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ENT

AN INTRODUCTION
AND PRACTICAL GUIDE
SECOND EDITION
ENT
AN INTRODUCTION
AND PRACTICAL GUIDE
SECOND EDITION

EDITED BY
James Russell Tysome MA PhD FRCS (ORL-HNS)
Consultant ENT and Skull Base Surgeon
Cambridge University Hospitals NHS Foundation Trust

AND
Rahul Govind Kanegaonkar FRCS (ORL-HNS)
Consultant ENT Surgeon
Medway NHS Foundation Trust

Visiting Professor in Otorhinolaryngology

Professor of Medical Innovation
Canterbury Christ Church University
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2018 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-1-138-19823-4 (Paperback)

This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been
made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or
liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in
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of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care
professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge
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or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for
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Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identifica-
tion and explanation without intent to infringe.

Library of Congress Cataloging‑in‑Publication Data

Names: Tysome, James Russell, author. | Kanegaonkar, Rahul Govind, author.

Title: ENT : an introduction and practical guide / [edited by] James Tysome, Rahul Kanegaonkar.
Description: Second edition. | Boca Raton, FL : CRC Press, Taylor & Francis Group, 2018. | Includes
bibliographical references and index.
Identifiers: LCCN 2017019190 (print) | LCCN 2017019740 (ebook) |
ISBN 9781315270524 (General eBook) | ISBN 9781351982337 (Adobe eBook) |
ISBN 9781351982320 (ePub eBook) | ISBN 9781351982313 (Mobipocket eBook) |
ISBN 9781138298149 (hardback : alk. paper) | ISBN 9781138198234 (pbk. : alk. paper)
Subjects: | MESH: Otorhinolaryngologic Surgical Procedures--methods |
Otorhinolaryngologic Diseases--surgery
Classification: LCC RF46.5 (ebook) | LCC RF46.5 (print) | NLM WV 168 | DDC 617.5/1--dc23
LC record available at https://lccn.loc.gov/2017019190

Index 161

viii Contents
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 that they deliver to their ENT patients.

The course manual is now a ‘Bible’ for junior students in nursing and
medicine, caring for patients on wards, clinics or in emergency rooms.
The Royal College of Surgeons has endorsed this course in the past and it
continues to maintain a high standard for postgraduate training. I 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

ix
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 to 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 might neither 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.

James R Tysome and Rahul G Kanegaonkar

x
INTRODUCTION
Otorhinolaryngology (ENT) is a diverse and challenging specialty. It is
often poorly represented in busy medical school curriculums and specialty
optionals at some Universities. Although an estimated 20% of cases seen in
primary care are ENT related, many general practitioners have little or no
formal training in this specialty.

This second edition has been revised and updated to reflect recent advances
in Otorhinolaryngology.

This book has evolved from the ‘Introduction to ENT’ course manual,
which has served many of us so well. Over 3000 doctors have attended this
course and its ‘Essential Guide’ counterpart.

This book covers both common and uncommon, including life-threatening

emergencies that may present themselves in both primary and secondary
care. Management pathways are described as are commonly performed
surgical procedures and possible complications. This book further provides
a basis for referral if required.

The updated colour illustrations concisely depict relevant clinical anatomy

without unduly simplifying the topic in question.

I am certain that this current 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
October 2016

xi
CONTRIBUTORS
Mr Ketan Desai FRCS
Associate Specialist in Otorhinolaryngologist
Royal Sussex County Hospital, Brighton, UK

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

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

Dr Dipalee Durve MRCPCH and FRCR

Consultant Radiologist
Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Mr James Tysome MA PhD FRCS (ORL-HNS)

Consultant ENT and Skull Base Surgeon
Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

Professor Rahul Kanegaonkar FRCS (ORL-HNS)

Consultant ENT Surgeon
Medway NHS Foundation Trust, Gillingham, UK
and
Visiting Professor in Otorhinolaryngology
Professor of Medical Innovation
Canterbury Christ Church University, Canterbury, UK

Dr Olivia Kenyon
ENT Senior House Officer
Cambridge University Hospitals, Cambridge, UK

Ms Sonia Kumar FRCS (ORL-HNS)

Fellow in Paediatric Otolaryngology
Great Ormond Street Hospital for Sick Children, London, UK

Dr Kaggere Paramesh
Specialist Registrar in Radiology
Guy’s and St Thomas’ NHS Foundation Trust, London, UK

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, London, UK

xii
Ms Joanne Rimmer FRCS (ORL-HNS)
Consultant ENT Surgeon/Rhinologist, Monash Health
Honorary Senior Lecturer, Monash University, Melbourne, Australia

Professor Francis Vaz FRCS (ORL-HNS)

Consultant ENT/Head and Neck Surgeon
University College London Hospital, London, UK

Mr Max Whittaker FRCS (ORL-HNS)

Specialist Registrar in Otorhinolaryngology
Kent, Surrey and Sussex Deanery, London, UK

CONTRIBUTORS xiii
1 CLINICAL ANATOMY
Max Whittaker

THE EAR
The ear is a highly specialized organ dedicated to Scaphoid fossa
the detection of both sound and head movement.
It is classically described as three separate but Helix Triangular fossa
functionally related subunits. The outer ear,
consisting of the pinna and external auditory
canal, is bounded medially by the lateral surface of Auricular
tubercle
the tympanic membrane. The middle ear contains Cymba conchae
the ossicular chain, which spans the middle ear
Antihelix Tragus
cleft and enables the transfer of acoustic energy
from the tympanic membrane to the oval window. Antitragus
Conchal bowl
The inner ear comprises both the cochlea, which Intertragic notch
converts mechanical vibrations to electrical
impulses in the auditory nerve, and the vestibular Lobule
apparatus.

The pinna acts to direct sound into the external Figure 1.1. Surface landmarks of the pinna.
auditory canal, and plays an important role in
sound localization. It consists predominantly of from each of the first and second branchial arches
an elastic cartilaginous framework over which the on either side of the first pharyngeal groove.
skin is tightly adherent (Figure 1.1). The cartilage is These rotate and fuse to produce an elaborate
dependent on a sheet of overlying perichondrium but surprisingly consistent structure. Incomplete
for its nutritional support; hence separation of this fusion may result in an accessory auricle or pre-
layer by a haematoma, abscess or inflammation auricular sinus, while failure of development of the
secondary to piercing may result in cartilage antihelix (from the fourth hillock) in a protruding
necrosis and permanent deformity (cauliflower or ‘bat’ ear.
ear). The lobule, in contrast, is a well-vascularized
fibrofatty skin tag. The external auditory canal is a tortuous passage
that redirects and redistributes sound from the
The pinna develops from six mesodermal conchal bowl to the tympanic membrane. The skin
condensations, the hillocks of His, as early as the of the lateral third of the external auditory canal is
sixth embryological week. Three hillocks arise thick, contains ceruminous glands, is hair-bearing

Clinical anatomy 1
and tightly adherent to the underlying mechanism that allows debris to be directed out
fibrocartilage. of the canal. Disruption of this mechanism may
result in debris accumulation, recurrent infections
In contrast, the skin of the medial two-thirds is (otitis externa) or erosion of the ear canal, as seen
thin, hairless, tightly bound to underlying bone in keratitis obturans.
and exquisitely sensitive.
The tympanic membrane is bounded
The sensory nerve supply of the canal is largely circumferentially by the annulus, and is
provided by the auriculotemporal and greater continuous with the posterior wall of the ear canal.
auricular nerves. There are minor contributions It consists of three layers: laterally, a squamous
from the facial nerve (hence vesicles arise on epithelial layer; a middle layer of collagen fibres
the posterolateral surface of the canal as seen in providing tensile strength; and a medial surface
Ramsay Hunt syndrome) and Arnold’s nerve, a lined with respiratory epithelium continuous with
branch of the vagus nerve (provoking the cough the middle ear.
reflex when stimulated with a cotton bud or during
microsuction). The squamous epithelium of the The 80 mm2 of the tympanic membrane surface
tympanic membrane and ear canal is unique and area is divided into pars tensa, accounting for the
deserves a special mention. The superficial layer majority, approximately 55 mm2, and pars flaccida,
of keratin of the skin of the ear is shed laterally or attic (Figure 1.2). These regions are structurally
during maturation. This produces an escalator and functionally different. The collagen fibres of

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 pars tensa are arranged as lateral radial fibres posterior half of the tympanic membrane, while
and medial circumferential fibres that distort the low-frequency sounds alter the anterior half.
membrane. As a result, the pars tensa ‘billows’
laterally from the malleus and buckles when The handle and lateral process of the malleus are
presented with sound, conducting acoustic energy embedded within the tympanic membrane and
to the ossicular chain. In contrast, the collagen firmly adherent at the umbo (“Lloyd’s ligament”).
fibres of the pars flaccida are randomly scattered The long process of the incus is also commonly
and this section is relatively flat. Interestingly, seen, although the heads of the ossicles are hidden
high-frequency sounds preferentially alter the behind the thin bone of the scutum superiorly.

2 ENT: An Introduction and Practical Guide

The middle ear ●● The relative lengths of the handle of malleus to
the long process of incus (1.3:1).
The middle ear is an irregular, air-filled space ●● The natural resonance of the outer and middle
containing the three ossicles: the malleus, ears.
incus and stapes. Its predominant function is ●● The phase difference between the oval and
to overcome impedance mismatch, energy lost round windows.
when transferring sound from one medium to ●● The buckling effect of the tympanic membrane
another, in this case converting air vibrations (2:1).
at the tympanic membrane to fluid vibrations In combination the total margin of improvement
within the cochlea. The ossicular chain is crucial amounts to 44:1.
in this process, by conducting vibrations to
the cochlea via the stapes footplate at the oval In order to optimise admittance, middle ear air
window. Without it the vast majority of acoustic pressure is equalized with atmospheric pressure.
energy would not be transmitted through the oval This is achieved via the Eustachian tube, which
window resulting in a conductive hearing loss of communicates with the nasopharynx, and opens
up to 50–60 dB. Clinically, ossicular discontinuity on chewing, swallowing and yawning, allowing
or fixation of the footplate by otosclerosis prevents air to pass into the middle ear cleft (Figure 1.3).
sound conduction to the inner ear, resulting in a The amount of air passing through the Eustachian
conductive hearing loss. tube varies greatly between individuals depending
on pressure gradient and volume of the mastoid
The middle ear mechanisms that improve sound air cell system; however, it is thought that the
transfer include: equalisation process occurs rapidly, between 0.15
●● The relative ratios of the areas of the tympanic and 0.34 seconds. In children, Eustachian tube
membrane to stapes footplate (17:1). dysfunction is common and may result in negative

Aditus (inlet) to
mastoid antrum

Malleus Facial n. (CN VII) in

facial canal
Incus Prominence of lateral
semicircular canal
Chordo tympani
Prominence of
facial canal
Tensor of tympani
Stapes
Tendon of
stapedius Promontory

Tympanic Tympanic
membrane plexus

Tympanic n.

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

Clinical anatomy 3
Flow of Flow of
endolymph endolymph

Vestibular
Ampulla afferent Head rotation Head rotation

4 ENT: An Introduction and Practical Guide

Membrane

Membrane
Membrane

potential (mV)

potential (mV)
potential (mV)

Time Time Time

Rest or constant rate of motion Acceleration Acceleration

Figure 1.4. The inner ear. Angular acceleration is detected by the ampullae of the lateral semicircular canals, while linear acceleration and static
head tilt are detected by the maculae of the utricle and saccule.
middle ear pressure, recurrent otitis media or functional pairs: the two horizontal semicircular
middle ear effusions. canals working in tandem, and the superior canals
paired with the contralateral posterior canals.
The inner ear
The sensory neuroepithelium of the semicircular
The inner ear consists of the cochlea and peripheral canals is limited to a dilated segment of the bony
vestibular apparatus (Figure 1.4). and membranous labyrinth, the ampulla. Within
this region, a crest perpendicular to the long
The cochlea is a two and three-quarter-turn
axis of each canal bears a mound of connective
snail shell that houses the organ of Corti. It is
tissue from which projects a layer of hair cells.
tonotopically arranged, with high frequencies
Their cilia insert into a gelatinous mass, the
detected at the base and low frequencies nearest the
cupula, which is deflected during rotational head
apical turn. Acoustic energy presented at the oval
movements.
window causes a travelling wave along the basilar
membrane, with maximal deflection at a frequency-
Within the utricle and saccule, the sensory patches,
specific region of the cochlea. This results in
called maculae are orientated in order to detect
depolarization of the inner hair cells at this region,
linear acceleration and head tilt in horizontal and
and through a process of mechanotransduction,
vertical planes, respectively. Hair cells in these
vibrational energy is converted to neural impulses
maculae are arranged in an elaborate manner
relayed centrally via the cochlear nerve.
and project into a fibro-calcareous sheet, the
The peripheral vestibular system is responsible otoconial membrane. As this membrane has a
for the detection of head movement. While the greater specific gravity than the surrounding
semicircular canals are stimulated by rotational endolymph, head tilt and linear movement result
acceleration, the saccule and utricle are dedicated in the otoconial membrane moving relative to the
to detecting static and linear head movements. underlying hair cells. The shearing force produced
This is achieved by two similar, but functionally causes depolarization of the underlying hair cells
different sensory receptor systems (Figure 1.4). with conduction centrally through the inferior and
superior vestibular nerves.
The semicircular canals are oriented in orthogonal
planes to one another and organized into

THE FACIAL NERVE

The facial nerve (CN VII) runs a tortuous course the nervus intermedius carrying parasympathetic
from the brainstem, through the temporal bone and sensory fibres. These are joined at the
before exiting the skull base at the stylomastoid internal acoustic canal by the motor fibres to
foramen and dividing within the parotid gland form the facial nerve, running anterosuperiorly
(Figure 1.5). Therefore, disease processes affecting through the meatal segment in relation to the
the inner ear, middle ear, skull base or parotid vestibulocochlear nerve. In the labyrinthine
gland may result in facial nerve paralysis. segment the nerve undergoes a posterior
deflection at the first genu, in close relation to the
The facial nerve arises from three nuclei in the geniculate ganglion, housing the cell bodies of
brainstem: the motor nucleus, superior salivatory the chorda tympani, and the greater superficial
nucleus in the pons, and the nucleus solitarius petrosal nerve exits via the facial hiatus to supply
in the medulla. During its intracranial segment the lacrimal gland. The facial nerve passes along
branches from the latter two nuclei join to form its tympanic horizontal portion within the medial

Clinical anatomy 5
SUPERIOR Motor nucleus
“Bill’s” bar
Superior salivary nucleus
(parasympathetic)
VII SVN
ANTERIOR POSTERIOR Tractus solitarius
(taste)
IVN Internal auditory
CN canal Simple sensory
Transverse
crest I
Singular Geniculate II
nerve ganglion Greater
INFERIOR
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

6 ENT: An Introduction and Practical Guide

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

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 (b). (VII = facial nerve, SVN = superior vestibular nerve, IVN = inferior vestibular nerve.)
wall of the middle ear to the second genu. At this
point it undergoes a further deflection inferiorly
to begin its vertical mastoid segment. Motor Temporal
branches are given off to stapedius and taste fibres Zygomatic
from the anterior two-thirds of the tongue are
received from the chorda tympani.

The facial nerve exits the skull base at the

stylomastoid foramen to begin its extratemporal Buccal
course, and adopts a more variable anatomy. Marginal mandibular
Lying in the tympanomastoid groove it courses
Cervical
anteriorly to enter the parotid gland, where it most
commonly forms superior and inferior divisions
before terminating in its five motor branches
(Figure 1.6). Additional branches supply the
Figure 1.6. External branches of the facial nerve.
posterior belly of digastric and stylohyoid muscles.

THE NOSE
The nose and nasal cavity serve a number of ●● Olfaction.
functions. While their principal function is ●● Drainage and aeration of the middle ear cleft
provision of an airway, secondary functions include: via the Eustachian tube.
●● Drainage and aeration of the paranasal sinuses.
●● Warming of inspired air. ●● Drainage for the nasolacrimal duct.
●● Humidification of inspired air. ●● Prevention of lung alveolar collapse via the
●● Filtering of large particulate matter by coarse nasal cycle.
hairs (the vibrissiae) in the nasal vestibule. ●● Voice modification.
●● Mucus production, trapping and ciliary ●● Pheromone detection via the Vomeronasal
clearance of particulate matter. organ of Jacobsen.
●● Immune protection (within mucus and via
presentation to the adenoidal pad).

Glabella Glabella

Nasion Nasal bone

Dorsum Hinion
Frontal process
of maxilla Septum
Supratip Upper lateral
cartilage
Tip
Lower
lateral
cartilage
Columella

Figure 1.7. Nasal landmarks and external nasal skeleton.

Clinical anatomy 7
Nasal skeleton The nasal cavities

The external nasal skeleton consists of bone in The nasal cavities are partitioned in the midline
the upper third (the nasal bones) and cartilage in by the nasal septum, which consists of both
the lower two-thirds. External nasal landmarks fibrocartilage and bone (Figure 1.8).
are illustrated in Figure 1.7 and ensure accurate
description when assessing the nose prior to As with the cartilage of the pinna, the cartilage
considering surgical intervention. of the septum is dependent on the overlying

Perpendicular
plate of ethmoid

Septal cartilage
Vomer

Crest

Palatine bone

Figure 1.8. The skeleton of the nasal septum.

adherent perichondrium for its nutritional support. The nasal cavity has a rich blood supply
Separation of this layer by haematoma or abscess originating from both the internal and external
may result in cartilage necrosis, perforation and a carotid arteries (Figure 1.10). As a result, epistaxis
saddle nose deformity. may result in considerable blood loss which should
not be underestimated. In cases of intractable
In contrast to the smooth surface of the nasal posterior nasal bleeding, the sphenopalatine
septum, the surface of the lateral wall is thrown artery may be endoscopically ligated by raising
into folds by three bony projections: the inferior, a mucoperiosteal flap on the lateral nasal wall.
middle and superior turbinates (Figure 1.9). These Bleeding from the ethmoidal vessels requires a
highly vascular structures become cyclically periorbital incision and identification of these
engorged resulting in alternating increased airway vessels as they pass from the orbital cavity into the
resistance and reduced airflow from one nasal nasal cavity in the fronto-ethmoidal suture.
cavity to the other over a period of 2–3 hours. This
physiological process, under hypothalamic control, The venous drainage of the nose and mid-face
may be more noticeable in patients with a septal communicates with the cavernous sinus of the
deviation or in those with rhinitis. middle cranial fossa via the superior ophthalmic

8 ENT: An Introduction and Practical Guide

Olfactory mucosa

Superior turbinate

Middle turbinate

Inferior turbinate

Eustachian tube cushion

Figure 1.9. 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 1.10. Arterial blood supply to the nose. The nose has a rich blood supply, supplied by both internal
(I) and external (E) carotid arteries.

vein, or deep facial vein and pterygoid plexus. The olfactory mucosa is limited to a superior region
As a result, infection in this territory may spread of the nasal cavity (Figure 1.9). Once dissolved in
intracranially, resulting in cavernous sinus mucus, olfactants combine with binding proteins
thrombosis and may be life-threatening. and stimulate specific olfactory bipolar cells.

Clinical anatomy 9
Their axons converge to produce 12−20 olfactory The paranasal sinuses are paired air-filled spaces
bundles, which relay information centrally to that communicate with the nasal cavity via ostia
secondary neurones within the olfactory bulbs at located on the lateral nasal wall (Figure 1.11). These
the cribriform fossae of the anterior cranial fossa. occur at different ages, with the maxillary sinuses

Posterior ethmoid ostia

Sphenoid sinus ostium
Anterior ethmoid ostia

Maxillary sinus ostia

Nasolacrimal duct

Sphenopalatine artery

Figure 1.11. The lateral wall of the nasal cavity. (The turbinates have been removed in order to allow
visualization of the ostia of the paranasal sinuses.)

present at birth and the frontal sinuses being the results in a spiral flow that directs mucus up and
last to fully form. In a minority of patients the medially to the ostium high on the medial wall.
frontal sinuses may be entirely absent. Mucus
produced by the respiratory epithelium within the The anterior and posterior ethmoidal air cells are
paranasal sinuses does not drain entirely by gravity. separated from the orbital contents by the lamina
In the maxillary sinus, for example, cilliary activity papyracea, a thin plate of bone derived from the

Frontal sinus

Anterior ethmoid sinus

Lamina papyracea
Middle turbinate
Osteomeatal complex
Maxillary sinus
Inferior turbinate

Septal cartilage

Figure 1.12. Coronal section of the paranasal sinuses.

10 ENT: An Introduction and Practical Guide

ethmoid bone. Infection within these paranasal The osteomeatal complex represents a region
sinuses may extend laterally through this layer, through which the paranasal sinuses drain
resulting in periorbital cellulitis and possible loss (Figure 1.12). Obstruction may lead to acute or
of vision. chronic sinusitis; hence opening this area is pivotal
when surgically treating sinus disease.

ORAL CAVITY
The oral cavity is bounded anteriorly by the inferiorly by the tongue base and superiorly by the
lips, posteriorly by the anterior tonsillar pillars, hard and soft palates (Figure 1.13).

Posterior tonsillar pillar

Hard palate (palatopharyngeus)
Soft palate

Uvula
Anterior tonsillar pillar
Tonsil (palatoglossus)
Sulcus terminalis
Retromolar region

Figure 1.13. The oral cavity.

The tongue consists of a mass of striated surface. The anterior two thirds, formed from
muscle separated in the midline by a fibrous the first arch, are coated by fungiform papillae,
membrane. Both the intrinsic muscles (contained which distinguish the five tastes: sweet, salty, sour,
entirely within the tongue) and the extrinsic bitter and umami. These are interspersed with the
muscles (inserted into bone) are supplied by the filiform papillae which do not contribute to taste
hypoglossal nerve, except for the palatoglossus but act to increase surface area, providing friction
(supplied by the pharyngeal plexus). A unilateral and enabling manipulation of food. Taste receptors
hypoglossal nerve palsy results in deviation of the are innervated by the chorda tympani, which
tongue towards the side of the weakness. hitchhikes with the lingual nerve to join the facial
nerve. The mandibular branch of the trigeminal
The tongue is derived from the mesoderm of nerve supplies touch and temperature sensation.
the first four branchial arches. Its embryological
origin is reflected in its pattern of innervation, The posterior third is predominantly derived
and arrangement of the fungiform, foliate, from the third and fourth arches, with a small
circumvallate and filiform papillae on its dorsal contribution from the second. Its surface is

Clinical anatomy 11
lined laterally by foliate papillae, with taste, The middle constrictor arises from the greater horn
touch and temperature sensation relayed by the of the hyoid bone, its fibres sweeping to enclose the
glossopharyngeal and superior laryngeal nerves. superior constrictor (as low as the vocal cords).

These two distinct regions are separated by a row The inferior constrictor consists of two
of circumvallate papillae in the form of an inverted striated muscles, the thyropharyngeus and
‘V’. The foramen caecum lies at the apex of this ‘V’ cricopharyngeus. A potential area of weakness
and represents the site of embryological origin of lies between the two muscles posteriorly: Killian’s
the thyroid gland (see below). Rarely, due to failure dehiscence. A pulsion divertivulum may form a
of migration, a lingual thyroid may present as a pharyngeal pouch at this site, leading to retention
mass at this site. and regurgitation of ingested material.

The floor of the mouth is separated from the The upper aero-digestive tract is divided into
neck by the mylohyoid muscle. The muscle fans the nasal cavity and nasopharynx, oral cavity
out from the lateral border of the hyoid bone to and oropharynx, larynx and hypopharynx
insert into the medial surface of the mandible (Figure 1.14).
as far back as the second molar tooth. A dental
root infection that is anterior to this may result The nasopharynx extends from the skull base to
in an abscess forming in the floor of the mouth the soft palate. It communicates with the middle
(Ludwig’s angina). This is a potentially life- ear cleft via the Eustachian tube (Figure 1.15).
threatening airway emergency and requires urgent This tube unwinds during yawning and chewing,
intervention to extract the affected tooth and drain allowing air to pass into the middle ear cleft
the abscess. and maintaining atmospheric pressure within
the middle ear. This mechanism depends on the
The hyoid bone lies at the level of the third
actions of levator and tensor veli palatini muscles,
cervical vertebra. The larynx is suspended from
hence a cleft palate is often associated with
this C-shaped bone, resulting in the rise of the
chronic Eustachian tube dysfunction. Equally,
laryngeal skeleton during swallowing.
blockage of the Eustachian tube may result in a
middle ear effusion. Whilst effusions are common
THE PHARYNX in children, unilateral effusions in adults should
raise suspicion of post-nasal space pathology,
such as a nasopharyngeal carcinoma arising from
The pharynx consists of a curved fibrous sheet, the fossa of Rossenmüller. The adenoid gland lies
the pharyngobasilar fascia, enclosed within three on the posterior nasopharyngeal wall, forming
stacked muscular bands: the superior, middle part of Waldeyers ring of immune tissue, along
and inferior constrictors. The muscle fibres of the with the palatine and lingual tonsils. Adenoid
constrictors sweep posteriorly and medially to meet enlargement may compromise airflow resulting in
in a midline posterior raphe. The pharyngeal plexus obstructive sleep apnoea, and may require surgical
provides the motor supply to the musculature of reduction.
the pharynx, except for the stylopharyngeus which
is supplied by the glossopharyngeal nerve. The oropharynx spans from the soft palate to the
level of the epiglottis. Its lateral walls are formed
The superior constrictor arises from the medial by the palatoglossus and palatopharyngeus
pterygoid plate, hamulus, pterygomandibluar muscles, between which lie the palatine tonsils.
raphe and mandible. The Eustachian tube passes These receive a rich blood supply from the lingual,
between its superior border and the skull base. facial and ascending pharyngeal branches of the
Stylopharyngeus and the glossopharyngeal and external carotid artery.
lingual nerves pass below the constrictor.

12 ENT: An Introduction and Practical Guide

Nasal cavity Sphenoid sinus

Adenoid pad
Tonsil of Gerlach
Hard palate
NASOPHARYNX

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

Thyroid isthmus

Figure 1.14. 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.

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.

Clinical anatomy 13
The laryngopharynx lies posterior to the larynx. cricopharyngeus marks the transition into the
It is bounded inferiorly by the cricoids, where the oesophagus.

THE LARYNX
The principal function of the larynx is that of secondary function. The three single cartilages of
a protective sphincter preventing aspiration of the larynx are the epiglottic, thyroid and cricoid
ingested material (Figure 1.16). Phonation is a cartilages. The three paired cartilages of the larynx

Interarytenoid bar Posterior

pharyngeal wall
Right arytenoid

Cricoid cartilage Left pyriform

fossa
Right vocal cord
Laryngeal inlet
Quadrangular
membrane
Epiglottis Left vallecula

Median Lingual tonsil

glossoepiglottic
fold

Figure 1.16. Endoscopic view of the larynx.

are the arytenoid, corniculate and cuneiform complete ring of cartilage in the airway, trauma may
cartilages. cause oedema and obstruction of the central lumen.

The arytenoid cartilages are pyramidal structures The formula describes airflow through the lumen
from which the vocal cords project forward and of a tube (Figure 1.17).
medially. Abduction (lateral movement) of the
cords is dependent on the posterior cricoarytenoid
muscle, hence this is described as the most
important muscle of the larynx. Additional r
instrinsic and extrinsic muscles provide adduction
and variable cord tension.
PB l PA
4
The motor supply of the muscles of the larynx is Flow (L/min) = (PA−PB) × v × r × π
l 8
derived from the recurrent laryngeal nerves. An
ipsilateral palsy results in hoarseness, while a bilateral PA = pressure A
PB = pressure B
palsy results in stridor and airway obstruction. v = viscosity
l = length
The cricoid is a signet ring-shaped structure which r = radius
supports the arytenoid cartilages. As the only
Figure 1.17. Flow through a tube.

14 ENT: An Introduction and Practical Guide

Reducing the lumen of a tube by half causes the relatively minor oedema may result in a dramatic
flow to fall to 1/16 of the original. Therefore, reduction in airflow.

THE THYROID AND PARATHYROID GLANDS

The thyroid is an endocrine gland, producing duct may result in formation of a thyroglossal cyst
thyroid hormone under hypothalamic–pituitary presenting as a midline neck mass, which, due to
control. It consists of two lobes connected by an its origins, clinically rises on tongue protrusion.
isthmus, and a variably-sized pyramidal lobe. Its
blood supply is derived from superior and inferior The four parathyroid glands also perform an
thyroid arteries, and occasionally the thyroid ima endocrine function, producing parathyroid hormone
artery running directly from the brachiocephalic and calcitonin involved in calcium regulation. The
trunk or right common carotid artery. Venous two inferior glands originate from the 3rd branchial
drainage is achieved via the superior, middle and pouch and migrate inferiorly to occupy variable
inferior thyroid veins. positions in the neck. As such, their blood supply is
equally variable, but most frequently via the inferior
The gland develops embryologically at the tongue thyroid arteries. The superior glands are formed by
base during weeks 3–4 and progresses inferiorly the 4th branchial pouch. Lying in close proximity to
anterior to the pharynx along the thyroglossal the thyroid, their blood supply is derived from the
duct to occupy its final position over the 2nd and inferior thyroid arteries.
3rd tracheal rings. Failure of degeneration of this

THE MAJOR SALIVARY GLANDS

Whilst minor salivary glands are scattered superficial and deep portions. Hence, an abscess
within the oral cavity, saliva is predominantly or malignant lesion within the parotid gland may
produced by three paired major salivary glands: result in facial paralysis.
the parotid, submandibular and sublingual glands
(Figure 1.18).

