sheath and the
The strap muscles are retracted laterally and the under-surface of the inferior lobe of the thyroid.
underlying gland dissected free using a combination ● The RLN is related to the inferior thyroid artery,
of sharp and blunt dissection. The gland is freed in which is identified laterally at the external
the para-carotid tunnel and the straps and carotid carotid and followed medially. The nerve is
retracted laterally. usually deep to the artery, but can be superficial
or between its branches.
The superior pole is dissected from an inferior to ● Identify the RLN superiorly just before it enters
superior direction. The superior vascular pedicle is the larynx caudal to the inferior pharyngeal
isolated, ligated and divided close to the gland to constrictor.
minimize damage to the superior laryngeal nerve.
This allows the superior pole to be freed from its Once the nerve has been identified, it is followed
fascial attachments. until it enters the larynx and the thyroid is carefully
dissected free. It is vital that the parathyroid glands
The thyroid gland is retracted medially, which also are identified and dissected free from the thyroid
rotates the larynx, exposing the tracheo-oesophageal with their blood supply. Divide the inferior thyroid
groove. The middle thyroid vein is identified and artery close to the thyroid gland to help achieve this.
divided. The recurrent laryngeal nerve (RLN)
lies in the tracheo-oesophageal groove and has a The thyroid gland remains attached to the trachea
variable course, but always enters the larynx at the by Berry’s ligament, a dense fascial condensation.

132 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

This is usually vascular and the gland is freed to is undertaken but is usually required after total
the midline using bipolar and sharp dissection. thyroidectomy.
If a hemi-thyroidectomy is being performed, the
isthmus is divided and over-sewn or transfixed. If The strap muscles are closed in the midline using
a total thyroidectomy is being performed, then the an absorbable suture, with a gap left inferiorly to
other lobe is excised in a similar fashion. allow blood to escape from around the trachea
and minimize the risk of airway obstruction from
Haemostasis is achieved with the careful use of a haematoma. The wound is closed in layers,
bipolar diathermy and great care taken around the with an absorbable suture for platysma and a
nerve. A drain is optional if a hemi-thyroidectomy subcuticular suture or staples to skin.

POSTOPERATIVE REVIEW
A patient undergoing a total thyroidectomy or with a low, then the local protocol is followed in conjunc-
known vocal cord palsy is extubated in theatre and the tion with the endocrinology team. Calcium may be
patient’s airway assessed prior to transfer to recovery. replaced orally or, if very low, intravenously, with
the addition of 1-α calcidol as required. The patient
Voice and cough should be assessed postoperatively. is also commenced on thyroid replacement with
A bovine cough or weak and breathy voice indicates either levothyroxine (T4) or, where radio-active
a RLN injury, which should be confirmed by naso- iodine is to be administered within the following
endoscopy. Clip removers or scissors must always be six weeks, liothyronine (T3). If a drain has been
at the patient’s bedside to enable immediate evacu- inserted, it is left in place overnight and removed
ation of a haematoma should this occur (this may when less than 20 mL has drained in a 24-hour
compromise the airway). period. The patient is discharged home once the
drain has been removed and, if applicable, when the
If a completion hemi-thyroidectomy or total calcium is normal.
thyroidectomy has been undertaken, postopera-
tive calcium levels may be checked after 4−6 hours Vocal cord movement is assessed at outpatient
and again the following morning. If the calcium is follow-up.

Hemi- and total thyroidectomy 133

 27 SUPERFICIAL
PAROTIDECTOMY
The plane of the facial nerve divides the parotid Complications
gland anatomically into superficial deep lobes,
although they are functionally the same gland. The ● Bleeding.
majority of parotid tumours occur in the superficial ● Infection.
lobe. Superficial parotidectomy is excision of the ● Facial weakness.
parotid gland superficial to the facial nerve. ● Numbness of the ear lobe secondary to dam-
age to the greater auricular nerve. This is to be
Indications expected in the majority of patients.
● Frey’s syndrome. The cut parasympathetic
● Benign or malignant tumour of the parotid nerve fibres re-innervate the sympathetic
gland (most common). channels to supply the sweat glands in the
● Chronic sialadenitis (rare). cheek. Gustatory sweating occurs, which is
● Sialolithiasis (rare). sweating of the face on the side of surgery
in anticipation of eating.
● Recurrence of tumour.
● Scar.
● Salivary fistula.

PREOPERATIVE REVIEW
Always check and document facial nerve function FNAC results and ensure that any preoperative
preoperatively (Figure 27.1). Review imaging and blood test results are available.

OPERATIVE PROCEDURE
Once the patient has been intubated and transferred by practicing placement of the electrodes, connection
to the operating table a head ring is placed under to the monitor and checking correct function.
the head, a sandbag under the shoulder, and the
head turned to the opposite side. A cotton wool ball may be placed in the EAC
and the patient prepared with aqueous iodine or
Facial nerve monitoring is used by most surgeons. Be chlorhexidine and draped to ensure that the
familiar with the facial nerve monitor used in the unit majority of the face is exposed.

134 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 and superficial fat layer. The platysma can be used
to identify the correct plane inferiorly. The flap
Temporal over the parotid gland can be raised using a blade
Zygomatic or scissors. Good retraction helps identify the
plane to prevent a breach through the skin, gland
or tumour capsule. As the anterior border of the
parotid gland is reached care must be taken to pre-
vent damage to the branches of the facial nerve as
Buccal
they emerge from the gland. The flap is retracted
anteriorly with sutures.
Marginal mandibular

Cervical The sternocleidomastoid muscle is identified

and its anterior border dissected free. The
greater auricular nerve will be encountered. It is
sometimes possible to preserve a posterior
Figure 27.1. External branches of the facial nerve. branch that supplies sensation to the ear lobe.
The posterior belly of the digastric muscle is
The most common incision used is the ‘lazy S’ exposed and traced back to its insertion into the
incision (Figure 27.2), although a face lift incision mastoid. The perichondrium of the tragus is
is becoming more popular. Infiltration with identified and the tragus exposed to its deep extent
adrenaline alone, or local anaesthetic and adrena- to reveal the tragal pointer. Another suture retracts
line, may be used to provide some haemostasis. the ear lobule posteriorly. The parotid gland
between the tragus and posterior belly of the
Once the incision has been made, an anterior skin digastric is carefully dissected to ensure wide expo-
flap is raised between the parotid gland capsule sure (Figure 27.3).

Superficial
lobe of parotid
‘Lazy s’ incision

Skin flap

Figure 27.2. Incision landmarks for a Figure 27.3. Superficial exposure of the parotid
parotidectomy. gland.

Superficial parotidectomy 135

There are several ways to find the facial nerve. A the descending portion of the facial nerve and
combination of the first three landmarks is usually follow it out of the stylomastoid foramen.
adequate to ensure safe dissection in the majority
of cases: Careful dissection on a broad front with precise
use of bipolar diathermy to ensure complete
1 Finding the nerve as it bisects the tympanomas- haemostasis will allow identification of the facial
toid groove. This is the most constant landmark. nerve trunk (Figure 27.4), which can be con-
2 Using the tragal pointer, the nerve lies approxi- firmed by use of a nerve stimulator. The main
mately 1 cm deep and 1 cm inferior to the tragal trunk typically divides into upper and lower
pointer. divisions, which divide in a variety of combina-
3 The nerve lies just deep and superior to the tions into the five terminal branches. There is
posterior belly of digastric near its attachment to often some cross-communication between the
the mastoid. branches. Each branch of the facial nerve is fol-
4 Where a large tumour lies directly over the lowed using a small, curved clip to dissect the
proximal aspect of the facial nerve, find a distal gland from the nerve. The gland may then be cut
branch, such as the marginal mandibular, and superficial to the nerve under direct vision using
follow the nerve in a retrograde manner. either a no. 12 scalpel or scissors. Bipolar dia-
5 Where the above measures fail, drill into the thermy must be used precisely to prevent thermal
mastoid portion of the temporal bone to identify damage to branches of the facial nerve. Parotid

Deep lobe of par otid

Superficial
lobe of par otid

Facial nerve trunk

Sternocleidomastoid

Posterior belly
of digastric

Figure 27.4. Identification of the facial nerve trunk.

tumours often lie directly over branches of the rarely, when no other option is available, one or
nerve. Care is taken not to enter the tumour, as more branches of the facial nerve may have to
this risks recurrence at a later date. be sacrificed. A drain is usually required and an
absorbable suture used to close platysma, with the
The parotid gland is carefully dissected free of skin closed with a non-absorbable monofilament
the facial nerve, preserving all branches. Very suture or staples.

136 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

POSTOPERATIVE REVIEW
Always check and document facial nerve function Sutures or skin staples are usually removed at 5−7
postoperatively and exclude a haematoma. The days with a follow-up arranged to review histology
drain will usually be left in place at least overnight. in the clinic.
The patient can be discharged home once the drain
has been removed.

Superficial parotidectomy 137

 28 TRACHEOSTOMY

A tracheostomy is a conduit from the skin of the neck Indications

to the trachea. It is classically performed in an open
surgical fashion, however, more recently percutaneous ● Real or anticipated airway obstruction.
techniques have been developed and are frequently ● Prolonged ventilation.
used. The formation of an open surgical tracheostomy ● Pulmonary toilet.
may be required in the emergency or elective setting.

METHODS

Thyroid cartilage

Cricothyroid membrane

Cricoid cartilage

First tracheal ring

Site of tracheotomy

138 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

● Cricothyroidotomy − This may be required in This is often performed with the benefit of
the emergency setting when access to the airway a flexible bronchoscope through the larynx
is required. The gap between the thyroid and from above to ensure correct positioning in the
cricoid cartilages (cricothyroid membrane) is trachea.
palpated. A horizontal stab incision facilitates the ● Trans-tracheal needle − Wide-bore needles are
insertion of a mini-tracheostomy. available which can be inserted and then con-
● Percutaneus tracheostomy − This technique has nected to a jet ventilation system to maintain
gained popularity with intensive therapy unit an airway. This is a temporary measure to allow
(ITU) interventionists. It is performed using oxygenation while a secure airway is inserted.
a Seldinger technique, where a guide wire is Since it does not allow for expiration, the upper
inserted through a trans-tracheal needle, which airway should be clear enough to allow for gases
has been placed in the midline through the skin to be expired.
into the trachea. A series of dilators are gradu- ● Surgical tracheostomy − This will be considered
ally ‘railroaded’ over this to widen the tract. in greater detail below.
Finally, the tracheostomy tube can be inserted.

