Oral Revalida Review 2019

OTORHINOLARYNGOLOGY – HEAD AND NECK SURGERY (ENT)

Lecturer: Valerie Kaye U. Sison, MD

*NOTE: Please study the trans together with the B. POSTERIOR RHINOSCOPY
lecture slides Instruments Needed: Pharyngeal Mirror and
Tongue Blade
Part 1: INTRODUCTION
Proper PE:
I. General Reminders -Get the Pharyngeal Mirror, and the Tongue
II. Instruments Blade
-bring your OWN Tuning Fork and Otoscope -Depress the tongue using the tongue blade on
-all other instruments are provided in the OPD the anterior 2/3 and insert the pharyngeal
mirror pass the uvula to visualize the superior
A. Head Mirror: get the one with the blue strap structures in the nasopharynx
for proper fitting *Importance: in cases of Epistaxis to
B. Nasal Speculum: choose the appropriate size differentiate Anterior from Posterior Epistaxis
for the age of the patient (adult/pedia)
C. Pharyngeal Mirror: smaller mirror Normal PE Findings: No post nasal drip, No
D. Laryngeal Mirror: larger mirror masses, No active bleeding
E. Gauze: 2 gauze per clerk for PE
C. ORAL CAVITY AND PHARYNGEAL
F. Tuning Fork: 512 Hz
EXAMINATION
G. Otoscope: select the accurate speculum size
Instruments Needed: Tongue Blade
for the patient (smallest diameter: pedia;
Proper PE:
largest diameter: adult)
-Inspect the oral cavity (buccal cavity, dentition,
gingiva, tongue, floor of the mouth and
III. Physical Examination
pharynx/pharyngeal wall)
*Patient Positioning: SNIFFING POSITION -Describe the findings accordingly

A. ANTERIOR RHINOSCOPY D. INDIRECT LARYNGOSCOPY

Instrument Needed: Nasal Speculum Instruments Needed: Gauze and Laryngeal
Proper PE: Mirror (larger mirror)
-Grasp the fulcrum with the thumb and point Proper PE:
the index finger outward -Pull out the tongue (BUT NOT TOO MUCH!)
-Open FULLY AND WIDE towards the lateral side -Insert the Laryngeal Mirror to visualize the
of the nostril, NOT TOWARDS THE SEPTUM larynx
because it is painful
-Upon opening the speculum, the first thing
that you will see will be the INFERIOR
TURBINATES

Normal PE Findings: Nasal septum midline,

Turbinates not hyepremic, not congested, No
nasal Discharge
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Visual Representation: F. PALPATION OF NECK MASSES:

-palpate for the thyroid, confirm if it is the

ANTERIOR thyroid if the mass moves with deglutition
(since the thyroid is embedded in the pre-
TRUE VOCAL
tracheal fascia)
CORDS
FALSE VOCAL
CORDSSINUS Part 2: COMMON OPD CASES
PYRIFORM
I. EXTERNAL EAR
ON RESPIRATION POSTERIOR

ON PHONATION

E. OTOSCOPY
Instrument Needed: Otoscope
Proper PE: ANATOMY (Discussion):
-Inspect the auricle, check for deformities, and -The normal length of the EAC is 24 mm of 2.4
discharge cm
-Palpate the tragus, anti-tragus, and -The outer 1/3 is the cartilaginous portion, and
surrounding structures, assess tenderness the inner 2/3 is the bony portion, with the
-Visualize the tympanic membrane properly: isthmus as the junction between the two.
Children: Downwards Backwards -The cartilaginous part has sebaceous glands
Adult: Upwards Backwards and apocrine glands, therefore it is where
*Importance: If the TM cannot be visualized: cerumen forms
IMPACTED CERUMEN
DIFFERENTIAL DIAGNOSES FOR EAR
*To check for mobility of the TM and to check PAIN/OTALGIA
for perforation perform the following F - Furunculosis
maneuvers: A - Acute Otitis Media
1. Toynbee: ‘’pisil ang ilong (pinch the nose), T – Trauma
sarado ang bibig (close the mouth), lunok H - Herpes Zoster Oticus
(swallow)’’ E – External Otitis
2. Valsalva: ‘’pisil ang ilong (pinch the nose), R – Referred Pain
sarado ang bibig (close the mouth), ire (bear
down)’’
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A. IMPACTED CERUMEN C. CIRCUMSCRIBED OTITIS EXTERNA

