History

The common symptoms in the ear are otalgia, hearing loss, vertigo, tinnitus, aural fullness, discharge, hissing, facial weakness, bleeding and blockage. Common symptoms relating to the nose and sinuses are epistaxis (bleeding nose), nasal obstruction, hyposmia (decreased smell)/anosmia (complete loss of smell), loss of taste, facial pain, post-nasal drip, facial asymmetry, diplopia (double vision), epiphora (abnormal tears due to a blocked collecting system), redness of the eye, nasal discharge, allergy, sneezing and hay fever. Common symptoms relating to the throat include pain, dysphagia (difficulty swallowing), dysphonia (abnormal voice production), reflux, referred pain, cough, haemoptysis, shortness of breath, snoring and drooling. Head and neck patients may also present with symptoms of lumps and pain.

When a patient presents with any of these symptoms (Table 2.1) it is important to characterise the symptoms in terms of site, severity, radiation, frequency, duration, exacerbating and relieving factors, associated features, the progression of symptoms and how it affects the patient’s activities of daily living. When taking a history, the past history needs to be noted, including previous surgery to the respective parts of the ear, nose and throat, head and neck and any associated conditions. A patient’s medication and adverse reactions to medication should be known, as well as their social history, including their smoking and alcohol consumption and environmental exposures such as noise, dust and any other potential allergens. The family history should be known and it is also wise to find out about any family tendencies regarding bleeding disorders and deafness.

Table 2.1 Symptoms of ear, nose and throat conditions

Examination of the head and neck

As stated, a systematic approach to examining the head should recognise the principles of ENT — head and neck and include this in the examination, along with the cranial nerves. This will make a complete examination of the area. It is important to be aware of referred pain (Fig 2.1); for example, the ear is supplied by multiple nerves and ear pain can present as referred pain from intraoral or laryngeal pathology. Look for signs of redness, swelling, tenderness, increased warmth and loss of function.

Figure 2.1 Referred or non-otologic otalgia

From Dhillon & East, 2006

Head and neck lumps

When a lump is assessed, remember the mnemonic ‘Surgeons Can Find The Lumps’: Each lump should be characterised according to:

Site, size, surface, sinus

Colour, contour, cough, compressibility

Fluctuance, fixation, fluid, filling and emptying

Temperature, transillumination, thrill, tenderness

Local features, lobulation, lymph nodes, lumps elsewhere.

Palpation of the head and neck involves palpation of the lymph nodes and the thyroid gland. It is important to palpate one side of the head and neck at a time and systematically approach all the groups of lymph nodes (Fig 2.2). Deep palpation of the jugular chain is important because these glands are deep to sternocleidomastoid. One should take care when compressing around the carotid.

Figure 2.2 Division of lymph node groups, levels I–VI (VII)

Based on Dhillon & East, 2006

The lymph node groups are divided into groups commonly known as 1–6. There is a seventh group but it is often not included. The groups are:

1. submental and submandibular triangle

2. upper jugular chain

3. mid-jugular chain

4. lower jugular chain

5. posterior triangle

6. anterior triangle

7. superior mediastinum.

The other areas that need to be palpated are the parotid, the posterior occipital nodes and the post-auricular region.

The lymph node groups drain specific areas of the head and neck, which in turn relates to the treatment of various head and neck cancers.

Table 2.2 outlines the process for performing a thyroid examination when thyroid disease is detected or suspected. Table 2.3 outlines an examination of the cranial nerves.

Table 2.2 Thyroid examination — performed if thyroid disease is detected or suspected

Look	Patient — hyper/hypothyroid, thyroid eye signs, proptosis — Graves’ disease, lid lag, chemosis a complication, voice — recurrent laryngeal nerve compression, goitre
Feel	Right versus left side, prominent nodules
	Percuss — retrosternal extension
	Auscultate — bruits
	Pemberton’s sign — a sign of SVC compression — raise arms above head and look for venous congestion in the head
Periphery	Pulse, reflexes

Table 2.3 Screening examination of the cranial nerves

I	Smell
II	Visual acuity, light reflex — direct and consensual, fields
III/IV/VI	Eye movements
V — V1, V2, V3	Sensation, motor — palpate jaw (masseter, temporalis)
VII	Facial movements: temporal — forehead; zygomatic — eye closure; buccal — cheek; marginal mandibular — lower lip; cervical — platysma
VIII	Tuning fork
IX/X	Gag reflex
XI	Sternocleidomastoid, trapezius — palpate
XII	Tongue mobility; palsy indicated by protrusion to affected side

A gait examination is often performed as part of the dizziness assessment and is covered in the neurologic examination.