FORMATION OF A SURGICAL TRACHEOSTOMY

A tracheostomy is usually performed under the midline and a transfixion suture used to pre-
general anaesthesia, although the use of local vent bleeding. With the thyroid isthmus divided,
anaesthesia may be necessary where the airway the trachea will be better exposed.
is too narrow to allow intubation. The skin is 5 A window into the trachea is fashioned − Inform
infiltrated with local anaesthetic and the tracheal the anaesthetist before entering the trachea.
mucosa injected just before an incision is made There are a number of methods of entering the
into the trachea. trachea. In children, a vertical slit is made in
the midline and stay sutures placed either side
The procedure requires the following steps: of the incision. These sutures are taped to the
child’s chest and used to hold open the hole if
1 Patient position − The patient is positioned
the tracheostomy tube displaces or when the
supine with the head in the midline. A sandbag tracheostomy tube is first changed at seven days.
is placed under the shoulders and a head ring is In adults, a window is cut just large enough to
used to support the head. This extends the neck admit the tracheostomy tube. In both cases the
allowing the laryngeal skeleton and trachea to be cricoid cartilage must not be injured. For this
readily palpated. It is always prudent to check the reason, the window or incision is made through
tracheostomy tube cuff at this point. A single tube the 2nd, 3rd or 4th tracheal rings (Figure 28.4).
may be chosen at the start of the procedure, but a
6 A tracheostomy tube is inserted − Ask the
variety of sizes should be available.
anaesthetist to deflate the cuff and withdraw the
2 Skin incision − A skin incision is made halfway
endotracheal tube until the tip is just above the
between the cricoid and the suprasternal notch window. The tracheostomy tube may be inserted,
and extended through platysma (Figure 28.1). the cuff inflated and the tube sutured into place
The anterior jugular veins and midline strap and appropriate dressings applied.
muscles will now come in to view (Figure 28.2).
3 Identification of the thyroid gland and trachea If an emergency tracheostomy is required, it is
− The strap muscles are separated in the midline essential to gain access and maintain the airway as
and retracted, bringing the trachea and thyroid quickly as possible. In these cases, a vertical midline
isthmus into view (Figure 28.3). incision is made to avoid all vascular structures
4 Division of the thyroid gland − The thyroid except the thyroid, which must be dealt with rapidly
gland is clamped through the isthmus, divided in in the emergency scenario.

Tracheostomy 139
 (a)

Cricoid cartilage

Right sternocleidomastoid
muscle
Horizontal skin crease incision

Suprasternal notch

(b)

Horizontal skin crease incision

Suprasternal notch

Figure 28.1. Tracheostomy incision.

Strap muscles
Linea alba

Figure 28.2. Identification of thyroid isthmus.

Complications

These may classified as immediate, early and late.

Immediate (within 24 hours of procedure) Cardiac arrest

Haemorrhage − thyroid vessels; jugular veins. Local damage to thyroid cartilage, cricoid cartilage,
Pneumothorax. recurrent laryngeal nerve(s).
Air embolism. Dislodgement or displacement of the tube.

140 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 First tracheal ring

Thyroid isthmus
Fourth tracheal ring

Figure 28.3. Division of thyroid isthmus.

First tracheal ring

Window

Figure 28.4. Tracheal window.

Early (24 hours−7 days) Tracheo-oesophageal fistula.

Dislodgement or displacement of tube. Dysphagia.
Surgical emphysema of neck.
Crusting. Late (after seven days)
Infection. Tracheal stenosis.
Tracheal necrosis. Difficulty with decannulation.
Tracheo-arterial fistula. Tracheo-cutaneous fistula.

TRACHEOSTOMY TUBE CARE AND SPEAKING VALVES

Tracheostomy tube care is often left to tracheos- ❚❘ Tracheostomy tubes
tomy nurse specialists or members of the nursing
staff. It is, however, essential that junior doctors are ● Cuffed.
able to care for patients with tracheostomy tubes ● Uncuffed.
in place and are aware of the potential complica- ● Fenestrated.
tions of having a tracheostomy. It is often the case ● With or without an inner cannula.
that out-of-hours emergencies and advice will be ● Adjustable flange.
directed towards the junior on-call surgeon.

All patients should have a spare tracheostomy tube A tracheostomy tube can be directly attached to
of the same size and one smaller, a tracheal dilator, a an anaesthetic circuit provided that there is a
10 mL syringe, a suction unit and catheters, gloves, 15 mm connector at the proximal end. Some tubes
Spencer-Wells forceps and lubrication for the tubes have this segment on the inner tube, so this should
at their bedside. always be available.

Tracheostomy 141
 First tracheal ring

Window

Figure 28.5. A cuffed tracheostomy tube.

Cuffed tubes (Figure 28.5) Uncuffed tubes

Advantages: These are often found in patients returning from

ITU after a prolonged stay as they allow suction and
● A cuff is required for:
physiotherapy. The tube is easy to replace and suit-
– Ventilation, continuous positive airway pressure.
able for long-term use. Patients can speak around
– Patients who aspirate as they cannot protect
it. They are not suitable for patients who aspirate or
their airway.
who need ventilation.
Patients with normal swallowing reflexes may find
their swallowing impaired as a result of pressure
exerted on their oesophagus and the impedance of Fenestrated tubes
laryngeal elevation by an inflated cuff.
The fenestration directs airflow through the patient’s
Disadvantages: vocal cords, oropharynx and nasopharynx. It helps
some patients to resume breathing normally and
● If the tube lumen becomes blocked, the patient’s can be used to wean them off their tracheostomy
airway is compromised leading to respiratory ar- tube. Remember that a fenestrated inner tube is also
rest as there is no capacity to breathe around the required.
tube, unless the cuff is deflated.
● The cuff can damage the tracheal mucosa, lead-
ing to ulceration and possible stenosis. Rarely, Tube with adjustable flange
this may also cause arterial erosion. (Figure 28.6)
● Children younger than 10 years have a narrow
trachea, and unlike in the adult, the larynx is This is designed for patients with deep-set tracheas
conical, with the cricoid cartilage forming the and fat necks.
narrowest segment. Tracheostomy tubes used in The flange can be adjusted to fit the depth of tissue
children are uncuffed. between incision and trachea.
Pressure = Force/Area
High-pressure, low-volume soft cuffs reduce the
incidence of pressure-induced complications, but it ❚❘ Cleaning inner tubes
is still important not to over inflate the cuff.
Most recommend water or warm salty water only.
The cuff should be deflated as soon as possible to Avoid alcohol, bleach and glutaldehyde. Flush the
allow for the insertion of a speaking tube or decan- tube and do not soak it as this increases the risk of
nulation cap. bacterial proliferation.

142 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 Tape

Flange

Figure 28.6. Tracheostomy tube in situ.

Humidification If a difficult tube change is anticipated, use an

exchange device (guide wire or a bougie) and
● Nebulizers 5 mL, 0.9% N/saline in mask consider changing the tube in the operating
over stoma. theatre.
● Heat moisture exchangers fit onto the
tracheostomy tube. The steps involved are as follows:
● Foam filter protectors such as the Buchanon
laryngectomy protector. 1 Explain to the patient what you plan to do.
Ensure that a good light source, preferably a
headlight, is available.
2 Extend the patient’s neck using pillows so the
❚❘ Tracheostomy dressings head is supported and hyper-oxygenate them
if required.
The objective is to keep the trachea, stoma and 3 Check the integrity of the cuff if used. Lubri-
adjacent skin clean and dry, and minimize skin cate it sparingly.
irritation and infection. Wet skin results in 4 Remove all old dressings and clean around the
maceration and excoriation. Hydrophilic polyure- stoma site.
thane foam dressings absorb moisture away from 5 Remove intraoral secretions with suction,
the skin. deflate the cuff and suction through the old
tube. Some secretions trapped around the
If a tracheostomy site shows signs of granulation, cuff will now fall into the trachea inducing
this can be treated with silver nitrate cautery, coughing.
although care should be taken not to damage 6 Allow the patient to recover and remove the
surrounding normal skin. old tube.
7 Insert a new tube, inflate the cuff if indicated
and insert the inner cannula.
8 Check chest movement, insert a clean dress-
❚❘ Changing a tracheostomy tube ing and apply the tapes before checking cuff
pressure.
Most surgeons recommend the first tube change to 9 If you are uncertain of the position of the tube,
be performed at one week. The first change should a flexible endoscope can be passed into the
be performed by an experienced practitioner or trachea through the tube lumen.
ideally by the surgeon. 10 Connect to any humidification devices.

Tracheostomy 143
GENERATING A VOICE
● Cuff deflation. to breathe in through their tracheostomy and out
● Fenestrated tracheostomy tube (and inner tube). through their mouth. Patients need to be monitored
● Smaller tracheostomy tube. for signs of respiratory distress in the early stages of
● Intermittent finger occlusion. using a one-way speaking valve.
● One-way speaking valves.

All of the above allow air to escape around or Contraindictions

through the tube into the larynx and the oro-
pharynx. One-way speaking valves allow air to be ● End-stage pulmonary disease.
inspired but not exhaled through the tube. ● Excessive secretions.
● Unstable medical.
Do not put a one-way speaking valve on a patient ● Anarthria.
with a cuffed fenestrated tube unless their inner ● Ventilatory status unstable.
tube is also fenestrated. If you do, they will struggle. ● Airway obstruction.
● Severe anxiety or cognitive dysfunction.
It can take time for a patient to get used to a ● Severe tracheal or laryngeal stenosis.
speaking valve, and they need to be encouraged ● Inability to tolerate cuff deflation.

144 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 29 VOICE

Voice is the method by which humans predomi- of the vocal cord mucosa. The vocal fold is a five-
nantly communicate. However, speech also allows layered structure that allows the mucosa
us to add emotion and expression to what we com- to move over Reinke’s space and the lower
municate. Changes in our voice, therefore, can alter elements that make up the vocal fold ligament.
the way we communicate or express ourselves. This movement is referred to as the mucosal
wave and it forms a vibration that is then
The production of voice, however, is not purely moulded by the UADT. The vocal folds may
based around the larynx as it is essential to have the vibrate 80−1000 times/second; therefore, if visual-
‘ballast’ from the lungs to produce the vibration ized with white light, the mucosal wave cannot be
created at the laryngeal level. This vibratory source visualized. Stroboscopic examination allows for
creates a sound that is shaped and moulded by the the production of a montage of different phases
articulators and resonators in the upper aero- in the cycle of the mucosal wave to be collected
digestive tract (UADT). A change in any of these and visualized on screen. This chapter deals specifi-
three areas can change the quality of the voice. cally with the history, examination and subsequent
management of patients with abnormalities of
The vibratory source creates a sound by chopping
the larynx.
up air from the trachea by the intricate movement

HISTORY
When taking a history it is essential to listen associated with other UADT symptoms such as
carefully to the voice itself, as often a diagnosis can dysphagia, odynophagia, a neck mass or otalgia,
be made by listening to the quality of the voice and indicates a potential malignant pathology.
the story that comes with it.
Preceding symptoms, such as an upper respiratory
It is essential to find out what the patient uses their tract infection (URTI), can affect the likelihood of
voice for − both their occupation and their hobbies. pathology forming, especially in a situation where
Certain professions put more strain on their the voice is strained as a result of the URTI.
voices (e.g., teachers and actors) and are prone to
pathology as a result. A thorough medical and drug history should be
taken to assess conditions that may affect the
The duration and progression of the hoarseness ballast (respiratory drive) to produce voice. Also,
are important to ask about as longstanding voice certain medications may affect voice as they may
changes are unlikely to be sinister, but a progressive precipitate coughing (ACEI’s) or may dry the
change in the voice over a few months, especially UADT (e.g., anticholinergic side-effects).