The parotid gland is a large, serous salivary gland

enclosed by an extension of the investing layer
of deep fascia of the neck. This parotid fascia is
unforgiving, and inflammation of the gland may
result in severe pain.
Parotid
Saliva produced by the parotid gland drains via gland
Stensen’s duct. The duct is approximately 5 cm in Submandibular
length and lies superficial to the masseter muscle. Sublingual
gland
gland
At the anterior border of this muscle it pierces the
fibres of the buccinator to enter the oral cavity
opposite the upper 2nd molar tooth.

The facial nerve passes into and divides within the Figure 1.18. The major salivary glands of the head
substance of the parotid gland to separate it into and neck.

Clinical anatomy 15
In addition, the retromandibular vein passes the floor of the oral cavity via Wharton’s duct, the
through the anterior portion of the gland and papilla lying adjacent to the lingual frenulum. The
is a useful radiological marker for defining the duct may become obstructed by a calculus, which
superficial and deep portions of the gland. causes painful enlargement of the gland.

The submandibular gland is a mixed serous and The sublingual glands lie anterior to hyoglossus
mucous salivary gland and forms the majority of in the sublingual fossa of the mandible. These
saliva production at rest. Its superficial portion fills mucus glands drain via multiple openings into
the space between the mandible and mylohyoid the submandibular duct and sublingual fold of the
muscle, while its deep part lies between the floor of the oral cavity.
mylohyoid and hyoglossus. The gland drains into

CERVICAL LYMPH NODES

The neck is divided into levels 1−6, which describe Level 4 – Anterior triangle including
groups of lymph nodes. The landmarks are: sternocleidomastoid from inferior border of
cricoid to superior border of clavicle.
Level 1 – Submental and submandibular triangles, Level 5 – Posterior triangle: lateral border of
bounded by the midline, digastric and the sternocleidomastoid, superior border of clavicle,
mandible. medial border of trapezius.
Level 2 – Anterior triangle including Level 6 – Paratracheal lymph nodes medial to the
sternocleidomastoid from skull base to the carotid.
inferior border of hyoid.
Level 3 – Anterior triangle including These levels allow description of the various
sternocleidomastoid from inferior border of types of neck dissection that are performed
hyoid to inferior border of cricoid. when managing malignant disease (Figure 1.19).
For example, a modified radical neck dissection
involves removal of levels 1−5.

Preauricular node

Postaural node

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

Supraclavicular V
Anterior triangle node IV
node

Figure 1.19. Lymph nodes groups and the triangles of the neck.

16 ENT: An Introduction and Practical Guide

SENSORY DISTRIBUTION OF THE FACE
The sensory nerve supply of the face is in a pattern of vesicular eruption consistent with
derived from branches of the trigeminal nerve the distribution of that division.
(Figure 1.20). Herpes zoster reactivation will result

Supraorbital

Supratrochlear
OPHTHALMIC DIVISION

External nasal lacrimal

Zygomaticotemporal
MAXILLARY DIVISION Zygomaticofacial
Infraorbital

Auriculotemporal
Buccal
MANDIBULAR DIVISION

Mental

Figure 1.20. Sensory distribution of the face.

DEEP NECK SPACES

A thorough anatomical understanding of the ●● Poststyloid – Containing carotid artery, internal
deep neck spaces is crucial in identifying and jugular vein, sympathetic chain and cranial
managing complications of oropharyngeal nerves IX, X and XI.
infections.
Peritonsillar or dental infections may spread
The parapharyngeal space is a potential space along this space to form parapharyngeal abscesses
in the form of an inverted pyramid running requiring urgent drainage.
from the skull base to the greater cornu of
The retropharyngeal space is a midline potential
the hyoid, bounded by the pharynx medially,
pterygomandibular raphe anteriorly and space between the alar and prevertebral faciae,
mandible laterally. It is divided into two extending from the skull base to the mediastinum.
It contains lymphatics draining the nasal and oral
compartments:
cavities, oropharynx and nasopharynx. As such it
●● Prestyloid – Containing maxillary artery, represents a path of least resistance for infection to
inferior alveolar, lingual and auriculotemporal spread to the intrathoracic compartment leading
nerves and fat. to mediastinitis.

Clinical anatomy 17
2 ENT EXAMINATION
Ketan Desai

A thorough clinical examination is essential in This chapter provides a systematic and thorough
the diagnosis and management of every patient. stepwise guide for clinicians assessing patients.

OTOSCOPY
Ensure that both you and the patient are seated Gently pull the pinna upwards and backwards to
comfortably and at the same level. straighten the ear canal (backwards in children).
Infection or inflammation may cause this
Examine the pinna, postaural region and adjacent manoeuvre to be painful.
scalp for scars, discharge, swelling and any skin
lesions or defects (Figure 2.1). Choose the largest Hold the otoscope like a pen and rest your
speculum that will fit comfortably into the ear and small digit on the patient’s zygomatic arch. Any
place it onto the otoscope. unexpected head movement will now push the

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.

18 ENT: An Introduction and Practical Guide

speculum away from the ear, preventing trauma. the otoscope to view all of the tympanic membrane
Use the light to observe the direction of the ear in a systematic manner. The ear cannot be judged
canal and the tympanic membrane. The eardrum to be normal until all areas of the tympanic
is better visualized by using the left hand for the membrane are viewed: the handle of malleus, pars
left ear and the right hand for the right ear. Insert tensa, pars flaccida (or attic) and anterior recess. If
the speculum gently into the meatus, pushing the view of the tympanic membrane is obscured
the tragus forward. This further straightens the by the presence of wax, this must be removed. If
ear canal. the patient has undergone mastoid surgery where
the posterior ear canal wall has been removed,
Inspect the entrance of the canal as you insert methodically inspect all parts of the cavity
the speculum. Pass the tip through the hairs of and tympanic membrane or drum remnant by
the canal but no further. Looking through the adjusting your position. The normal appearance
otoscope, examine the ear canal and tympanic of a mastoid cavity varies; practice and experience
membrane (Figure 2.2). Adjust your position and 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 tympanic membrane. 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 AND WEBER TUNING FORK TESTING

Although there have been various reports Traditionally, a 512 Hz tuning fork is used for
regarding the reliability of tuning fork tests (1), testing. Low-frequency tuning forks provide
they are simple, quick and invaluable aids in the greater vibrotactile stimulation (which can be
diagnosis of hearing loss (2). Tuning fork tests can misinterpreted as an audible signal by the patient),
be used to confirm audiometric findings, especially while high-frequency tuning forks have a higher
if the hearing test does not seem to be congruent rate of decay (i.e. the tone does not last long after
with the clinical findings. They are also useful as a the tuning fork has been struck). There is evidence
quick bedside test for checking that the patient has to suggest, however, that a 256 Hz tuning fork is
not suffered a dead ear following surgery. more reliable than a 512 Hz tuning fork (3, 4).

ENT examination 19
The commonest tuning fork tests performed If Rinne’s test is −ve on the right and +ve on the
are the Rinne’s and Weber’s tests. They must be left, and Weber’s test lateralizes to the left side, this
performed in conjunction in order to diagnose a suggests a right sensorineural hearing loss in the
conductive or sensorineural hearing loss. right ear.

Rinne’s test Anterior rhinoscopy

A 512 Hz tuning fork is struck on the elbow. It The head mirror is often approached with some
is essential that the examiner checks that they trepidation by the junior ENT surgeon, who
can hear the tuning fork as this also serves as a may feel self-conscious as the mirror can be
comparative test of hearing. The tuning fork is cumbersome. Many departments use headlights as
presented to the patient with the prongs of the an alternative.
fork held vertically and in line with the ear canal.
The patient is asked if they can hear a sound. The A right-handed examiner should position the
tuning fork is held by the ear for a few moments Bull’s lamp over the patient’s left shoulder at head
before its base is firmly pressed against the mastoid height and wear the head mirror over their right
process behind the ear. The patient is asked, ‘Is it eye. The lamp light can be directed onto the head
louder in front or when I place it on your head?’ mirror and the beam focused onto the patient.

As air conduction (AC) is better than bone Examine the profile of the nose, looking for
conduction (BC) in a normal hearing ear, the external deviation of the nasal dorsum. Check
tuning fork is heard louder in front of the ear than for bruising, swelling, signs of infection, nasal
when placed behind the ear (i.e. AC > BC). This discharge and scars.
is described as Rinne +ve; if bone conduction is
greater than air conduction, this is Rinne –ve. Gently raise the tip of the nose to allow you
to examine the vestibule of the nose and the
Weber’s test anteroinferior end of the nasal septum.

A 512 Hz tuning fork is struck on the elbow and The Thudichum speculum is held in the
firmly placed on the patient’s forehead. The patient nondominant hand (i.e. the left if the examiner is
is asked, ‘Is the sound louder in your left ear, right right-handed), leaving the dominant hand free to
ear, or somewhere in the middle?’ use any instruments.

As the hearing in both ears should be the same, in Hold the metal loop on your index finger with the
a normal subject the sound heard will be ‘in the finger pointing towards you and the prongs away
middle’. from you.

Interpretation Swing your middle finger to one side of the

Thudichum and your ring finger to the other.
In order to diagnose a conductive or sensorineural You can now squeeze the Thudichum and use
hearing loss, both Rinne’s and Weber’s tests must the prongs to open the nares to examine the
be performed (Figure 2.3). nasal cavity. This provides a view of the nasal
septum, inferior turbinate and head of the
If Rinne’s test is +ve on the left and −ve on the middle turbinate. A flexible nasolaryngoscope or
right, and Weber’s test lateralizes to the right a rigid endoscope is required in order to assess
side, this suggests a conductive hearing loss in the the middle meatus, posterior nasal cavity and
right ear. postnasal space.

20 ENT: An Introduction and Practical Guide

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 children, especially if a foreign body is experience temporary dizziness following the

suspected, it is often kinder simply to lift the procedure.
tip of the nose rather than use a Thudichum
speculum. Alternatively, an otoscope provides an Position the patient supine (or sitting in a chair)
excellent view. with the head turned to the opposite side. With
the microscope illuminating the ear, take this
Nasal patency is assessed by placing a metal opportunity to study the pinna, canal opening and
speculum under the nose. Misting or condensation surrounding skin for scars or sinuses.
on the 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
Explain to the patient that microsuction is thumb, place the middle finger into the conchal
required in order to remove debris and wax from bowl and gently pull the pinna posteriorly. This
the external auditory canal. Warn the patient will open and straighten the ear canal. If the ear
that they will hear a loud hissing noise and may canal is narrow, use a smaller speculum or ask the

ENT examination 21
patient to open their mouth (this manoeuvre often which can be used as a guide to the level of
increases the anteroposterior diameter of the canal anaesthesia.
as the condyle of the mandible is related to the
anterior canal wall). The nasoendoscope may be used with or without
a sheath, depending on local decontamination
Assess the canal wall and contents. Remember protocols. Clean the tip of the scope with an
that the hairy outer third of the canal is relatively alcohol wipe to prevent condensation and apply
insensitive but the thin inner skin is extremely a thin film of lubricant gel to the distal 5 cm of
sensitive. Any contact with the speculum or the nasoendoscope. Ensure the gel does not cover
suction will produce a great deal of discomfort. the tip of the scope as this will occlude your view.
The patient’s saliva provides an effective alternative.
Using a wide bore sucker, begin by removing
debris within the lateral hairy portion of the Ask the patient to breathe through their mouth
canal. Aim to touch only the debris and not the and, holding the end of the scope between the
canal skin. Try to remove all the debris, especially index finger and thumb, place the tip of the
in cases of otitis externa where debris will result nasoendoscope into the nasal cavity. Ensure full
in an ongoing infection if not removed. A wax control of the scope by placing the middle finger
hook may be used as an alternative method for on the tip of the patient’s nose. If a patient were to
wax removal. fall forward, the nasoendoscope will not be driven
into the nasal cavity.
If the debris or wax is too hard or the procedure
too uncomfortable for the patient, a course of Insert the scope into the nostril and pass it along
sodium bicarbonate ear drops (two drops three the floor of the nose with the inferior turbinate
times a day for two weeks) will be required before laterally and septum medially. Posteriorly, the
a further attempt at wax removal is made. Eustachian tube orifice and postnasal space will
come into view (see Chapter 1, Figure 1.2). If the
If the tympanic membrane is obscured, septum is deviated and the scope cannot be easily
microsuction along the anterior canal wall until advanced, try to pass it between the inferior and
the tympanic membrane is visible (the tympanic middle turbinates (laterally) and the septum
membrane is continuous with the posterior canal (medially). If this is too uncomfortable for the
wall and can be damaged if microsuction follows patient, the other nasal cavity may be used.
the posterior canal wall).
With the postnasal space in view, ask the patient to
If there is trauma to the ear canal or if bleeding breathe in through their nose. This opens the inlet
occurs, prescribe a short course of antibiotic into the oropharynx. Use the control toggle to flex
ear drops, warning the patient of the risk of the distal end of the scope inferiorly and gently
ototoxicity. advance.

The uvula and soft palate will slide away and the
Flexible nasolaryngoscopy base of tongue and larynx will come into view (see
Chapter 1, Figure 1.14).
Explain the procedure to the patient and ask
the patient which side of their nose is the easier Adopt a system to ensure that all aspects of this
to breathe through, selecting this side for region are examined. The following is a guide:
examination. Spray the chosen side with local tongue base, valleculae, epiglottis (lingual and
anaesthetic or insert a cotton wool pledget soaked laryngeal surfaces), supraglottis, interarytenoid
in local anaesthetic. Patients often describe bar, vocal cords (appearance and mobility),
numbness of the upper lip or back of their tongue, subglottis, pyriform fossae and posterior

22 ENT: An Introduction and Practical Guide

pharyngeal wall. The larynx may be difficult Remove the scope gently and supply patients with
to view in those patients with an infantile tissues to use after completing the examination.
epiglottis or prominent tongue base. Where this is
encountered, ask the patient to point their chin up Rigid nasoendoscopy
to the ceiling to draw the tongue base forward and
bring the larynx into view. To assess the pyriform Rigid endoscopy of the nasal cavity requires a
fossae, ask the patient to blow their cheeks out systematic examination involving three passes
while you pinch their nose. If secretions obscure with either a 0° or 30° scope (Figure 2.4).
your view, ask the patient to swallow.

1st

2nd

3rd

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

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

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

ENT examination 23
(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.

tongue pointing superiorly, examine the floor of the soft palate. Ask the patient to look up to the
the mouth and inferior surface of the tongue. The ceiling and examine the hard palate.
openings of the submandibular ducts are found
just lateral to the frenulum of the tongue. Palpate the tongue including the tongue base.
Submucosal tumours in these structures can
Using both tongue blades again, examine the often be palpated before they are seen. Where
retromolar regions and lateral borders of the the history is suggestive of an abnormality of the
tongue. submandibular gland or duct, bimanual palpation
should be used.
Ask the patient to keep their tongue in their mouth
and keep breathing. Gently depress the anterior Examination of the neck and
half of the tongue, avoiding the posterior third facial nerve function
as this can make patients gag. Examine both
tonsils, comparing their relative size. Inspect the Inspect the general appearance of the patient,
oropharynx, including uvula and movements of noting any facial scars or asymmetry of facial tone

24 ENT: An Introduction and Practical Guide

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

ENT examination 25
3 COMMON ENT
PATHOLOGY
Ketan Desai

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

IMPACTED WAX
Ear wax is composed of secretions from sebaceous canal mixed with dead squamous cells. It becomes
and apocrine glands in the lateral third of the ear impacted in 10% of children, 5% of healthy adults

26 ENT: An Introduction and Practical Guide

and nearly 60% of the elderly (1). Although often from previous syringing. In otolaryngology
asymptomatic, it may cause a conductive hearing departments wax is removed under the microscope
loss and discomfort. Impacted wax needs to be using a Zoellner sucker, wax hook, Jobson–Horne
removed to facilitate examination of the tympanic probe or crocodile forceps. Care should be taken
membrane. In primary care, removal is facilitated to avoid trauma to the ear canal. The use of cotton
by the use of ceruminolytic agents (2) or ear buds by the patient should be discouraged as this
syringing. Syringing is, however, contraindicated impacts wax and traumatises the ear canal causing
in those who have a tympanic membrane otitis externa.
perforation or who have developed otitis externa

ACUTE OTITIS MEDIA (AOM)

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

OTITIS MEDIA WITH EFFUSION (OME) (GLUE EAR)

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

Common ENT pathology 27

ACUTE MASTOIDITIS
Acute mastoiditis is an inflammatory process and hydration (5). A contrast-enhanced CT scan
affecting the mastoid air cells; it occurs most is used to exclude a brain abscess, lateral sinus
commonly in children. It is an uncommon thrombosis, and assess temporal bone anatomy.
complication of AOM. Patients are generally If there is failure to improve, where there is an
unwell, with spiking temperatures. There is a established postaural abscess, or if the suspicion
postauricular abscess with lateral and anterior of complications demands surgical intervention
displacement of the pinna and tenderness over the a cortical mastoidectomy and grommet insertion
mastoid bone. Early cases may respond to medical with placement of a corrugated drain within the
treatment with intravenous antibiotics, analgesia postauricular wound is undertaken.

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

PERICHONDRITIS AND PINNA CELLULITIS

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

SUDDEN SENSORINEURAL HEARING LOSS (SSHL)

This is a unilateral or bilateral subjective seconds to hours and on objective testing
deterioration in hearing, which develops over is confirmed to be sensorineural in nature.

28 ENT: An Introduction and Practical Guide

A conductive hearing loss should first be excluded with or without intervention. Standard treatment
by careful examination of the ear, tuning fork tests is with prednisolone (oral for one week first line
and a pure tone audiogram. In 88% of cases, no and or injected into the middle ear if there is no
obvious cause is found, but a careful history and imporvement) (9). There is poor evidence for
examination should consider potential infective, efficacy with aspirin, betahistine (10), acyclovir and
autoimmune, vascular, traumatic, neoplastic inhaled carbogen (oxygen mixed with 5% CO2) (11).
and neurological causes (8). Competing theories Unilateral loss may be managed in the outpatient
for idiopathic cases include viral and vascular setting, but those with bilateral loss require
insults to the inner ear and rupture of the cochlear admission for investigation (blood tests to exclude
membrane. Approximately 60% of patients improve autoimmune causes and MRI scanning).

FACIAL NERVE PALSY

There are a wide variety of causes for a facial Although there is inconclusive evidence to support
nerve palsy. Lower motor neurone lesions are the use of antivirals, acyclovir (800 mg five times a
distinguished from upper motor neurone lesions day for 10 days) is also often prescribed (13) along
by the absence of forehead movement (forehead with one week of oral prednisolone. Any patient
movement is spared in upper motor neurone with a facial nerve palsy who is unable to close
lesions as a result of the bilateral upper motor their eye (House–Brackmann grade 4–6) must use
neurone distribution supplying this area). All artificial tears and tape their eyes closed at night
patients must have their degree of facial weakness in order to protect the cornea. If the eye becomes
recorded using the House–Brackmann scale. painful or red, an urgent ophthalmic opinion
should be sought.
Lower motor neurone pathology can occur
anywhere along the path of the affected nerve. Approximately 60% of patients with an idiopathic
An assessment of the cranial nerves, ear, parotid palsy recover to House–Brackmann grade 1 or 2.
gland, oral cavity and neck examination is A further 12% suffer a recurrence on the same or
mandatory. contralateral side.

Causes include Bell’s palsy, Ramsay Hunt Ramsay Hunt syndrome

Syndrome, malignant otits externa, ear or parotid
surgery, middle ear disease, temporal bone This condition is caused by herpes zoster. The
fracture and iatrogenic trauma. facial palsy is accompanied by painful vesicles
on the pinna or external auditory canal, and
Bells palsy occasionally the soft palate. The onset is rapid,
and the 8th nerve may become involved with
This syndrome of facial paralysis is a diagnosis concurrent hearing loss and vertigo.
of exclusion. Although described as idiopathic,
there is evidence to suggest that the palsy occurs Treatment is similar to that of Bell’s palsy (14, 15).
due to herpes reactivation. A thorough history
and examination are required. An MRI is only Acute suppurative otitis media
indicated if this is a recurrent palsy or if the palsy (ASOM)
fails to recover (12).
An acute otitis media may result in a facial nerve
Initial treatment is with oral prednisolone (1 mg palsy, typically if the bony canal of the facial nerve
per kg, typically 60 mg for an adult) for seven days. is dehiscent within the middle ear cleft. Treatment

Common ENT pathology 29

includes intravenous antibiotics, oral steroids Trauma
and CT of the temporal bone may be of value in
order to exclude chronic suppurative otitis media Every patient undergoing middle ear surgery must
(CSOM). A myringotomy may be considered have their facial nerve function recorded pre- and
appropriate if there is no clinical improvement post-operatively. Iatrogenic damage requires
following 24–48 hours of medical treatment. surgical reexploration and nerve repair.

FOREIGN BODIES – EAR

Foreign bodies within the external ear canal
commonly affect children and may be difficult
to remove. Children will need to be held by a
parent or nurse, and the first attempt at removal
is often the only chance. If the foreign body
cannot be removed, a short general anaesthetic
in the following few days is indicated to allow
removal. The exception are batteries, which are
corrosive and must be removed that day. Objects
can be removed under the microscope using wax
Wax
hook, microsuction or irrigation (Figure 3.1).
hook
The use of crocodile forceps can result in medial
displacement of the foreign bodies and their use
should be restricted to objects that can be grasped.
Insects should be drowned using olive oil prior Bead
to removal. Do not attempt to flush out tablets,
seeds or nuts (organic materials) as these swell and Figure 3.1. Removal of a bead from the external
become more difficult to remove. auditory canal.

TYMPANIC MEMBRANE TRAUMA

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

TEMPORAL BONE FRACTURES

The temporal bone contains many vital structures, ossicles, internal carotid artery, jugular vein
including the facial nerve, cochlea, labyrinth, and sigmoid sinus. Temporal bone fractures

30 ENT: An Introduction and Practical Guide

are traditionally classified as longitudinal, facial nerve injury and cerebral spinal fluid (CSF)
transverse and oblique in relation to the petrous otorrhoea.
ridge of the temporal bone. The usefulness of
this classification system has been questioned Facial nerve function immediately after injury
and a newer system of categorizing injuries on must be documented. CT scanning is helpful in
CT as oticcapsule violating and oticcapsule excluding intracranial injury, identifying damage
sparing, has been shown to be more predictive to important intratemporal structures and
of complications (16). Initially, advanced trauma classifying the type of fracture. Immediate onset
life support (ATLS) management takes priority as severe facial nerve paralysis is suggestive of nerve
temporal bone fractures can be associated with transection and may require surgical exploration.
significant head injury. Clinical signs include However, most traumatic facial nerve palsies are
blood in the ear canal, haemotympanum and delayed in onset, secondary to fracture-related
Battle’s sign (postauricular bruising). Of more nerve oedema and are treated conservatively with
concern are sensorineural hearing loss, vertigo, steroids.

FOREIGN BODIES – NOSE

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

Wax hook

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

Common ENT pathology 31

NASAL TRAUMA
Nasal trauma may result in a deviated nasal bridge. If the nasal bones are deviated, and the patient
A patient who has sustained nasal injury, with desires it, the nose can be manipulated under local
suspected deviation of the nasal bones should first or general anaesthesia (18). It is essential that this
be assessed for other injuries (ATLS protocol). is performed within 14 days of the initial injury
as the bridge may become fixed, making simple
The nose should be examined to exclude a septal manipulation impossible. Risks include epistaxis,
haematoma and any epistaxis managed. Swelling periorbital bruising and septal haematoma.
over the nose may prevent an accurate assessment Patients should be warned that the aim is to
of the position of the nasal bones. Hence, the straighten the bony bridge and that their nose
patient should be recalled 5–7 days post injury and may appear different after the injury. The nose will
the nasal bridge reassessed. remain unstable until the bones have rehealed and
so further injury should be avoided.

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

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

PERIORBITAL CELLULITIS
Periorbital cellulitis is an ENT emergency and spread of infection from the ethmoidal air cells
patients may become blind within a matter of laterally into the orbital cavity. Patients often
hours. A subperiosteal abscess may arise due to describe a recent upper respiratory tract infection.

32 ENT: An Introduction and Practical Guide

These patients must be discussed promptly with collection should be discussed promptly with
a senior colleague so that they can be reviewed or a senior so that they can be reviewed or their
their management discussed. management discussed.

The eyelid may be swollen with associated An urgent CT scan of the paranasal sinuses is
chemosis, and there may be proptosis of the eye. essential. For young children preparations may
It is important to assess red colour vision, in be made to perform the scan under general
particular, and this may be performed using an anaesthetic, proceeding to surgery if the imaging
Ishihara chart. Visual acuity and eye movements reveals a collection. Children should receive
also require regular monitoring. Restricted eye appropriate analgesia, intravenous antibiotics
movement or pain on eye movement is often (normally a third generation cephalosporin) and,
associated with an abscess. if there is evidence of sinusitis, paediatric nasal
decongestant.
Given that the condition predominantly occurs
in children, such an examination can be Surgical decompression of a subperiosteal abscess
challenging and it is worth seeking paediatric and is performed endoscopically or via a Lynch–
ophthalmological consultations early. Patients Howarth incision. A drain is required if an open
with periorbital cellulitis or a potential intraorbital approach is used.

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

Common ENT pathology 33

PERITONSILLAR ABSCESS
Also known as a quinsy, a peritonsillar abscess between a third of the way, and half way from the
is a collection of pus that develops between the base of the uvula to the last upper molar).
tonsillar capsule and the surrounding superior
constrictor muscle. This condition mainly occurs Incision and drainage can be performed in the
in young adults, as a result of acute tonsillitis. same location using a no.11 blade with tape
wrapped around the blade to expose only the distal
On examination, the patient has trismus (an 1 cm.
inability to fully open the mouth), and the uvula is
pushed away from the midline by swelling under The incision can be opened by the use of Tilley’s
the soft palate. If large, a quinsy may cause airway dressing forceps, and a Yankauer sucker can be
compromise. used to remove the purulent material.

The soft palate is first sprayed with local Patients are usually admitted and treated as for severe
anaesthetic, and the collection aspirated to tonsillitis with intravenous antibiotics, although
confirm the presence of pus. A 19G white needle where symptoms completely resolve after drainage,
on a luer-lock and 10 or 20 mL syringe is used outpatient antibiotic therapy may be sufficient. It is
(1 cm of the tip of the needle sheath can be cut off helpful to send a sample to microbiology to guide
and the remainder of the sheath replaced on the antibiotic therapy, although patients are usually
needle to act as a guard preventing over-insertion). managed with benzylpenicillin and metronidazole.
The needle is pointed towards the back of the If the abscess recollects, or there is neck swelling, a
mouth (rather than drifting laterally), and the parapharyngeal abscess should be suspected and a
area of maximal fluctuance aspirated (or on an arc CT scan performed to investigate this.

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

34 ENT: An Introduction and Practical Guide

EPIGLOTTITIS
Severe inflammation of the epiglottis in children is should neither be examined nor cannulated.
fortunately now rare as a result of the Haemophilus A senior anaesthetist and ENT surgeon must be
influenzae Type B vaccine (20, 21). called. The patient is taken to theatre in order
to secure the airway by intubation, although an
Children present with stridor; drooling is emergency tracheostomy may occasionally be
common, and ‘sitting upright’ (in the ‘sniffing the required. Patients are kept intubated and treated
morning air’ position) to maximize the available with intravenous antibiotics until a leak around
airway. the cuff of the endotracheal tube is observed, an
indication of decreased airway swelling.
Any potential stimulant can send them into
complete airway obstruction. These children

SMOKE INHALATION
Patients who have been exposed to dense smoke Nasolaryngoscopy should be performed to
are often admitted under chest physicians. The visualize the larynx and this may need to be
upper airway must not be neglected. The effects repeated if symptoms deteriorate. Steroids can
of smoke injury on the larynx can develop over be useful in reducing mucosal oedema. These
several hours and these patients should be closely patients should be discussed with a senior
monitored in hospital in a high dependency promptly, because development of marked
setting. Singeing of the nasal hair, soot in laryngeal inflammation may prevent intubation
the nasal cavity or passages or oral mucosa, and necessitate a tracheostomy to secure the
and voice change indicate smoke inhalation. airway.