Pathophysiology: Constant manipulation of the Causative Agent: Staphylococcus aureus

ear canal, pushing the cerumen inside. Management: same with Diffuse Otitis Externa
Management:
*NOTE: THERE IS NO SUCH THING AS ACUTE
1. Manual Extraction can be done however it is
OTITIS EXTERNA ONLY
painful that’s why cerumenolytics are used
DIFFUSE/CIRCUMSCRIBED OTITIS EXTERNA
2. Cerumenolytics:
a. Na docusate D. OTOMYCOSIS
b. Hydrogen Peroxide – uncomfortable for
children because it can produce popping sounds Causative Agents:
c. Mineral Oil -Aspergillus niger (presentation: cotton-like
with black dots)
*BABY OIL – baby oil DOES NOT HAVE -Candida albicans (presentation: curd like)
CERUMENOLYTIC PROPERTIES, AND CAN ONLY -mixture of both
ACT ON THE SURFACE.
Pathophysiology: alteration of the acidic pH of
B. DIFFUSE OTITIS EXTERNA the EAC, promoting fungal growth
Management:
Causative Agent: Pseudomonas aeruginosa
1. Clotrimazole Otic Drops (antifungal, may
Typical in the History: History of Swimming
have longer duration of treatment)
Management:
2. Aural toilette (manual cleaning of the EAC)
1. Ear Wick Insertion:
3. Acetic acid (to restore the acidic pH of the
-cut a gauze and insert inside the narrowed EAC
EAC)
(very painful)
4. Avoid manipulation
-allow 1 cm of the wick to protrude outside the
EAC so that it will function as a conveyor for the II. MIDDLE EAR
otic drops
-when the swelling of the ear canal resolves, the
wick will fall off on its own

2. Otic Drops
FOR ALL OTIC DROPS THE PRESCRIPTION WILL
BE:
Sig: Apply 3 drops on the affected ear, 3x a day
for 7 days

1. PND (Polymixin B, Neomycin,

Dexamethasone)
2. PNF (Polymixin B, Neomycin, Fluocinolone
acetate)

Polymixin B: perforates the wall to allow

penetrance of Neomycin
Neomycin: antimicrobial
Dexamethasone/Fluocinolone acetate: anti-
inflammatory (steroids)
Oral Revalida Review 2019

Think of it as a cube (6 sides) B. CHRONIC OTITIS MEDIA

Presentation: Otorrhea, Conductive Hearing
Loss
PE: perforated tympanitic membrane

Management:

1. Topical Antibiotics (Fluoroquinolones):

Ofloxacin, Ciprofloxacin
2. Analgesics

COMPLICATIONS OF OTITIS MEDIA

A. EXTRACRANIAL
F – Facial nerve paralysis
L – Labyrinthitis
A – Apical petrositis (Gradenigo’s Syndrome:
LATERAL TYMPANIC S – Subperiosteal abscess
MEMBRANE S – Sensorineural Hearing Loss
Medial Cochlear Promontory
B. INTRACRANIAL
Anterior Eustachian Tube
Posterior Aditus E – Extradural abscess
Superior Tegmen Tympani L – Lateral sinus thrombophlebitis
Inferior Jugular Bulb M – Meningitis
O – Otitic hydrocephalus
S – Subdural abscess
A. ACUTE OTITIS MEDIA
B – Brain abscess
Typical History: Previous URTI (cough and
III. NASAL CAVITY
colds)
Pathophysiology:
-Eustachian tube dysfunction; secretion from
the nasopharynx goes to the ear via the ET
-Children are more predisposed since they have
more horizontal and shorter ET