Voice 145
EXAMINATION
Initially, a general ENT examination is helpful, light source allows the mucosal wave to be captured
specifically looking at the oral cavity, oropharynx and processed by the human retina, enabling visual-
and nasal cavity, because these are the articulators ization of the differences between mucosal waves and
and resonators and therefore affect voice. also pathologies. Without a strobe the vibrations of
the mucosal wave are too fast for the human retina
Laryngeal examination then follows. The voice to register. The strobe splits the wave up and puts
clinic often uses rigid laryngoscopy or flexible together a cycle of its different aspects in a slower
nasolaryngoscopy with a stack system. A stroboscopic fashion for the retina to distinguish.

PATHOLOGY
Voice changes at the laryngeal level occur because of 3 Poor vibration or mucosal wave as a result of
the following changes: pathology.

1 Mass effect on the vocal fold. Common voice conditions and their treatment
2 Incomplete closure of the vocal folds. options are described below.

REINKE’S OEDEMA
In this situation the patient has had a long-standing proton pump inhibitor. If the patient ceases
deepening of the voice. They are often smokers, smoking but the voice does not return to normal
but acid reflux may also play a part. Pathologi- and the findings are still the same on laryngoscopy,
cally, oedema occurs within Reinke’s space in the then a superior cordotomy on the non-vibratory
vocal fold, increasing the mass of the vocal fold and surface of the vocal cord can be undertaken and
therefore deepening the voice. some of the oedema reduced.

The correct treatment is smoking cessation and

the use of anti-reflux therapy in the form of a

VOCAL FOLD NODULES (‘SINGER’S’ NODULES)

These are often associated with actors or sing- (i.e., acting or singing) can strain the voice and
ers, however, professional singers often have an lead to trauma and the formation of nodules.
excellent understanding of their voice and do not Others (e.g., teachers and instructors in a noisy
often present with nodules. Often the strain of environment such as a swimming pool) may
pushing one’s voice in inappropriate scenarios also suffer.

BILATERAL NODULES
The larynx often shows bilateral nodules at the two-thirds.This does not allow for good closure
junction of the anterior third and posterior of the vocal folds and results in a change in voice.

146 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

For the vast majority of these we use speech and appropriately. Rarely do they require surgical
language therapy to educate the patient on use intervention.
of the voice and to help them use their voice

VOCAL FOLD PALSY

Patients present with a recent-onset, ‘breathy’ voice see if the patient can compensate for the
which becomes tired with use. The two vocal folds immobility and make the other cord come across
do not meet and therefore a lot of air escapes and a further to make more contact and improve the
‘breathy’ voice is created. voice. If this fails or for malignant aetiology
(e.g., terminal lung cancer damaging the
Sinister aetiology should be excluded as the nerve
recurrent laryngeal nerve), speedier intervention
supply to the larynx is from the vagus via the recur-
is necessary. This requires an injection thyroplasty
rent laryngeal nerve. Imaging, including the skull
to medialize the immobile vocal cord, either as
base through to the upper chest, should be under-
an outpatient or under general anaesthetic. An
taken for a left cord palsy as the recurrent laryngeal
alternative is to medialize the vocal cord exter-
nerve descends to the aortic arch on this side, and
nally using a piece of silastic or Goretex through
from skull base into the root of the neck for a right
a window in the thyroid cartilage. (Pictures are
cord palsy (CT scan +/− MRI skull base).
required for injection thyroplasty under LA/GA
Initially for an idiopathic vocal fold palsy speech and open thyroplasty.)
and language therapy should be undertaken to

LARYNGEAL CANCER
These patients usually present with a long history Laryngeal cancer can be treated in a variety of ways.
of smoking and/or high alcohol intake. They have a Small laryngeal cancers can be treated with nar-
progressively worsening voice over 6−12 weeks and row field radiotherapy or be resected using a laser
may have associated otalgia, odynophagia, dyspha- at the time of laryngoscopy. Larger tumours can be
gia and even associated neck lymphadenopathy. treated with radiotherapy or chemo-radiotherapy
covering a larger field for associated lymph nodes.
Nasoendoscopy usually demonstrates an irregu- The largest laryngeal cancers – those that have
larity of the vocal fold but the patient requires a invaded the thyroid cartilage − are often treated
laryngoscopy and biopsy of this suspicious area. with a laryngectomy. This involves removal of the
In smokers a premalignant diagnosis of dysplasia larynx and the creation of a permanent end stoma.
may be made on histology. This is just as important The management of the patient should be discussed
as the patient needs to be aware of this and stop in the context of a multidisciplinary head and neck
smoking to reduce the chance of progressing to an team meeting.
invasive malignancy.

LARYNGEAL PAPILLOMATOSIS
Human papilloma virus (HPV) can cause viral may be compromised, but more often hoarseness is
warts. In the larynx this can be extremely trouble- produced due to incomplete closure of the glottis
some. If a viral wart impinges the glottis, the airway and/or poor mucosal wave formation.

Voice 147
There are many treatments. Surgical interventions ciated with some laryngeal scarring and although
are often reserved for significant airway obstruction some patients will require multiple procedures it is
or for significant change in voice due to mass effect. wise to minimize the trauma to the larynx unless
The problem is that each surgical procedure is asso- there is good reason to operate on it.

HAEMORRHAGIC POLYP
This pathology is not infrequently seen following leads to a change in voice. This sometimes heals,
an upper respiratory tract infection, where the voice but occasionally persists and matures. If persistent,
has been used and then a small telangectatic vessel it may require surgical excision with a micro-
bleeds. This slight irregularity on the vocal cord laryngoscopy with or without laser resection.

VOCAL CORD GRANULOMA

Patients typically have undergone recent surgery tube. Also of importance in the pathology may be
requiring endotracheal intubation or have been on gastropharyngeal reflux of acid.
the Intensive Care Unit with an endotracheal tube
in situ for a few days. The pathology forms typically Treatment often involves aggressive anti-reflux
on the posterior medial aspect of the vocal cord treatment over a six-week period, but if
over the vocal process of the arytenoid cartilage. symptoms and signs persist, surgical resection
The granuloma forms due to healing exposed may be undertaken with a micro-laryngoscopic
cartilage as a result of trauma from an endotracheal technique.

VOCAL CORD CYSTS

This pathology presents clinically with a change in cated voice clinic, with full speech and language ther-
voice but it can be very variable in its severity and apy support. However, if surgery is to be entertained,
frequency. It may relate to the actual type of vocal it should be carefully undertaken raising a microflap,
cord cyst as some are superficial mucosal cysts and dissecting the cyst out and causing minimal mucosal
some are deeper intracordal cysts. These can be very trauma. This should not be underestimated as it can
difficult to treat and should be managed in a dedi- prove to be a significant surgical challenge.

MICRO-LARYNGOSCOPY
This is an examination under general anaesthetia anaesthetist (i.e., with a micro-laryngoscopy
and is often undertaken for diagnostic or therapeu- tube, supraglottic/subglottic or transtracheal jet
tic procedures on the larynx. The use of the micro- ventilation).
scope offers magnification, depth of field, bimanual
The endoscope, light source, suction, lubrication
handling of instrumentation and the use of other
and dental guard should all be checked prior to
attachments such as a CO2 laser.
starting with the laryngoscopy. The laryngoscope
Before commencing a laryngoscopy the patient is inserted carefully to get a view of the larynx and
should be placed in ‘the sniffing the morning air’ then suspended with a Lewis suspension arm. At
position, which is flexion of the neck and extension this point the microscope or a Hopkins rod may be
of the atlanto-occipital joint. A decision on how used for more careful examination of the larynx in
to maintain the airway should be made with the preparation for the biopsy or surgical undertaking.

148 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 15
30 TYMPANOPLASTY
AIRWAY MANAGEMENT

Airway management is one of the most critical oedema of the mucosa, which further narrows the
emergency situations in ENT practice. A sound airway with resulting compromise.
understanding of the anatomy, physiology and
management of a patient with airway problems A further point to note is the difference between an
is essential. In light of the order of resuscitation adult’s airway and a child’s. In the child, the airway
priorities − Airway, Breathing, Circulation (ABC) is both absolutely and relatively smaller than in the
− the importance of airway management cannot adult. The larynx is higher and external landmarks are
be underestimated. less easily identifiable. The trachea lies nearer the skin
in children, diving into the chest at a steeper angle
An additional point to consider is that as the than in the adult. Important contents of the thorax
airflow increases through a narrowed segment, (e.g., the domes of the lungs and the great vessels) lie
pressure is decreased. This is known as the higher in the child. In addition, since the neonate is
Bernoulli phenomenon. This draws the mucosa an obligatory nasal breather, nasal obstruction result-
into an already narrowed airway inducing local ing from bilateral choanal atresia may be fatal.

MANAGEMENT OF THE COMPROMISED AIRWAY

Presentation and management of the compromised airway obstruction. This is determined by the
airway varies according to the site of presentation worsening of stridor or stertor, although stridor
and aetiology (Table 30.1). These affect both the that becomes quiet may indicate imminent
severity and speed of onset of symptoms and the complete airway obstruction.
categorization of management into urgent or non-
urgent. However, the approach taken to manage Stertor is rough noisy breathing, similar to snoring,
airway obstruction is similar for all. caused by vibration of partially obstructing soft
tissue in the pharynx.
It is essential in the management of the patient
Stridor is a harsh, high-pitched, almost musical
with a compromised airway that a team approach is
sound, caused by vibration of partially obstructing
used. The most senior members of the anaesthetic
soft tissue in the larynx or upper trachea.
and ENT teams should be informed and involved
in the management at an early stage. More than one Inspiratory stridor is during inspiration only, often
option or plan should be discussed before a crowing sound, and is due to obstruction at the
significant intervention is undertaken. glottis, supraglottis or subglottis level.