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

Common ENT pathology 35

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

FOREIGN BODIES (UPPER AERODIGESTIVE TRACT)

Oral cavity – Foreign bodies are usually easily The hypopharynx can be examined with the
visible on examination with a headlight. It is also flexible nasoendoscope looking carefully in the
possible to palpate the floor of the mouth, tongue pyrifom fossae and post-cricoid region. Pooling
and other structures to identify a foreign body. The of saliva in the hypopharynx is suggestive of an
foreign body can be carefully removed perorally oesophageal foreign body.
with conventional instruments.
If the foreign body is not easily visualized in the
Oropharynx – Foreign bodies, typically fish bones,
hypopharynx or oesophagus a soft tissue neck film
may not be readily visible. Careful examination of
or chest film (anterior posterior (AP) and lateral) is
the tonsils, posterior pharyngeal wall, tongue base
required. Where a fish bone is difficult to locate CT
and valleculae is essential, using both the headlight
is more accurate (25, 26).
and flexible nasoendoscope. Visual examination
is typically sufficient to exclude a foreign body.
However, a lateral soft tissue x-ray is indicated, If the bolus contains no bony or sharp material,
although some fish bones are not radio-opaque these can be initially managed with fizzy drinks or
(23). Foreign bodies can be carefully removed per- pineapple juice. Buscopan or diazepam can relieve
orally using Magill forceps. any spasm and allow the bolus to pass into the
stomach. If a soft bolus is in the lower oesophagus,
Hypopharynx/oesophagus – Foreign bodies then a flexible oesophagogastroduodenoscopy
ranging from meat or fish bones, soft food bolus, (OGD) is a safer option to push the bolus into the
to batteries and coins can obstruct in this region. stomach.
Patients will complain of a foreign body sensation,
pain, dysphagia or drooling. If the foreign body is If the foreign body is a bone, sharp fragment or
above the cricopharyngeus, patients can reliably non-organic, especially a battery, then removal is
locate the site of impaction (24). required urgently to avoid oesophageal perforation
and subsequent complications, including
The most common sites of oesophageal obstruction
parapharyngeal or mediastinal abscess, which can
are at the:
be fatal.
●● Cricopharyngeus
●● Arch of aorta Larynx/Trachea – A foreign body in the larynx or
●● Tracheal bifurcation trachea can cause stridor, voice change, choking,
●● Gastrooesophageal junction. cyanosis, difficulty in breathing, tachypnoea

36 ENT: An Introduction and Practical Guide

and pneumonia. In an emergency where total or opinion sought regarding the need for formal
partial obstruction causes compromise, a back endoscopy, which is highly likely.
slap or abdominal thrust (Heimlich manoeuvre) is
employed (27). Most inhaled foreign bodies enter the trachea and
then lodge in the right main bronchus.
In stable patients suspected of having inhaled a
foreign body, further investigation is mandatory. Foreign bodies at the laryngeal inlet can be
In young children, the distinction between removed using an anaesthetic laryngoscope
ingestion and inhalation is often blurred and they and Magill forceps. Foreign bodies in the
should undergo both chest PA inspiration and trachea and main bronchus require formal
expiration views and abdominal films. A senior tracheobronchoscopy.

LEAKAGE OR LOSS OF TRACHEOESOPHAGEAL VOICE

PROSTHESIS
The speech and language therapist or ENT can be given to fitting a more expensive, anti-
specialist nurse usually undertakes the routine fungal voice prosthesis (28, 29).
management of the voice prosthesis in patients
Peripheral leakage around the voice prosthesis
who have undergone laryngectomy. It is
is less common and potentially more difficult to
important, however, that all ENT doctors are able
resolve. Leakage is caused by the tracheoesophageal
to manage a leaking voice prosthesis or inadvertent
puncture (TEP) becoming larger than the voice
dislodgement.
prosthesis. This can be related to tumour recurrence
or infection, which must be excluded. A number
In all cases of leakage the patient should be advised
of techniques are available to the appropriately
to remain nil by mouth until after appropriate
trained individual, including fitting of a larger voice
assessment to minimize aspiration. To assess the
prosthesis, allowing the TEP to shrink and using a
leakage ask the patient to swallow a small sip of
smaller voice prosthesis or even removing the voice
coloured fluid (e.g. coloured cordial or food dye
prosthesis and allowing the TEP to close. If no one
in water) while carefully looking at the valve and
suitable is available, the patient is kept nil by mouth
stoma with a headlight.
and a fine bore feeding tube can be passed through
the lumen of the voice prosthesis or a nasogastric
Central leakage through the voice prosthesis is
tube placed for feeding until such patient can be
the most common. This signifies damage to the
appropriately managed.
valve by Candida colonization or inadvertent
damage during cleaning of the voice prosthesis. If patients inadvertently dislodge the voice
The problem is resolved by fitting a new voice prosthesis, most are taught to pass a dilator, 14Fr
prosthesis by an appropriately trained healthcare Jacques or Foley catheter to keep the TEP patent,
professional. If no one is available, the patient is or to attend hospital for the same. If the voice
kept nil by mouth and a fine bore feeding tube prosthesis is not located, then it is prudent to pass
can be passed through the lumen of the voice a nasoendoscope via the stoma to ensure that the
prosthesis or a nasogastric tube placed for feeding voice prosthesis has not been inhaled. A new voice
until a new voice prosthesis can be fitted. If this prosthesis can be fitted by an appropriately trained
becomes a recurrent problem, then consideration healthcare professional.

Common ENT pathology 37

aciclovir and/or prednisolone for the early
REFERENCES treatment of Bell’s palsy: The BELLS study.
1 McCarter DF, Courtney AU, Pollart SM. Health Technol Assess 13(47): iii–iv, ix–xi,
2007. Cerumen impaction. Am Fam Physician 1–130.
75:1523–8. 14 Uscategui T, Doree C, Chamberlain IJ,
2 Burton MJ, Doree C. 2009. Ear drops for the Burton MJ. 2008. Antiviral therapy for
removal of ear wax. Cochrane Database System Ramsay Hunt syndrome (herpes zoster
Rev 1: CD004326. oticus with facial palsy) in adults. Cochrane
3 SIGN. Diagnosis and management of Database System Rev 4: CD006851. doi:
childhood otitis media in primary care. 10.1002/14651858. CD006851.pub2.
Available at: www.sign.ac.uk/guidelines/ 15 Uscategui T, Doree C, Chamberlain IJ,
fulltext/66/index. html. Burton 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 System Rev 3:
5 Geva A, Oestreicher-Kedem Y, Fishman G, CD006852. doi: 10.1002/14651858. CD006852.
Landsberg R, DeRowe A. 2008. Conservative pub2.
management of acute mastoiditis in children. 16 Little SC, Kesser BW. 2006. Radiographic
Int J Pediatr Otorhinolaryngol 72: 629–34. classification of temporal bone fractures:
6 Jones SEM, Mahendran S. 2004. Interventions Clinical predictability using a new system.
for acute auricular haematoma. Cochrane Arch Otolaryngol Head Neck Surg 132: 1300–4.
Database System Rev 2: CD004166. 17 Purohit N, Ray S, Wilson T, Chawla OP. 2008.
7 Davidi E, Paz A, Duchman H, Luntz M, The ‘parent’s kiss’: An effective way to remove
Potasman I. 2011. Perichondritis of the auricle: paediatric nasal foreign bodies. Ann R Coll
Analysis of 114 cases. Isr Med Assoc J 13: 21–4. Surg Engl 90: 420–22.
8 O’Malley MR, Haynes DS. 2008. Sudden 18 Chadha NK, Repanos C, Carswell AJ. 2009.
hearing loss. Otolaryngol Clin N Am 41: Local anaesthesia for manipulation of nasal
633–49. fractures: Systematic review. J Laryngol Otol
9 Wei BPC, Mubiru S, O’Leary S. 2006. Steroids 123: 830–6.
for idiopathic sudden sensorineural hearing 19 Ketcham AS, Han JK. 2010. Complications
loss. Cochrane Database System Rev 1: and management of septoplasty. Otolaryngol
CD003998. doi: 10.1002/14651858. CD003998. Clin North Am 43: 897–904.
pub2. 20 Guardiani E, Bliss M, Harley E. 2010.
10 Agarwal L, Pothier DD. 2009. Vasodilators Supraglottitis in the era following widespread
and vasoactive substances for idiopathic immunisation against Haemophilus
sudden sensorineural hearing loss. Cochrane influenzae type B: Evolving principle in
Database System Rev 4: CD003422. doi: diagnosis and management. Laryngoscope 120:
10.1002/14651858.CD003422.pub4. 2183–8.
11 Bennett MH, Kertesz T, Perleth M, Yeung P. 21 Sobol SE, Zapata S. 2008. Epiglottitis and
2007. Hyperbaric oxygen for idiopathic sudden Croup. Otolaryngol Clin N Am 41: 551–66.
sensorineural hearing loss and tinnitus. 22 Vieira F, Allen SM, Stocks RM, Thompson JW.
Cochrane Database System Rev 1: CD004739. 2008. Deep neck infection. Otolaryngol Clin N
doi: 10.1002/14651858.CD004739. pub3. Am 41: 459–83.
12 Danner CJ (2008). Facial nerve paralysis. 23 Ell SR, Parker AJ. 1992. The radio-opacity of
Otolaryngol Clin N Am 41: 619–32. fishbones. Clin Otolaryngol Allied Sci 17(6):
13 Sullivan FM, Swan IR, Donnan PT et al. 2009. 514–6.
A randomised controlled trial of the use of

38 ENT: An Introduction and Practical Guide

24 Connolly AAP, Birchall M, Walsh-Waring 27 UK Resuscitation Council. 2010. Adult basic
GP, Moore-Gillon V. 1992. Ingested foreign life support. Resucitation Guidelines 25–6.
bodies: Patient-guided localization is a useful 28 Leder SB, Acton LM, Kmiecik J et al.
clinical tool. Clin Otolaryngol Allied Sci 17(6): 2005. Voice restoration with the advantage
520–4. tracheoesophageal voice prosthesis.
25 Lue AJ, Fang WD, Manolidis S. 2000. Use of Otolaryngol Head Neck Surg 133(5): 681–4.
plain radiography and computed tomography 9 Soolsma J, van den Brekel MW, Ackerstaff AH
2
to identify fish bone foreign bodies. et al. 2008. Long-term results of Provox
Otolaryngol Head Neck Surg 123(4): 435–8. ActiValve, solving the problem of frequent
6 Shrime MG, Johnson PE, Stewart MG. 2007.
2 candida- and ‘underpressure’- related voice
Cost-effective diagnosis of ingested foreign prosthesis replacements. Laryngoscope 118(2):
bodies. Laryngoscope 117(5): 785–93. 252–7.

Common ENT pathology 39

4 EPISTAXIS
Joanne Rimmer

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

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

AETIOLOGY
Epistaxis can be classified into primary (e.g. juvenile nasopharyngeal angiofibroma) or
(idiopathic), or secondary to a specific cause malignant sinonasal tumours or environmental
such as trauma (6). Around 80% of epistaxis is (e.g. airborne particulate matter) (7).
idiopathic. Causative factors can be divided into
local and systemic (Table 4.1). Systemic causes include antiplatelet or
anticoagulant drugs (e.g. aspirin, clopidogrel,
The most commonly identified local cause of warfarin, heparin), haematological disorders (e.g.
epistaxis is trauma – digital, surgical or accidental. haemophilia, leukaemia, thrombocytopenia), liver
Other local causes include infection, inflammation, failure and hereditary haemorrhagic telangiectasia
foreign body, endocrine (e.g. pregnancy), benign (HHT).

40 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, 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
Trauma Drugs (e.g. aspirin, clopidogrel, warfarin)
Infection (e.g. URTI, acute rhinosinusitis) Haematological disorders (e.g. haemophilia, leukaemia,
Inflammation (e.g. rhinitis) thrombocytopaenia)

Foreign body Liver failure

Endocrine (e.g. pregnancy) Hereditary haemorrhagic telangiectasia (HHT)
Neoplastic (benign or malignant)

HISTORY
In the elective outpatient setting this can be taken anterior (running out of the nose) or posterior
at leisure; in an acute bleed it is often done whilst (swallowing blood) – although it may be both
treatment is being initiated. Important points with profuse bleeding, previous episodes and
about the bleeding itself include onset, duration, any treatment given and precipitating factors,
side (may often start on one side then appear including recent trauma or surgery. If trauma is
to become bilateral due to overflow), whether involved, significant head injury must be excluded.

Epistaxis 41
Key factors in the past medical history include it may determine whether a patient is safe to be
hypertension, coagulopathies and HHT. Relevant discharged after a significant bleed – a frail elderly
drugs include antihypertensives, antiplatelet agents patient living alone may not be.
and anticoagulants. Social history is important as

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

EXAMINATION
In the outpatient clinic (or if the acute bleed has is seen and the situation permits, complete
settled) this can be done thoroughly. In the acute the examination using a rigid 0° Hopkins rod
situation it may not be possible to fully examine endoscope to evaluate both nasal cavities and
the patient, depending on the degree of bleeding. postnasal space.

If you are able to do so, begin with anterior In emergency situations, wear gloves, an eye shield,
rhinoscopy using a Thudichum’s speculum and and an apron or gown. Suction is required during
headlight. This allows inspection of the anterior examination and treatment, and other equipment
septum including Little’s area, a likely site of should be available to allow further management,
the bleeding vessel. If no obvious bleeding point as detailed below.

TREATMENT
It is important to correct over-anticoagulation and warfarinized patient has a significantly elevated
hypertension, and medical or haematological input INR then withholding warfarin is advisable until
may be required. Thrombocytopaenia should be the bleeding is controlled and the INR back in the
corrected with platelet transfusion; packs should therapeutic range. The use of low dose diazepam has
be avoided if possible as they cause further trauma been advocated in the past, particularly in anxious
to the nasal mucosa with inevitable rebleeding hypertensive patients, but there is little evidence for
on removal. Absorbable packs, such as oxidized its use; controlling the epistaxis is more effective in
cellulose or gelatin sponge soaked in adrenaline reducing both blood pressure and anxiety (9).
or tranexamic acid, are a useful alternative. There
is little to be gained from stopping aspirin therapy See Figure 4.2 for a basic treatment algorithm for
as the half-life of platelets is seven days, but if a epistaxis.

42 ENT: An Introduction and Practical Guide

Epistaxis

No active bleeding Active bleeding

Haemodynamically Haemodynamically
stable unstable

Examination
± cautery

No further Bleeding Anterior pack

bleeding persists and resuscitate

No further Bleeding
bleeding persists
Consider discharge if
small volume of blood loss,
otherwise admit for observation

Repack with
posterior pack

Admit Bleeding
Resuscitate persists
FBC, G&S
Clotting screen if indicated
Observation
Admit
Resuscitate
FBC, G&S
Clotting screen if indicated
Plan for surgery

Figure 4.2. A treatment algorithm for epistaxis.

CAUTERY
The ideal management option is to identify and The bleeding vessel is identified and topical
cauterize the bleeding vessel. This controls the anaesthesia, ideally combined with a
epistaxis, avoids packing and in many cases allows vasoconstrictor (e.g. co-phenylcaine – 5%
the patient to be discharged. As most bleeding lidocaine with 0.5% phenylephrine), is applied on
vessels arise in Little’s area, silver nitrate cautery is cotton wool. Silver nitrate cautery of the vessel
often possible with anterior rhinoscopy. is then performed directly; if it is an ‘end-on’

Epistaxis 43
vessel, it can be helpful to cauterize around If an obvious vessel or bleeding point is not seen
™
it before touching the vessel itself. Naseptin anteriorly, it may be possible to examine more
cream (0.1% chlorhexidine dihydrochloride, 0.5% posteriorly with a rigid endoscope. Whilst the use
neomycin sulphate) is applied to the cauterized of silver nitrate cautery is possible for posterior
area twice daily for two weeks. An alternative, epistaxis, it is more difficult to be precise and avoid
such as chloramphenicol ointment, should be touching other parts of the nose with the stick
used in patients with peanut allergy, as Naseptin ™ (10). If available, bipolar electrocautery is more
contains arachis (peanut) oil. practical for use with an endoscope, allowing
diathermy of the specific bleeding point (11).

ANTERIOR NASAL PACKING

If the epistaxis is not controlled with simple be inflated with a little water; newer devices
measures, then packing is required. In the first have a concealed balloon that requires inflation
instance this is anterior nasal packing, which is (Figure 4.3(b)).
most commonly performed with a nasal tampon.
Various anterior 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
lubricating hydrocolloid-covered packs such as simply push the septum across without providing
Rapid Rhino .™ adequate compression. If bleeding continues,
a contralateral pack should be inserted.
The insertion technique is the same for all types.
The nasal tip is elevated with one hand and the Anterior packing may also be performed
pack pushed firmly in along the floor of the nose with a long length of ribbon gauze soaked in
with the other. It is preferable to support the bismuth iodoform paraffin paste (BIPP). This
back of the patient’s head to facilitate complete is layered into the nose, along its whole length,
insertion in one smooth movement. Ensure that using Tilley dressing forceps (Figure 4.4). This
the pack is inserted parallel to the palate as the is not a pleasant experience for the patient
nasal cavity runs straight back, not upwards whose head will need supporting posteriorly
(Figure 4.3(a)). Once in place, sponges need to during the packing, but it can be a very effective

(a) (b)

Figure 4.3. (a) Insertion of a nasal pack. (b) A nasal pack in situ.

44 ENT: An Introduction and Practical Guide

way of providing more compression than nasal
tampons.

It is standard practice in most departments to

admit patients once they have been packed, for
observation and pack removal within 24 hours, if
stable. However, local protocols will be in place,
and some patients may be discharged with their
pack(s) in situ, to return for follow-up and pack
removal in the outpatient department (12).

Recent studies have reported the use of a

haemostatic matrix to control epistaxis, as a
successful alternative to anterior nasal packing
(13). These commercially available products
contain gelatin ± human thrombin and are
prepared in a syringe, which allows easy
Figure 4.4. BIPP ribbon gauze packing of the nasal instillation into the nose. If bleeding is controlled,
cavity. patients do not require hospital admission.

POSTERIOR NASAL PACKING

If bleeding continues despite adequate anterior 12 or 14 French) is an alternative. The catheter is
nasal packing, the next step is a posterior pack. passed along the floor of the nose until the tip is
There are various commercial balloon devices seen behind the soft palate. Once inflated with
designed for this (Figure 4.5). Although not 5–10 mL of water (not saline as this can corrode
licensed for this use, a female Foley catheter (size the balloon), the catheter is gently pulled back into

Figure 4.5. Inflated epistaxis balloon in situ.

Epistaxis 45
the posterior choana. The catheter is clipped to sleep apnoea), vagal (from nasopharyngeal
prevent deflation of the balloon and to hold it in stimulation) and cardiac (including myocardial
place; an umbilical clip or a simple artery clip can infarction) (14). Patients who require posterior
be used. An anterior BIPP pack is placed around packing need close observation as it implies
the catheter. It is essential to ensure that the significant epistaxis.
catheter or clip does not rest on the nares as they
can rapidly cause pressure necrosis of the alar rim Packs, either anterior or posterior are left in for
with subsequent notching. Gauze or cotton wool up to 24 hours and no longer than 48 hours. If the
should be used to protect the alar margin. patient has any risk factors for endocarditis, oral
antibiotic cover (e.g. amoxicillin) is given while
Other complications reported with posterior packs are in place.
nasal packing are respiratory (e.g. obstructive

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

VESSEL LIGATION
Endoscopic sphenopalatine artery (SPA) ligation is If SPA/maxillary artery ligation fails to control
now commonly employed as the primary surgical bleeding, or in cases of traumatic epistaxis (with
procedure for epistaxis when operative intervention possible ethmoid fracture), then the anterior
is required (15). The SPA is the major blood supply to and posterior ethmoid arteries can be ligated.
the posterior aspect of the nasal cavity, and may have This is performed via an external approach
multiple branches that require ligating individually. using a modified Lynch–Howarth incision.

Transantral maxillary artery ligation, via a If bleeding continues despite these measures, then
Caldwell Luc approach in most cases, has become the external carotid artery may be ligated in the
less popular with the advent of the endoscopic SPA neck (16).
technique, which is much less invasive.

EMBOLIZATION
Some centres will have access to radiological procedure, as angiography is required to
embolization. This may be employed if other identify the bleeding vessel before particulate
measures have failed, or if general anaesthesia embolization can be performed. Patients must
must be avoided due to significant comorbidities. be warned of the risk of stroke, skin and palate
Patients must be actively bleeding for this necrosis (17).

46 ENT: An Introduction and Practical Guide

HEREDITARY HAEMORRHAGIC TELANGIECTASIA
This autosomal dominant condition warrants 2 Janfaza P, Montgomery WW, Salman SD.
specific mention, as its most common symptom 2001. Nasal cavities and paranasal sinuses.
is epistaxis. There are multiple telangiectasias of In: Janfaza P, Nadol JB, Galla RJ, Fabian RL,
the nasal mucosa which are very fragile and bleed Montgomery WW, editors. Surgical Anatomy
with minimal trauma. Patients are generally well- of the Head and Neck. Lippincott Williams &
informed and will often not seek medical treatment Wilkins, Philadelphia.
unless the bleeding becomes severe or protracted. 3 Mackenzie D. 1914. Little’s area or the Locus
Cautery and nasal packing should be avoided if at Kiesselbachi. J Laryngol 1: 21–2.
all possible. If packing is required, an absorbable 4 Woodruff GH. 1949. Cardiovascular epistaxis
pack such as a gelatin sponge soaked in adrenaline and the naso-nasopharyngeal plexus.
is the most appropriate method, as the nasal mucosa Laryngoscope 15: 1238–47.
will be further traumatized by pack insertion and 5 Chiu TW, Shaw-Dunn J, McGarry GW. 1998.
subsequent removal. If formal packing is required, it Woodruff’s naso-nasopharyngeal plexus:
should ideally be removed in theatre under general How important is it in posterior epistaxis?
anaesthetic, when potassium titanyl phosphate (KTP) Clin Otolaryngol 23: 272–9.
or argon laser can be used to target the individual 6 Melia L, McGarry GW. 2011. Epistaxis:
lesions, or more definitive treatment such as Update on management. Curr Op Otolaryngol
septodermoplasty or nasal closure can be performed Head Neck Surg 19: 30–5.
(18). Vessel ligation and embolization provide only a 7 Bray D, Monnery P, Toma AG. 2004. Airborne
temporary solution, but may allow time to arrange environmental pollutant concentration and
for more definitive treatment as above. Such cases hospital epistaxis presentation: A 5-year
may require discussion with a specialist centre. review. Clin Otolaryngol 29: 655–8.
8 Shakeel M, Trinidade A, Iddamalgoda T,
Supriya M, Ah-See KW. 2010. Routine clotting
KEY POINTS: screen has no role in the management of
epistaxis: Reiterating the point. Eur Archiv
●● Epistaxis is a common problem Otorhinolaryngol 267: 1641–4.
that is potentially life-threatening; 9 Thong JF, Lo S, Houghton R, Moore-Gillon V.
resuscitation may be required. 2007. A prospective comparative study to
●● Cautery of the bleeding point is often examine the effects of oral diazepam on blood
successful, as most primary epistaxis pressure and anxiety levels in patients with
arises from the anterior septum. acute epistaxis. J Laryngol Otol 121: 124–9.
●● Anterior with or without posterior nasal 10 Webb CJ, Beer H. 2004. Posterior nasal
packing may be required to control cautery with silver nitrate. J Laryngol Otol
profuse bleeding. 118: 713–4.
●● Recalcitrant cases require timely 11 Ahmed A, Woolford TJ. 2003. Endoscopic
operative intervention. bipolar diathermy in the management of
epistaxis: An effective and cost-efficient
treatment. Clin Otolaryngol 28: 273–5.
12 Van Wyk FC, Massey S, Worley G, Brady S.
REFERENCES 2007. Do all epistaxis patients with a nasal
1 McGarry GW. 2008. Epistaxis. In: Gleeson pack need admission? A retrospective study
MJ, editor. Scott-Brown’s Otorhinolaryngology of 116 patients managed in accident and
Head & Neck Surgery. 7th ed. Hodder Arnold, emergency with a peer-reviewed protocol.
London. J Laryngol Otol 121: 222–7.

Epistaxis 47
13 Mathiasen RA, Cruz RM. 2005. Prospective, 16 Srinivasan V, Sherman IW, O’Sullivan G. 2000.
randomized, controlled clinical trial of a novel Surgical management of intractable epistaxis:
matrix hemostatic sealant in patients with An audit of results. J Laryngol Otol 114: 697–700.
acute anterior epistaxis. Laryngoscope 115: 17 Sadri M, Midwinter K, Ahmed A, Parker A.
899–902. 2006. Assessment of safety and efficacy of
14 Rotenberg B, Tam S. 2010. Respiratory arterial embolization in the management
complications from nasal packing: Systematic of intractable epistaxis. Eur Archiv
review. J Otolaryngol Head Neck Surg 39: Otorhinolaryngol 263: 560–6.
606–14. 8 Rimmer J, Lund VJ. 2015. Hereditary
1
5 Douglas R, Wormald P. 2007. Update on
1 haemorrhagic telangiectasia. Rhinology
epistaxis. Curr Op Otolaryngol Head Neck Surg 53: 195–203.
15: 180–3.

48 ENT: An Introduction and Practical Guide

5 AUDIOLOGY
Neil Donnelly

The principal function of audiological testing is Tests of hearing are divided into behavioural
to establish hearing thresholds accurately and and objective. When presented with sound, each
to determine whether there is any impairment. aspect of the auditory pathway responds in a way
If impairment is detected, testing is used to that can be measured. This response may be the
establish the site, type (conductive, sensorineural test subject performing a specific task to indicate
or mixed) and severity of the hearing loss hearing a sound stimulus (behavioural response)
(Figure 5.1). or the measurement of a physical property of the

–10

0
NORMAL
10

30 MILD

40
Hearing level (dB)

50
MODERATE
60

80 SEVERE

100
PROFOUND
110

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

Figure 5.1. Levels of hearing loss.

Audiology 49
system (objective response). Objective tests do not sensation. They do, however, allow for certain
require the active cooperation of a subject and are inferences to be made regarding a subject’s ability
not a true measure of hearing, which is a subjective to hear.

BEHAVIOURAL AUDIOMETRY
Pure tone audiometry is a scale of human hearing where 0 dB HL reflects
the threshold of hearing of an otologically normal
Indication individual irrespective of its frequency. It is against
this normal hearing population that an individual’s
●● To establish hearing thresholds. hearing is compared.

Pure tone audiometry is used to provide threshold Pure tone audiometry is performed in accordance
information and to identify the presence and with the British Society of Audiology’s recommended
magnitude of any hearing loss. Thresholds are procedures (1). Testing is ideally carried out in a
usually measured both for air conduction (via sound proof acoustic booth to minimize background
headphones) and for bone conduction (via a bone noise. Frequency-specific sound stimuli are first
vibrator). The information provided by pure tone delivered via headphones to test air conduction
audiometry may be plotted graphically as an thresholds. Patients are instructed to indicate (by
audiogram. The audiogram represents hearing pressing a button) when they hear a tone, however
sensitivity (dB HL) across a discrete frequency faint. Testing begins with the better hearing ear
spectrum (125–8000 Hz). A wide variety of symbols and frequencies (250–8000 Hz) are tested in a
are used to denote the findings (Figure 5.2). specified order. Stimuli are initially presented at
30 dB above expected threshold. This is increased
O Right air conduction thresholds
in 20 dB steps if not initially heard. The stimulus
is then lowered in 10 dB steps until no longer
X Left air conduction thresholds heard and raised in 5 dB steps until a threshold
∆ Unmasked bone conduction becomes evident. There must be a minimum of two
[ Right bone conduction thresholds
responses at that level. The threshold is marked
on the audiogram with the appropriate symbol.
] Left bone conduction thresholds Bone conduction thresholds are undertaken with a
Threshold poorer at that level, but bone vibrator placed on the mastoid process of the
cannot be determined because of ear with the worst air conduction thresholds. It is
limited output of the audiometer only possible to test frequencies between 250 and
4000 Hz. The maximum output of the bone vibrator
Figure 5.2. Symbols commonly used in pure tone is approximately 70 dB; stimulation beyond these
audiometry.
levels may result in the vibrations being felt rather
than heard.
The reason for using a hearing level scale rather
than sound pressure level (SPL) scale reflects the Air conduction thresholds represent the sensitivity
fact that the threshold of hearing as measured of the hearing mechanism as a whole (conductive,
in SPL is not the same across all frequencies. For sensorineural and central components), whereas
example, less energy is required to detect a 1000 Hz bone conduction thresholds represent the
sound at threshold (7.5 dB SPL) than at 125 Hz sensitivity of the hearing mechanism from the
(47.5 dB SPL); the resulting audiogram would be cochlear onwards. Any difference between the
particularly difficult to interpret. The dB HL scale two thresholds is referred to as an air–bone gap

50 ENT: An Introduction and Practical Guide

(ABG). An ABG is attributed to a problem in the For example, when the hearing acuity of the ears
conduction mechanism and hence referred to as a is very different it is possible that when testing the
conductive hearing loss. worse ear, the better ear detects the test signal more
easily. In this situation special techniques (masking)
In reality, sound through bone conduction reaches are employed to ‘exclude’ the non-test ear.
the cochlea in three ways:
In order to understand cross-hearing it is
1 Sound escapes to the external ear canal and is necessary to understand how sound travels to
subsequently transferred to the cochlea through the cochlea during audiological testing using the
the normal middle ear mechanism. headphones and the bone vibrator. When a sound
2 Vibrations travel directly through the middle is presented via headphones to one ear, part of the
ear ossicles and then to the cochlea. energy escapes and vibrates the skull. This sound
Vibrations reach the cochlea directly through
3 energy is transmitted via bone conduction to the
the skull. cochlea of the opposite side and is attenuated
(loses sound energy) by approximately 40 dB
If there is an external or middle ear pathology (Figure 5.3(a)).
resulting in a conductive hearing loss, sound will
be poorly transmitted by the first two routes, A bone vibrator, on the other hand will vibrate the
resulting in poorer bone conduction thresholds entire skull regardless of where it is placed, with
than expected. This effect is greatest at 2 kHz and sound energy being transmitted to both cochleas
explains the Carhart notch seen in otosclerosis. It with little or no attenuation (0 dB). It therefore
also explains why correcting a conductive hearing corresponds to the best hearing cochlea, regardless
loss can result in an apparent over closure in the of the side tested (Figure 5.3(b)). For this reason, it
bone conduction thresholds. is the sensitivity of the better hearing cochlea that
determines whether masking is required, not the
As discussed above, pure tone audiometry presents better hearing ear.
sound to one ear at a time, and the response
measured. However, in certain conditions it is not The three particular rules are employed to help
possible to be certain that the intended (test) ear determine whether masking is needed (2).
is the one actually responding. In some cases the
non-test ear can pick up the sound just as well or Rules of masking
better, a phenomenon known as cross-hearing
(Figure 5.3). Rule 1 – When testing air conduction, if the
threshold between the two ears differs by
40 dB or more at any frequency, the worse
(a) (b) ear becomes the test ear and the better ear is
masked.
Rule 2 – When testing bone conduction, if the
–40 dB
not-masked bone conduction threshold at
any frequency is better than the worse ear
air conduction threshold by 10 dB or more,
the worse ear by air conduction becomes the
test ear and the better ear is masked. This
provides ear-specific masked bone conduction
thresholds.
Figure 5.3. (a) Transcranial attenuation through air Rule 3 – When testing air conduction, if rule 1
and (b) bone conduction. has not been applied (i.e. interaural AC

Audiology 51
difference less than 40 dB), but the not- as mild, moderate, severe or profound
masked bone conduction threshold is better (Figure 5.4(a–d)).
by 40 dB, then the not-masked air conduction ●● With a pure conductive hearing loss, the
is attributed to the worse ear. The worse ear ear specific masked bone conduction
becomes the test ear and the better ear is then threshold is normal while there is a gap
masked. of more than 10 dB between the air
and bone conduction thresholds (Figure 5.4(b)).
Interpretation of an audiogram This gap is known as the air–bone gap (ABG).
●● With a pure sensorineural hearing loss, both
●● Air and bone conduction thresholds equal the ear-specific air and the bone conduction
to or better than 20 dB are considered to be thresholds are worse than 20 dB, but there is no
within normal limits (Figure 5.4(a)). Beyond ABG (Figure 5.4(c)).
20 dB, the degree of hearing loss is classified

(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
1 2 5 2 5 0 500 1000 2000 4000 8 0 0 0 1 2 5 2 5 0 500 1000 2000 4000 8 0 0 0
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.