The voroscope (Fig 2.3) has revolutionised the ENT — head and neck examination. A good headlight from theatre will often suffice. Sometimes only a light source and head mirror are available.

Figure 2.3 Voroscope

Photos courtesy of Mr Sarin Wongprasartsuk

Flexible nasal endoscopy has also revolutionised the diagnosis of ENT — head and neck conditions. It has become an integral part of the examination and enabled office-based diagnosis. There are many hidden areas in ENT — head and neck examination and the nasoendoscope has permitted access to the internal nose, sinus outflow tracts, post-nasal space, larynx, hypopharynx, tongue base and sometimes the proximal oesophagus (Fig 2.4).

Figure 2.4 Nasolaryngoscope

From Dhillon & East, 2006

After the thorough history and complete physical examination have been performed, investigations are ordered. A differential diagnosis should be considered and the mnemonic VITAMIN CID may be helpful.

Vascular

Infective: may involve bacterial, viral, fungal and parasitic problems

Tumour: subdivided into benign and malignant

Accident

Metabolic causes such as diabetes and renal impairment

Immune/autoimmune conditions

Nutritional causes

Congenital

Idiopathic

Drugs and alcohol

Investigations are ordered to:

• confirm the diagnosis

• rule out other diagnoses

• quantify the severity of the disease

• follow the progression of the disease

• look for complications of any therapy.

The common investigations include:

• A blood test — FBE, allergy investigations (e.g. RAST — radioallergosorbent test).

• A biopsy — always be aware of the potential for bleeding and look for any pulsations as any red lesion may be actually a vascular malformation. Lesions high in the nose should be treated with caution as there may be a communication with the CSF space.

• Fine needle aspirate (FNA) — preferred to an open biopsy of any neck lump to prevent seeding of tumour cells. Can be combined with ultrasound guidance for increased accuracy.

• Swabs can be taken to include bacterial, fungal and viral cultures.

• Radiology — includes ultrasound, X-ray, barium swallow, CT, MRI and nuclear medicine.

• The audiogram is an important component of hearing assessment.

• Vestibular function testing is often performed.

• Laryngeal videostroboscopy allows visualisation of the vocal cords.

• Rhinomanometry is used for assessment of nasal air flow.

• Clinical photographic documentation is important in assessing assaults and the preoperative assessment for some cosmetic procedures.

The last four investigations are usually ordered by ENT — head and neck specialists.

Role of the ear

The purpose of the ear is to transform sound energy into electrical impulses. Sound is conducted via the external canal, the tympanic membrane and the ossicular chain, then converted into electrical impulses by the cochlea. These impulses pass up the cochlear component of the auditory nerve.

The balance system or vestibular apparatus comprises: the lateral, posterior and superior semicircular canals; the utricle and the utricle saccule; and the endolymphatic sac. This sensory apparatus is supplied by the vestibular component of the vestibulocochlear nerve.

The cochlea and vestibular apparatus are found in the petrous temporal bone.

Nearby blood vessels

The sigmoid sinus runs from the superolateral aspect of the temporal bone coursing inferomedially to exit the skull via the jugular foramen. The internal carotid artery enters the floor of the petrous temporal bone via the carotid canal, passes below the cochlea and travels horizontally till it reaches the sphenoid and carotid siphon. The superior petrosal sinus courses along the postero-superior aspect of the temporal bone from the cavernous sinus to the transverse sinus. It lies in the outer margin of the tentorium cerebelli. The labyrinthine artery, which is a branch of the basilar artery or anterior inferior cerebellar artery, supplies the petrous temporal bone entering via the internal auditory canal.

External ear

Middle ear

Otitis media

Otitis media is an inflammation of the middle ear/mastoid cavity. Its underlying cause is an abnormality of the Eustachian tube that ceases to aerate the middle ear, leading to a range of possible complications (Figs 2.6 and 2.7). A negative pressure forms in the cleft and an effusion results. There are many causes of a dysfunctional Eustachian tube. In children, the Eustachian tube is shorter and more horizontal, therefore, more prone to blocking. Causes include: viral URTI, cleft palate and a post-nasal space tumour. The effusion may become secondarily infected resulting in acute otitis media (AOM). Common organisms are: Streptococcus pneumoniae, Haemophilus influenzae and Moraxella.

Figure 2.6 Extracranial complications of otitis media

From Dhillon & East, 2006

Figure 2.7 Intracranial complications of otitis media

From Dhillon & East, 2006

AOM presents with otalgia, fever and a red, inflamed ear drum. The treatment may include antibiotics and antipyretic analgesia. The tympanic membrane may spontaneously rupture, resulting in a discharging ear and immediate pain relief.