A rapid assessment of the patient is made to assess Expiratory stridor is during expiration only, usually
whether they are in danger of imminent upper at a slightly lower pitch than inspiratory stridor, and

Airway management 149

is due to obstruction of the subglottis or deteriorate, then a decision must be taken to
extrathoracic trachea. secure the airway with a cuffed endotracheal
tube. Ideally, this should be performed in the
Biphasic stridor involves both inspiration and operating theatre where all the anaesthetic
expiration, and, while representing laryngeal equipment for managing difficult airways is
obstruction, is a hallmark of severe obstruction. available as well as the surgical instruments for
Wheeze is a high-pitched husky or whistling tracheostomy and rigid bronchoscopes.
sound, caused by narrowing of soft tissue in the
intrathoracic airways. A plan is made jointly by the senior ENT surgeon
and anaesthetist to determine how they will secure
In addition, patients will have a high respiratory the airway. This depends on the suspected level of
rate, poor chest expansion, low oxygen levels of sat- obstruction. Orotracheal or nasotracheal intubation
urations, tachycardia and may be tiring with rising may be attempted by the anaesthetist if it is thought
carbon dioxide. The most common is obstruction that there is sufficient space to pass a tube through
in the larynx. While it may be possible in an adult to the obstruction safely. The surgeon and scrub nurse
examine the larynx using a flexible nasoendoscope must be scrubbed with tracheostomy and bron-
in order to assess the degree of obstruction, this choscopes open and set up in order to intervene
must not be attempted in a child. When presented if needed. Other temporary airway adjuncts that
with a child with imminent airway compromise, should be considered to gain access to the subglot-
such as suspected epiglottitis, never examine the tis include a transtracheal cannula or cricothy-
child, take bloods or request an x-ray. The priority roidotomy with jet ventilation. If intubation fails
is to secure the airway, ideally in theatre. Any inter- or is thought not to be possible, then the decision
vention may precipitate complete airway obstruc- is taken either to perform a tracheostomy or gain
tion, which must be avoided. It is very rare that a initial access to the airway by bronchoscopy with a
patient presents in complete airway obstruction. In rigid ventilating bronchoscope.
this case, it is likely that an anaesthetist
will already be with the patient. If they are unable
to intubate the patient, then an immediate KEY POINTS:
tracheostomy must be performed in order to
secure the airway. This is described in Chapter 28. 1 A is for airway and the presentation
of an acutely problematic airway is a
Immediate management includes calling for senior
medical and surgical emergency.
help, and giving oxygen and adrenaline nebulizers.
2 Act sooner rather than later, especially
Heliox can also buy valuable time. It is composed
if you suspect a progressive problem.
of 21% oxygen and 79% helium and has a lower
3 Consider medical management that
density than air, which improves flow in the airways
may be of use to hold the situation
resulting in better oxygen delivery. The adminis-
without causing the patient distress
tration of steroids gives benefit a few hours later
(adrenaline nebulizers, steroids, heliox).
by reducing mucosal oedema. If in the emergency
4 Involve senior members of the ENT,
room, the patient should be monitored in the
anaesthetic and if appropriate nursing/
resuscitation area. If the patient is stable, they are
paediatric teams as soon as possible.
managed in a high dependency or critical care unit.
5 Think before you act as you may
Where a patient is not severely compromised, a
precipitate a worsening of the problem.
more thorough evaluation may be made, including
appropriate imaging and a plan made depending
on the aetiology.
Table 30.1 is a summary of the most common aeti-
If the patient is in complete airway obstruction ologies that can result in airway obstruction along
or, despite the above measures, continues to with the level of obstruction.

150 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

Table 30.1. Aetiology of airway obstruction.

Level of Aetiology
obstruction Pathological Anatomical
Nasopharynx Tumour Choanal atresia (unilateral or bilateral)
Infection Crouzon’s disease
Foreign body Apert’s syndrome
Oropharynx/ Infection (tonsillitis, Ludwig’s angina) Short lower jaw (especially
Hypopharynx Bleeding (post-tonsillectomy) micrognathia)
Tumour Large tongue
Burns
Trauma
Anaphylaxis
Supraglottis Infection (epiglotitis, supraglottitis) Laryngomalacia
Bleeding
Tumour (squamous cell carcinoma, respiratory
papillomatosis)
Cyst of vallecular or epiglottis
Anaphylaxis
Foreign body
Glottis Infection (croup) Laryngeal cleft
Tumour (squamous cell carcinoma, respiratory Laryngeal web
papillomatosis)
Vocal cord palsy
Polyp
Oedema (postoperative anaphylaxis)
Foreign body
Subglottis Infection (croup) Congenital subglottic stenosis
Tumour (squamous cell carcinoma, respiratory Subglottic haemangioma
papillomatosis)
Stricture (post-intubation,
post-tracheostomy)
Extrinsic compression (thyroid, lymph nodes,
tumour)
Foreign body
Tracheal Infection (tracheitis) Tracheosophageal fistula
Tumour (squamous cell carcinoma, respiratory
papillomatosis
Stricture (post-tracheostomy)
Foreign body
Bleeding (post-tracheostomy)
Burns

Airway management 151

 31 RADIOLOGY

LATERAL SOFT TISSUE FILM

This is a plain x-ray performed in the acute setting adult or child. A normal lateral soft tissue film is
for investigation of an ingested foreign body in an illustrated in Figure 31.1.

Angle of the mandible

Epiglottis

Hyoid bone
Valleculae

Thyroid cartilage

Trachea

Figure 31.1. Landmarks visible on a lateral soft tissue film of the neck. The soft tissue space anterior to the
vertebral column should always be inspected.

Always check for prevertebraI soft tissue swelling. between C1−C4 and a whole vertebral body’s width
is allowed anterior to C5−C7.
The maximum normal width anterior to the upper
cervical vertebral bodies (C1−C4) should measure There is a wide variety in the radio density of
up to 7 mm. The maximal normal width increases swallowed foreign bodies. Whilst some ingested
to 22 mm in the lower cervical vertebrae (C5−C7). foreign bodies are radio-opaque and clearly visible
This is more easily estimated by remembering on a lateral soft tissue film, many are not. Helpful
that up to a third of the vertebral body is allowed secondary radiological signs that suggest the

152 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

presence of an impacted foreign body include should be maintained for endoscopy. Similarly,
widening of the prevertebral soft tissue space (as a normal variants with calcification within the cricoid
result of surgical emphysema due to perforation or or arytenoids can be mistaken for bones due to
retropharyngeal abscess formation), tenting of the their curvilinear calcification.
cervical oesophagus producing a gas shadow in the
upper cervical oesophagus or straightening of the A chest x-ray may be an alternative test if the
normal cervical lordosis. suspected level of the obstruction is in the thoracic
oesophagus or airways.
Common sites for impingement of chicken or fish
Common sites of oesophageal foreign body
bones include the palatine tonsils, tongue base,
impaction are:
valleculae and pyriform fossae. The oesophagus is
narrowed just below the level of the cricopharyn- ● At the level of the cricopharyngeus.
geus and at the level of the aortic arch. It is here that ● Where the arch of the aorta indents the
foreign bodies are commonly located. oesophagus.
● Where the right main bronchus indents the
A normal soft tissue lateral film cannot exclude oesophagus.
a radiolucent foreign body and a low threshold ● At the cardiac sphincter.

CONTRAST SWALLOW
A contrast swallow may be indicated for the the pharynx and oesophagus. It can be used to dem-
following: onstrate strictures, tumours, pharyngeal pouches,
● Globus sensation. tracheo-oesophageal fistulae, oesophageal dysmotil-
● Suspected pharyngeal pouch. ity and gastro-oesophageal reflux. A non-ionic
contrast medium such as Omnipaque is used in
● Suspected foreign body.
● Suspected oesophageal lesion. cases where there is a clinical suspicion of aspira-
tion as barium can remain in the chest indefinitely
The barium or contrast swallow is a fluoroscopic and alternatives such as gastrograffin can cause a
technique using low-dose pulsed x-rays to examine chemical pneumonitis.

ULTRASOUND NECK
Ultrasound is a safe, easily accessible test. Super- be determined. In children it can be used to assess
ficial structures such as the thyroid, parotid and lesions such as thyroglossal cysts or fibromatosis
submandibular glands are easily evaluated and colli (sternomastoid tumour). The presence or
beautifully depicted. Morphology of lymph nodes absence and velocity of coloured blood flow in
and the presence of any suspicious features, as congenital lesions such as venolymphatic malfor-
well as diagnostic fine needle aspiration (FNA), mations and haemangiomas can be assessed as an
can be performed. The presence of collections and adjunct to further cross-sectional imaging, such
whether they would be amenable to drainage can as MRI.

CT AXIAL VIEWS OF THE NECK

CT of the neck is usually performed in the in the acute setting is limited and scanning
acute setting for assessing adenopathy or a times can be lengthy for the improved spatial
collection. MRI is better at delineating soft tissue resolution required for the small structures in
planes and has no ionizing burden, but availability the neck.

Radiology 153
CT OF THE TEMPORAL BONE
CT of the temporal bone is used as a preoperative and inner ear can be assessed as well as the aeration
planning tool in cases of cholesteatoma where dis- of the surrounding mastoid air cells. It is also useful
ease spread resulting in bony erosion is particularly in cases where hyperostosis is seen as a complica-
significant (Figure 31.2). The bony ossicular chain tion of meningitis.

(a) (b)

Anterior limb of
superior SCC
Superior
Mastoid semicircular Mastoid Posterior limb of
air cells canal (SCC) air cells superior SCC

(c) (d)
Labyrinthine portion
Anterior limb of superior SCC of the facial nerve
Subarcuate artery Internal auditory meatus
Mastoid
Mastoid Crus commune antrum Utricle (vestibule)
air cells
Lateral SCC
Posterior SCC
Endolymphatic duct
Posterior SCC

(e) (f)
Geniculate ganglion
External Apical turn of the cochlea
Malleus Horizontal portion of auditory
the facial nerve Basal turn of the cochlea
Incus canal
Internal auditory meatus Round window niche
Stapes head
Saccule
Endolymphatic sac

(g)
Internal carotid artery
External Eustachian tube
auditory
Basal turn of the cochlea
canal
Cochlear aqueduct

Figure 31.2. (a−g) Axial CT views of the right temporal bone (superior to inferior).

A CT scan is reviewed in order specifically to assess: ● Facial nerve dehiscence.

● Position and dehiscence of the tegmen/middle
● Extent of disease. fossa plate.
● Pneumatization of the temporal bone. ● Ossicular chain continuity.
● Position of the sigmoid sinus. ● A breach of the inner ear.

154 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

CT OF THE SINUSES
CT of the sinuses has now replaced plain A CT scan is reviewed in order specifically to assess:
film radiography and is indicated in patients
1 Extent of disease.
who do not respond to medical treatment of
2 Position of the septum − a deviated septum may
sinusitis. It can demonstrate severity and
require correction in order to access the parana-
distribution of disease, patency of the osteo-
sal sinuses (Figure 31.3).
meatal complexes and any anatomical variants
3 Position of lamina papyracea and uncinate process.
such as concha bullosa (an accessory air cell
4 Attachment of the middle turbinate.
within the middle turbinate), Haller and Onodi
5 Presence of a concha bullosae.
cells and to aid surgery. Both coronal sections
6 Length of the lateral lemniscus (Keros
and axial sections are required.
classification; Table 31.1).
7 Position of the optic nerves (axial views).

Anterior ethmoidal air cell Lateral lemniscus

Lamina papyracea
Middle turbinate
Uncinate process
Inferior turbinate
Maxillary sinus

Septum

Figure 31.3. Coronal section of the paranasal sinuses.

Table 31.1. The Keros classification refers to the vertical height of

the lateral lemniscus. Types 2 and 3 are at greater risk of CSF leak
during functional endoscopic sinus surgery.

Vertical height of the lateral lemniscus

Type 1 1−3 mm
Type 2 4−7 mm
Type 3 8−16 mm

MAGNETIC RESONANCE IMAGING

Indications MRI is increasingly used in the head and neck due
to its capacity to image the soft tissues. This modal-
● Assessment of the tongue base. ity remains the investigation of choice in the assess-
● Assessment of parotid lesions. ment of tongue base or parotid lesions. In the case
● Intracranial pathology (e.g., CPA lesions). of the latter, the retromandibular vein allows one

Radiology 155
to distinguish between the larger superficial and sudden sensorineural hearing loss and unexplained
smaller deep lobe tumours. The extent of tongue vertigo or dizziness. It may also be used to assess
carcinoma is best defined radiologically, with patients with delayed or absent recovery of a facial
particular regard to whether the midline has been nerve paralysis.
crossed, whether there is involvement of the man-
dible and any spread posteriorly to the epiglottis.
This investigation is contraindicated in patients
with metal foreign bodies and implants (e.g., pace-
❚❘ MRI IAMs makers, cochlear implants, etc.).