52 ENT: An Introduction and Practical Guide

●● In a mixed hearing loss, the ear-specific bone ●● Asymmetry in thresholds is considered
conduction thresholds are worse than 20 dB and significant if there is more than 10 dB difference
there is an ABG greater than 10 dB (Figure 5.4(d)). between the ears at two adjacent frequencies.

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

100 30
2
Normal 1
Conductive
Number of phonemes correctly repeated
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.

Audiology 53
OBJECTIVE AUDIOMETRY
Tympanometry probe tone unless testing infants less than four
months old, for whom a 1 kHz stimulus is used.
Indications A proportion of the sound energy is transmitted
through the middle ear apparatus and the rest is
●● In conjunction with audiometry to characterize reflected. The probe microphone records reflected
hearing loss. sound energy. The more compliant the middle
●● To document normal middle ear compliance. ear system, the less energy reflected. Because the
compliance of the tympanic membrane is maximal
Tympanometry is not a test of hearing, but is used when the pressure between its two sides is equal, it
in conjunction with pure tone audiometry to help is possible to measure the middle ear pressure by
determine the nature of any hearing loss. altering the pressure in the external ear canal via
the pump channel in the ear probe.
Tympanometry measures the compliance of the
middle ear system. Factors influencing middle The test generates a tympanogram. This is a
ear compliance include the integrity and mobility graphical representation of the compliance of the
of the tympanic membrane and ossicular chain, tympanic membrane as a function of the change in
the presence of fluid and middle ear pressure. pressure in the external ear canal. Tympanograms
Tympanometry is therefore used clinically to are most commonly described according to the
provide information regarding the state of the Jerger system of classification (3). There are three
tympanic membrane, ossicular chain, middle ear types:
cleft and Eustachian tube function.
Type A – Demonstrates a well-defined peak
The test involves placing a small probe in the ear compliance of between +100 and −150 daPa
canal to form an airtight seal. The probe contains (Figure 5.6(a)). It signifies normal middle ear
a sound generator, microphone and pump, all pressure.
connected to a tympanometer. A sound stimulus Type B – Demonstrating no obvious peak
is passed down the ear canal to the tympanic across the pressure range (Figure 5.6(b)).
membrane. The stimulus used is a 226 Hz Interpretation depends on the measured ear

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.

54 ENT: An Introduction and Practical Guide

canal volume. This should be less than 1 cm3 Type C – Demonstrates a well-defined compliance
in a child and less than 1.5 cm3 in an adult. If peak at less than −150 daPa (Figure 5.6(c)).
the ear canal volume is normal, the flat trace is This most commonly signifies Eustachian tube
likely to represent a middle ear effusion. If the dysfunction or a partial middle ear effusion.
ear canal volume is increased, then the finding
is likely to represent a tympanic membrane Tympanometry does not provide information
perforation or presence of a patent grommet. about hearing, and inferences must be made in
conjunction with information from other tests.

AUDITORY EVOKED POTENTIALS

Indications Four types of AEP are in common clinical usage:

●● To establish likely hearing thresholds. 1 Electrocochleography – This measures electrical

●● To identify cochlear or retro-cochlear pathology. activity within the cochlea and first-order
cochlear nerve fibres in response to sound.
Auditory evoked potentials (AEPs) describe the The electrocochleogram (ECochG) records
electrical activity within the cochlea and along three potentials: the cochlear microphonic
the auditory pathway in response to auditory (CM), the summating potential (SP) and the
stimulation. The test involves a sound stimulus action potential (AP). Common clinical uses
being presented to the test ear. This results in include frequency-specific estimation of hearing
electrical activity within the auditory pathway. thresholds in the very young or difficult to
Scalp electrodes detect this and other non-auditory test and the determination of endolymphatic
activity. The electrodes pass information to an hydrops in Ménière’s disease.
amplifier which amplifies and filters differences Auditory brainstem responses (ABR) – The
2
between pairs of electrodes. The stimulus is auditory brainstem response is a series of
presented repeatedly and the recordings averaged. five waves occurring within 10 ms of a sound
The process of amplification, filtering and averaging stimulus (Figure 5.7). Each wave is attributed
results in evoked potential (signal) being separated to a different part of the auditory pathway from
from non-auditory electrical activity (noise). distal auditory nerve to inferior colliculus.

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 in waves.

Audiology 55
ABR has a number of clinical uses, principally steady state responses (ASSR) analysis is based
the estimation of hearing thresholds using wave on the fact that related electrical activity
V. Because the ABR is present from birth it is a coincides with the stimulus repetition rate and
useful hearing screening tool for neonates. The relies on statistical detection algorithms. The
precise latency of each waveform has previously test can be used as an automated assessment of
been exploited to detect pathology affecting the auditory thresholds.
cochlear nerve, in particular as a screening test Cortical auditory evoked potentials (CAEPs) –
4
for vestibular schwannomas. In this condition Evoked potentials occurring beyond 50 ms are
there can be a delay in the latency of wave V. referred to as CAEPs. They span the transition
This has now been superseded by contrast- from obligatory to cognitive responses. They
enhanced magnetic resonance imaging (MRI). can be generated using frequency stimuli. The
Auditory steady state responses (ASSR) – This
3 accurate correspondence with true frequency-
is a test that uses frequency-specific stimuli specific hearing thresholds make this a useful
modulated with respect to amplitude and test in medico-legal assessment of hearing
frequency. Higher modulation rates generate for compensation cases and for diagnosis in
AEP derived from the brainstem. Auditory suspected non-organic hearing loss.

OTOACOUSTIC EMISSIONS
Indications distortion product OAEs (DPOAEs). The test
involves placing a small insert in the ear canal,
●● Hearing screening. which contains a sound generator and microphone
and is attached to an OAE machine. A stimulus
Otoacoustic emissions (OAEs) represent sound is generated and any ensuing emission measured.
energy generated by the contraction and expansion The test is performed in a quiet environment. In
of outer hair cells in the cochlear. These echoes can addition to being able to infer hearing thresholds
be measured by sensitive microphones placed in of better than 40 dB HL, these tests provide
the ear canal. OAEs are classified into two groups: frequency-specific information in the speech
spontaneous (only present in 50% of population) frequencies (500–4000 Hz).
and evoked. Evoked OAEs are emissions generated
in response to a sound stimulus and are present in Absent evoked OAEs do not necessarily reflect
the majority of individuals with hearing thresholds a cochlear hearing loss and can arise if the ear
better that 40 dB HL. In fact, OAEs are present canal is blocked or if there is middle ear pathology
in 99% of individuals with thresholds better than (i.e. an effusion). If OAEs are genuinely absent,
20 dB and always absent with thresholds over no inference as to the degree of loss can be made,
40 dB. Between 20 and 40 dB there is a zone of which can range from mild (zone of uncertainty)
uncertainty. For this reason they have been widely to profound. Additionally, robust OAEs may be
adopted as a hearing screening tool (4). found in individuals with auditory neuropathy
spectrum disorder, who may have a profound
Clinically, two main types of evoked OAEs are hearing loss.
used: transient evoked OAEs (TEOAEs) and

56 ENT: An Introduction and Practical Guide

●● Graham J, Baguley D. 2009. Ballantyne’s
KEY POINTS: Deafness. Wiley-Blackwell, Chichester.
●● Katz J, Medwetsky L, Buckard RF, Hood LJ 6th
●●Ensure testing equipment is edition 2010). Handbook of Clinical Audiology.
maintained and meets the appropriate Lippincott Williams & Wilkins.
National Physical Laboratory
calibration schedule.
REFERENCES
●●Expertise is required for both the 1 British Society of Audiology. 1981.
testing and interpretation of results. Recommended procedures for pure-tone
●●Ensure that appropriate ear-specific audiometry using a manually operated
information is obtained. Have instrument. Br J Audiol 15: 213–6.
masking rules been applied? 2 British Society of Audiology. 1986.
●●No single test provides all the answers. Recommendations procedures for masking in
pure tone threshold audiometry. Br J Audiol 20:
●●Beware of discrepancies. Where
307–14.
outcomes of tests are unexpected
3 Jerger J. 1970. Clinical experience with
and do not fit with observed auditory
impedance audiometry. Arch Otolaryngol 92:
function, check that the equipment
311–24.
is functioning normally and that the
4 Rea PA, Gibson WP. 2003. Evidence for
test subject is performing the test
surviving outer hair cell function in
appropriately.
congenitally deaf ears. Laryngoscope 113:
2030–4.

✱✱RECOMMENDED READING
●● Browning GG (2nd edition 1998). Clinical
Otology & Audiology. Butterworth-Heinemann,
London.

Audiology 57
6 TONSILLECTOMY
James Tysome

Indications ●● To access a parapharyngeal abscess.

●● Rarely to access an elongated styloid process in
●● Recurrent acute tonsillitis. the management of Eagle 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 for
●● In cases of an unknown primary (i.e. a metastatic this procedure varies from unit to unit. Whilst the
deposit in a neck lymph node), tonsillectomy may Scottish Intercollegiate Guidelines Network (SIGN)
be indicated in order to exclude this as a site for recommendations are helpful (suggesting patients
the primary in conjunction with a panendoscopy. who suffer five or more episodes of tonsillitis per
●● As part of an uvulopalatopharyngoplasty annum benefit from this procedure) a decision must
performed for the treatment of snoring. be made on a case-by-case basis (1, 2).

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

OPERATIVE PROCEDURE
Once anaesthetized and the airway secured an appropriately-sized blade is inserted and the
with an endotracheal tube (ET), a shoulder mouth gently opened. The tongue is positioned
bolster is placed under the patient and the neck in the midline by sweeping the tongue base with
extended. The patient’s eyes must be taped closed. digital manipulation. Draffin rods are used to
A headlight is worn by the surgeon and the patient support and lift the gag. The head must remain
draped. supported on the operating table.

The operation is performed from the head of the Secretions are cleared from the oral cavity using
operating table. A Boyle–Davis mouth gag with suction (Figure 6.1(a)).

58 ENT: An Introduction and Practical Guide

(a) (b)

Tongue blade

Tonsil
Anterior pillar
Grasping forceps Gutter

Soft palate Soft palate

Diathermy forceps

Gutter

(e)

Clip on
lower pole

Figure 6.1. Bipolar tonsillectomy.

Tonsillectomy 59
In order to remove the right tonsil, Dennis–Brown Haemostasis is achieved using bipolar diathermy
or Luc’s forceps are held in the surgeon’s left hand or further ties. Once haemostasis has been
and the superior pole of the right tonsil is gently achieved, the gag is relaxed for 30 seconds and
grasped and pulled medially (Figure 6.1(b)). This, the mouth reopened. The fossae are inspected for
in most cases, produces a visible gutter in the bleeding and dealt with accordingly. Gentle use of
anterior tonsillar pillar, which marks the lateral the sucker to remove blood from the base of the
limit of the tonsil. The mucosa is incised using tongue and under the soft palate is accompanied
McIndoe scissors or cauterized with bipolar by the passage of a Jacques suction catheter
forceps (Figure 6.1(c)). The scissors can then be through the nose to remove a potential ‘coroner’s’
gently inserted into the incision and opened to clot from the postnasal space. If not removed,
develop the plane between the tonsil and the this clot may fall into and obstruct the airway, to
superior constrictor muscle fibres. At this stage, be retrieved only later by the coroner. Suction is
the forceps are repositioned with the superior attached and the catheter gently withdrawn.
blade within this developed plane and the inferior
blade over the medial surface of the tonsil. The Boyle–Davis gag is relaxed and carefully
removed. The endotracheal tube may on occasion
A Gwynne–Evans dissector or bipolar diathermy
herniate into the tongue blade and hence the patient
forceps may be used to separate the muscle fibres
may be inadvertently extubated. This will result in a
from the white capsule of the tonsil, which should
significant airway compromise and must be avoided.
gradually peel away. Bleeding is inevitable during
this part of the procedure but identifying the
A survey of the teeth must be performed to
tonsillar capsule early and staying within the
document any dental trauma (or loss which will
correct plane will minimize its extent. Continued
require retrieval of the tooth). The jaw must also
traction with the forceps is the key to a clean and
be assessed to exclude a temporo-mandibular
brisk dissection (Figure 6.1(d)).
joint dislocation. It is also essential to confirm
that all the tonsil swabs have been removed.
As the dissection proceeds, a small ‘stalk’ of
Tonsillectomy using coblation has grown in
tissue tethers the tonsil at its inferior pole. This
popularity, particularly in paediatric cases where
usually bears a significant feeding arterial vessel
an intracapsular tonsillectomy can be performed,
(the tonsillar branch of the ascending pharyngeal
which decreases postoperative pain and can lead
artery) which requires clipping with a curved
to a more rapid recovery. However, it does carry
Negus clip and tying with silk (Figure 6.1(e)).
a greater risk of tonsil regrowth that may require
The clip is then slowly removed as the tie is thrown
further surgery in the future.
and the tie then trimmed. The tonsillar fossa
is packed with a tonsil swab while dissection is
performed on the opposite side.

POSTOPERATIVE REVIEW AND FOLLOW-UP

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

60 ENT: An Introduction and Practical Guide

POST-TONSILLECTOMY HAEMORRHAGE
This is a potentially life-threatening emergency haemorrhage. This can be achieved by diathermy
and should be managed as such. Patients must or application of a tie. However, the tissue is
be assessed in the Emergency Department. generally friable in these situations; laying a strip
Assessment should include the ABC algorithm of Surgicel within the tonsillar fossa and over-
with early cannulation using wide-bore cannulae. sewing the anterior and posterior pillars together
Blood must be taken for a full blood count, with a heavy stitch may be required.
clotting screen and group and save.

If the bleeding has spontaneously stopped, patients REFERENCES

are admitted for observation. 1 Management of sore throat and indications
for tonsillectomy, a national clinical guideline
If bleeding persists behind a tonsillar clot, this (April 2010). Scottish Intercollegiate Guidelines
should be removed with a Yankauer sucker or Network, Guideline 117.
Magill’s forceps. A tonsil swab or ribbon gauze 2 Lowe D, Van der Meulen J, Cromwell D
soaked in 1:5000 adrenaline can be held over the et al. 2007. Key messages from the National
bleeding point and may achieve haemostasis. Prospective Tonsillectomy Audit. Laryngoscope
117(4): 717–24.
If these measures fail, the patient is transferred
to theatre for emergency surgical arrest of the

Tonsillectomy 61
7 ADENOIDECTOMY
Ketan Desai

Indications ●● In conjunction with grommet insertion.

Adenoidectomy may decrease the risk of further
●● Obstructive sleep apnoea. persistent bilateral otitis media with effusion
requiring grommets in the future.

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

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

62 ENT: An Introduction and Practical Guide

Haemostasis is confirmed by tilting the head Gentle traction is used to elevate the soft palate.
forward and inspecting for any bleeding. A mirror is inserted into the oral cavity and used
Further brisk bleeding requires repacking to assess the adenoidal pad. If enlarged, suction
of the postnasal space. Occasionally, suction diathermy is used to cauterize the surface of
diathermy or adrenaline soaked packs may be the pad.
required.
The stem of the suction diathermy is angled to
Suction diathermy allow access to the adenoidal pad. Great care
must be taken to avoid injury to the surrounding
This technique has recently gained popularity structures, including the Eustachian tube
(Figure 7.1) (1, 2). Evidence suggests that suction cushions. Adequate clearance is gained
diathermy adenoidectomy results in less intra- when both choanae are clearly visible and
operative blood loss, less remnant adenoidal the posterior pharyngeal wall has a smooth
tissue and less postoperative nasal regurgitation contour.
of food (3).
Complications
Once anaesthetized, the patient is placed supine
and a shoulder roll inserted in order to extend ●● Bleeding.
the neck. A Boyle–Davis mouth gag is inserted ●● Infection.
and supported with Draffin rods. Jacques ●● Grisel’s syndrome – atlanto-axial subluxation
catheters are passed through each nostril and due to ligamentous laxity as a result of
the distal ends are drawn out of the oral cavity. 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 63
POSTOPERATIVE REVIEW
Patients may develop minor neck stiffness and
regular analgesia should be taken for up to a week. REFERENCES
Prophylactic oral antibiotics may also be prescribed. 1 Hartley BE, Papsin BC, Albert DM. 1998.
If torticollis occurs, this may indicate Grisel’s Suction diathermy adenoidectomy. Clin
syndrome 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
reduces the risk of viral transmission and the endoscope. Clin Otolaryngol 31: 440–2.
development of secondary haemorrhage. In 3 Suction Diathermy Adenoidectomy (December
children this requires one week off school. Should 2009). NICE guidance IPG328. www.nice.org.
bleeding occur, the patient should attend the uk/nicemedia/live/12127/46633/46633.pdf.
Emergency Department immediately.

64 ENT: An Introduction and Practical Guide

8 GROMMET INSERTION
Rahul Kanegaonkar

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

PATIENT INFORMATION AND CONSENT

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

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

Grommet insertion 65
The anteroinferior quadrant is identified and a needle is usually required to push the grommet
a myringotome used to make a radial incision into place (Figure 8.1(h)).
from the umbo towards the annulus (Figure
8.1(b)). As the incision is performed, a note A grommet inadvertently pushed into the middle
is made of the presence of an effusion and its ear may be retrieved by a senior colleague.
appearance (Figure 8.1(c)). This is removed
gently with suction using a fine end attached to a The use of topical ear drops immediately following
Zoellner sucker. 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 8.1(e), (f)). Once firmly grasped, Complications
the long axis of the grommet should be in line with
the long axis of the forceps (Figure 8.1(g)). ●● 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 perforation (3).

(a) Promontory (b)

Long process
of incus
Line of
Round incision
window Myringotome
niche

(d)
(f)
(e)

Middle
ear effusion

Sucker

(g) (h) (i)

Grommet
in place
Curved needle
Crocodile forceps

Figure 8.1. Grommet insertion.

66 ENT: An Introduction and Practical Guide

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

Grommet insertion 67
9 SEPTOPLASTY
Joanne Rimmer

Nasal obstruction due to a deviated nasal septum Indications

was previously corrected by submucous resection
(SMR). This involves excising much of the septal ●● Nasal obstruction secondary to a deviated nasal
cartilage and bone, irrespective of the deviation, septum. Patient selection is paramount. Those
leaving an ‘L-strut’ of dorsal and caudal septum with nasal obstruction due to septal deviation
for support. This procedure has given way to alone have an excellent outcome (3). If the
septoplasty, which involves resection of as little obstruction is mainly due to mucosal disease
septal cartilage and bone as possible (Figure 9.1), (e.g. allergic rhinitis) then the results are often
specifically at areas of deviation, and aims to less satisfactory (4).
reposition the septum in the midline (1). This ●● Cosmetic correction of a deviated nose as part
retains more septal support, and reduces the risk of a septorhinoplasty. If there is severe deviation
of postoperative septal perforation (2). of the mid- and lower thirds of the nose, such

Perpendicular plate
of ethmoid
Keystone area

Quadrilateral
cartilage Vomer

Maxillary crest

Figure 9.1. The nasal septum.

68 ENT: An Introduction and Practical Guide

as in the twisted nose, then an extracorporeal ●● In the management of epistaxis where a
septoplasty technique may be required (5). deviated septum prevents adequate nasal
●● To facilitate the use of nasal continuous positive packing.
airway pressure (CPAP) devices in obstructive ●● To harvest septal cartilage for use as an
sleep apnoea (OSA). autograft.
●● Access for endoscopic sinonasal or skull base
procedures.

OPERATIVE PROCEDURE
An appropriately informed, consented and Compensatory hypertrophy
anaesthetized patient is positioned supine, head of the right inferior turbinate
up or in a beach chair position, with a head ring
for support. Topical nasal preparations such as
Moffett’s solution (a variable mixture of cocaine,
adrenaline, normal saline and sodium bicarbonate)
(6) or co-phenylcaine spray (5% lidocaine and 0.5%
phenylephrine) may be instilled into the nose to
improve the surgical field. The patient’s eyes are
taped closed or lubricating ointment is instilled.
The surgeon wears a headlight, although the
procedure may be performed endoscopically (7).

Skin preparation is not routinely used. The patient

is draped with a head towel and the face is exposed
from the eyebrows to upper lip. The nasal cavities
and septal deviation are then assessed using a
Killian’s or Cottle’s nasal speculum. It is important
to identify the side and site of the deviation, and
relate this to the patient’s obstructive symptoms Figure 9.2. Septal deviation to the left.
(Figure 9.2).

A short nasal speculum is held with one blade on mucocutaneous junction (Killian’s incision)
either side of the caudal edge of the quadrilateral (Figure 9.4). It is often easier to find the correct
cartilage, and both sides of the septum are infil plane of dissection using a Killian’s incision, but it
trated with a solution of 2% lidocaine with 1:80,000 is difficult to address very caudal septal deviations
adrenaline using a dental syringe (Figure 9.3(a)). though this incision. The incision is usually made
The mucoperichondrium should blanche following on the left (for a right-handed surgeon), but in
infiltration, which aids haemostasis. certain cases (e.g. caudal septal dislocation to the
right) the surgeon may elect to make the incision
A number 15 scalpel blade is used to incise on the right.
the mucoperichondrium down to cartilage
(Figure 9.3(b)). This incision can be placed along It is important to find the correct plane for
the caudal edge of the quadrilateral cartilage at dissection; this is subperichondrial, between the
the septocolumellar junction (hemitransfixion cartilage and the perichondrium. It is all too
incision) or approximately 0.5 cm behind the easy to dissect the plane between perichondrium

Septoplasty 69
(a) (b)

Figure 9.3. Infiltration of the septal mucosa (a) before an incision is made (b).

Hemitransfixion incision

Killian’s incision

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

and mucosa in error. Perichondrium has a pale may be pressed firmly into the incision against the
pink appearance due to its blood supply, whereas cartilage to assist dissection (Figure 9.5).
septal cartilage has a shiny white/pale blue colour.
If a hemitransfixion incision has been made, Once the plane has been identified, insert
sharp pointed scissors are helpful initially as the a Freer elevator between the cartilage
mucopericondrium is tethered anteriorly due to and mucoperichondrium and raise the
McGilligan’s fibres. The shortest nasal speculum mucoperichondrial flap carefully along the full

70 ENT: An Introduction and Practical Guide

The procedure from this point is determined by the
site and extent of the deviation. If the quadrilateral
cartilage is attached to a deviated bony septum,
incise the osseochondral junction to release it
posteriorly. The area of cartilaginous deviation
may be amenable to resection, in which case
Exposed the quadrilateral cartilage is fully incised at the
cartilage appropriate point (often the most deviated part),
Mucoperichondrial and then a partial contralateral flap is elevated
flap posteriorly from the transcartilaginous incision to
allow removal of the intervening piece of cartilage
or bone (Figure 9.6(a–c)). If removing bony septum
Figure 9.5. A Freer elevator is used to dissect the is required, scissors or through-cutting forceps
mucoperichondrium from septal cartilage. (e.g. Jansen-Middleton forceps) should be used in
order to avoid twisting the perpendicular plate of
the ethmoid (PPE), as there is a theoretical risk
length of the septum. It is often easier to elevate of skull base fracture at the cribriform plate with
the flap superiorly first, where it is less adherent, subsequent cerebrospinal fluid (CSF) leak.
and continue inferiorly and posteriorly with gentle
sweeping movements. When removing quadrilateral cartilage, it is vital
to understand the major areas of support that
Care must be taken not to tear the flap, which can should not be resected. The most important is the
be particularly difficult over spurs or fracture lines. keystone area (Figure 9.1); this is the junction of
Another area of difficulty is at the junction of the the quadrilateral cartilage, PPE, nasal bones and
septal cartilage and maxillary crest bone inferiorly, upper lateral cartilages. The cartilage and bone
as the mucoperiosteum overlying the latter is more should not be completely separated at this point
tightly adherent than the mucoperichondrium to avoid dorsal collapse. It is advisable to leave
is to the quadrilateral cartilage, and the two are at least 1 cm dorsal and caudal struts of septal
not in continuity. It can be helpful to raise the cartilage for support, although in practice one
mucoperiostium more posteriorly over the vomer would aim to leave much more cartilage in place
first, and then continue the dissection anteriorly if feasible. Bony spurs inferiorly may be resected
with a hockey stick dissector. using a fishtail gouge. The septal cartilage may

(a) (b) (c)

Transcartilaginous
incision

Figure 9.6. An incision is made through the septal cartilage (a). A Freer elevator is passed through the
incision and the mucoperichondrium elevated off the cartilage on the contralateral side (b). Turbinectomy
scissors may be used to excise the deviated cartilage (c).

Septoplasty 71
be incised (often along fracture lines) in order to necessary in severe and/or caudal deviations, and
help repositioning, and various scoring, cutting is avoided if possible to reduce the risk of septal
and suturing techniques have been described, perforation.
particularly to address the most difficult problem
of caudal deviation (8,9). Once the deviation has been corrected, the incision
is closed with a 4/0 or 5/0 absorbable suture. The
It is sometimes necessary to elevate a complete same suture should be used to ‘quilt’ the septum
contralateral mucoperichondrial flap, in which with continuous through-and-through mattress
case the plane can be followed over the caudal sutures. This reduces the risk of septal haematoma
edge of the quadrilateral cartilage onto the right formation by closing the dead space (Figure 9.7).
side and dissected as above. This is usually only Nasal packing is not routinely inserted.

Figure 9.7. Continuous quilting suture of the nasal septum, secured anteriorly.

POSTOPERATIVE REVIEW
The patient can be discharged the same day or the ●● Ongoing symptoms – Either related to
next day according to local protocol. Discharge persistent/recurrent deviation as septal cartilage
medication should include analgesia and nasal has ‘memory’, or to concurrent mucosal disease.
douches. Patients are advised to take 7–14 days off ●● Septal perforation – Usually asymptomatic, but
work, avoid nose-blowing for one week and avoid may cause crusting, bleeding or whistling.
heavy lifting or strenuous exercise for two weeks. ●● Cosmetic change – Significant collapse (saddle
Follow-up should be after three months. nose) is rare, but subtle changes are probably
underrecognised by patients and surgeons.
Complications

●● Bleeding – Some oozing is normal but heavy REFERENCES

epistaxis requires return to hospital and may 1 Fettman N, Sanford T, Sindwani R. 2009.
warrant nasal packing. If a septal haematoma Surgical management of the deviated septum:
develops it will require draining and packing. Techniques in septoplasty. Otolaryngologic Clin
●● Infection. N Am 42: 241–52.