Otitis media with effusion (OME) presents with a conductive hearing loss and a dull ear drum. Most cases of OME in children (about 90%) will resolve within three months, as there is often a preceding URTI. In adults, a new onset effusion with no precedent URTI needs to be investigated. The post-nasal space needs to be visualised. In longstanding effusions, a middle ear ventilation tube (grommet) is inserted to resolve the effusion.

Complications of AOM are those resulting from mastoiditis and include:

• subperiosteal abscess — presents with a protruding ear; pus escapes from the mastoid cavity via a communication posterior and superior to the pinna

• intracranial complications — extradural, subdural, intracerebral abscesses; meningitis

• labyrinthitis

• facial nerve palsy

• lateral sinus thrombosis

• petrositis — infection of the apex of the petrous temporal bone; CN VI palsy; trigeminal neuralgia CN V.

CT scan findings consistent with mastoiditis are opacification of the middle ear/mastoid cleft associated with bony destruction of the normal bony trabeculae.

A chronic discharging ear for more than three months is termed chronic suppurative otitis media (CSOM). It results from chronic infection, with an associated biofilm formation or may be caused by a cholesteatoma.

A cholesteatoma is a sac of keratinised squamous epithelium that has the potential to grow and erode the surrounding structures resulting in hearing loss, discharge and potential intracranial complications.

A bacterial biofilm is a colony of bacteria that has formed a resistant matrix often on an inert surface. Bacterial biofilms result in chronic infections in the ear, nose and throat.

Inner ear

Hearing loss

There are many causes of hearing loss, as indicated in Table 2.5.

Table 2.5 Causes of hearing loss

Cause	Conductive hearing loss	Sensorineural hearing loss
Congenital	Atresia of ear, ossicular abnormalities	Prenatal: genetic, rubella
Acquired	External: wax, otitis externa, foreign body	Perinatal: hypoxia, jaundice
	Middle ear: middle ear effusion, chronic suppurative otitis media, cholesteatoma,	Trauma: noise, head injury, surgery
	Perforated drum, otosclerosis, traumatic perforation of drum	Inflammatory: chronic otitis, meningitis, measles, mumps, syphilis
	Ossicular disruption	Degenerative: presbyacusis
		Ototoxicity: aminoglycosides, cytotoxics
		Neoplastic: acoustic neuroma
		Idiopathic: Ménière’s disease, sudden deafness

Based on Dhillon & East 2006

When evaluating hearing loss, the outer ear, middle ear, inner ear and central pathways need to be considered. The time frame, whether sudden or acute versus chronic, needs to be ascertained. A prior history of trauma, noise exposure and associated symptoms is a valuable clue.

A complete examination with tuning fork tests is required and an audiogram will guide the diagnosis (Figs 2.8a and b).

Figure 2.8a Tuning fork tests

From Dhillon & East, 2006

Figure 2.8b Audiograms

From Dhillon & East, 2006

CT, MRI and other auditory tests such as stapedial reflexes (a test of middle ear function/fixation of the stapes in otosclerosis), otoacoustic emissions (a test for cochlear function) and auditory brain stem responses (ABR) (a test of the central pathway) will assist with localisation of the problem.

Vertigo

Vertigo can be disabling. The vestibular apparatus may be overactive or underactive. An imbalance between the left and right sides may result in vertigo. There are many causes (Fig 2.9).

Figure 2.9 Otologic causes of dizziness

From Dhillon & East, 2006

The most common causes of vertigo are:

• Benign paroxysmal positional vertigo (BPPV) — a disorder of the semicircular canals where otoliths (small calcium particles) float free in the semicircular canals and stimulate the ampullae of the canals. The treatment is a particle repositioning manoeuvre such as the Epley manoeuvre.

• Ménière’s — a syndrome characterised by the triad of rotatory vertigo, hearing loss and tinnitus — often associated with aural fullness. There are many theories that relate to an imbalance in the flow of endolymph in the inner ear.

• Vestibular neuronitis — often a viral aetiology, with no involvement of the auditory system.

• Labyrinthitis — often a viral aetiology involving the whole of the labyrinth and therefore both balance and hearing are affected.

When assessing a patient with a balance problem, the components of balance disorders that need to be addressed are the cardiovascular system (CVS), central nervous system (CNS)/peripheral nervous system (PNS), cerebellum, vestibular system and vision. Often the causes are irreversible and may progress. The ongoing therapy involves physiotherapy and occupational therapy to make sure it is safe for a patient to return home.