Normal anatomy, including the VIIth and VIIIth Both high-resolution CT and MRI are important
nerve roots and the vestibular aqueduct, are exqui- in the investigation of congenital deafness as well
sitely demonstrated. as the surgical planning of any treatment. There
is a wide range of anatomical abnormalities,
Most ENT surgeons will request this investigation some linked to syndromes, including the
for cases of asymmetric sensorineural hearing loss Mondini spectrum and widening of the
(>15 dB HL difference in two adjacent frequencies), vestibular aqueduct.

156 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 32 MANAGEMENT OF
NECK LUMPS
The management of masses in the head and neck An understanding of the anatomy of the neck and
region may seem daunting because of the wide the associated pathologies relevant to the various
variety of pathology and the consequences of positions in the neck is helpful. Delineation of
missing an important diagnosis. This exceptionally whether a lump is in the midline (often suggestive
common clinical finding can be seen across the age of a thyroid or thyroglossal cyst pathology) or later-
groups and important factors must be elicited in ally, either in the anterior or posterior triangle of
order to obtain the correct diagnosis. the neck, can assist in the diagnosis.

HISTORY
A careful history should be elicited from the tract symptoms, such as dysphonia, dysphagia,
patient. Age of onset of the neck lump should be odynophagia, otalgia and breathing disorders, can
documented as congenital pathology presents in be helpful in localizing pathology. Personal habits
the early years and more often malignant patholo- such as smoking and high alcohol intake can
gies present later in life. Upper aero-digestive highlight a risk for malignant potential.

EXAMINATION
A thorough examination of the head and neck induce a significant gag reflex). A flexible fibre-
should be undertaken. The oral cavity should be optic nasolaryngoscope is usually required to
illuminated with a headlight and examined with assess the postnasal space, larynx and hypophar-
two tongue depressors. If appropriate, the tongue ynx. Any masses in the neck should be identified
base should be palpated as pathology may be deep in a careful and methodical examination of
and not obvious to the eye (this does, however, the neck.

SPECIAL INVESTIGATIONS
The use of special investigations can be divided into When investigating a lump in the neck the principal
those pertinent to preparing a patient for a general investigation of choice, almost always, is fine needle
anaesthetic and those relevant to the pathology of aspirate cytology (FNAC). This is a process by
the head and neck. which cells are sampled by means of multiple passes

Management of neck lumps 157

of a needle through the mass while simultaneously is superb at looking at most of the head and neck,
aspirating with a syringe. The cells in the barrel of is easy to obtain and quick to undertake, but can
the needle are then sprayed onto a cytology slide be prone to dental artefact in and around the oral
and either air-dried or fixed chemically, depending cavity. Magnetic resonance imaging (MRI) is an
on the preference of the cytology department. This excellent tool to look at soft tissues, especially of the
test is often undertaken by the cytology department tongue, postnasal space and oral cavity. It does often
itself. This is a crucial investigation and there are carry a longer waiting time to be performed, is
only a few instances where an FNAC of a neck lump more claustrophobic to have undertaken and takes
is not appropriate. longer to be scanned.

Imaging of masses in the neck is commonplace. Investigations pertinent to general anaesthesia

The choice of imaging is dependent on the patient should be discussed at a local preadmission
and the institution where it is to be performed. level and each department should have an
Ultrasonography is an excellent, non-invasive tool appropriate protocol for preparing a patient
to delineate structures but is difficult to interpret for general anaesthesia.
by the surgeon. Computerized tomography (CT)

TREATMENT
The treatment of any neck mass is dependent on malignant disease of the upper aero-digestive
the diagnosis. Reactive lymphadenopathy second- tract may be treated with surgery, radiotherapy,
ary to tonsillitis requires treatment of the tonsillitis chemo-radiotherapy or a combination of these.
with antibiotics. Congenital pathologies may be All treatment plans will be decided in the context
observed if asymptomatic but, if causing problems, of a multidisciplinary team meeting.
often warrant surgical excision. The primary

LYMPHADENOPATHY
Lymphadenopathy can be benign or
malignant. The benign causes of lymphadenopathy
are multiple and too large a group to be discussed
in this chapter. However, a lymph node in the neck
should be approached as though it is malignant
until it is shown that it is not. Our index of suspi- Scalp/skin
cion is changed by different aspects of the history,
clinical examination and special investigations
performed. Metastatic lymphadenopathy typically Oropharynx/oral
cavity
follows a predictable path dependent on the pri-
mary site of the tumour (Figure 32.1). This should Larynyx/hypopharynx
be borne in mind when searching for the primary Nasopharynx
Oral cavity
tumour. Lymphoma is a diagnosis that should be
considered but is difficult to diagnose on FNAC. GI tract/lung
Often a lymph node biopsy is required for formal
exclusion or typing of Figure 32.1. Metastatic spread from primary sites
the lymphoma. in head and neck cancer.

158 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

THYROGLOSSAL DUCT CYST
This congenital anomaly occurs due to residual contemplated and one must be certain there is
portions of the tract that forms during the descent other thyroid tissue left behind after its removal.
of the thyroid gland during embryological develop-
ment. The cysts can form at any point along the Surgery is in the form of a Sistrunk’s procedure or
descent of the thyroid and are often found in a midline neck dissection clearing the tissue from the
paramedian position, between the trachea and the midline of the neck and the cyst whilst taking out
base of tongue. the mid-portion of the hyoid bone. Removal of the
mid-portion of the hyoid bone is undertaken due
These should be investigated with an ultrasound to the intimacy of the embryological descent with
scan to look at the mass, but also to check for a the hyoid and its removal significantly decreases the
normal thyroid gland, as surgical excision is often recurrence rate of these cysts.

BRANCHIAL CYST
Branchial cysts are another congenital pathology or MRI scan of the neck to give relationships to
that typically present in the first two decades of life. the great vessels and also to characterize the
They may present as an asymptomatic mass but can mass further.
be seen to enlarge, especially in association with
upper respiratory tract infections. The position of Surgical excision should not be undertaken lightly
these is quite characteristic, being hidden under the and should be considered almost like a selective
junction of the upper third and lower two-thirds of neck dissection, such that the accessory, hypoglos-
the sternocleidomastoid muscle. sal and vagus nerves are identified and preserved
together with the internal jugular vein and the
FNAC often demonstrates a straw-coloured liquid. carotid artery.
Imaging should be undertaken in the form of a CT

THYROID MASSES
Thyroid masses are commonplace and warrant expertise; however, most people with a mass in
a whole chapter. However, certain aspects of the the thyroid will have at least an ultrasound
history should be elicited, namely aspects of the and FNAC to guide the surgeon in their
lump and growth rate, pain, dysphagia, hoarse- management plan.
ness and stridor, together with aspects of risk
factors, such a family history or exposure to Treatment is dependent on the appearances of the
ionizing radiation. FNAC and ultrasound, together with the patient’s
feeling about the lump, as cosmesis is an indication
Many people argue about investigation of the for removal of a goitre.
thyroid mass. This depends on the institution’s

SALIVARY GLAND TUMOURS

This is an extensive subject, but it is useful to have Eighty per cent of salivary gland tumours arise in
an understanding of it. the parotid, 10% in the submandibular gland and

Management of neck lumps 159

10% in the sublingual or minor salivary glands. Of weakness (e.g., facial nerve weakness in parotid
the parotid tumours 80% are benign and of these malignancies).
80% are pleomorphic adenomas.
FNAC is very useful and can be very helpful in the
Hallmark symptoms and signs of malignant pathol- decision-making process for these tumours.
ogy include rapid growth of mass, pain and nerve

160 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 33 VERTIGO AND DIZZINESS

Vertigo and dizziness affect approximately a third complaining of vertigo, and another 10/1000 with
of the general population before the age of 65 symptoms of dizziness or giddiness (2). A balance
years, and approximately two-thirds of women disorder in the elderly may result in a fall, and the
and one third of men at 80 years (1). Annually, subsequent injuries sustained leading to death in
5/1000 patients present to their general practitioner this age group (3, 4, 5).

BALANCE OVERVIEW
Normal human balance relies on vision, pro- (Figure 33.1). This sensory information is relayed
prioception and the peripheral vestibular organs centrally, and integrated and interpreted within the

Input Integration and Output

interpretation

Vision Gaze stabilization

Peripheral
vestibular system

Templates

Proprioception Postural control

Figure 33.1. Overview of the balance system.

Vertigo and dizziness 161

brain in order to maintain posture and stabilize templates. A mismatch results in symptoms of diz-
vision. Interpretation involves cross-referencing ziness, unsteadiness or vertigo.
this sensory information with previously generated

HISTORY
Taking a thorough history is the key to Subsequent episodes, their duration, frequency
establishing a diagnosis. It is essential to allow and precipitants, will confirm a working diagnosis.
a patient to speak freely at the start of the The most recent episode is also worth exploring as
consultation. Although some of this information symptoms may evolve as central changes partially
may be of little diagnostic value, it does allow compensate for the peripheral or central pathology.
some insight into their principal concerns and also It is always worth considering more than a single
establishes rapport with the patient. It is often the pathology to be responsible for a patient’s symp-
case that this will be the first time that ‘anyone has toms (e.g., benign paroxysmal positional vertigo
listened’. (BPPV) and a peripheral vestibular deficit).

A detailed history of the first episode is essential. A past medical and surgical history must always
When, where and what possible precipitants were be taken. This must include details regarding the
associated with this event should be sought. The patient’s vision and mobility, and a family or per-
duration and form of dizziness/vertigo should sonal history of migraine must always be explored.
also be established. Associated symptoms should In females, a delicate and difficult subject is that of
be documented (e.g., nausea, vomiting, hearing spontaneous miscarriage, but may suggest an autoim-
loss, tinnitus, loss of consciousness, photophobia, mune or embolic aetiology. A note should be made of
headache). previous or current anxiety or depression (6).

EXAMINATION
A full neuro-otological examination is required clinical investigation (7). Dix-Hallpike testing is also
in every patient presenting with vertigo. Although required in every case to demonstrate any form of
a working diagnosis may have been made it is nystagmus, but in particular geotropic torsional
essential both to confirm and exclude possible nystagmus consistent with posterior semicircular
concurrent pathology. This includes cranial nerve canal BPPV (8). Vertical or horizontal nystagmus,
examination, eye movement in all four planes for or nystagmus that does not fatigue, is unusual and
nystagmus, smooth pursuit, saccades, latent patients require MRI scanning to exclude central
squint, and assessment for cerebellar signs. pathology. It is essential to document the latency
Romberg’s test (on both floor and foam) and and duration of any nystagmus seen and whether
Fukuda step testing should also be performed. the nystagmus settled completely.
Whilst the latter is generally regarded to
localize a peripheral vestibular deficit (rotation A thorough assessment also includes lying and
occurs towards the weaker side), the Halmagyi standing blood pressure recording and functional
head thrust test is a far more sensitive and specific gait assessment.