72 ENT: An Introduction and Practical Guide

2 Goode RL, Smith LF. 2001. Nasal septoplasty and scientific basis for the topical preparation of
and submucous resection. In: Atlas of Head & the nose. Clin Otolaryngol 29: 582–7.
Neck Surgery – Otolaryngology. 2nd ed. p. 462–4. 7 Champagne C, Ballivet de Régloix S,
Lippincott Williams & Wilkins, Philadelphia. Genestier L, Crambert A, Maurin O,
3 Moore M, Eccles R. 2011. Objective evidence Pons Y. 2016. Endoscopic vs. conventional
for the efficacy of surgical management of septoplasty: A review of the literature. Eur Ann
the deviated septum as treatment for chronic Otorhinolaryngol Head Neck Dis 133: 43–6.
nasal obstruction: A systematic review. Clin 8 Jang YJ, Yeo NK, Wang JH. 2009. Cutting and
Otolaryngol 36: 106–13. suture technique of the caudal septal cartilage
4 Karatzanis AD, Fragiadakis G, Moshandrea J, for the management of caudal septal deviation.
Zenk J, Iro H, Velegrakis GA. 2009. Septoplasty Archiv Otolaryngol Head Neck Surg 135:
outcome in patients with and without allergic 1256–60.
rhinitis. Rhinology 47: 444–9. 9 Kenyon GS, Kalan A, Jones NS. 2002.
5 Wu PS, Hamilton GS 3rd. 2016. Extracorporeal Columelloplasty: A new suture technique to
septoplasty: External and endonasal techniques. correct caudal septal cartilage dislocation. Clin
Facial Plast Surg 32: 22–8. Otolaryngol 27: 188–91.
6 Benjamin E, Wong DKK, Choa D. 2004.
‘Moffett’s’ solution: A review of the evidence

Septoplasty 73
10 SEPTORHINOPLASTY
Joanne Rimmer

There are numerous techniques involved in Indications

rhinoplasty surgery which are beyond the scope
of this book. Briefly, it can be divided into the ●● Functional – To correct nasal obstruction that
endonasal (closed) approach and the external would not be otherwise successfully managed
(open) approach (1, 2). The endonasal approach is with simple septoplasty alone.
discussed here. ●● Cosmetic correction of a deviated nose
(±septum).

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

OPERATIVE PROCEDURE
An appropriately informed, consented and The septum is infiltrated with 2% lidocaine with
anaesthetized patient should be positioned supine 1:80,000 adrenaline as for a septoplasty (Chapter 9).
or in a beach chair position, head up, with a Infiltration is continued superiorly in the nasal
head ring for support. Topical nasal preparations vestibules, along the lines of intercartilaginous
such as Moffett’s solution (a variable mixture of incisions (Figure 10.1). It is continued into the
cocaine, adrenaline, normal saline and sodium soft tissue overlying the dorsum of the nose, and
bicarbonate) or co-phenylcaine spray (5% lidocaine particularly at the incision sites for external lateral
and 0.5% phenylephrine) may be instilled into the osteotomies. The nasal hairs are removed with a
nose to improve the surgical field. The patient’s scalpel blade or short curved scissors.
eyes are taped closed (over the lateral aspect only)
or lubricating ointment is instilled. A headlight is Septoplasty is performed via a left hemitransfixion
worn, although overhead operating lights may be incision as described in Chapter 9. Once this is
used in the external approach. completed, bilateral intercartilaginous incisions are
made between the upper and lower lateral cartilages
Skin preparation is used around the nose. The (Figure 10.1). The groove between the cartilages
patient is draped with a head towel so that the face is best displayed using an alar retractor with
is exposed from eyebrows to upper lip. external pressure from the surgeon’s middle finger.

74 ENT: An Introduction and Practical Guide

Upper lateral cartilage
Line of an intercartilaginous
Lower lateral cartilage incision

Figure 10.1. Intercartilaginous incision.

Care is taken not to incise the cartilages themselves.

On the left, the incision is continued caudally into
the hemitransfixion incision. On the right, the
incision is extended caudally and through into
the left hemitransfixion incision to complete a full
transfixion incision, although this does not need to
extend completely to the base of the columella.

The dorsal nasal skin and soft tissue envelope is

then degloved with a number 15 scalpel blade or
curved scissors, taking care not to buttonhole
the skin by staying on cartilage/bone. The skin
should be freed superiorly to the nasion and
approximately halfway down the lateral walls to Figure 10.2. An osteotome may be used to remove
allow adequate visualization of the nasal dorsum a dorsal hump once the overlying soft tissue envelope
with an Aufricht retractor and the scissors to has been lifted. The line of the osteotomy is illustrated.
pass freely from one side of the nose to the other.
Release the procerus muscle at the nasion using a
periostial elevator.

A dorsal hump can be removed with a 6–8 mm

osteotome, taking care not to buttonhole the skin
at either side (Figure 10.2). The dorsum should
then be rasped smooth.

Bilateral external lateral osteotomies are

performed with a 2 mm osteotome, via two small Figure 10.3. Medial and lateral osteotomy.
stab incisions made with a number 11 scalpel
blade on either side of the nose. The line of the osteotomies may also be performed endonasally
osteotomy is ‘postage-stamped’ with multiple via a stab incision just anterior to the head of the
small osteotomies along the lines shown in inferior turbinate. Bilateral medial osteotomies
Figure 10.3. The assistant stabilizes the patient’s are performed internally, using a 4–6 mm
head while the surgeon employs the mallet. Lateral osteotome via the nasal cavity or through the

Septorhinoplasty 75
intercartilaginous incision. It should be positioned The incisions are closed with a 4/0 or 5/0
perpendicular to the caudal end of the nasal bone, absorbable suture. The same suture should be used
just lateral to the septum. The line of the osteotomy to ‘quilt’ the septum with through-and-through
is shown in Figure 10.3. The assistant gently taps mattress sutures to reduce the risk of septal
with the mallet, while the surgeon palpates the haematoma formation by closing the dead space
edge of the osteotome with the second hand to as for standard septoplasty. Steristrips are applied
ensure its position and to prevent buttonholing the over the dorsum and to support the tip, and a
skin. Firm digital pressure is used to reposition the triangular plaster of Paris is placed over these.
bones appropriately. Nasal packing is not routinely inserted.

In more complex cases, tip sutures or grafts may be

required; these are often better undertaken via an
external approach.

POSTOPERATIVE REVIEW
The patient can be discharged the same day or the ●● Ongoing obstructive symptoms – Either related
next day according to local protocol. Discharge to persistent/recurrent deviation as septal
medication should include analgesia. Patients are cartilage has ‘memory’, or to concurrent
advised to take 10–14 days off work, avoid nose- mucosal disease.
blowing for one week and avoid heavy lifting or ●● Septal perforation – Usually asymptomatic but
strenuous exercise for two weeks. They are warned may cause crusting, bleeding or whistling.
to expect periorbital bruising and swelling. Initial ●● Ongoing cosmetic concerns – Patients should
follow-up is after 7–10 days for removal of the plaster, be advised of a 5%–10% revision rate following
after which patients can begin to douche the nose. primary rhinoplasty surgery.

Complications
REFERENCES
●● Bleeding – Some oozing is normal but heavy 1 Daniel RK. 2010. Mastering Rhinoplasty. 2nd ed.
epistaxis requires return to hospital and may Springer-Verlag, Berlin Heidelberg.
warrant nasal packing. If a septal haematoma 2 Nolst Trenite GJ. 2005. Rhinoplasty: A Practical
develops it will require draining and packing. Guide to Functional and Aesthetic Surgery of the
●● Infection. Nose. 3rd ed. Kugler Publications, The Hague.

76 ENT: An Introduction and Practical Guide

11 TURBINATE SURGERY
Joanne Rimmer

Indications

●● Nasal obstruction secondary to inferior

turbinate (IT) hypertrophy refractory to
medical treatment.

OPERATIVE PROCEDURE
There is an ever-increasing number of methods
to reduce ITs, and a Cochrane review found no
high quality evidence for any one technique over
another (1). All are performed in an appropriately
informed, consented and anaesthetized patient
positioned supine or in a beach chair position,
head up, with a head ring for support. Topical
nasal preparations such as Moffett’s solution
(a variable mixture of cocaine, adrenaline,
normal saline and sodium bicarbonate) or
co-phenylcaine spray (5% lidocaine and 0.5%
phenylephrine) may be instilled into the nose to
improve the surgical field. A headlight may be Figure 11.1. Outfracture of the right inferior turbinate.
worn by the surgeon or a rigid Hopkins rod used
for endoscopic techniques. The patient’s eyes are
taped closed. Skin preparation is not routinely Radiofrequency or coblation
used. The patient is draped with a head towel with turbinoplasty
the nose exposed.
A Thudichum’s speculum is used to allow
Outfracture of inferior visualization of the IT. A radiofrequency or
turbinate coblation turbinate probe, both of which are
commercially available, is inserted into the
A Hill’ elevator is used to first infracture inferior turbinate soft tissue, medial to the bone,
(medialize) the IT and then outfracture (lateralize) and then activated. Three passes are generally
it (Figure 11.1). performed, superiorly, inferiorly, and at the

Turbinate surgery 77
(a) (b)

Figure 11.2. Radiofrequency turbinoplasty. (a) Points of turbinate probe contact. (b) Probe in situ.

midpoint of the IT (Figure 11.2). The specific can be used to reduce the soft tissue inferiorly and
techniques vary depending to the device used, but laterally prior to elevation of the medial mucosal
the radiofrequency energy is transmitted to the flap (4). A specific turbinoplasty microdebrider
submucosal soft tissue of the IT, ablating it, with a attachment is also available, which is inserted
subsequent reduction in the size of the IT (2, 3). through a stab incision as above and allows
powered removal of IT bone and soft tissue (5).
A similar technique using a submucosal
monopolar diathermy needle has been employed
for many years, but it tends to cause significant
postoperative crusting in the nose and the results
are less predictable than newer techniques used.

Inferior turbinoplasty

Multiple methods and instruments are used

to remove the IT soft tissue and bone whilst
preserving the medial mucosa, either with a
head light or endoscopically. In all cases, the IT
is infiltrated with 2% lidocaine with 1:80,000
adrenaline using a dental syringe. In the cold steel
technique, a scalpel blade is used to make a stab
incision over the anterior end of the IT bone. A
Freer elevator is used to elevate the medial mucosa
off the bone approximately one-half to two-
thirds along the length of the IT. This flap is then
detached inferiorly using turbinectomy scissors
which are then used to remove the turbinate
bone and lateral soft tissue. The mucosal flap is
then replaced and can be supported with a length
of absorbable packing. This can be done with a Figure 11.3. Turbinectomy. Care must be taken to
headlight or endoscopically, and the microdebrider avoid damage to the nasolacrimal duct.

78 ENT: An Introduction and Practical Guide

Turbinectomy A length of absorbable packing may be placed
along the cut surface. If there is significant
This may be done using a headlight or endoscope. bleeding a nasal tampon may be required, in which
The IT is first infractured as above, then case the patient should be kept overnight and the
turbinectomy scissors are used to trim it along its pack removed the following morning.
inferomedial aspect (Figure 11.3).

POSTOPERATIVE REVIEW
The patient can be discharged the same day or the ●● Ongoing/recurrent symptoms – Any benefit may
next day according to local protocol. Discharge be temporary, and ongoing medical treatment of
medication includes analgesia and nasal douche; rhinitis may be required postoperatively.
regular intranasal steroid treatment for rhinitis
should be recommenced after a few days. Patients
are advised to take one week off work and to avoid REFERENCES
nose-blowing for one week and heavy lifting or 1 Jose J, Coatesworth AP. 2010. Inferior turbinate
strenuous exercise for two weeks. Follow-up may surgery for nasal obstruction in allergic rhinitis
be arranged. after failed medical management. Cochrane
Database Syst Rev 8: CD005235.
2 Benjamin E, Wong DKK, Choa D. 2004.
Complications
‘Moffett’s’ solution: A review of the evidence
and scientific basis for the topical preparation.
●● Bleeding – This may be torrential
3 Lin HC, Lin PW, Friedman M, Chang HW,
and patients should be warned of the
Su YY, Chen YJ, Pulver TM. 2010. Long-
potential need for a blood transfusion.
term results of radiofrequency turbinoplasty
The risk is higher with turbinectomy than
for allergic rhinitis refractory to medical
turbinoplasty.
therapy. Archiv Otolaryngol Head Neck Surg
●● Nasal crusting – Turbinectomy leaves a large
136: 892–5.
raw area, unlike turbinoplasty; diathermy can
4 Di Rienzo Businco L, Di Rienzo Businco
also cause crusting.
A, Lauriello M. 2010. Comparative study
●● Adhesions – Between the IT and septum.
on the effectiveness of coblation-assisted
●● Empty nose syndrome – Excessive removal of
turbinoplasty in allergic rhinitis. Rhinology 48:
IT tissue has been implicated in worsening
174–8.
symptoms of obstruction, possibly due to a loss
5 Barham HP, Knisely A, Harvey RJ, Sacks
of sensation of nasal airflow; hence, the newer
R. 2015. How I do it: medial flap inferior
turbinoplasty procedures do not remove the
turbinoplasty. Am J Rhinol Allergy 29: 314–5.
medial mucosa.

Turbinate surgery 79
12 ENDOSCOPIC SINUS
SURGERY (ESS)
Joanne Rimmer

Also referred to as ‘functional endoscopic sinus ●● Recurrent acute rhinosinusitis.

surgery’ (FESS), the aim of endoscopic sinus surgery ●● Complications of acute rhinosinusitis.
(ESS) is to improve the function of the paranasal ●● Mucocoele.
sinuses and/or to allow better instillation of topical ●● Sinonasal tumour excision.
medication. Mucosal stripping is avoided and the ●● Orbital or optic nerve decompression.
natural sinus ostia are opened whenever possible. ●● Endoscopic repair of CSF leak.
There are also a number of extended applications of ●● Endoscopic approach to pituitary/anterior skull
ESS, including those listed below (1). base lesions.

Indications

●● Chronic rhinosinusitis with or without nasal

polyps, refractory to maximum medical
treatment.

PREOPERATIVE REVIEW
A CT scan of the sinuses is mandatory, and should evaluate the extent of disease, any previous surgery
be available at the time of surgery. This must or bony loss, and any anatomical variants (2).
be reviewed pre-operatively by the surgeon to

OPERATIVE PROCEDURE
An appropriately informed, consented and not taped or covered, but lubricating ointment is
anaesthetized patient should be positioned supine, instilled. This allows immediate identification of
head up or in a beach chair position, with a head any orbital movement or bleeding, and for the eye
ring for support. Topical nasal preparations such to be balloted while observing the lateral nasal
as Moffett’s solution (a variable mixture of cocaine, wall for any evidence of movement (suggesting a
adrenaline, normal saline and sodium bicarbonate) dehiscent lamina papyracea). Skin preparation is
or dilute adrenaline are instilled into the nose to not routinely used. The patient is draped with a
improve the surgical field. The patient’s eyes are head towel, exposing the nose and eyes.

80 ENT: An Introduction and Practical Guide

A 0° rigid Hopkins rod endoscope is used to
inspect the nasal cavities bilaterally using the Middle turbinate
three-pass technique (see Chapter 2). The first pass
is along the floor of the nose to the postnasal space, Middle meatus

assessing the inferior meatus (Figure 12.1). The

second is into the middle meatus (Figure 12.2), and
the third into the superior meatus and olfactory
niche; the sphenoid ostium may be identified Freer elevator Inferior turbinate
during this pass. Important landmarks to note are
the septum, inferior and middle turbinates, and
the posterior choana.
Figure 12.3 Gentle medialization of the left middle
turbinate to access the middle meatus.

Middle turbinate

Middle meatus

Nasal Middle turbinate

septum
Uncinate process
Inferior turbinate

Floor of
nasal cavity
Nasal septum

Figure 12.1 View of first pass along the floor of the

left nasal cavity.

Figure 12.4 Palpation of the free posterior edge of

the uncinate process with a Freer elevator.

Middle turbinate The middle turbinate should not be forcefully

medialized as this risks skull base fracture with
Middle meatus
cerebrospinal fluid (CSF) leak. It can be gently
medialized, but if very large and obstructing, then
Nasal a wedge can be removed from the anterior end
septum
with a through cutting punch whilst preserving the
majority as an anatomical landmark (Figure 12.3).
Inferior turbinate

The uncinate process is palpated with a Freer

elevator to identify its free posterior border and its
Figure 12.2 The second pass allows access to the anterior attachment (Figure 12.4).
middle meatus (left).
An uncinectomy is performed to expose the
At this point, it is helpful to insert neuropatties natural ostium of the maxillary sinus, with
or ribbon gauze soaked in 1:10,000 adrenaline either an anterograde (anterior to posterior) or
into the middle meatus, using a Freer elevator for retrograde (posterior to anterior) technique. In
accurate positioning. This will provide further the anterograde method, the Freer elevator or a
decongestion and vasoconstriction to improve the sickle knife is used to incise along the anterior
surgical field. attachment of the uncinate process from inferior

Joanne Rimmer 81
Middle turbinate Middle
turbinate

Maxillary sinus ostium

Nasal septum Ethmoid bulla

Inferior
Nasal septum turbinate

Figure 12.7 View of the left middle meatal

antrostomy and ethmoid bulla after removal of the
Figure 12.5 Incision along the anterior attachment uncinate process.
of the uncinate process.

to superior (Figure 12.5). Care should be taken not A curved sucker may be passed into the maxillary
to enter the orbit with this incision. sinus to remove any mucus or pus. The antrostomy
may be widened if necessary using a backbiting
Endoscopic scissors are used to cut through the forceps or the microdebrider. The ethmoid bulla is
remaining superior and inferior attachments of opened using 45° angled Blakesley–Wilde forceps
the uncinate process, or straight Blakesley–Wilde or a small curette behind its inferior edge.
forceps can be used with a twisting motion to
avoid tearing the mucosa (Figure 12.6). The anterior ethmoids are opened with a curette
or Blakesely–Wilde forceps (Figure 12.8), as are
The retrograde technique is said to reduce the the posterior ethmoids, if indicated. Appropriately
risk of orbital penetration. A backbiting forceps trained and experienced surgeons may perform
is placed behind the free posterior edge of the sphenoid sinus and frontal recess surgery, as
uncinate process at its most inferior point and required.
the uncinate is detached inferiorly. A 45° angled
through-cutter is then used to remove it along its If bleeding is minimal then no packing is required.
anterior attachment. Depending on the surgeon’s preference and the
amount of bleeding, packing may be inserted into
Once the uncinectomy is complete, the natural the middle meatus, in the form of adrenaline-
maxillary ostium should be visible and the soaked ribbon gauze or newer absorbable packing
ethmoid bulla will also be in view (Figure 12.7). materials.

Middle turbinate
Opened anterior
ethmoid air cells

Nasal Curette
septum

Inferior turbinate
Nasal septum
Blakesley-Wilde
forceps

Figure 12.8 Opening of the left anterior ethmoid

Figure 12.6 Removal of the left uncinate process. cells.

82 ENT: An Introduction and Practical Guide

POSTOPERATIVE REVIEW
If non-absorbable nasal packing is inserted, it can for the underlying disease process (e.g.
be removed in recovery, on the ward or the next chronic rhinosinusitis with or without nasal
morning depending on the amount of oozing. The polyps), and that symptoms can recur. They
patient may be discharged the same day or the next are, therefore, advised to continue long-term
day as per local protocol. Discharge medication treatment with intranasal steroids and douche
can include analgesics, oral and/or topical nasal after surgery.
steroids and nasal douche. Antibiotics may be ●● Orbital injury or bleeding – This occurs in
given. Patients are advised to avoid nose-blowing approximately 0.2% of cases (3).
for one week and have 7–14 days off work, avoid ●● CSF leak – This occurs in approximately 0.06%
heavy lifting or strenuous exercise during this of cases (3).
time. Follow-up should be after two weeks to allow
for outpatient decrusting of the nasal cavities.
REFERENCES
Complications 1 Wormald P-J. 2005. Endoscopic Sinus Surgery:
Anatomy, Three-Dimensional Reconstruction,
●● Bleeding – Some oozing is normal but heavy and Surgical Technique. Thieme Medical
epistaxis may warrant nasal packing or, rarely, Publishers, New York.
return to theatre. Perioperative haemorrhage 2 Lund VJ, Stammberger H, Fokkens WJ
occurs in approximately 5% of cases, with et al. 2004. European position paper on the
significant postoperative bleeding in less anatomical terminology of the internal nose
than 1% (3). and paranasal sinuses. Rhinology 50(Suppl. 24):
●● Infection. 1–34.
●● Nasal crusting – This is minimized with regular 3 Hopkins C, Browne JP, Slack R, Lund VJ,
douching and early outpatient review. Topham J, Reeves BC, Copley LP, Brown P,
●● Adhesions – These usually occur between the van der Meulen JH. 2006. Complications
middle turbinate and the lateral nasal wall, but of surgery for nasal polyposis and chronic
can occur between the inferior turbinate and rhinosinusitis: the results of a national audit in
the septum if traumatized during surgery. England and Wales. Laryngoscope 116: 1494–9.
●● Recurrent symptoms – It is important that
patients are made aware that ESS not a cure

Joanne Rimmer 83
13 NASAL POLYPECTOMY
Joanne Rimmer

Indications ●● Histological identification in cases of unilateral

polyps.
●● Nasal polyposis causing obstructive symptoms
despite maximum medical management.

PREOPERATIVE REVIEW
As nasal polypectomy is now invariably performed any anatomical variants (1). Nasal polypectomy
as an endoscopic procedure, a CT scan of the is commonly combined with endoscopic sinus
sinuses is mandatory. This should be available at surgery (ESS), as there is evidence that even
the time of surgery and should be reviewed pre- limited ESS in addition to polypectomy can reduce
operatively by the surgeon, to evaluate the extent revision rates over a 5-year period (2).
of disease, any previous surgery or bony loss and

OPERATIVE PROCEDURE
An appropriately informed, consented and A 0° rigid Hopkins rod endoscope is used to
anaesthetized patient should be positioned supine, inspect the nasal cavities bilaterally. Representative
head up or in a beach chair position, with a head biopsies are taken from both sides. Neuropatties
ring for support. Topical nasal preparations or ribbon gauze soaked in 1:10,000 adrenaline are
such as Moffett’s solution (a variable mixture of inserted bilaterally for further decongestion and
cocaine, adrenaline, normal saline and sodium vasoconstriction.
bicarbonate) or co-phenylcaine spray (5% lidocaine
and 0.5% phenylephrine) are instilled into the Polyps are commonly removed using powered
nose to improve the surgical field, if the extent of instrumentation in the form of a microdebrider.
polyposis allows. The patient’s eyes are not taped This instrument consists of an oscillating cutting
or covered, but lubricating ointment is instilled. blade within a sheath, attached to irrigation and
This allows immediate identification of any orbital suction. Care must be taken to ensure that the tip
bleeding. Skin preparation is not routinely used. of the instrument can be seen at all times to avoid
The patient is draped with a head towel, exposing damage to adjacent structures. Alternatively,
the nose and eyes. grasping instruments such as Blakesley–Wilde

84 ENT: An Introduction and Practical Guide

forceps are used; 45° angled forceps may be useful If bleeding is minimal then no packing is required.
for more complete clearance superiorly. Care Depending on the surgeon’s preference and the
must be taken not to exert too much force when amount of bleeding, packing may be inserted
removing tissue; gentle pressure or a twisting in the form of adrenaline-soaked ribbon gauze
motion should be sufficient. or newer absorbable packing materials, or more
rarely a nasal tampon.

POSTOPERATIVE REVIEW
If non-absorbable nasal packing is inserted, advised to continue long-term treatment with
it can be removed in recovery, on the ward or intranasal steroids and douche after surgery.
the next morning, depending on the amount ●● Persistent anosmia – Surgical polypectomy does
of oozing. The patient may be discharged the not guarantee the return of a sense of smell, and
same day or the next day as per local protocol. may even reduce it.
Discharge medication can include analgesics, oral ●● Orbital injury or bleeding – This is unlikely
and/or topical nasal steroids and nasal douche. in the absence of formal ESS, but the lamina
Antibiotics may be given. Patients are advised papyracea may be dehiscent in nasal polyposis.
to avoid nose-blowing for one week and have ●● Cerebrospinal fluid (CSF) leak – Again, this is
7–14 days off work, avoiding heavy lifting or unlikely in the absence of formal ESS, but polyp
strenuous exercise during this time. Follow-up removal in the region of the olfactory niche may
should be after two weeks to allow for outpatient damage the cribriform plate.
decrusting of the nasal cavities.

Complications REFERENCES
1 Lund VJ, Stammberger H, Fokkens WJ
●● Bleeding – Some oozing is normal, but heavy et al. 2004. European position paper on the
epistaxis may warrant nasal packing or rarely anatomical terminology of the internal nose and
return to theatre. paranasal sinuses. Rhinology 50(Suppl. 24): 1–34.
●● Infection. 2 Hopkins C, Slack R, Lund V, Brown P, Copley L,
●● Recurrent symptoms/polyps – It is important to Browne J. 2009. Long-term outcomes from the
make patients aware that polypectomy is not English national comparative audit of surgery
a cure for the underlying disease process, and for nasal polyposis and chronic rhinosinusitis.
that polyps tend to recur. They are, therefore, Laryngoscope 119: 2459–65.

Nasal polypectomy 85
14 TYMPANOPLASTY
Neil Donnelly and Olivia Kenyon

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

86 ENT: An Introduction and Practical Guide

PREOPERATIVE ASSESSMENT
Table 14.1. Sade classification (2).
History

Establish the nature of the symptoms and the Grade Description

impact that these have on the patients’ quality of 1 Mild retraction of pars tensa
life; this will help when counseling them. Does the 2 Retraction touching the incus or stapes
ear discharge? How often? Is it painful?
3 Retraction touching the promontory
Is there any subjective hearing loss? Is there any 4 Tympanic membrane adherent to the
associated vertigo or tinnitus? What about the promontory
other ear? Is there any other relevant ENT history?
Investigations
Examination
Pure tone audiometry, including air conduction
Document the position (central or marginal) and appropriately masked bone conduction, is
and size of the perforation. Is there an associated an essential part of the assessment and should be
cholesteatoma? Describe the status of the middle performed within 3 months of surgery.
ear (dry or infected). Is it possible to comment on
the state of the ossicular chain? Imaging of the temporal bone is not usually
required for a simple perforation. If there is
If there is a pars tensa retraction pocket, it is cholesteatoma and a concurrent mastoidectomy
helpful to use the descriptive Sade classification procedure is planned, a high resolution fine-cut
(See Table 14.1). Document the state of the CT scan of the temporal bones is recommended to
contralateral ear. act as a ‘road map’ 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
Alternatives to surgery risk – 10%−30%).
●● Chorda tympani injury with taste disturbance
In addition to discussing surgery, it is important (usually temporary).
to advise patients of the alternatives available ●● Ear numbness (particularly with a post-
to them. In the case of a central perforation, auricular incision).
these include observation coupled with water ●● Hearing loss (dead ear <1%).
precautions, particularly if there are few symptoms ●● Tinnitus (rare).
and the impact on lifestyle is minimal. A trial of ●● Vertigo (rare).
a hearing aid is an option if hearing loss is the ●● Facial nerve palsy (usually temporary and
primary symptom. rare).

Tympanoplasty 87
OPERATIVE PROCEDURE
Preoperatively, it is important to ensure the ●● Scan – has the scan been checked?
patient is adequately marked, has an up-to-date ●● Shave − is hair removal adequate?
audiogram within 3 months and still has the
perforation (Figure 14.1). Procedure steps

Injection of local anaesthetic

The use of a local anaesthetic such as 2% with

1:80,000 adrenaline is used to aid vasoconstriction
and postoperative analgesia. The procedure can
be performed under local anaesthetic, but general
anaesthesia is more common. The ear canal skin
is infiltrated with local anaesthetic providing
hydrodissection, thus making it easier to dissect
and less likely to bleed. The site of any intended
external incision is then infiltrated.

Figure 14.1. Tympanic membrane perforation. Remove margins of the perforation

Do not assume that the anaesthetist is familiar With the perforation clearly in view a gently
with the type of surgery planned. In particular, curved needle can be used to make a series of tiny
discuss the need for intraoperative hypotension perforations around it (Figure 14.2). It is helpful
to reduce bleeding and lack of paralysis to enable to start inferiorly and work superiorly to prevent
facial nerve monitoring. bleeding from the edge obscuring the view. The
small perforations are joined together and the
Patients are placed supine, with their head on a inner ring of tissue can be gently pulled away using
head ring, rotated away from the operative ear. crocodile or cupped forceps leaving a freshened
and slightly larger perforation.
A small amount of hair removal may be required.
We recommend the use of a facial nerve monitor
if it is used for all otological cases (other than
insertion of a grommet). The entire theatre team
becomes familiar with how to set it up and there
is no ambiguity as to whether it is required for a
particular procedure. It is also useful in the event
of any unexpected pathology. Strapping patients to
the table is helpful and allows them to be rotated
during surgery, which can improve visualization of
middle ear structures. A useful check list prior to
scrubbing up is to consider five Ss:

●● Side − correct side?