Management
1. Systemic Antibiotics (Tympanic Membrane
has poor penetrance for Topical Antibiotics)
Amoxicillin
-Adult: Sig: 600mg/tab, 1 tab every 8 hours for 7
days
-Children: 80-90 mkday divided into three doses
ANTERIOR EPSITAXIS: Kiesselbach’s Plexus
2. Analgesics
1. Superior Labial Artery (br. Facial Artery)
2. Anterior Ethmoidal Artery
3. Posterior Ethmoidal Artery
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4. Sphenopalatine Artery
5. Greater Palatine Artery

POSTERIOR EPISTAXIS: Woodruff’s Plexus

1. Posterior Ethmoidal Artery
2. Sphenopalatine Artery

DIFFERENTIAL DIAGNOSES

1. URTI
2. Allergic Rhinitis
3. Acute Rhinosinusitis
4. Chronic Rhinosinusitis

A. URTI – often viral and self limiting, give

supportive therapy

B. ALLERGIC RHINITIS

*ALLERGIC RHINITIS vs. ACUTE

RHINOSINUSITIS

Signs and ALLERGIC ALLERGIC

Symptoms RHINITS RHINOSINUSITIS
Nasal S/Sx Nasal Nasal
Congestion Obstruction
Discharge Watery Mucopurulent

D. CHRONIC RHINOSINUSITIS (>12 weeks;

without resolution of symptoms)

*If non-resolving: can do FESS (Functional

Endoscopic Sinus Surgery)

*Intranasal Corticosteroids: ONLY GIVEN ONCE

A DAY FOR ALLERGIC RHINITIS

C. ACUTE RHINOSINUSITIS (<12 weeks;

complete resolution of symptoms)

CRITIERIA FOR DIAGNOSIS: (2 or more with 1

being the first two)
a. Nasal OBSTRUCTION
b. Mucopurulent Discharge
c. Facial Pain
d. Hyposmia/Anosmia
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IV. ORAL CAVITY GRADING SCALES FOR THE TONSILS

A. Anatomy 1. Brodsky Grading Scale

B. Waldeyer’s Ring: 2 paired and 2 unpaired

Unpaired:
1. Adenoids (Pharyngeal tonsils):
regresses by 21 years of age; consider
malignancy if still persistent
2. Lingual tonsils

Paired:
2. Friedman Grading Scale (considers Surgically
1. Tubal tonsil (aka Gerlach tonsils)
2. Palatine tonsil (aka Faucial tonsils) Removed Tonsils as Grade 0)

C. BLOOD SUPPLY

DIFFERENTIAL DIAGNOSES FOR THROAT PAIN:

1. Acute Tonsillopharyngitis
2. Laryngopharyngeal Reflux (do Reflux Score
Index)
3. Foreign Body
Oral Revalida Review 2019

V. NECK

DIFFERENTIAL DIAGNOSES FOR NECK MASSES

1. Cervical lymphadenopathy (common among children; give antibiotic treatment for 7 days or more)
2. TB lymphadenopathy (request for: CXR, Neck UTZ, TB work up)
3. Nasopharyngeal mass (request for Nasal Endoscopy)
4. Branchial cleft cyst
5. Thyroglossal duct cyst (cyst that moves upon tongue protrusion; located at the base of the tongue)
6. Goiter

GOITER

-Duration of neck mass

-Progression of size (if too rapid: t/c Anaplastic Carcinoma)
-Ask for Hyper/Hypothyroid Symptoms
-Request for Neck Ultrasound
-Check for Thyroid Function

*if 1-2 cm and is deep: Ultrasound Guided FNAB

*if superficial and palpable: can do FNAB right away