SPECIAL INVESTIGATIONS
All patients must undergo a pure tone audiogram suggest a cerebellopontine angle tumour, which must
and tympanometry. A sensorineural asymmetry may therefore be excluded. A full audio-vestibular battery

162 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

is required in the majority of subjects referred to a function. Eye movements may be recorded with
balance service (exceptions may include BPPV that electrodes attached to the face, electronystagmog-
settles completely following particle reposition- raphy (ENG), or by videoing pupil movement,
ing manoeuvres). Not only do these investigations videonystagmography (VNG). Saccades, smooth
support a working diagnosis, but in approximately pursuit and optikokinetic movement may also be
5−10% of cases reveal unexpected unilateral or bilat- assessed with this recording method. Additional
eral peripheral vestibular hypofunction. tests include rotational chair and vestibular evoked
myogenic potentials (VEMPs).
As it is not possible to directly access the
peripheral vestibular organs, an indirect Patients with a history and assessment in keeping with
assessment based on the vestibulo-ocular reflex central pathology should also undergo an MRI scan
is generally used (Figure 33.2). to exclude a space-occupying lesion or demyelination.
Patients with chronic ear disease or suspected supe-
Bithermal caloric testing remains a simple and rior semicircular canal dehiscence require a fine-cut
valuable method of comparing lateral semicircular computed tomography scan of the temporal bones.

Lateral Medial
rectus rectus

Oculomotor nucleus
Abducens nucleus

Vestibular nucleus

Neural firing rate

Head tur ning

Figure 33.2. The vestibulo-ocular reflex. As a result of head rotation, endolymph flow within the semicircu-
lar canals causes movement of the cupulae within the ampullae of the lateral semicircular canals and relative
shearing of the underlying stereocilia. Neural impulses increase on the right and decrease on the left. Neural
connections to the IIIrd and VIth cranial nuclei result in contraction of the left lateral rectus and right medial
rectus to stabilize gaze.

Vertigo and dizziness 163

COMMON VESTIBULAR PATHOLOGY
Listed below are common vestibular conditions ❚❘ Acute peripheral vestibular
amenable to treatment (Table 33.1). Management
deficit (labyrinthitis/vestibular
pathways are also illustrated in Figure 33.3.
neuritis)
This relatively common cause of vertigo arises
❚❘ Benign paroxysmal positional due to a sudden failure of one peripheral
vertigo (BPPV) vestibular organ. This results in labyrinthine
asymmetry, and the sensory mismatch that
This is the commonest cause of vertigo in all occurs causes severe persistent rotatory vertigo
age groups. Patients classically describe rota- and profuse vomiting.
tory vertigo when rising or turning over in bed.
Although the vertigo lasts for seconds, they feel Patients frequently describe a recent flu-like ill-
unsteady for a great deal longer, but are then ness. They classically wake with severe continuous
able to go about their normal daily activities. rotatory vertigo that persists for 3−5 days. Initially,
There is no associated hearing loss or tinnitus. patients must lie still as any movement results in
Spells last for days to weeks and usually settle worsening symptoms. Thereafter, movements may
spontaneously. Patients invariably, though not be tolerated but compensation for normal activi-
universally, describe a previous head injury or an ties may take weeks or months. Prochlorperazine, a
episode of ‘labyrinthitis’. peripheral vestibular sedative, is indicated in such
situations but should be limited to seven days as
long-term use may limit central compensation and
Symptoms arise due to debris derived from the
hence functional recovery.
otoconial membrane of the utricle. Head
rotation results in this debris striking the
delicate cupula of the posterior semicircular Clinical examination may reveal rotation on
canal, profoundly stimulating the associated Fukuda step testing. More reliable is the head thrust
hair cells and causing vertigo (Figure 33.2). The test, where a catch-up saccade may be evident.
mismatch that occurs may also result in nausea,
vomiting and anxiety. Patients who do not compensate, benefit from
generic or customized physiotherapy. Those with
visual vertigo (over-reliance on visual input) benefit
In the most common form, posterior canal from combining physiotherapy exercises and visu-
BPPV, on Dix-Hallpike testing, following a ally stimulating environments (12). Those who fail
short latency, geotropic torsional nystagmus will to improve must be reassessed and possible limita-
gradually appear, increase in severity and sub- tions to compensation excluded (Table 33.2).
side completely. This will correlate well with the
symptoms of vertigo experienced by the patient
during the test. Having confirmed the diagno-
sis, an Epley manoeuvre should be performed. ❚❘ Vertiginous migraine
This is curative in approximately 90% of cases. A
repeat manoeuvre may on occasion be required. Also known as migraine variant, this common
Alternative particle repositioning manoeuvres cause of vertigo produces spells of vertigo or
for posterior semicircular canal BBPV include dysequilibrium that last for several days and
Brandt-Daroff (9) and Semont (10) manoeuvres. in women are frequently associated with
Gan’s manoeuvre may be used if the anterior menstruation. Patients often describe phonopho-
semicircular canal is involved (11). bia or photophobia and prefer to rest in a quiet,

164 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

 Vertigo,
dizziness or giddiness

Rotatory vertigo, Continuous Vertigo or Intermittent Chronic ear ‘Lightheadedness’ Aural fullness, Sudden hearing
lasting seconds, on rotatory vertigo disequilibrium disequilibrium on discharge or due to rapid hearing loss, loss or asymmetric
rising or turning with persistent lasting two to four rapid movement. intermittent ‘ear breathing. Anxiety rotatory vertigo sensorineural
nystagmus, not days associated and tinnitus. Hours
over in bed. with periods or, History of poor infections’. state. Clinical with nausea and hearing loss.
Torsional fatigable associated with vision, peripheral Otoscopy examination Occasional
previous history of vomiting.
nystagmus on hearing loss nor classic migraine neuropathy, demonstrates TM normal. Nystagmus during episodes of
Dix-Hallpike tinnitus. Nausea then subsequent osteoarthritis. retraction with episodes. dysequilibrium
and vomiting. spells lasting days. Sensorineural
testing. keratin/debris. or vertigo.
No associated hearing loss.
hearing loss nor
tinnitus. Patients
prefer bed rest in
a quiet darkened
room.

• PTA • PTA • PTA • PTA • PTA • PTA • PTA

• FVT • MRI • CT scan • FVT • MRI IAM’s • MRI IAM’s
temporal bones • FVT

EXCLUDE PSYCHOLOGICAL OVERLAY

Acute peripheral Vertiginous Multilevel Hyperventilation

pc-BPPV Cholesteatoma Menière’s disease Acoustic neuroma
vestibular deficit migraine vestibulopathy syndrome

• Epley manoeuvre • Vestibular • Dietary • Physiotherapy • Surgical • Cognitive • Salt free diet • Regular
rehabilitation in restrictions rehabilitation intervention behavioural assessment
Vertigo and dizziness 165

• Bendroflurozide
those who fail • Antimigrainous therapy • Surgical • Surgical
to recover Tx intervention intervention

Figure 33.3. Management pathways for common vestibular pathology. (PTA–pure tone audiometry, FVT–formal vestibular testing).
Table 33.1. Common causes of dizziness (in order tricyclic antidepressants, calcium channel blockers
of frequency). or beta-blockers.

● Benign paroxysmal positional vertigo (BPPV)

●
●
Labyrinthitis/vestibular neuritis
Vertiginous migraine
❚❘ Multilevel vestibulopathy
● Multilevel vestibulopathy
● Cholesteatoma (CSOM) Dizziness and vertigo are common symptoms in
● Hyperventilation syndrome elderly patients.
● Menière’s disease
● Acoustic neuroma Unilateral decline in one sensory pathway may be
● Multiple sclerosis compensated for centrally with little or no func-
● Vertebro-basillar insufficiency tional loss. A reduction in the quality and quantity
● Superior semicircular canal dehiscence of sensory information from multiple sensory
pathways, in addition to central changes within
the brain (e.g., ischaemic episodes) may result in
multilevel vestibulopathy. Patients benefit from a
darkened room. There is no associated hearing combination of physiotherapy exercises (generic,
loss nor tinnitus. customized or strength and balance exercises) and
lifestyle changes (e.g., the use of a walking stick,
Although no abnormalities are likely to be found visual acuity/cataract correction).
on clinical examination, ENG/VNG testing may
support central changes. All patients should
undergo MRI scanning in order to exclude ❚❘ Cholesteatoma (CSOM)
central pathology.
Squamous epithelium within the middle ear may
Treatment consists of dietary changes (avoidance of expand to erode into the inner ear. While most
chocolate, caffeine, red wine, cheese and processed patients present with intermittent or chronic ear
meat). The majority of patients benefit from this discharge, with hearing loss, some also complain of
approach alone, although some may also require intermittent vertigo and unsteadiness.

Table 33.2. Limitations of vestibular compensation.

Visual impairment Cataracts

Poor visual acuity
Eye movement disorders
Visual impairment
Peripheral vestibular system Prolonged vestibular sedative use (e.g., prochlorperazine)
Recurrent or progressive vestibular insults
Proprioception Immobility
Psychological factors Anxiety
Depression
Agoraphobia
Central pathology Cerebrovascular disease
Intracranial pathology
Rehabilitation Delay in starting vestibular rehabilitation
Poor motivation
Concurrent illness

166 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

❚❘ Hyperventilation syndrome
Hyperventilation, associated with anxiety, may result
in light-headedness and dizziness. In some, anxiety
may be the residual effect of a previous vestibular
insult which the patient may have compensated for.
Symptoms can be reproduced by asking a patient to
breathe rapidly through pursed lips. Such patients
benefit from a cognitive behavioural therapy review.

❚❘ Menière’s disease
Previously over-diagnosed, this rare cause for ver-
tigo arises due to mixing of perilymph and endo-
lymph within the inner ear. This results in an initial
feeling of aural fullness followed by hearing loss,
severe rotatory vertigo and tinnitus.
Figure 33.4. Right acoustic neuroma.
Attacks are unpredictable and severe. A pure
tone audiogram will demonstrate a sensorineural transmitted from and to the intracranial cavity. This
hearing loss, initially in the low frequencies in the not only results in momentary vertigo in response
affected ear and then, as attacks continue, hearing to loud sounds (Tullio’s phenomenon), but also
loss across all frequencies. It is essential to exclude results in patients hearing their eyes moving.
a central pathology (e.g., a cerebello-pontine angle
tumour) and hence an MRI scan must be per-
formed. Bithermal calorics will reveal a peripheral
vestibular weakness. Attacks eventually subside, but KEY POINTS:
at the expense of the hearing in the affected ear.
1 An understanding of the sensory
Treatment includes Buccastem for acute episodes, pathways and their central interpreta-
and bendrofluorazide or betahistine to reduce the tion provides a valuable guide to the
frequency and severity of attacks. diagnosis and management of patients
who complain of vertigo and dizziness.
For those not controlled medically, surgery may be 2 While a number of conditions exist
indicated. Procedures include grommet insertion, that may result in vertiginous spells,
gentamicin ablation, medical or surgical labyrin- treatment is either curative or enor-
thectomy and vestibular nerve section. mously beneficial in the vast majority
of patients.
Other relatively uncommon conditions that may 3 The commonest cause of vertigo, BPPV,
present with vertigo or dizziness include multiple should be excluded in all cases by Dix-
sclerosis, acoustic neuroma (Figure 33.4) and Hallpike testing.
vertebro-basillar ischaemia. In each an MRI scan is
required to establish a diagnosis.