●● Spikes − facial nerve monitor. Figure 14.2. Incision and freshening the edge of
●● Straps − is the patient secured to the table? the perforation.

88 ENT: An Introduction and Practical Guide

Incision

There are three standard approaches for

performing otological procedures. The choice
usually comes down to surgeon preference.
Adequate exposure of the entire perforation is
essential and will influence which approach is
used. It may also be necessary to perform a limited
canalplasty to remove any bone obscuring the
view of the perforation, particularly if there is an
anterior canal wall overhang obscuring an anterior
perforation.
Figure 14.3. Tympanomeatal flap.
●● Permeatal – If the external auditory canal
(EAC) permits a view of the entire perforation
and is wide enough to accommodate a large except in cases of very small perforations, where
speculum, this approach can be used for both a fat or fascial graft can be ‘tucked’ through the
small and large perforations. It is helpful to use perforation. A posteriorly placed bucket handle
as wide a speculum as the EAC will allow. This incision is made, extending from the 12 o’clock
can be secured with a clear plastic drape. position of the tympanic membrane (TM)
●● Postauricular – A curved incision is made (adjacent to the lateral process of the handle
approximately 1 cm behind the postauricular of malleus) to beyond the 6 o’clock position
crease through the skin and subcutaneous tissue (Figure 14.3). Microscissors are required for
onto the temporalis fascia in its upper half. the thicker meatal skin of the superior EAC.
A semicircular incision is made through the The flap is elevated using an elevator such as a
periosteum just posterior to the bony EAC. The Rosen ring until the annulus is reached. A fine
skin of the posterior EAC is then elevated prior elevator such as a Hugh’s is used to elevate the
to making a re-entry incision into the EAC. annulus and enter the middle ear. By entering
the middle ear postero-inferiorly, injury to the
Tapes passed through the ear canal and out via the chorda tympani is minimized. Once the TM
reentry incision can be used to retract the pinna is reflected anteriorly along the handle of the
and lateral meatal skin out of the field of view. malleus (Figure 14.1), it should be possible to see
the medial surface of the anterior extent of the
●● Preauricular (endaural) – An incision is made perforation. For a larger perforation, it is helpful
just anterior to the anterior helix of the pinna to elevate the TM off the handle of malleus. An
and runs inferiorly between the helix and the ophthalmic keratome knife is extremely useful
tragus. It is continued into the roof of the EAC. for dividing the adherent fibres attaching the TM
A limb can be extended down the posterior wall to the umbo.
of the EAC. The meatal skin lateral to this limb
can then be elevated laterally over the bony
margin of the ear canal. A two-prong retractor Check the ossicular chain
is then used to give exposure.
Visually inspect the ossicles, in particular the
incudostapedial joint (ISJ). Gently palpate the
Tympanomeatal flap malleus handle and observe the movement of the
malleus and incus (limited if there is attic fixation),
Whatever approach is used, it is usually confirm the integrity of the ISJ and mobility of the
necessary to elevate a tympanomeatal flap, stapes footplate.

Tympanoplasty 89
Graft harvest

The two commonest graft materials used are

temporalis fascia and a composite cartilage
perichondrium graft. Temporalis fascia is simply
harvested via a post- or preauricular incision. To
enable it to be easier to manipulate, it is scraped
flat and left to dry. Cartilage can be harvested
from the concha cymba, concha cavum or fossa
triangularis if using a post-auricular incision,
or from the tragus if performing a permeatal or
end-aural approach. The composite perichondrium
cartilage graft technique uses a single shield or Figure 14.4. Underlay composite cartilage ‘island’
island-shaped graft that remains attached to its graft.
perichondrium to reconstruct part or all of the
tympanic membrane. Cartilage composite grafts
have a very high success rate for repair of both
small and large perforations, and are resilient to
retraction without adversely affecting hearing
outcomes (3).

Graft sizing

A helpful technique is to cut a paper template

to accurately size the perforation or region of
tympanic membrane that requires reconstruction.
If using fascia, the graft will need to be bigger than Figure 14.5. Graft in position.
the template. If using a composite island graft,
the cartilage can be trimmed to the size of the Ear packing
perforation, while retaining a perichondrial apron
to aid with graft placement. The surface of the tympanic membrane is gently
covered to protect it and allow epithelium to grow
over the graft. The dressing used is dependent on
Graft placement the preference of the surgeon. This can be done with
a thin strip of clear silastic, small pieces of BIPP
The graft is placed beneath the tympanic ribbon gauze or with gel foam blocks. The external
membrane in an underlay fashion (Figure 14.4) auditory canal is then filled with further short strips
and manipulated such that the entire TM defect of BIPP ribbon gauze (or similar) or a Pope wick in
is sealed (Figure 14.5). The graft should lie flat order to keep the meatal skin in place and prevent
against the undersurface of the TM. If using a blunting of the angle between the TM and ear canal.
composite graft, the perichondrium lies laterally
on the undersurface of the TM. Surface tension Closure
is usually adequate to keep the graft in place, but
additional support can be obtained by placing The wounds are closed in layers, preferably with an
small Gelfoam™ or Spongostan™ pieces in the absorbable suture such as 4/0 Vicryl or Monocryl.
middle ear. The tympanomeatal flap is then A head bandage may or may not be required
relocated in its original position. (4 hours is usually adequate).

90 ENT: An Introduction and Practical Guide

POSTOPERATIVE REVIEW
Postoperatively it is good practice to document the Advise the patient to keep the ear dry until after
facial nerve function and to confirm that there is review. Postoperative follow-up is usually 2–4
still hearing in the operated ear by performing a weeks after surgery, at which time the dressings are
Weber test. The majority of myringoplasty cases removed from the ear.
can be 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 2 Sade J, Berco E. 1976. Atelectasis and
has an up-to-date, ear-specific, secretory Otitis media. American Journal of
appropriately masked audiogram Otolaryngology 85(Suppl. 25): 66–72.
within 3 months prior to surgery. 3 Dornhoffer J. 2003. Cartilage tympanoplasty:
●●CT scan − A high-resolution temporal Indications, techniques and outcomes in a 1000
bone CT scan provides a useful patient series. Laryngoscope 113(11): 1844–56.
‘roadmap’ for mastoid surgery.
●●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 91
15 MASTOIDECTOMY
Neil Donnelly and Olivia Kenyon

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

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

ASSESSMENT
History semicircular canal fistula. As with any otological
procedure, the condition of the contralateral ear is
Cholesteatomas typically present with a painless an important consideration.
discharging ear (often with an unpleasant odour)
and an associated hearing loss. Less commonly, Examination
they can present with one of the more serious
complications of CSOM with cholesteatoma, Document the origin of the cholesteatoma. Does it
including meningitis, acute mastoiditis, facial originate in the attic, from a marginal perforation
nerve palsy and vertigo secondary to a lateral or a pars tensa retraction pocket? Describe

92 ENT: An Introduction and Practical Guide

the status of the middle ear (dry or infected?) ●● The extent of cholesteatoma (often unreliable).
including the state of the ossicular chain. ●● Whether the sigmoid sinus is dominant or
Document the state of the contralateral ear. situated anteriorly.
●● The level of the middle fossa dura and whether
Investigations this is dehiscent.
●● The course of the facial nerve and whether this
Pure tone audiometry, including air conduction is dehiscent.
and appropriately masked bone conduction, is ●● Whether there is erosion of the otic capsule.
an essential part of the assessment and should be ●● The state of the ossicles.
performed within 3 months of surgery.
A number of different mastoidectomy
An axial high-resolution fine-cut CT scan of the techniques can be employed in the treatment of
temporal bones with coronal reconstructions is cholesteatoma. These include:
an important component of management. This
is not performed for diagnostic purposes, which ●● Combined approach tympanoplasty (CAT),
is clinical, but serves as a ‘roadmap’ for planning also known as a canal wall up mastoidectomy
surgery to determine: (Figure 15.1(a)).

(a) (b)

(c)

Figure 15.1. (a) Combined approach tympanoplasty. (b) Attico antrostomy. (c) Modified radical mastoidectomy.

Mastoidectomy 93
●● Atticotomy or small cavity mastoidectomy, A good otologist should be trained in all three
also known as front-to-back mastoidectomy techniques so that the procedure performed can be
(Figure 15.1(b)). This is increasingly combined tailored to the specific disease and requirements of
with an endoscopic approach. the patient.
●● Modified radical mastoidectomy also known
as a canal wall down mastoidectomy (Figure
15.1(c)).

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

The risks of surgery include:

OPERATION
Preoperatively, it is important to ensure the prostheses, the availability of a KTP laser with
patient is adequately marked and has an up-to- appropriately trained operator or a range of
date audiogram. Review the CT scan and otoendoscopes.
determine whether any complicating factors are
anticipated. Ensure that the anaesthetist is aware of the
need for intra-operative facial nerve monitoring
Check the availability of any specialist equipment and relative hypotension to reduce bleeding. A
with the scrub team. This may include an adequate reinforced endotracheal tube is preferred to a
selection of the preferred ossicular replacement laryngeal mask.

94 ENT: An Introduction and Practical Guide

The patient is placed supine, with their head on incision and mastoid process (Figure 15.2(a)).
a head ring, rotated away from the operative ear. A useful checklist prior to scrubbing up is to
A small amount of periauricular hair removal consider five Ss:
may be required. Most otologists regard the use of
a facial nerve monitor for cholesteatoma surgery ●● Side − is the side correct?
as mandatory if the hospital is in possession ●● Spikes − facial nerve monitor.
of the device. Strapping patients to the table is ●● Straps − is the patient secured to the table?
extremely helpful and allows them to be rotated ●● Scan – has the CT scan been checked?
during surgery to improve visualization of difficult ●● Shave – is hair removal adequate?
areas. Many surgeons mark the planned postaural

(a) (b)

Figure 15.2. (a) Local anaesthetic infiltration. (b) Postaural incision. (c) Cutaneous incision elevated in
superficial temporal plane. (d) Anteriorly based periosteal flap.

Mastoidectomy 95
Combined Approach is useful for dividing the adherent fibres
Tympanoplasty attaching the TM to the umbo (“Llyod’s
ligament”).
4 Check the ossicular chain – Visually inspect
Procedure steps
the ossicles and their relationship with the
1 Injection of local anaesthetic – The use of a
cholesteatoma. If the ossicular chain is intact,
local anaesthetic such as 2% xylocaine with a decision regarding whether it will be possible
1:80,000 adrenaline is used to infiltrate the to clear disease adequately without disrupting
canal skin and the region of the postauricular it must be made. With a more extensive
incision (Figures 15.2(a) and (b)). cholesteatoma involving the mesotympanum,
2 Incision (postauricular) – A curved incision
it may be necessary to remove disease in order
is made 1−2 cm behind the postauricular to get a view of the incus and or stapes. In
crease through skin and subcutaneous tissue these cases, there is often erosion of the long
onto loose aorta tissue lateral to temporalis process of the incus. If the incudostapedial
fascia in its upper half (Figure 15.2(c)). An joint is intact, it is divided with a joint knife
incision is made through the periosteum of the and the incus carefully removed without
mastoid and an anteriorly based subperiosteal damaging the stapes superstructure. The neck
flap raised (Figure 15.2(d)) using a periosteal of the malleus is then divided with malleus
elevator. The skin of the posterior EAC is then nippers and the head of the malleus removed;
elevated prior to making a reentry incision the handle of malleus can either be removed or
into the EAC. Tapes passed through the ear left in situ. Removal of the handle of malleus
canal and out via the reentry incision are can make reconstruction simpler and reduce
used to keep the pinna and lateral meatal skin recurrent cholesteatoma.
5 Cortical mastoidectomy – Using a 5 or 6 mm
retracted.
This approach provides excellent exposure cutting burr, the cortical bone is removed to
of the cortical bone of the mastoid and the root make a cavity, the superior margin of which
of the zygomatic process. is the tegmen tympani, posterior margin
3 Tympanomeatal flap and disease isolation –
the sigmoid sinus and anterior margin the
The goal is to isolate the middle ear component bony wall of the external auditory canal. As
of the cholesteatoma, while preserving the bone is removed, air cells will come into view
healthy remnant of the tympanic membrane. depending on the degree of sclerosis of the
As with a myringoplasty, a posteriorly placed mastoid. It is important to find the tegmen and
bucket handle incision is made, extending sigmoid sinus and then skeletonize them (leave
from the 12 o’clock position of the TM a thin layer of bone) with a diamond burr. This
(adjacent to the lateral process of the handle ensures that optimal access is achieved and
of malleus) to beyond the 6 o’clock position. that the surgeon does not become lost down a
The superior aspect of the tympanomeatal deep dark hole. The bone of the posterior canal
flap incision is taken right up to the margin is thinned while looking into the cavity and
of cholesteatoma. Microscissors are used to down the EAC. With progressive bone removal,
cut around the neck of the cholesteatoma. the mastoid antrum is encountered. With the
It may be necessary to divide the chorda mastoid antrum open, the bony bulge of the
tympani cleanly if it is involved in the disease. lateral semicircular canal comes into view, as
The resulting flap of posterior canal skin and does the lateral process of the incus. Extreme
tympanic membrane remnant is elevated caution is required as drilling on an intact
and reflected anteroinferiorly. At the same ossicular chain may result in a sensorineural
time, the TM may be elevated off the handle hearing loss. Anterosuperiorly, the dissection
of malleus. An ophthalmic keratome knife continues forward with a smaller cutting burr

96 ENT: An Introduction and Practical Guide

into the root of the zygomatic process between lateral aspect of the template on the cartilage)
the tegmen and bone of the superior EAC to leaving a peripheral apron of perichondrium
provide access to the attic. The dissection is surrounding the cartilage. The cartilage
continued anteriorly until the anterior attic is is scored down to perichondrium, twice
accessible; this can otherwise be a common site horizontally and twice vertically. The result is
for residual disease. Throughout the procedure, nine separate pieces, resembling a chessboard,
cholesteatoma and granulations may require that are attached to the perichondrium. This
piecemeal removal in order to maintain technique removes the natural convexity of
visualization. The final cavity should be smooth conchal cartilage and makes the graft easier
and disease-free. to manipulate in the ear. The graft is placed in
6 Posterior tympanotomy – This refers to the the middle ear in an underlay fashion with the
removal of the triangle of bone between perichondrium laterally. The perichondrium
the facial nerve, chorda tympani and fossa is placed over the bony meatal wall, lateral to
incudis and is best performed with a small the bony annulus, but medial to the annular
diamond burr. The first step is to find the ligament and tympanomeatal flap, to anchor the
mastoid segment of the facial nerve while graft and prevent medialization. The cartilage
drilling parallel to it with copious irrigation. should extend snugly to the bony annulus or
Once located, it is possible to remove the overlap if there is concern about recurrence.
bone lateral to the nerve in order to encounter 8 Ossiculoplasty – A partial or total ossicular
the intra-osseous chorda. By removing the replacement prosthesis (typically titanium
bone between the facial nerve and chorda or hydroxyapatite) is positioned to bridge the
tympani, the facial recess is opened, providing ossicular gap between the tympanic membrane
a view of the stapes (if present) and sinus and stapes head or footplate respectively.
tympani. In addition to the anterior attic, the The head of the prosthesis lies against the
sinus tympani is a frequent site for residual undersurface of the cartilage checkerboard.
cholesteatoma; a good posterior tympanotomy 9 Ear packing – The surface of the reconstructed
provides optimal visualization of this tricky tympanic membrane is gently covered
area which can be supplemented with angled with small pieces of BIPP ribbon gauze, or
otoscopes. alternative ear pack such as Gelfoam®. The
7 Tympanic membrane reconstruction – A ossiculopasty is inspected via the posterior
composite cartilage graft (cartilage and tympanotomy to ensure that this remains in
perichondrium) is an excellent material for an optimal position prior to filling the external
this and has a high resilience to retraction auditory canal with additional short strips of
without adversely affecting hearing outcomes BIPP ribbon gauze.
(1). Cartilage is harvested from the concha 10 Closure – The postauricular wound is closed in
cymba or concha cavum via the postauricular layers with absorbable sutures, packing head
incision. The posterior bony annulus and attic bandage with mastoid dressing is placed if
are smoothed off. A tape passed through the required.
canal and brought out through the mastoid
cavity can be used to remove residual squames Postoperatively, the facial nerve function is
from the bony margin. A paper template documented. A postoperative lower motor neurone
is prepared to size the attic and tympanic palsy is extremely worrying and the operating
membrane reconstruction is required. surgeon must be informed. While the palsy may
This is done prior to harvesting the cartilage be due to the local anesthetic, if the nerve fails
to ensure a large enough piece of cartilage is to recover, surgical exploration by the operating
taken. Once harvested, the cartilage is shaped surgeon and a second senior otologist is required.
to the template (taking care to place the Facial nerve re-anastamosis may be attempted.

Mastoidectomy 97
A Weber test or scratch test is also performed to 2 weeks after surgery, at which time the dressings
confirm that there is still hearing in the operated are removed. Postoperative antibiotics are not
ear. While the majority of mastoidectomy cases usually necessary.
require an overnight stay, an increasing number
are being performed as day-case procedures.
REFERENCE
Patients are is advised to keep their ear dry until 1 Dornhoffer J. 2003. Cartilage tympanoplasty:
after review. Postoperative follow-up is usually indications, techniques and outcomes in a 1,000
patient series. Laryngoscope 113(11): 1844−56.

98 ENT: An Introduction and Practical Guide

16 STAPEDECTOMY
Neil Donnelly and Olivia Kenyon

Stapedectomy literally means the surgical removal fenestration in the stapes footplate (stapedotomy).
of the stapes bone. The term has come to refer to This procedure is used to correct the conductive
the operation in which the stapes superstructure hearing loss that arises as a result of otosclerosis
is replaced by an artificial piston attached to (Figure 16.1).
the incus (typically) and placed through a

Figure 16.1. 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, Eventually, the stapes becomes fixed, resulting in
leading to new bone formation around the reduced transmission of sound to the cochlea and
edge of the oval window and stapes footplate. significant 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 is in an autosomal dominant manner. However, due
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 99
Examination stapes, higher frequencies become affected. There
may be a mixed conductive and sensorineural
Tuning fork tests are useful to confirm clinically loss if there is additional cochlear otosclerosis.
a conductive hearing loss. It is necessary to Characteristically, a Carhart’s notch is seen, where
document the state of both ears and exclude other a dip in the bone conduction occurs maximally
causes of conductive hearing loss (e.g. otitis media at 2 kHz. This is due to the loss of the middle ear
with effusion or a retraction pocket with ossicular component of sound conduction at this natural
erosion). In active disease, hypervascularity of frequency of resonance of the ossicular chain.
the promontory may be seen as a pinkish blush
through the tympanic membrane. This is known Tympanometry demonstrates a normal type A
as Schwartze’s sign. tympanogram, confirming normal middle ear
compliance. Stapedial reflexes are typically absent
Investigations on the affected side.

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

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 important ●● Failure to close the air−bone gap within 10 dB
to advise patients of the alternatives available to (approximately 5%).
them. Many patients will elect for observation ●● Late failure.
once the diagnosis has been made. ●● Tinnitus.
●● Vertigo.
A trial of a hearing aid is a riskfree and effective ●● Facial nerve injury (rare).
option that should be encouraged prior to
electing for surgery. Another alternative is a bone
conduction device such as BAHA.

Complications

The risks of surgery include:

●● Bleeding.
●● Infection.
●● Chorda tympani injury with taste disturbance.
●● Dead ear or hearing loss (approximately 1%).

100 ENT: An Introduction and Practical Guide

OPERATION
The side to be operated on should be clearly marked tympanomeatal flap is raised, hinged along the
and the risks of the procedure explained. The ear malleus and out of the way, providing access to
must be dry, with no active infection. A recent the posterior contents of the mesotymanum and
(within 3 months) audiogram should also be present. allowing the necessary view of the long process
of incus, incudostapedial joint, stapedius
Check the availability of any specialist equipment tendon and stapes footplate. If access is limited,
with the scrub team. This includes an adequate a House curette is used to remove the bone
selection of the preferred stapedectomy prosthesis posterior and superior to the stapes until the
and, depending on the technique used, a KTP laser desired view is achieved (Figure 16.2(a)).
with an appropriately trained operator. 4 Check of the ossicular chain – Palpate the
ossicular chain with a needle. Confirm that the
As with other otological procedures, ensure stapes footplate is fixed and that the malleus
the anaesthetist is aware of the need for intra- and incus are mobile.
operative facial nerve monitoring and relative 5 Division of the incudostapedial joint (ISJ) – The
hypotension to reduce bleeding. ISJ is divided with a joint knife or fine right-
angled hook. The joint can be clearly identified
Patients are placed supine, with their head on a by gently elevating the incus. Division of the
head ring, rotated away from the operative ear. joint should be in line with, and away from, the
A small sandbag is placed beneath the shoulders stapedius tendon.
to extend the neck as this makes it easier to 6 Division of the stapedius tendon – The
access the posterosuperior region of the tympanic stapedius tendon is divided with a laser, sharp
membrane. As with other otological cases, facial sickle knife or microscissors.
nerve monitoring and strapping the patient to the 7 Removal of stapes superstructure – The
table can be useful adjuncts. posterior crus of the stapes is divided with
a laser or skeeter drill. The anterior crus is
Stapedectomy divided by down-fracturing towards the
promontory (Figure 16.2(b)).
Procedure steps 8 Fenestration – A small fenestration
(stapedotomy) is made in the stapes footplate
1 Injection of local anaesthetic – Local anaesthetic using a skeeter drill, laser or hand-held
(e.g. 2% xylocaine with 1:80 000 adrenaline) trephine. The fenestration typically has a
is used to infiltrate the canal skin in order to diameter of 0.8 or 0.7 mm to accommodate a
thicken the tympanomeatal flap and reduce 0.6 mm prosthesis (Figure 16.2(c)).
bleeding. It is common practice in many clinics 9 Prosthesis – A stapedectomy prosthesis is
to perform the entire procedure under local placed within the fenestration and secured
anaesthesia, with a periauriclar block. around the long process of the incus (Figure
Incision – Typically a permeatal or endaural
2 16.2(d)). Small pieces of fat, harvested
approach is used. from the ear lobule, are placed around the
3 Tympanomeatal flap – A posterior bucket prosthesis to prevent leakage of perilymph. A
handle incision is made, extending from the vein graft may be placed over the fenestration
12 o’clock position of the TM to the 6 o’clock to perform the same task.
position. The meatal incision should not be 10 Ear packing – The tympanomeatal flap is
too close to the annulus as it is often necessary replaced and the ear lightly packed with small
to remove some of the bony annulus. The pieces of BIPP ribbon gauze/sponge.

Stapedectomy 101
(a) (b)

Figure 16.2. Steps involved when performing a stapedectomy. (a) Elevated tympanomeatal flap. (b) Divided
stapedius tendon and stapes crura. (c) Fenestrated footplate. (d) Artificial stapes piston in place.

POSTOPERATIVE REVIEW
The facial nerve function is documented and a Patients are given advice to keep their ear dry until
Weber test is performed to confirm that there after review, and to avoid straining. Postoperative
is still hearing in the operated ear. The eyes are follow-up is usually 2 weeks after surgery, at which
examined and any nystagmus noted. While some time the dressings are removed.
stapedectomy cases require an overnight stay,
increasing numbers are being performed as day-
case procedures.

102 ENT: An Introduction and Practical Guide

17 BONE-ANCHORED
HEARING AID
James Tysome

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
implant, abutment and a sound processor. hearing aid due to otitis externa, chronically
The implant is placed surgically into the skull discharging ears despite middle ear surgery,
behind the ear and forms a solid attachment to allergy to hearing aid moulds or congenital
bone through osseo-integration. The abutment malformation of the middle or external ear,
traverses the subcutaneous tissues and skin to including canal and pinna atresia.
allow attachment of the sound processor. This ●● Unilateral complete sensorineural hearing loss.
facilitates sound conduction through vibrations, Placed behind the deaf ear, the BAHA facilitates
which are transmitted via the abutment and the conduction of sound through the skull to
implant complex and through the skull to the good ear. This prevents the head shadow
reach the cochlea. BAHA offers superior effect from the deaf side, although in general
sound quality to a conventional bone conductor does not improve directionality.
hearing aid.

PREOPERATIVE REVIEW
Ensure that patients have completed their a trial of a bone conductor worn on a headband.
audiological assessment for BAHA, which includes Mark the side on which the BAHA is to be placed.

OPERATIVE PROCEDURE
The implants have become wider over recent years, The surgery is now usually performed under local
allowing longer abutments up to 14 mm to be anaesthetic. The patient is positioned supine with
safely used. This has resulted in the use of a tissue the head facing 45° away from the surgeon. Shave
preservation technique without the need for a skin the postauricular area, prepare the skin and drape
flap or thinning of subcutaneous tissues. This has (Figure 17.1(a)).
resulted in shorter operative time and retention
of the normal hair that grows back around the Mark the position of the implant 55 mm from the
abutment, with a vast decrease in infections that external auditory meatus in the direction shown
cause most long-term problems with BAHAs. (Figure 17.1(b)). Use the dummy sound processor

Bone-anchored hearing aid 103

(a) Shaved area (b) (c)

55 mm

(d) (e) (f)

(g) (h)

Figure 17.1. (a) Postauricular shave. (b) Marking implant position and incision. (c) Linear skin incision. (d)
Drilling. (e) Countersunk hole ready for implant. (f) Implant and abutment mounted on drill for one-stage
insertion. (g) Placing implant and abutment together. (h) Implant complete.

in order to ensure that the eventual position of A cruciate incision is made in the periosteum and
the processor will not impinge on the ear and the the corners elevated to access the bone. Drill the
arm of glasses if worn. Measure the skin depth at hole for the implant, using the hand-held drill
the mark using a needle. This allows calculation with sufficient irrigation. Drill a 3 mm guide
of the appropriate abutment length to traverse perpendicular to the skull. Palpate the base of the
the skin. Methylene blue can also be used to hole carefully to ensure that dura is not exposed. If
mark the implant site on the periosteum. A 2 cm bone remains, deepen the hole to a depth of 4 mm.
linear incision is marked 1 cm from the proposed A countersink is then used to widen the hole
implant position (Figure 17.1(c)). (Figure 17.1(d), (e)).

Local anaesthesia (2% xylocaine, 1:80,000 One-stage implants are used in the majority
adrenaline) is instilled and an incision made down of cases, consisting of the implant screw and
to the periosteum. Tissues are elevated until the abutment as one unit (Figure 17.1(f)). Mount the
blue implant site mark is seen on the periosteum. implant onto the drill using a no-touch technique.

104 ENT: An Introduction and Practical Guide

The implant is a self-tapping screw. It is essential A two-stage technique may be used in children,
that this is placed perpendicular to the skull. particularly where a 3 mm implant is used where
(Figure 17.1(g)). Punch a hole in the overlying skin the 3 mm guide drill encounters dura. In this
with a 4 mm dermatological punch and make situation, the implant alone is inserted along
radial incisions in order to enable the abutment with a cover screw. After osseointegration has
to pass through the skin. The incision is closed taken place, around 3 months later, a hole can
(Figure 17.1(h)) and a non-adherent dressing be punched through the skin and the abutment
applied and secured in place with a healing cap screwed onto the implant.
attached firmly to the abutment.

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 1 week to remove ●● Infection.
the healing cap and dressings. The patient is taught ●● Bleeding or haematoma.
to care for their implant, which requires daily ●● Failure of implant.
cleaning with a soft toothbrush. The hearing aid is ●● Cerebrospinal fluid leak.
fitted and programmed soon after.

Bone-anchored hearing aid 105

18 PANENDOSCOPY
Ram Moorthy

Panendoscopy refers to the formal assessment ●● Laryngoscopy.

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

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 the ease of the
spine x-ray. Loose teeth or dental crowns require 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
make certain they are functioning correctly. with the nose and mouth exposed. The body is
An appropriate range of endoscopes, Hopkins draped 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
anaesthesia and the patient placed supine on the palpated. For all procedures, except examination
operating table. Either a pillow or head ring and of the PNS, an appropriate mouth guard is
shoulder roll are used to allow the neck to be placed to protect the upper teeth. If the patient is
slightly flexed and the head extended to achieve edentulous 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
former being secured on the left if the surgeon is in order to ensure that bleeding does not obscure
right-hand dominant. the surgeon’s view.

106 ENT: An Introduction and Practical Guide

19 DIRECT- AND
MICROLARYNGOSCOPY
Ram Moorthy

Indications ●● Investigation of a patient with dysphagia.

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

OPERATIVE PROCEDURE
The patient is intubated with a microlaryngeal be required to allow assessment of the anterior
tube which is of a standard length but of smaller commissure.
diameter to allow better visualization.
A 0° Hopkins rod is passed through the lumen
The mouth is held open with the non-dominant of the laryngoscope. Careful assessment is made
hand. The laryngoscope is gently inserted and the of the supraglottis, glottis and subglottis and
tongue followed until the oropharynx is reached, appropriate photographs taken. In paediatric
with any secretions suctioned. patients, a probe is used to assess mobility of the
cords and the cricoarytenoid joints. Representative
The endotracheal tube acts as a guide and can biopsies can be taken from any lesions.
be followed directly to the larynx. Inspect the
lingual and laryngeal surfaces of the epiglottis The operating microscope can now be used if the
and the remainder to the supraglottis including following procedures are undertaken (Figure 19.1):
the arytenoids. Once the vocal cords including
the anterior commissure, are visible, the ●● A magnified view of the larynx is required to
laryngoscope handle can be attached and the allow accurate excision of a lesion or vocal cord
suspension arm fixed to the handle to support injection.
the laryngoscope when microlaryngoscopy is ●● Both hands are required to perform the
required. An anterior commissure laryngoscope procedure.
which has a narrower cross-sectional profile, may ●● Laser excision of a laryngeal lesion.