Vestibular function testing may be of assistance in diagnosing the probable cause, as is imaging. MRI is used to assess the brain, brainstem and retrocochlear region, whereas CT is used to assess the middle ear anatomy.

Tinnitus

Defined loosely as noise generated somewhere in the head, tinnitus (Fig 2.10) is annoying to the patient and can be extremely disabling.

Figure 2.10 Tinnitus

From Dhillon & East, 2006

There are many causes for tinnitus, but the most common is idiopathic.

Idiopathic tinnitus cannot be cured with an operation. It is known that if all the hearing mechanism was removed, tinnitus would still be reported by the patient because of a phenomenon known as brain plasticity — it creates the sound and amplifies it at the level of the patient’s awareness.

The treatment for idiopathic tinnitus is supportive, relying on some form of distraction therapy such as:

• having a clock radio on at night prior to going to sleep

• having a hearing aid that introduces sound (a masking sound) into the affected side

• psychological retraining — this aims to refocus a patient away from tinnitus. One can explain tinnitus to patients as likening it to tuning in to external sounds such as an air conditioning fan or a car going past. If you concentrate on it, you hear it. If you don’t concentrate on it then you don’t hear it and so with tinnitus it will stop bothering you.

Reversible causes, such as outer, middle or inner ear pathology, need to be ruled out. An audiogram is a good screening test. CT and MRI may be ordered.

Management

When approaching a presentation of facial nerve palsy, the function of the branches should be considered and addressed in order of importance.

Anatomy/physiology

The nose and sinuses are made up of a number of components (Figs 2.11 and 2.12).

Figure 2.11 Structure of lateral nasal wall

From Dhillon & East, 2006

Figure 2.12 Paranasal sinuses

From Dhillon & East, 2006

Blood supply

The blood supply is from both the external and internal carotid circulation.

The septum is supplied by the facial artery, greater palatine artery, sphenopalatine artery, anterior ethmoid artery and the posterior ethmoid artery. It has a prominent plexus called Little’s area in the centre of the cartilaginous septum.

The lateral nasal wall has its blood supply predominantly from the sphenopalatine artery, with contributions from the anterior and posterior ethmoid arteries.

Nerve supply

The nerve supply of the nose reflects its function: to smell, to warm and humidify the air that has been breathed in and to function as the airway. There are several neural components which help regulate the function.

Paranasal sinuses

There are generally four named sinuses: frontal, ethmoid, maxillary and sphenoid sinuses. They are paired — left and right. They are variable in their development and are often asymmetric. These sinuses drain via pathways that are normally 2–5 mm wide.

Epistaxis

Most commonly epistaxis is anterior and unilateral (approximately 90%) from Little’s area. Posterior epistaxis is uncommon; it presents bilaterally and is often severe from the sphenopalatine artery.

Contributing factors include:

Treating epistaxis is based on the following principles.

Nasal obstruction

Often when we refer to the nose we actually mean the nose and paranasal sinuses. Patients will often present with the complaint of a blocked nose and pain around the area of their sinuses. Associated symptoms include hyposmia, anosmia and loss of taste. More sinister symptoms might be facial sensory loss — V1 or V2, or diplopia.

The cause of nasal obstruction can relate to anatomical, mucosal and pathologic factors. Remember the nasal airway extends from the skin of the nostril to the post-nasal space.

Anatomical factors include deviated nasal septum, nasal bones, anatomical variants of the normal sinus outflow tracts and adenoid hypertrophy.

Mucosal factors include turbinate mucosal hypertrophy. The turbinates have a blood and nerve supply and the epithelium is respiratory with glandular elements. Therefore, they shrink and enlarge in response to conditions that affect:

Pathological factors may include:

Beware of new onset unilateral nasal hypertrophy in adults — you must rule out a tumour. There are certain conditions to watch out for:

Sinusitis/nasal polyps/allergy

Sinusitis often develops as a complication of nasal obstruction. Secretions build up secondary to obstruction of the normal sinus outflow tract and infection often develops. This causes the symptoms of pressure-type pain in the face, fever and discharge. Maxillary sinus pain occurs in the cheek, ethmoids (midface, between the eyes), frontals (forehead) and sphenoid (the vertex of the skull).

Complications of sinusitis include:

Intracranial complications of the ethmoid, frontal and sphenoid sinuses include meningitis, extradural abscess, subdural abscess, subarachnoid abscess and intra-cerebral abscess.

The following points are also worth noting.

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