Superior semicircular canal dehiscence is a rare REFERENCES

condition whereby a defect in the bony covering 1 Shepard NT, Telian SA (1996a). Balance Dis-
of the superior semicircular canal results in a third order Patient. Basic Anatomy and Physiology
window through which a pressure wave may be Review. Singular Publishing Group, Inc.

Vertigo and dizziness 167

 2 The Royal College of General Practitioners 7 Halmagyi GM, Curthoys IS (1988). A clinical sign
and Office of Population Census and Surveys of canal paresis. Archives of Neurology 45: 737−9.
(1986). Morbidity Statistics from General 8 Dix, R, Hallpike C (1952). The pathology,
Practice. HMSO, London. symptomatology and diagnosis of certain
3 Blake AJ, Morgan K, Bendall MJ et al (1988). common disorders of the vestibular system.
Falls by elderly people at home: Prevalence Annals of Otology, Rhinology and Laryngology 6:
and associated factors. Age and Ageing 17: 987−1016.
365−72. 9 Brandt T, Daroff R (1980). Physical
4 Campbell AJ, Reinken J, Allan BC, Martinez GS therapy for benign paroxysmal positional
(1981). Falls in old age: A study of frequency vertigo. Archives of Otolaryngology
and related clinical factors. Age and Ageing 10: 106: 484−5.
264−70. 10 Semont A, Freyss G, Vitte E (1988). Curing the
5 Stevens JA, Olson S (2000). Reducing falls and BPPV with a liberatory maneuver. Advances in
resulting hip fractures among older women. Otorhinolaryngology 42: 290−3.
MMWR Recomm Rep 49: 3−12. 11 Gans R (2000). Overview of BPPV: Treatment
6 McKenna L, Hallam RS, Hinchcliffe R (1991). methodologies. Hearing Review 7: 50−4.
The prevalence of psychological distur- 12 Pavlou M, Lingeswaran A., Davies RA, et al
bance in neuro-otology outpatients. Clinical (2004). Simulator based rehabilitation in
Otolaryngology 16: 452−6. refractory dizziness. J Neurol 251: 983−95.

168 ENT: AN INTRODUCTION AND PRACTICAL GUIDE

INDEX
ABC (of resuscitation) 149 anosmia, post-polypectomy 97 benign paroxysmal posi-
epistaxis 52 antral washout 90–1 tional vertigo 162, 163,
abscess see also transantral maxillary 164, 165, 167
nasal septum 43 artery ligation biopsy, lymph node 158
parapharyngeal 46 arterial supply, nasal cavity 20 see also fine needle aspiration
peritonsillar 44–5 in epistaxis 50, 51 cytology
retropharyngeal 46 ligation 55–6 biphasic stridor 150
acoustic neuroma (vestibular arytenoid cartilage 24, 25 bipolar diathermy/electrocautery
schwannoma) 63, 65, 104, atticotomy 105 epistaxis 53
165, 167 audiology (incl. audiometry) parotidectomy 136
adenoidectomy 72–4 30–1, 59–66 thyroidectomy 133
aero-digestive tract, upper preoperative tonsillectomy 69, 70
foreign bodies see foreign mastoidectomy 104–5 bismuth iodoform paraffin paste
bodies stapedectomy 112 (BIPP) 53, 54
rigid endoscopy 118 tympanoplasty 99, 103 bleeding see haemorrhage; hae-
voice production and 145 auditory brainstem responses mostasis
see also airway management 65–6 blood vessels see arterial supply;
(A); respiratory tract infec- auditory canal/meatus (ear canal) venous drainage
tions external bone(s), nasal 18
air-bone gap (ABG) 60, anatomy 12–13 trauma 42
61, 62 examination 29–30 bone-anchored hearing aid 115–17
air conduction, testing 60, 61 foreign bodies 40–1 bone conduction, testing 60, 61
airway management (A) inflammation 37 branchial cyst 159
(incl. obstructed air- tympanoplasty approach breathing management (B) 149
way) 149–51 via (permeatal) 101 epistaxis 52
aetiology of obstruction 151 see also canal wall down bronchoscopy, rigid 118, 126–7
epistaxis 52 mastoidectomy; canal wall
see also aero-digestive tract; up mastoidectomy canal wall down mastoid-
respiratory tract infections internal (IAM), MRI 156 ectomy 105
anaesthesia auditory evoked potentials 65–6 canal wall up mastoidectomy 105
general, neck lump investiga- auricle see pinna cancer see malignant tumours
tions under 158 auricular nerve, greater 13 carcinoma, tongue, MRI 156
local see local anaesthetic iatrogenic damage 134, 135 cardiac arrest in trache-
anatomy 12–29 auriculotemporal nerve 13 ostomy 139
abnormalities causing airway carotid artery, external
obstruction 151 balance 161–2 anatomy 20, 50
ear 12–16 disturbances 162–8 ligation 56
facial nerve 16, 26 balloon devices in epistaxis 54 cartilage(s)
larynx 24, 24–5 barium swallow 153 grafts, tympanoplasty
nose 18–22, 78 bat ear 12 102, 110
oral cavity 22–4 behavioural audiometry 59, 60–2 laryngeal 24–5
pharynx 24 Bell’s palsy 40 nasal 18

Index 169
 intercartilaginous incisions cochlea tonsillectomy 69, 70, 71
in septorhinoplasty 84–5 anatomy 14 turbinate surgery 87
quadrilateral in septoplasty bone conduction reaching 60 distortion product otoacoustic
81–2 computed tomography emissions 66
cauliflower ear 12, 39 congenital deafness 156 dizziness 161–7
cavernous sinus 18 neck 153, 158 dressings, tracheostomy 143
cavities, nasal 18–22 sinuses 155
cellulitis temporal bone 154 ear
periorbital 43–4 mastoidectomy 105 anatomy 12–16
pinna 39 tympanoplasty 99, 103 examination 29–33
cerebellopontine angle tumour in vertigo or dizziness 163 foreign bodies 40–1
104, 162, 167 conductive hearing loss earwax impaction 37–8
cerebrospinal fluid (CSF) leak examination and investiga- electrocautery see diathermy
endoscopic sinus surgery 95 tions 112 electrocochleography 65
nasal polypectomy 97 pure tone audiometry 61, embolization, nosebleed 56
cervical lymph nodes see lymph 62, 112 emergency tracheostomy 139
nodes otosclerosis causing 14, 111 empty nose syndrome 89
cervical oesophagus, en- congenital (anatomical) causes of endaural approach to tympano-
doscopy 122 airway obstruction 151 plasty 101
children congenital deafness, imaging 156 endoscopic investigations 118–26
adenoidectomy 72, 74 constrictor muscles of laryngeal 25, 33–4, 118,
airway management 149, 150 pharynx 24 119–20
bone-anchored hearing contrast swallow 153 nasal 25, 31–2, 33–4
aid 117 cortical auditory evoked poten- endoscopic surgery
cuffed tracheostomy tubes 142 tials 66 paranasal sinuses 92–5
epiglottis 45 cortical mastoidectomy 107–9 sphenopalatine artery
eustachian tube dysfunction 14 cosmetic concerns/complications ligation 55
foreign body septoplasty 82 endotracheal intubation
ear 40 septorhinoplasty 86 micro-laryngoscopy 119
nose 42 cricoid cartilage 24, 25, 26 tonsillectomy 68
upper aerodigestive tract 47 cricopharyngeus 24 herniation into tongue
otitis media with effusion pharyngoscope at 122 blade 70
38, 75 cricothyroidotomy 139 epiglottis 45
periorbital cellulitis 43 CSF leak see cerebrospinal epistaxis 20, 50–8
rhinoscopy 32 fluid leak postoperative
tracheostomy 139 cuffed tracheostomy tubes 142 septoplasty 82
cholesteatoma 104–10, 165, 166 curettage, adenoidal 72–3 septorhinoplasty 86
CT 105, 106, 154 cysts ethmoidal air cells 22
surgery 104–10 branchial 159 ethmoidal artery ligation 56
chorda tympani nerve thyroglossal duct 159 eustachian tube dysfunction,
anatomy 16, 22 vocal cord 148 children 14
in mastoidectomy, evoked potentials, auditory 65–6
damage 106 deafness see hearing loss examination 29–36
circulatory management (C) 149 diathermy/electrocautery ear 29–33
epistaxis 52 adenoidectomy 73 with epistaxis 52
circumvalate papillae 23 epistaxis 53 facial nerve function 36
cleaning of tracheostomy parotidectomy 136 neck 35–6
tubes 142 thyroidectomy 133 lumps 157

170 INDEX
 nose and larynx 33–4 sinus surgery 93 heart arrest in trache-
oral cavity 34–5 submucosal out-fracture of ostomy 139
preoperative inferior turbinate 88 hemithyroidectomy 131–3
mastoidectomy 104 Frey’s syndrome 134 hemorrhagic telangiectasia, he-
stapedectomy 111 functional endoscopic sinus sur- reditary 56
tympanoplasty 99 gery 92–5 hereditary hemorrhagic telangi-
with vertigo and dizzi- fungal sinusitis 43 ectasia 56
ness 162 herpes zoster 27, 40
with voice problems 146 general anaesthesia, neck lump human papilloma virus
expiratory stridor 149–50 investigations under 158 (HPV) and laryngeal
external ear see outer ear globus sensation 121 papillomatosis 147–8
glottis, causes of obstruction 151 humidification, tracheostomy
face glue ear (otitis media with effu- 143
sensory nerve supply 27 sion) 38, 75, 125 hyperventilation syndrome
venous drainage 18 grafts, tympanoplasty 102, 110 165, 167
weakness/palsy 36 granuloma, vocal cord 148 hypopharynx, foreign bodies
facial nerve Grisel’s syndrome 73, 74 46, 46–7
anatomy 16, 26 grommet insertion 75–7
chorda tympani branch see adenoidectomy and 72 iatrogenic damage
chorda tympani nerve facial nerve 40, 110
functional assessment 36 haematoma greater auricular nerve
iatrogenic damage 40, 110 nasal septal 43 134, 135
palsy 40 pinna 39 nasolacrimal duct damage,
parotid gland excision super- haemorrhage (bleeding) avoidance 88
ficial to 134–7 nasal see epistaxis see also complications of specific
fenestrated tracheostomy postoperative procedures
tubes 142 adenoidectomy 74 imaging/radiology 152–6
fenestration in stapes footplate endoscopic sinus surgery 95 foreign bodies 46, 47,
(stapedotomy) 111, 113 polypectomy 97 152–3
fine needle aspiration cytology septoplasty 82 neck 153, 158
(FNAC) tonsillectomy 70–1 see also specific modalities
neck lumps 157–8 turbinate surgery 88, 89 incudostapedial joint
salivary gland tumours 160 haemostasis division 113
flange, adjustable, tracheostomy septoplasty 80 incus 14
tubes with 142 tonsillectomy 70 inhalation
flexible nasolaryngoscopy 33–4 hearing aid, bone-anchored foreign body see foreign
foreign bodies 115–17 bodies
ear 40–1 hearing loss (incl. deafness) smoke 45–6
nose 42, 51 conductive see conductive injury see fractures; trauma
upper aero-digestive tract hearing loss inner ear anatomy 14–16
(ingested/inhaled) congenital, imaging 156 inspiratory stridor 149
46–7, 126 levels 59 intercartilaginous incisions in
imaging 46, 47, 152–3 mixed, pure tone audiometry septorhinoplasty 84–5
fractures, temporal bone 41–2 in 62 internal ear anatomy 14–16
see also out-fracture sensorineural see sensorineu-
Freer’s elevator ral hearing loss Keros classification of lateral
antral washout 90 hearing tests (audiology) 30–1, lemniscus length 155
septoplasty 79, 80, 81 59–66 Killian’s incision 79, 81