Direct- and microlaryngoscopy 107

Microscope

Suspension arm

Laryngoscope

Figure 19.1. Microlaryngoscopy. A laryngoscope is passed and suspended by its handle. A microscope
provides a binocular view of the larynx.

Complications ●● Hoarse voice.

●● Sore throat.
●● Bleeding. ●● Dysphagia.
●● Infection. ●● Airway compromise, which may necessitate
●● Damage to teeth, gums, lips and tongue. tracheostomy.

POSTOPERATIVE REVIEW
●● If the patient is difficult to intubate and there undertaken prior to transfer to recovery.
is a high likelihood that the airway will be If there is any concern, reintubation and
unstable on extubation, a tracheostomy should tracheostomy may be required.
be 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 48 hours, or to talk normally, with no shouting
in theatre and assessment of the airway and/or whispering.

108 ENT: An Introduction and Practical Guide

20 PHARYNGOSCOPY
Sonia Kumar

Indications ●● Identifying a synchronous tumour in a patient

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

OPERATIVE PROCEDURE
The non-dominant hand is used to gently open the of the cervical oesophagus. The tip of the scope is
mouth and the pharyngoscope inserted (Figure advanced gently into the upper oesophagus. A 0°
20.1). The tongue will guide the surgeon inferiorly Hopkins rod can be passed through the lumen to
towards the oropharynx. Suction is required at this
point, as secretions will obscure the surgical field.
The tongue base, valleculae, tonsils, posterior and
lateral pharyngeal walls are carefully examined.

The pharyngoscope is passed behind the endo-

tracheal or nasotracheal tube in order to visualize
the posterior pharyngeal wall, pyriform fossae and
post-cricoid region.
It is essential that the surgeon has a clear view at all
times. Never attempt to force the pharyngoscope as
this risks causing an oesophageal perforation (Figure
20.2). If this leads to mediastinitis, the mortality
rate is 50%. At the cricopharyngeal bar, the lumen
may come to a blind end and the temptation is
to push the scope blindly. Wait patiently for the
muscle to relax. Otherwise, the larynx may be gently
lifted forward to allow identification of the lumen Figure 20.1. Insertion of the pharyngoscope.

Pharyngoscopy 109
Figure 20.2. At the cricopharyngeus, the scope is
gently advanced in order to avoid tearing.

take photographs of any abnormality, prior to taking

representative biopsies using an appropriate biopsy Figure 20.3. Suction is often required once the
forceps (Figure 20.3). In patients with an unknown pharyngoscope is within the cervical oesophagus.
primary malignancy, biopsies of the tongue base Biopsy forceps are required if a biopsy is to be
and tonsils are usually taken if no obvious primary taken.
malignancy can be identified.

At the end of the procedure, ensure haemostasis dental trauma which must be documented in the
and remove the teeth guard, checking for any 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 ●● Hoarse voice.
not 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.

110 ENT: An Introduction and Practical Guide

21 RIGID
OESOPHAGOSCOPY
Ram Moorthy

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 gastrooesophageal junction. ●● Removal of foreign body, especially star foreign
It is important to ensure that suction and biopsy bodies (bone) and batteries.
forceps of an appropriate length are available. A ●● To enable dilatation, with balloon or bougie, of
variety of appropriately shaped forceps are also stricture, stenosis or spasm.
available to help with foreign body removal.

OPERATIVE PROCEDURE
The procedure is performed under general scope, especially if the lumen is not visible, which
anaesthesia. The airway is secured with an can traumatise the mucosa and potentially cause
appropriately sized microlaryngoscopy tube. an oesophageal perforation.

The patient is positioned supine on the operating If an abnormality is identified, use the etched
table with a head ring or equivalent, the lower marks on the oesophagoscope to estimate the
cervical spine is flexed and the upper cervical distance from the incisors, and document this in
spine is extended, as is the atlanto-occipital joint the operation note. Representative biopsies are
(‘sniffing the morning air’ position). taken.

A mouth guard, or wet swab if edentulous, A soft food bolus obstruction can be pushed down
is placed to protect the teeth and gums. and into the stomach.
The procedure is similar to that for rigid
pharyngoscopy. The tongue is followed back Sharp foreign bodies must be removed with care
to the oropharynx and the oesophagoscope is to minimize trauma to the oesophageal mucosa.
passed behind the endotracheal or nasotracheal If possible the foreign body can be manoeuvred
microlaryngoscopy tube. The oesophagoscope into the lumen of the oesophagoscope and the
is manoeuvred into the post-cricoid region. The oesophagoscope removed.
tip of the oesophagoscope is gently lifted to allow
identification of the lumen of the oesophagus Carefully assess the mucosa as the oesophagoscope
and the scope is gently advanced. Never force the is removed and, if there is any suspicion of a

Rigid oesophagoscopy 111

mucosal tear or perforation, a nasogastric tube is procedure by removing the mouth guard or swab,
passed under direct vision prior to completing the checking the teeth and temporomandibular joint.

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 and inform a senior member of the team.
for perforations after pharyngoscopy.

If a patient becomes pyrexic, tachycardic, Complications

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

112 ENT: An Introduction and Practical Guide

22 EXAMINATION OF POST
NASAL SPACE
Sonia Kumar

Indications ●● Persistent unilateral middle ear effusion in an

adult.
●● Mass or ulcer of the nasopharynx. ●● Unexplained epistaxis.
●● Investigation of patients 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 malignancy. Biopsies are taken, if indicated, with
into and obscure the view of the rest of the upper straight Blakesley–Wilde or Tilley–Henckel forceps.
aerodigestive tract. Adrenaline-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. Complications
A decongestant or topical anaesthetic with
adrenaline is applied to the nose, usually in the ●● Bleeding/epistaxis.
anaesthetic room. ●● Infection.
●● Otitis media with effusion secondary to
A 0° Hopkins rod with an appropriate light source inadvertent damage to the Eustachian tube
is passed into the nasal cavity, and the nasopharynx orifice.

Examination of post nasal space 113

23 RIGID BRONCHOSCOPY
Sonia Kumar

Indications ●● Assessment of subglottic or tracheal

stenosis.
●● Removal of foreign body from the trachea or
main bronchi. In many cases the proximal trachea can be
●● Assessment of a tracheal lesion. assessed, as described in Chapter 24, with a
laryngoscope and a 0° Hopkins rod.

OPERATIVE PROCEDURE
Bronchoscopes are available in a number of sizes. glottic opening, which minimizes the risk damage
Selection of an appropriately sized bronchoscope is to the vocal cord from the tip of the bronchoscope.
essential for paediatric patients. Before the patient
is anaesthetized, ensure that the bronchoscope Once the bronchoscope is in the proximal
is assembled correctly and that the anaesthetic trachea, the anaesthetic circuit is connected
connectors are compatible (Figure 23.1). Confirm and the bronchoscope is advanced towards the
that the light source is working and that the carina. By gently turning the head to the left, the
camera has been attached. Appropriate optical bronchoscope can be advanced into the right
forceps must be available if foreign body removal main bronchus, and vice versa. Secretions can be
is required. removed using narrow suction tubing, which can
be advanced by an assistant or scrub nurse.
Safe bronchoscopy requires good teamwork and
communication between the surgeon and the If a foreign body, especially an organic foreign
anaesthetist. When the patient is well oxygenated body is visualized, it is vital that a small volume
and the anaesthetist feels it is appropriate, the of 1:10,000 adrenaline is instilled via the suction
endotracheal tube or laryngeal mask is withdrawn tubing to reduce mucosal oedema and to allow
and a mouth guard placed over the upper teeth. vasoconstriction. This improves access and
Using the anaesthetic laryngoscope, the larynx minimizes the risk of bleeding which can make
is visualized as the non-dominant hand supports removal of the foreign body very challenging.
the laryngoscope. The bronchoscope is held in the Appropriate optical forceps are then used to
dominant hand and advanced until the larynx remove the foreign body. The bronchoscope is
is reached. The bronchoscope may be rotated reinserted to ensure that there are no more foreign
through 90° to facilitate passage through the bodies and to assess for mucosal damage.

114 ENT: An Introduction and Practical Guide

Connector to anaesthetic circuit

Suction tubing port

Hopkins rod

Ventilating bronchoscope
Prism

Figure 23.1. Diagram of a ventilating bronchoscope.

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

Rigid bronchoscopy 115

24 SUBMANDIBULAR
GLAND EXCISION
Ram Moorthy

This is a common surgical procedure performed ●● Benign tumours of the gland. If there is any
by both ENT surgeons as well as oral and suspicion of malignancy, then a Level I neck
maxillofacial surgeons for benign and malignant dissection is more appropriate than simple
disease. excision of the gland.
●● Following open trauma to the gland,
The standard transcervical approach is exploration and removal may be necessary to
described below. Nonstandard techniques include avoid salivary fistula formation.
submental, retroauricular, transoral, endoscopic ●● Drooling.
and robot-assisted surgery (1).

Indications

●● Recurrent submandibular gland sialadenitis.

●● Obstructive sialolithiasis.

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

OPERATIVE PROCEDURE
Once intubated and transferred to the operating appropriately prepared and draped to expose the
table, position the patient supine on a head ring corner of the mouth, and also the angle and lower
and shoulder roll with a slight head-up tilt. The border of the jaw to the superior border of the
head is turned to the contralateral side. The skin is clavicle to the midline.

116 ENT: An Introduction and Practical Guide

(a)

(b)

Facial
Facial

(e)

Lingual

Figure 24.1. (a–e) Submandibular gland excision steps.

Mark the lower border of the mandible and the Make an incision through the skin, subcutaneous
site of the skin incision, which lies two finger tissue and platysma. The marginal mandibular
breadths (approx. 5 cm) below the lower border nerve can be damaged in the early stages of the
of the mandible, in order to avoid the marginal procedure.
mandibular nerve (Figure 24.1(a)). The incision,
ideally in a skin crease runs forward from the The nerve does not always have to be formally
anterior edge of the sternocleidomastoid muscle and identified but knowledge of the relevant clinical
is approximately 5−7 cm in length (Figure 24.1(b)). anatomy is important as the nerve lies deep to the

Submandibular gland excision 117

platysma but superficial to the gland and the facial retracted and dissected free of the underlying
vein. In some cases, especially for the management digastric muscle. The posterior border of the
of malignant disease, identification of the nerve mylohyoid muscle is identified and the muscle is
can be helpful to avoid iatrogenic injury, e.g. retracted anteriorly to allow dissection of the deep
superficial to posterior facial vein as it crosses the aspect of the gland.
mandible (4,5).
The gland is retracted postero-inferiorly and, as
Stay close to the under-surface of the platysma dissection proceeds, Wharton’s duct is exposed,
and carefully observe for the nerve when elevating which tents and exposes the lingual nerve and
sub-platysmal flaps. The superficial layer of the deep its ganglion (Figure 24.1(d)). The lingual nerve is
cervical fascia is incised inferior to the lower border dissected off the duct, paying careful attention to
of the gland and elevated in an inferior to superior haemostasis, especially in the small plexus near
direction. The common facial vein is ligated and the ganglion. The duct is followed and ligated
divided close to the inferior border of the gland and as distally as possible to complete the excision.
elevated superiorly away from the gland (Figure Occasionally, the facial artery will need to be
24.1(c)). Ligation of the posterior facial vein near the ligated again as it courses over the mandible. The
inferior border of the gland and superior elevation hypoglossal nerve is identified during dissection of
with the investing fascia (Hayes–Martin manoeuvre) the deep aspect of the gland (Figure 24.1(e)).
is an effective technique to avoid injury to the
marginal mandibular nerve. A drain may be inserted and the wound is closed
in layers.
Once the gland is exposed, the facial artery is
identified, ligated and divided. The gland is

POSTOPERATIVE REVIEW
Examine the patient for nerve injury and 2007. Sub-mandibular gland excision: 15 years
haematoma. The drain can usually be removed in of experience. J Oral Maxillofac Surg 65(5):
the morning and the patient discharged home with 953−7.
routine wound care advice. 3 Chua DY, Ko C, Lu KS. 2010. Submandibular
mass excision in an Asian population: A 10-year
Non-absorbable skin sutures are removed after review. Ann Acad Med Singapore 39(1): 33−7.
seven days. 4 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.
REFERENCES 5 Riffat F, Buchanan MA, Mahrous AK, Fish
1 Beahm DD et al. 2009. Surgical approaches to
BM, Jani P 2012. Oncological safety of the
the submandibular gland. A review of literature. Hayes-Martin manoeuvre in neck dissections
Int J Surg 7(6): 503–9. for node-positive oropharyngeal squamous cell
2 Preuss SF, Klussmann JP, Wittekindt C,
carcinoma. J Laryngol Otol 126(10): 1045–8.
Drebber U, Beutner D, Guntinas-Lichius O.

118 ENT: An Introduction and Practical Guide

25 HEMI- AND TOTAL
THYROIDECTOMY
Ram Moorthy

Indications ●● Scar.
●● Hoarseness due to recurrent laryngeal nerve
●● Thyroid nodule or goitre. injury.
–– Suspicious (usually hemi-thyroidectomy) ●● Loss of the upper vocal range due to damage to
or confirmed (usually total thyroidectomy) the superior laryngeal nerve, which is especially
malignancy. important in singers.
–– Compressive symptoms. ●● Breathing difficulties and, rarely, tracheostomy
–– (Cosmesis). if bilateral vocal cord palsy after total
●● Thyrotoxicosis − a total thyroidectomy is thyroidectomy.
usually undertaken. ●● Hypocalcaemia.
●● Risk of requiring thyroid replacement following
Complications hemi-thyroidectomy alone.

●● Bleeding.
●● Infection.

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

OPERATIVE PROCEDURE
The patient is placed supine on the operating table Monitoring may either be intermittent or
with a shoulder roll and head ring. The skin is continuous. The electrodes are typically attached
prepared and draped. or integrated into the endotracheal tube.
A nerve monitor may be used to monitor the Surgery can be performed with standard
integrity of the recurrent laryngeal nerve. instruments or with a variety of electrosurgical

Hemi- and total thyroidectomy 119

Skin

Platysma muscle

Strap muscles

Sternocleidomastoid muscle Trachea

Thyroid gland Recurrent laryngeal nerve
Internal jugular vein Oesophagus

Common carotid artery

Figure 25.1. Axial section through the neck at the level of the thyroid isthmus.

techniques or with the surgical robot now The gland is freed in the para-carotid tunnel and
available. the straps and carotid retracted laterally.

A horizontal skin crease collar incision is made The superior pole is dissected from an inferior to
approximately 1−2 finger breadths (2.5–5 cm) superior direction. The superior vascular pedicle is
above the sternal notch. Marking the incision prior isolated, ligated and divided close to the gland to
to anaesthesia helps identify an appropriate skin minimize damage to the superior laryngeal nerve.
crease. This allows the superior pole to be freed from its
fascial attachments.
The incision passes through skin, subcutaneous
tissue and platysma (Figure 25.1). Sub-platysmal The thyroid gland is retracted medially, which
flaps are elevated as far as the superior thyroid also rotates the larynx, exposing the tracheo-
notch superiorly and the supra-sternal notch oesophageal groove. The middle thyroid vein is
inferiorly. The anterior jugular veins lie within the identified and divided. The recurrent laryngeal
sub-platysmal plane and may require ligation and nerve (RLN) lies in the tracheo-oesophageal
division. An appropriate retractor or sutures are groove and has a variable course, but always
used to retract the flaps out of the operative field. enters the larynx at the cricothyroid joint. Safe
identification of the RLN can be made in several
The investing layer of deep fascia is incised and ways including:
the strap muscles (sternothyroid and sternohyoid)
lying in the midline will come into view. The ●● The RLN runs within Beahrs’ triangle, which is
strap muscles are separated in the midline. formed by the common carotid, inferior thyroid
Sternothyroid may occasionally need to be artery, and the recurrent laryngeal nerve.
divided for large goitres. This is performed as The RLN runs within Lore’s triangle which is
high as possible to preserve innervation from ansa formed by the trachea, the carotid sheath and
hypoglossi. the under-surface of the inferior lobe of the
thyroid.
The strap muscles are retracted laterally and ●● The RLN is related to the inferior thyroid artery,
the underlying gland dissected free, using a which is identified laterally at the external
combination of sharp and blunt dissection. carotid and followed medially. The nerve is

120 ENT: An Introduction and Practical Guide

usually deeper than the artery, but can be If a hemi-thyroidectomy is being performed, the
superficial or between its branches. isthmus is divided and over-sewn or transfixed,
●● Identify the RLN superiorly just before it enters if required. If a total thyroidectomy is being
the larynx caudal to the inferior pharyngeal performed, then the other lobe is excised in a
constrictor. similar fashion.

Once the nerve has been identified, it is followed Haemostasis is achieved with the careful use of
until it enters the larynx and the thyroid is bipolar and great care taken around the nerve.
carefully dissected free. It is vital that the A drain is optional.
parathyroid glands are identified and dissected
free from the thyroid with their blood supply. The strap muscles are closed in the midline using
Divide the inferior thyroid artery close to the an absorbable suture, with a gap left inferiorly to
thyroid gland to help achieve this. allow blood to escape from around the trachea and
to minimize the risk of airway obstruction from a
The thyroid gland remains attached to the trachea haematoma.
by Berry’s ligament, a dense fascial condensation.
This is usually vascular and the gland is freed to The wound is closed in layers.
the midline using bipolar and sharp dissection.

POSTOPERATIVE REVIEW
A patient undergoing a total thyroidectomy or level is low, then the local protocol is followed
with a known vocal cord palsy is extubated in in conjunction with the endocrinology team.
theatre and the patient’s airway assessed prior to Calcium may be replaced orally or, if very low,
transfer to recovery. intravenously, with the addition of 1-α calcidol
as required. The patient is also commenced on
Voice and cough should be assessed postoperatively. thyroid replacement with either levothyroxine (T)
A bovine cough or weak and breathy voice indicates or, where radioactive iodine is to be administered
an RLN injury which should be confirmed by within the following six weeks, liothyronine (T).
nasoendoscopy. Clip removers or scissors must
always be at the patient’s bedside to enable If a drain has been inserted, it is left in place
immediate evacuation of a haematoma should this overnight and removed when less than 20 mL
occur with compromise of the airway. has drained in a 24-hour period. The patient is
discharged home once the drain has been removed
If a completion hemi-thyroidectomy or total and, if applicable, when the calcium is normal.
thyroidectomy has been undertaken, postoperative
calcium levels may be checked after 4−6 hours Vocal cord movement is assessed at outpatient
and again the following morning. If the calcium follow-up.

Hemi- and total thyroidectomy 121

26 SUPERFICIAL
PAROTIDECTOMY
Ram Moorthy

The plane of the facial nerve divides the parotid Complications

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

PREOPERATIVE REVIEW
Always check and document facial nerve function FNAC results and ensure that any preoperative
preoperatively (Figure 26.1). Review imaging, blood test results are available.

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

122 ENT: An Introduction and Practical Guide

Once the incision has been made, an anterior skin
flap is raised between the parotid gland capsule
Temporal and superficial fat layer. The platysma, medially,
Zygomatic and greater auricular nerve, laterally, can be used
to identify the correct plane inferiorly. The flap
over the parotid gland can be raised using a blade
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
Buccal
parotid gland is reached care must be taken to
Marginal mandibular prevent damage to branches of the facial nerve as
Cervical they emerge from the gland. The flap is retracted
anteriorly with sutures.

The sternocleidomastoid muscle is identified

Figure 26.1. External branches of the facial nerve. and its anterior border dissected free. The
greater auricular nerve will be encountered. It
is sometimes possible to preserve a posterior
to ensure that the majority of the face is exposed,
branch that supplies sensation to the ear lobe. The
especially the ipsilateral eye and corner of the mouth.
posterior belly of the digastric muscle is exposed
and traced back to its insertion in the mastoid.
The most common incision used in the ‘lazy-S’
The perichondrium of the tragus is identified and
incision (Figure 26.2), although a face lift
the tragus exposed to its deep extent to reveal the
incision is becoming more popular. Infiltration
tragal pointer. Another suture retracts the ear
with adrenaline alone, or local anaesthetic
lobule posteriorly. The parotid gland between the
and adrenaline, may be used to provide some
tragus and posterior belly of digastrics is carefully
haemostasis.
dissected to ensure wide exposure.

There are several ways to find the facial nerve. A

combination of the first three landmarks is usually
adequate to ensure safe dissection in the majority
of cases:

1 Finding the nerve as it bisects the

tympanomastoid groove. This is the most
constant landmark.
2 Using the tragal pointer, the nerve lies
approximately 1 cm deep and 1 cm inferior to
the nerve. The nerve lies just deep and superior
Lazy-S incision
to the posterior belly of digastric near its
attachment to the mastoid.
Where a large tumour lies directly over the
3
proximal aspect of the facial nerve, find a distal
branch, such as the marginal mandibular, and
follow the nerve in a retrograde manner.
Where the above measures fail, drill into
4
the mastoid portion of the temporal bone to
Figure 26.2. Incision landmarks for a parotidectomy.

Superficial parotidectomy 123

identify the descending portion of the facial to the nerve under direct vision using a No. 12
nerve and follow it out of the stylomastoid scalpel, scissors or electrosurgery device (e.g.
foramen. ligasure). Bipolar diathermy must be used precisely
to prevent thermal damage to branches of the
Careful dissection on a broad front with precise facial nerve.
use of bipolar diathermy to ensure complete
haemostasis will allow identification of the facial Parotid tumours often lie directly over branches of
nerve trunk (Figure 26.3), which can be confirmed the nerve. Care is taken not to enter the tumour, as
by use of a nerve stimulator. The main trunk this risks recurrence at a later date.
typically divides into upper and lower divisions,
which divide in a variety of combinations into The parotid gland is carefully dissected free of the
the five terminal branches. There is often some facial nerve, preserving all branches. Very rarely,
cross-communication between the branches. Each when no other option is available, typically due
branch of the facial nerve is followed using a small, to malignancy, one or more branches of the facial
curved clip to dissect the gland from the nerve, nerve may have to be sacrificed. A drain is usually
ensuring that no pressure or compression of the required and an absorbable suture used to close
nerve occurs, which would result in postoperative the platysma, with the skin closed with a non-
weakness. The gland may then be cut superficial absorbable monofilament suture or staples.

Deep lobe of parotid

Superficial
lobe of parotid
Facial nerve trunk

Sternocleidomastoid
Posterior belly
of digastric

Figure 26.3. Identification of the facial nerve trunk.

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

124 ENT: An Introduction and Practical Guide

27 TRACHEOSTOMY
Francis Vaz

A tracheostomy is a conduit from the skin of the Indications

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

METHODS

Thyroid cartilage

Cricothyroid membrane

Cricoid cartilage

First tracheal ring

Site of tracheotomy

Tracheostomy 125
●● Cricothyroidotomy – This may be required This is often performed with the benefit of a
in the emergency setting when access to the flexible bronchoscope through the larynx from
airway is required. The gap between the thyroid above to ensure correct positioning in the
and cricoid cartilages (cricothyroid membrane) trachea.
is palpated. A horizontal stab incision facilitates ●● Transtracheal needle – Wide-bore needles
the insertion of a mini-tracheostomy. are available which can be inserted and
●● Percutaneus tracheostomy – This technique has then connected to a jet ventilation system
gained popularity with intensive therapy unit to maintain an airway. This is a temporary
(ITU) interventionists. It is performed using measure to allow oxygenation while a secure
a Seldinger technique where a guide wire is airway is inserted.
inserted through a transtracheal needle which Since it does not allow for expiration, the upper
has been placed in the midline through the skin airway should be clear enough to allow for gases
into the trachea. A series of dilators are gradually to be expired.
‘railroaded’ over this to widen the tract. ●● Surgical tracheostomy – This will be considered
Finally, the tracheostomy tube can be inserted. in greater detail below.

FORMATION OF A SURGICAL TRACHEOSTOMY

A tracheostomy is usually performed under in the midline and a transfixion suture
general anaesthesia, although the use of local used to prevent bleeding. With the thyroid
anaesthesia may be necessary where the airway isthmus divided, the trachea will be better
is too narrow to allow intubation. The skin is exposed. A single tube may be chosen at this
infiltrated with local anaesthetic and the tracheal point, but a variety of sizes should be available.
mucosa injected just before an incision is made The tube cuff should be checked for leaks at
into the trachea. this point.
5 A window into the trachea is fashioned – Inform
The procedure requires the following steps: the anaesthetist before entering the trachea.
There are a number of methods of entering the
1 Patient position – The patient is positioned trachea. In children, a vertical slit is made in
supine with the head in the midline. A sandbag the midline and stay sutures placed on either
is placed under the shoulders and a head ring is side of the incision. These sutures are taped
used to support the head. This extends the neck to the child’s chest and used to hold open the
allowing the laryngeal skeleton and trachea to hole if the tracheostomy tube displaces or
be readily palpated and elevated into the neck. when the tracheostomy tube is first changed
2 Skin incision – A skin incision is made halfway at seven days. In adults, a window is cut just
between the cricoid and the suprasternal notch large enough to admit the tracheostomy tube.
and extended into the subplatysmal tissues In both cases the cricoid cartilage must not be
(Figure 27.1). The anterior jugular veins and injured. For this reason, the window or incision
midline strap muscles will now come into view is made through the 2nd, 3rd or 4th tracheal
(Figure 27.2). rings (Figure 27.4).
Identification of the thyroid gland and trachea –
3 A tracheostomy tube is inserted – Ask the
6
The strap muscles are separated in the midline anaesthetist to deflate the cuff and withdraw
and retracted, bringing the trachea and thyroid the endotracheal tube until the tip is just above
isthmus into view (Figure 27.3). the window. The tracheostomy tube may be
4 Division of the thyroid gland – The thyroid inserted, the cuff inflated and the tube sutured
gland is clamped through the isthmus, divided into place and appropriate dressings applied.

126 ENT: An Introduction and Practical Guide

(a)

Cricoid cartilage

Right sternocleidomastoid
muscle
Horizontal skin crease incision

Suprasternal notch

(b)

Horizontal skin crease incision

Suprasternal notch

Figure 27.1. Tracheostomy incision.

Strap muscles
Linea alba

Figure 27.2. Identification of thyroid isthmus.

If an emergency tracheostomy is required, it Complications

is essential to gain access and maintain the
airway as quickly as possible. In these cases, a These may be classified as immediate, early and late.
vertical midline incision is made to avoid all
Immediate (within 24 hours of procedure)
vascular structures except the thyroid, which
Haemorrhage − thyroid vessels, jugular veins.
must be dealt with rapidly in the emergency
Pneumothorax.
scenario.
Air embolism.

Tracheostomy 127
First tracheal ring

Thyroid isthmus
Fourth tracheal ring

Figure 27.3. Division of thyroid isthmus.

First tracheal ring

Window

Figure 27.4. Tracheal window.

Cardiac arrest Infection.

Local damage to thyroid cartilage, cricoid Tracheal necrosis.
cartilage, recurrent laryngeal nerve(s). Tracheoarterial fistula.
Dislodgement or displacement of the tube. Tracheooesophageal fistula.
Dysphagia.
Early (24 hours−7 days)
Dislodgement or displacement of tube. Late (after 7 days)
Surgical emphysema of neck. Tracheal stenosis.
Crusting. Difficulty with decannulation.
Tracheocutaneous fistula.

TRACHEOSTOMY TUBE CARE AND SPEAKING VALVES

Tracheostomy tube care is often left to will be directed towards the junior on-call
tracheostomy nurse specialists or members surgeon.
of the nursing staff. It is, however, essential
that junior doctors are able to care for At their bedside, all patients should have a spare
patients with tracheostomy tubes in place tracheostomy tube of the same size and one
and are aware of the potential complications smaller, a tracheal dilator, a 10 mL syringe, a
of having a tracheostomy. It is often the case suction unit and catheters, gloves, Spencer Wells
that out-of-hours emergencies and advice forceps and lubrication for the tubes.

128 ENT: An Introduction and Practical Guide

Tracheostomy tubes Disadvantages:

●● Cuffed. ●● If the tube lumen becomes blocked, the patient’s

●● Uncuffed. airway is compromised leading to respiratory
●● Fenestrated. arrest as there is no capacity to breathe around
●● With or without an inner cannula. the tube, unless the cuff is deflated.
●● Adjustable flange. ●● The cuff can damage the tracheal mucosa, leading
●● Suction assisted. to ulceration and possible stenosis. Rarely,
however, this may also cause arterial erosion.
A tracheostomy tube can be directly attached to an ●● Children younger than 10 years, have a narrow
anaesthetic circuit provided that there is a 15 mm trachea, and unlike in an adult, the larynx is
connector at the proximal end. Some tubes have conical, with the cricoid cartilage forming the
this segment on the inner tube, so this should narrowest segment. Tracheostomy tubes used in
always be available. children are uncuffed.