Index 171
labyrinthitis 164 maxillary sinus washout 18 nodules, vocal fold 146–7
laryngeal nerve injury/palsy, re- Ménière’s syndrome 165, 167 nose
current 147 MerocelR™ (nasal packing) anatomy 18–22, 78
in thyroidectomy 131 53, 54 bleeding from see epistaxis
avoidance 132 metastases, lymph node endoscopy 25, 31–2, 33–4
laryngeal nerve injury/palsy, su- investigations 158 foreign bodies 42, 51
perior, in thyroidectomy tonsillar malignancy 68 obstruction
131 micro-laryngoscopy 119–20, 148 with deviated septum 78
larynx microsuction, ear 32–3 with inferior turbinate hy-
anatomy 25–6 middle ear anatomy 14 pertrophy 87
endoscopy 25, 33–4, 118 migraine, vertiginous 164, 165 packing see packing
microscopic 119–20, 148 monopolar diathermy, surgical procedures see specific
foreign bodies 47 turbinates 87 procedures
obstruction 150 motor neuron palsy, upper vs trauma 42–3
voice affected by abnormalities lower 36
of 145–8 mucoperichondrium in septorhi- objective audiometry 59, 63–4
lateral soft tissue films 152–3 noplasty 79, 80 oesophagus
lemniscus, lateral, length assess- mucus drainage 20–2 endoscopy 118, 122, 126–7
ment 155 multilevel vestibulopathy foreign bodies 46–7, 153
local anaesthetic 165, 166 olfactory mucosa 20
stapedectomy 113 myringoplasty 98, 99 see also anosmia
tympanoplasty 99 optimum discrimination
combined approach 107 nasolacrimal duct damage, turbi- score 63
lower motor neuron palsy 36 nectomy 88 oral cavity
lymph nodes, cervical nasolaryngoscopy, flexible 33–4 anatomy 23–4
anatomy 27 see also rhinoscopy examination 34–5
investigations 158 nasopharynx foreign bodies 46–7
metastases see metastases anatomy 24 orbital injury in nasal polypec-
palpation 36 obstruction, causes 151 tomy 97
lymphoma 158 neck 157–60 oropharynx, obstruction 151
approach in thyroidectomy foreign bodies 46
magnetic resonance imaging 131–2 Osler–Weber–Rendu syndrome
155–6 examination see examination (hereditary hemorrhagic
neck 153, 158 imaging 153, 158 telangiectasia) 56
in vertigo or dizziness 163, 167 lumps 157–60 ossicular chain
malignant otitis externa 37 neoplasm see malignant tumours; checking
malignant tumours (cancer) tumours stapedectomy 113
larynx 147 nerve supply tympanoplasty 102, 107
tongue, MRI 156 external auditory canal 13 CT 154
tonsils 68 face 27 repair (ossiculoplasty)
malleus 13–14 oral cavity 22–3 98, 110
marginal mandibular nerve see also specific nerves osteomeatal complex 22
damage in submandibular neuritis, vestibular 164 osteotomies, septorhinoplasty 85
gland excision 128, 128–9 neuroepithelium, sensory (of otitis externa 37
mastoidectomy 104–10 semicircular canals) 16 otitis media
mastoiditis, acute 38–9 neuroma, acoustic (vestibular acute 38
maxillary artery ligation, trans- schwannoma) 63, 65, 104, acute suppurative 40
antral 56 165, 167 chronic secretory

172 INDEX
 mastoidectomy 104 peritonsillar abscess respiratory tract infections,
tympanoplasty 98 44–5 upper 145
with effusion (glue ear) permeatal approach to tympano- see also aero-digestive tract;
38, 75, 125 plasty 101 airway management
otoacoustic emissions 66 pharynx retromandibular vein 26
otosclerosis, conductive hearing anatomy 24 retropharyngeal abscess 46
loss in 14, 111 endoscopy 118, 121–3 rhinoscopy, anterior 31–2
otoscopy 29–30 see also hypopharynx; na- see also nasolaryngoscopy
out-fracture of inferior turbinate sopharynx; oropharynx; rhinoseptoplasty 78, 84–6
87, 88 uvulopalatopharyngoplasty rigid endoscopy
outer ear pinna (auricle) nose 34
anatomy 12–14 anatomy 12 upper aerodigestive tract 118
examination 29–30 cellulitis 39 Rinne’s test 30–1
examination 29–30
packing haematoma 39 Sade classification 99
ear, postoperative polyps salivary glands 26
stapedectomy 113 laryngeal haemorrhagic excision 128–30, 134–7
tympanoplasty 102–3, 110 148 tumours 128, 134, 135, 136,
nasal nasal, removal 96–7 159–60
anterior 53–4 positional vertigo, benign schwannoma, vestibular
endoscopic sinus surgery 94 paroxysmal 162, 163, (acoustic neuroma)
polypectomy 97 164, 165, 167 63, 65, 104, 165, 167
posterior 54–5 post-auricular incision in tympa- semicircular canals
paediatric patients see children noplasty 101 anatomy 14–16
panendoscopy 118 in combined approach 107 superior, dehiscence 167
papillomatosis, laryngeal 147–8 postnasal space examination sensorineural hearing loss
paranasal sinuses see sinuses 118, 125 bone-anchored hearing
parapharyngeal abscess 46 pre-auricular approach to tym- aid 115
‘parent’s kiss’ 42 panoplasty 101 MRI 156
parotid gland 134–7 prosthesis pure tone audiometry
anatomy 26 ossiculoplasty 110 in 61, 62
excision superficial to facial stapedectomy 113 sudden 39
nerve 134–7 voice, leaking or dislodged sensory nerve supply
MRI 155–6 47–8 external auditory canal 13
tumours 134, 135, 136, 159–60 pure tone audiometry 60–2 face 27
pars flaccida 13 preoperative oral cavity 22–3
pars tensa 13 mastoidectomy 104–5 sensory neuroepithelium (of
retraction pockets 98, 99 stapedectomy 112 semicircular canals) 16
percutaneous tracheostomy 139 tympanoplasty 99 septoplasty 78–83
perichondritis 39 septorhinoplasty 78, 84–6
perichondrium quinsy 44–5 septum, nasal
in septorhinoplasty, dissection abscess 43
regarding 79 radiology see imaging and specific anatomy 18, 78
in tympanoplasty, grafts modalities deviated 78–83
102, 110 Ramsay Hunt syndrome 13 haematoma 43
periorbital cellulitis 43–4 Rapid Rhino™ (nasal perforation (iatrogenic) 82, 86
peripheral vestibular deficit, packing) 53 shingles (herpes zoster) 27, 40
acute 164, 165 Reinke’s oedema 146 singer’s nodules 146–7

Index 173
sinuses, paranasal 20–2 supraglottitic obstruction, trauma
CT 155 causes 151 iatrogenic see iatrogenic
endoscopic surgery 92–5 supraglottitis 45 damage
inflammation (acute surgery nose 42–3
sinusitis) 43 damage due to see iatrogenic tympanic membrane 41
washout 90–1 damage see also fractures
sinusitis, acute 43 in epistaxis 55 tumours (neoplasms)
skeleton, nasal 18 surgical tracheostomy 139–40 cerebellopontine angle 104,
smell sensation see anosmia; systemic causes of epistaxis 50, 51 162, 167
olfactory mucosa epistaxis due to 51
smoke inhalation 45–6 taste sensation 22–3 malignant see malignant
smoking and laryngeal temporal bone tumours
cancer 147 fractures 41–2 salivary gland 128, 134, 135,
soft tissue lateral films 152–3 imaging 154 136, 159–60
tissue inflammation immedi- mastoidectomy 105 tuning fork tests 30–1
ately above vocal cords 45 tympanoplasty 99, 103 pre-stapedectomy 112
sound pressure levels in audiom- temporal fascia grafts, tympano- turbinates
etry 60 plasty 102 anatomy 20
speaking valve 144 thyroglossal duct cyst 159 surgery 87–9
speech audiometry 63 thyroid gland turbinectomy 88
pre-stapedectomy 112 excision 131–3 complications 89
sphenopalatine artery ligation 55 identification in tracheos- turbinoplasty, inferior 88
stapedectomy 111–14 tomy 139 tympanic membrane 98–103
stapedius tendon division 113 masses 159 anatomy 13–14
stapedotomy 111, 113 thyropharyngeus 24 examination 30
stertor 149 tongue perforation
strap muscles anatomy 22–3 closure (myringoplasty)
thyroidectomy 132, 133 carcinoma, MRI 156 98, 99
tracheostomy 139 tonsillectomy 68–71 removal of margins 100–1
stridor 149–50 tonsillitis 44 reconstruction see tympano-
stylopharyngeus 24 recurrent acute 68 plasty
subglottic causes of obstruc- tracheal obstruction 151 trauma 41
tion 151 foreign bodies 47, 126 tympanomeatal flap
sublingual gland tracheoesophageal voice pros- stapedectomy 113
anatomy 26 thesis, leaking or dislodged tympanoplasty 101–2
excision 128–30 47–8 combined approach 107
tumours 128, 159 tracheostomy 138–44 tympanometry 63–4
submandibular gland, tubes pre-stapedectomy 112
anatomy 26 care 141–3 tympanoplasty 98–103
submucosal diathermy of inferior insertions 139 combined approach 105
turbinate 87 transantral maxillary artery tympanotomy, posterior 109–10
submucosal out-fracture of ligation 56
inferior turbinate 87, 88 transient evoked otoacoustic ultrasound, neck 153, 158
submucosal resection, septal emissions 66 uncinectomy 93–4
deviation 78 transmeatal (permeatal) ap- uncuffed tracheostomy
suction diathermy adenoidec- proach to tympanoplasty tubes 142
tomy 73 101 upper motor neuron palsy 36
suppurative otitis media, acute 40 trans-tracheal needle 139 uvulopalatopharyngoplasty 68

174 INDEX
vascular supply see arterial sup- cysts 148 prosthesis, leaking or dis-
ply; venous drainage granuloma 148 lodged 47–8
venous drainage, nose and haemorrhagic polyps 148
face 18 soft tissue inflammation im- warfarinized patients,
vertigo 161–7 mediately above 45 epistaxis 53
vestibular schwannoma vocal fold wax, impacted
(acoustic neuroma) nodules 146–7 37–8
63, 65, 104, 165, 167 palsy 147 Weber’s test 30–1
vestibular system 164–8 voice wheeze 150
anatomy 14–16 generation/production 145 Woodruff ’s plexus and
assessment 163 tracheostomy patient epistaxis 50
pathology 164–8 144
vestibulo-ocular reflex 163 laryngeal abnormalities X-rays (plain), lateral soft
vocal cords affecting 145–8 tissue 152–3

Index 175