Pressure = Force/Area
Cuffed tubes (Figure 27.5)
Low-pressure, high-volume cuffs reduce the
Advantages: incidence of pressure-induced complications, but it
is still important not to over-inflate the cuff.
●● A cuff is required for:
– Ventilation, continuous positive airway The cuff should be deflated as soon as possible
pressure. to allow for the insertion of a speaking tube or
– Patients who aspirate as they cannot protect decannulation cap.
their airway.
Patients with normal swallowing reflexes may find Uncuffed tubes (note Figure 27.6)
their swallowing impaired as a result of pressure
exerted on their oesophagus and the impedance of These tubes are often found in patients returning
laryngeal elevation by an inflated cuff. from ITU after a prolonged stay as they allow

Flange

Outer tube

Inflated cuff

Obturator tip

Figure 27.5. A cuffed tracheostomy tube.

Tracheostomy 129
suction and physiotherapy. The tubes are easy to ●● Foam filter protectors such as the Buchanan
replace and suitable for long-term use. Patients can laryngectomy protector.
speak around it. They are not suitable for patients
who aspirate or who need ventilation.
Tracheostomy dressings
Fenestrated tubes
The objective is to keep the trachea, stoma and
The fenestration directs airflow through adjacent skin clean and dry, and minimize
the patient’s vocal cords, oropharynx and skin irritation and infection. Wet skin results
nasopharynx. It helps some patients to resume in maceration and excoriation. Hydrophilic
breathing normally and can be used to wean them polyurethane foam dressings absorb moisture
off their tracheostomy tube. Remember that a away from the skin.
fenestrated inner tube is also required.
If a tracheostomy site shows signs of granulation,
Tube with adjustable flange this can be treated with silver nitrate cautery,
although care should be taken not to damage
This is designed for patients with deep-set tracheas surrounding normal skin.
and fat necks.
Changing a tracheostomy tube
The flange can be adjusted to fit the depth of tissue
between incision and trachea. Most surgeons recommend the first tube change
to be performed at 1 week. The first change should
Cleaning inner tubes be performed by an experienced practitioner or,
ideally, by the surgeon.
Most recommend water or warm salty water only.
Avoid alcohol, bleach and glutaraldehyde. Flush If a difficult tube change is anticipated, use an
the tube and do not soak it as this increases the exchange device (guide wire or a bougie) and
risk of bacterial proliferation. consider changing the tube in the operating
theatre.
Humidification
The steps involved are as follows:
●● Nebulizers 5 mL, 0.9% N/saline in mask over
stoma. 1 Explain to the patient what you plan to do.
●● Heat moisture exchangers fit onto the Ensure that a good light source, preferably a
tracheostomy tube. headlight, is available.

Tape

Flange

Figure 27.6. Tracheostomy tube in situ.

130 ENT: An Introduction and Practical Guide

2 Extend the patient’s neck using pillows so the 6 Allow the patient to recover and remove the
head is supported and hyperoxygenate them if old tube.
required. 7 Insert a new tube, inflate the cuff if indicated
3 Check the integrity of the cuff if used. and insert the inner cannula.
Lubricate it sparingly. 8 Check chest movement, insert a clean dressing
4 Remove all old dressings and clean around the and apply the tapes before checking cuff
stoma site. pressure.
5 Remove intraoral secretions with suction, 9 If you are uncertain of the position of the
deflate the cuff and suction through the old tube, a flexible endoscope can be passed into
tube. Some secretions trapped around the the trachea through the tube lumen.
cuff will now fall into the trachea inducing 0 Connect to any humidification devices.
1
coughing.

GENERATING A VOICE WITH A TRACHEOSTOMY

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

All of the above allow air to escape around Contraindictions

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

Tracheostomy 131
28 VOICE
Francis Vaz

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

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

132 ENT: An Introduction and Practical Guide

A thorough medical and drug history should precipitate coughing (angiotensin converting
be taken to assess conditions that may affect the enzyme inhibitors [ACEIs]) or may dry the UADT
ballast (respiratory drive) to produce voice. Also, (e.g. anticholinergic side effects).
certain medications may affect voice as they may

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

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

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

REINKE’S OEDEMA
In this situation the patient has had a long- The correct treatment is smoking cessation and the
standing deepening of the voice. They are often use of anti-reflux therapy in the form of a proton
smokers, but acid reflux may also play a part. pump inhibitor. If the patient ceases smoking
Pathologically, oedema occurs within Reinke’s but the voice does not return to normal and the
space in the vocal fold, increasing the mass of findings are still the same on laryngoscopy, then a
the vocal fold and therefore deepening the voice superior cordotomy on the non-vibratory surface
(Figure 28.1). of the vocal cord can be undertaken and some of
the oedema reduced.

VOCAL FOLD NODULES (‘SINGER’S’ NODULES)

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

Voice 133
Airway
Squamous epithelium
Basement membrane

Superficial lamina propria

(Reinke’s space)

Intermediate lamina
propria Vocal
ligament
Deep lamina propria

Vocalis muscle

Figure 28.1. Cross section of the vocal cords.

two-thirds. This does not allow for good closure of For the vast majority of these we use speech and
the vocal folds and results in a change in voice. language therapy to educate patients on use of the
voice and to help them use their voice appropriately.
Rarely do they require surgical intervention.

VOCAL FOLD PALSY

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

LARYNGEAL CANCER
These patients usually present with a long history have developed a progressively worsening voice
of smoking and/or high alcohol intake. They over 6–12 weeks and may have associated otalgia,

134 ENT: An Introduction and Practical Guide

odynophagia, dysphagia and even associated neck Laryngeal cancer can be treated in a variety of
lymphadenopathy. ways. Small laryngeal cancers can be treated with
narrow field radiotherapy or be resected using a
Nasoendoscopy usually demonstrates an laser at the time of laryngoscopy. Larger tumours
irregularity of the vocal fold, but the patient can be treated with radiotherapy or chemo-
requires a laryngoscopy and biopsy of this radiotherapy covering a larger field for associated
suspicious area. lymph nodes. The largest laryngeal cancers – those
that have invaded the thyroid cartilage and those
In smokers a premalignant diagnosis of dysplasia that may be obstructive to the airway − are often
may be made on histology. This is just as treated with a laryngectomy. This involves removal
important, as the patient needs to be aware of of the larynx and the creation of a permanent end
this and to stop smoking to reduce the chance of stoma. The management of the patient should be
progressing to an invasive malignancy. Prior to discussed in the context of a multidisciplinary
biopsy a staging computed tomography of the neck head and neck team meeting.
and chest is useful.

LARYNGEAL PAPILLOMATOSIS
Human papilloma virus (HPV) can cause viral obstruction or for significant change in voice due
warts. In the larynx this can be extremely to mass effect. The problem is that each surgical
troublesome. If a viral wart impinges the glottis, procedure is associated with some laryngeal
the airway may be compromised, but more often scarring, and although some patients will require
hoarseness is produced due to incomplete closure multiple procedures it is wise to minimize the
of the glottis and/or poor mucosal wave formation. trauma to the larynx unless there is good reason to
operate on it.
There are many treatments. Surgical interventions
are often reserved for significant airway

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

VOCAL CORD GRANULOMA

Patients typically have undergone recent surgery vocal cord over the vocal process of the arytenoid
requiring endotracheal intubation or have been cartilage.
on the Intensive Care Unit with an endotracheal
tube in situ for a few days. The pathology forms The granuloma forms due to healing exposed
typically on the posterior medial aspect of the cartilage as a result of trauma from an

Voice 135
endotracheal tube. Also of importance in the symptoms and signs persist, surgical resection
pathology may be gastropharyngeal reflux of acid. may be undertaken with a micro-laryngoscopic
technique.
Treatment often involves aggressive anti-
reflux treatment over a 6-week period, but if

VOCAL CORD CYSTS

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

MICROLARYNGOSCOPY
This is an examination under general anaesthesia the anaesthetist (i.e. with a micro-laryngoscopy
and is often undertaken for diagnostic or tube, supraglottic/subglottic or transtracheal jet
therapeutic procedures on the larynx. The use of ventilation).
the microscope offers magnification, depth of field,
bimanual handling of instrumentation and the use The endoscope, light source, suction, lubrication
of other attachments, such as a CO2 laser. and dental guard should all be checked prior to
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 preparation for the biopsy or surgical undertaking.

136 ENT: An Introduction and Practical Guide

29 AIRWAY MANAGEMENT
Francis Vaz

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

MANAGEMENT OF THE COMPROMISED AIRWAY

Presentation and management of the compromised More than one option or plan should be discussed
airway varies according to the site of presentation before significant intervention is undertaken.
and aetiology (Table 29.1). These affect both the
severity and speed of onset of symptoms and A rapid assessment of the patient is made to
the categorization of management into urgent assess whether they are in danger of imminent
or nonurgent. However, the approach taken to upper airway obstruction. This is determined
manage airway obstruction is similar for all. by the worsening of stridor or stertor, although
stridor that becomes quiet may indicate imminent
It is essential in the management of the patient complete airway obstruction.
with a compromised airway that a team approach
is used. The most senior members of the Stertor is rough noisy breathing, similar
anaesthetic and ENT teams should be informed to snoring, caused by vibration of partially
and involved in the management at an early stage. obstructing soft tissue in the pharynx.

Airway management 137

Table 29.1. Aetiology of airway obstruction.

Aetiology
Level of
obstruction Pathological Anatomical
Nasopharynx Tumour Choanal atresia
Infection (unilateral or bilateral)
Foreign body Crouzon syndrome
Apert syndrome
Oropharynx/ Infection (tonsillitis, Ludwig’s angina) Short lower jaw
Hypopharynx Bleeding (post-tonsillectomy) (especially
Tumour micrognathia)
Burns Large tongue
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 papillomatosis) Laryngeal web
Vocal cord palsy
Polyp
Oedema (postoperative anaphylaxis)
Foreign body
Subglottis Infection (croup) Congenital subglottic
Tumour (squamous cell carcinoma, respiratory papillomatosis) stenosis
Stricture (post-intubation, post-tracheostomy) Subglottic haemangioma
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

Stridor is a harsh, high-pitched, almost Expiratory stridor is during expiration only,

musical sound, caused by vibration of partially usually at a slightly lower pitch than inspiratory
obstructing soft tissue in the larynx or upper stridor, and is due to obstruction of the subglottis
trachea. or extrathoracic trachea.

Inspiratory stridor is during inspiration only, often Biphasic stridor involves both inspiration and
a crowing sound, and is due to obstruction at the expiration, and, while representing laryngeal
glottis, supraglottis or subglottis level. obstruction, is a hallmark of severe obstruction.

138 ENT: An Introduction and Practical Guide

Wheeze is a high-pitched husky or whistling A plan is made jointly by the senior ENT surgeon
sound, caused by narrowing of soft tissue in the and anaesthetist to determine how they will
intrathoracic airways. secure the airway. This depends on the suspected
level of obstruction. Orotracheal or nasotracheal
In addition, patients will have a high respiratory intubation may be attempted by the anaesthetist
rate, poor chest expansion, low oxygen saturations, if it is thought that there is sufficient space to
tachycardia and may experience fatigue with pass a tube through the obstruction safely. The
rising carbon dioxide. While it may be possible surgeon and scrub nurse must be scrubbed with
in an adult to examine the larynx using a flexible tracheostomy and bronchoscopes open and set up
nasoendoscope in order to assess the degree of in order to intervene if needed. Other temporary
obstruction, this must not be attempted in a child. airway adjuncts that should be considered to gain
When presented with a child with imminent access to the subglottis include a transtracheal
airway compromise, such as suspected epiglottitis, cannula or cricothyroidotomy with jet ventilation.
any instrumentation may cause significant distress If intubation fails or is thought not to be possible,
and a decline in the airway. The priority is to secure then the decision is taken either to perform
the airway, ideally in theatre. It is very rare that a a tracheostomy or gain initial access to the
patient presents in complete airway obstruction. In airway by bronchoscopy with a rigid ventilating
this case, it is likely that an anaesthetist will already bronchoscope.
be with the patient. If they are unable to intubate
the patient, then an immediate tracheostomy must Table 29.1 is a summary of the most common
be performed in order to secure the airway. This is aetiologies that can result in airway obstruction,
described in Chapter 27. along with the level of obstruction.

Immediate management includes calling for

senior help, and giving oxygen and adrenaline
nebulizers. Heliox can also buy valuable time. It KEY POINTS:
is composed of 21% oxygen and 79% helium and
has a lower density than air, which improves flow ●●A is for airway, and the presentation
in the airways resulting in better oxygen delivery. of an acutely problematic airway is a
The administration of steroids gives benefit a few medical and surgical emergency.
hours later by reducing mucosal oedema. If in the ●●Act sooner rather than later,
emergency room, the patient should be monitored especially if you suspect a progressive
in the resuscitation area. If patients are stable, they problem.
are managed in a high dependency or critical care
unit. Where a patient is not severely compromised, ●●Consider medical management that
a more thorough evaluation may be made, may be of use to hold the situation
including appropriate imaging and a plan made without causing the patient distress
depending on the aetiology. (adrenaline nebulizers, steroids, heliox).
●●Involve senior members of the ENT,
If the patient is in complete airway obstruction anaesthetic and if appropriate
or, despite the above measures, continues to nursing/paediatric teams as soon as
deteriorate, then a decision must be taken to possible.
secure the airway with a cuffed endotracheal tube. ●●Think before you act, as you may
Ideally, this should be performed in the operating precipitate a worsening of the
theatre where all the anaesthetic equipment for problem.
managing difficult airways is available, as well as
the surgical instruments for tracheostomy and
rigid bronchoscopes.

Airway management 139

30 RADIOLOGY
Dipalee Durve and Kaggere Paramesh

LATERAL SOFT TISSUE FILM

This is a plain x-ray performed in the acute setting measure up to 7 mm. The maximal normal width
for investigation of an ingested foreign body in an increases to 22 mm in the lower cervical vertebrae
adult or child. A normal lateral soft tissue film is (C5−C7).
illustrated in Figure 30.1.
This is more easily estimated by remembering
Always check for prevertebral soft tissue swelling. that up to a third of the vertebral body
is allowed between C1−C4 and a whole
The maximum normal width anterior to the vertebral body’s width is allowed anterior to
upper cervical vertebral bodies (C1−C4) should C5−C7.

Angle of the mandible

Epiglottis

Hyoid bone
Valleculae

Thyroid cartilage

Trachea

Figure 30.1. Landmarks visible on a lateral soft tissue film of the neck. The soft tissue space anterior to the
vertebral column should always be inspected.

140 ENT: An Introduction and Practical Guide

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

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

ULTRASOUND NECK
Ultrasound is a safe, easily accessible test. to drainage can be determined. In children it can
Superficial structures such as the thyroid, parotid be used to assess lesions such as thyroglossal cysts
and submandibular glands are easily evaluated and or fibromatosis colli (sternomastoid tumour). The
beautifully depicted. Morphology of lymph nodes presence or absence and velocity of coloured blood
and the presence of any suspicious features (Table flow in congenital lesions such as venolymphatic
30.1), as well as diagnostic fine needle aspiration malformations and haemangiomas can be assessed
(FNA), can be performed (1). The presence of as an adjunct to further cross-sectional imaging,
collections and whether they would be amenable such as MRI.

Radiology 141
Table 30.1. Morphology of lymph nodes in the neck.

Benign lymph node Malignant lymph node

Size Variable; reactive lymph nodes Size alone cannot be used to differentiate
can be very large in the neck. benign vs malignant.
Increase in nodal size in a patient with
known malignancy is suspicious for
involvement.
Shape Elliptical (short to long axis ratio Round (short to long axis ratio >0.5).
of <0.5).
Border Usually not sharp borders. Sharp borders – due to intranodal tumour
infiltration causing increase in acoustic
impedance between node and surrounding
tissues.
However, metastatic lesions in advanced
stages may have ill-defined borders due to
extracapsular spread of tumour.
Echogenicity Intermediate echogenicity. Usually hypoechoic relative to adjacent
musculature.
However metastatic nodes from papillary
thyroid carcinoma usually hyperechoic due
to intranodal deposition of thyroglobulin.
Echogenic hilum Usually seen in nodes >5 mm. May be absent due to tumour infiltration but
can also be seen in malignant nodes.
Therefore cannot be used as sole criterion
for evaluation of neck nodes.
Intranodal necrosis Not seen. May be cystic (liquefaction necrosis) or
echogenic (coagulation necrosis).
Found in metastatic and tuberculous lymph
nodes and regardless of nodal size should
be considered pathological.
Calcification Usually not seen. Some cancers, e.g. papillary or medullary
thyroid cancers, can have calcification,
usually peripheral, punctate with acoustic
shadowing.
Vascular distribution Hilar vascularity. Peripheral or mixed vascularity.

COMPUTED TOMOGRAPHY AXIAL VIEWS OF THE NECK

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

142 ENT: An Introduction and Practical Guide

COMPUTED TOMOGRAPHY OF THE TEMPORAL BONE
CT of the temporal bone is used as a preoperative ossicular chain and inner ear can be assessed as
planning tool in cases of cholesteatoma where well as the aeration of the surrounding mastoid air
disease spread resulting in bony erosion is cells. It is also useful in cases where hyperostosis is
particularly significant (Figure 30.2). The bony seen as a complication 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 the facial nerve
of superior SCC
Subarcuate Internal auditory
artery meatus
Mastoid
Mastoid Crus Utricle (vestibule)
antrum
air cells commune
Lateral SCC
Posterior SCC
Endolymphatic duct
Posterior SCC

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

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

Figure 30.2. (a−g) Axial CT views of the right temporal bone (superior to inferior).

Radiology 143
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.

CT OF THE SINUSES
CT of the sinuses has now replaced plain film 1 Extent of disease.
radiography and is indicated in patients who do Position of the septum − a deviated septum
2
not respond to medical treatment of sinusitis. may require correction in order to access the
It can demonstrate severity and distribution of paranasal sinuses (Figure 30.3).
disease, patency of the osteomeatal complexes and 3 Position of lamina papyracea and uncinate
any anatomical variants such as concha bullosa process.
(an accessory air cell within the middle turbinate), 4 Attachment of the middle turbinate.
Haller and Onodi cells and to aid surgery. Both
5 Presence of a concha bullosa.
axial sections and coronal reformats are required.
6 Length of the lateral lemniscus (Keros
classification; Table 30.2).
A CT scan is reviewed in order specifically to 7 Position of the optic nerves (axial views).
assess:

Anterior ethmoidal air cell Lateral lemniscus

Lamina papyracea
Middle turbinate
Uncinate process
Inferior turbinate
Maxillary sinus

Septum

Figure 30.3. Coronal section of the paranasal sinuses.

Table 30.2. The Keros classification refers to the vertical height of the
lateral lemniscus. Types 2 and 3 are at greater risk of cerebrospinal
fluid 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

144 ENT: An Introduction and Practical Guide

MAGNETIC RESONANCE IMAGING
Indications Most ENT surgeons will request this investigation
for cases of asymmetric sensorineural hearing loss
●● Assessment of the tongue base. (>15 dB HL difference in two adjacent frequencies),
●● Assessment of parotid lesions. sudden sensorineural hearing loss and unexplained
●● Intracranial pathology (e.g. cerebellopontine vertigo or dizziness. It may also be used to assess
angle lesions). patients with delayed or absent recovery of a facial
nerve paralysis.
MRI is increasingly used in the head and neck
due to its capacity to image soft tissues. This
This investigation is contraindicated in patients
modality remains the investigation of choice in the
with metal foreign bodies and implants (e.g.
assessment of tongue base or parotid lesions. In the
pacemakers, cochlear implants, etc.).
case of the latter, the retromandibular vein allows
one to distinguish between the larger superficial
Both high-resolution CT and MRI are important
and smaller deep lobe tumours. The extent of
in the investigation of congenital deafness as well
tongue carcinoma is best defined radiologically
as the surgical planning of any treatment. There
with particular regard to whether the midline
is a wide range of anatomical abnormalities, some
has been crossed, whether there is involvement of
linked to syndromes, including the Mondini
the mandible, and any spread posteriorly to the
spectrum and widening of the vestibular aqueduct.
epiglottis.

MRI IAMs

Normal anatomy, including the VIIth and VIIIth

nerve roots and the vestibular aqueduct, are
exquisitely demonstrated (note Figure 30.4).

Left cochlea
Left lateral
Right internal semicircular canal
auditory meatus
Left cerebellopontine
angle
Cerebellum

Figure 30.4. Normal MRI view of the internal auditory meatii (see Chapter 1, Figure 1.5 regarding the
relative positions of the nerves within the internal auditory meatus).

Radiology 145
POSITRON EMISSION TOMOGRAPHY – COMPUTED
TOMOGRAPHY IMAGING (PET-CT)
PET has the ability to detect abnormal metabolic –– Radiation therapy causes oedema making
activity at cellular level in organs that do not yet tissue planes indistinct, also difficult to
appear morphologically different on other imaging detect recurrence.
modalities. ●● Detection of recurrence of cranial base
neoplasms.
●● Directing biopsy.
Uses of PET-CT in head and ●● Detection of unknown primary tumour site:
neck malignancy –– Cervical node metastases common with
occult carcinoma.
PET-CT is useful in giving physiological and –– PET-CT used to detect areas that are
anatomical information and particularly PET-avid and may be a source of the
important in detection and follow-up of head and malignancy (Figure 30.5).
neck tumours. ●● Staging head and neck tumours.

PET-CT is used for: PET-CT pitfalls (2):

●● Detection of recurrent disease: ●● Physiological FDG uptake – normal in several

–– Neck dissection and flap reconstruction head and neck areas and may cause false
distort normal anatomy making detection of positives.
recurrent disease very difficult on CT alone. ●● Recent surgery.

(a) (b)

Figure 30.5. (a) CT and (b) PET-CT fused with PET avid nodes in supraglottic SCC.

146 ENT: An Introduction and Practical Guide

●● Recent radiation and chemotherapy.
●● Inflammatory tissue. REFERENCES
●● Tumours with low FDG avidity e.g. salivary 1 Ahuja, W. et al. 2008. Ultrasound of malignant
gland and necrotic neoplasms can cause false cervical lymph nodes. Cancer Imag 8: 48–56.
negative results. 2 Meltzer et al. 2005. Combined PET-CT in
head and neck – diagnostic uses and pitfalls.
Radiographics 25(4): 913–30.

Radiology 147
31 MANAGEMENT OF
NECK LUMPS
Francis Vaz

The management of masses in the head and triangle of the neck, can assist in the diagnosis
neck region may seem daunting because of the (Table 31.1).
wide variety of pathology and the consequences
of missing an important diagnosis. This Table 31.1. General considerations in the
exceptionally common clinical finding can be diagnosis of a neck lump.
seen across age groups and important factors must
be elicited in order to obtain the correct diagnosis. Age (yrs) Position

An understanding of the anatomy of the neck and <20 Inflammatory Midline – Thyroglossal cyst
the associated pathologies relevant to the various Congenital Dermoid
Lymphoma Lymph node
positions in the neck is helpful. Delineation of
20–40 Salivary disease Thyroid
whether a lump is in the midline (often suggestive
Thyroid disease Lateral – Lymph node
of a thyroid or thyroglossal cyst pathology) Inflammatory Salivary
or laterally, either in the anterior or posterior Malignancy (upper)
>40 Malignancy

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

EXAMINATION
A thorough examination of the head and neck tongue base should be palpated as pathology
should be undertaken. The oral cavity should may be deep and not obvious to the eye (this
be illuminated with a headlight and examined does, however, induce a significant gag reflex).
with two tongue depressors. If appropriate, the A flexible fibreoptic nasolaryngoscope is usually

148 ENT: An Introduction and Practical Guide

required to assess the postnasal space, larynx should be identified in a careful and methodical
and hypopharynx. Any masses in the neck examination of the neck.

SPECIAL INVESTIGATIONS
The use of special investigations can be divided Ultrasonography is an excellent, noninvasive
into those pertinent to preparing a patient for tool to delineate structures but is difficult for the
a general anaesthetic and those relevant to the surgeon to interpret. Computerized tomography
pathology of the head and neck. (CT) is superb for looking at most of the head and
neck, is easy to obtain and quick to undertake, but
When investigating a lump in the neck the can be prone to dental artifacts in and around the
principal investigation of choice, almost always, oral cavity. Magnetic resonance imaging (MRI) is
is fine needle aspirate cytology (FNAC). This is a an excellent tool to look at soft tissues, especially of
process by which cells are sampled by means of the tongue, postnasal space and oral cavity. It does
multiple passes of a needle through the mass while often carry a longer waiting time to be performed,
simultaneously aspirating with a syringe. The is more claustrophobic to undertake, and takes
cells in the barrel of the needle are then sprayed longer to be scanned.
onto a cytology slide and either air-dried or fixed
chemically, depending on the preference of the Investigations pertinent to general anaesthesia
cytology department. This test is often undertaken should be discussed at a local pre-admission level,
by the cytology department itself. This is a crucial and each department should have an appropriate
investigation and there are only a few instances protocol for preparing a patient for general
where an FNAC of a neck lump is not appropriate. anaesthesia.

Imaging of masses in the neck is commonplace.

The choice of imaging is dependent on the patient
and the institution where it is to be performed.

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

LYMPHADENOPATHY
Lymphadenopathy can be benign or malignant. in this chapter. However, a lymph node in
The benign causes of lymphadenopathy are the neck should be approached as though it
multiple and too large a group to be discussed is malignant until it is shown that it is not.

Management of neck lumps 149

Our index of suspicion is changed by different
aspects of the history, clinical examination, and
special investigations performed. Metastatic
lymphadenopathy typically follows a predictable
path dependent on the primary site of the tumour
(Figure 31.1). This should be borne in mind when Scalp/skin
searching for the primary tumour. Lymphoma is a
diagnosis that should be considered, but is difficult
to diagnose on FNAC. Often a lymph node biopsy/ Oropharynx/oral
core biopsy is required for formal exclusion or cavity
typing of the lymphoma. Larynyx/hypopharynx
Nasopharynx
Oral cavity
GI tract/lung

Figure 31.1. Metastatic spread from primary sites in

head and neck cancer.

THYROGLOSSAL DUCT CYST

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

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

150 ENT: An Introduction and Practical Guide

selective neck dissection, such that the accessory, preserved, together with the internal jugular vein
hypoglossal and vagus nerves are identified and and the carotid artery.

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

SALIVARY GLAND TUMOURS

This is an extensive subject, but it is useful to have Hallmark symptoms and signs of malignant
an understanding of it. pathology include rapid growth of mass, pain
and nerve weakness (e.g. facial nerve weakness in
Eighty percent of salivary gland tumours arise in parotid malignancies).
the parotid, 10% in the submandibular gland and
10% in the sublingual or minor salivary glands. Of FNAC is very useful and can be very helpful in the
the parotid tumours, 80% are benign and, of these, decision-making process for these tumours.
80% are pleomorphic adenomas.

Management of neck lumps 151

32 VERTIGO AND DIZZINESS
Rahul Kanegaonkar

Vertigo and dizziness affect approximately one with another ten per thousand with symptoms of
third of the general population before the age of dizziness or giddiness (2). A balance disorder in
65 years (1). Annually, five out of every thousand the elderly may result in a fall, with the subsequent
patients present to their general practitioner injuries sustained leading to serious injury and
complaining of symptoms classified as vertigo, even death.

BALANCE OVERVIEW
Normal human balance function relies on and provide information regarding self and
vision, the peripheral vestibular organs, environmental movement (spatial awareness).
proprioception and hearing (Figure 32.1). This Interpretation involves cross-referencing this
sensory information is relayed centrally, where sensory information with previously generated
it is integrated and interpreted within the brain templates. A mismatch results in symptoms of
in order to maintain posture, stabilize vision dizziness, unsteadiness or vertigo.

HISTORY
Taking a thorough history is the key to establishing of dizziness/vertigo should also be established.
a diagnosis. It is essential to allow patients to speak Associated symptoms should be documented (e.g.
freely at the start of the consultation. Although nausea, vomiting, hearing loss, tinnitus, loss of
some of this information may be of little diagnostic consciousness, photophobia and headache).
value, it does allow some insight into their principal
concerns and also establishes rapport with the Subsequent episodes, their duration, frequency
individual patient. It is often the case that this will and precipitants will confirm a working diagnosis.
be the first time that ‘anyone has listened’. The most recent episode is also worth exploring as
symptoms may evolve as central changes partially
A detailed history of the first episode is essential. compensate for the peripheral or central pathology.
When, where and what possible precipitants It is always worth considering more than a single
were associated with the event should be sought pathology responsible for a patient’s symptoms
(e.g. had the patient rolled over in bed, a recent (e.g. benign paroxysmal positional vertigo (BPPV)
change in medication). The duration and form and a peripheral vestibular deficit).

152 ENT: An Introduction and Practical Guide

Input Integration and Output
interpretation

Gaze stabilization
Vision

Peripheral vestibular system

Templates

Postural control

Proprioception

Spatial awareness

Hearing

Figure 32.1. Overview of the balance system.

A past medical and surgical history must always of migraine. In females, a delicate and difficult
be taken, including details regarding the patient’s subject is that of spontaneous miscarriage, but may
vision and mobility and a family or personal history suggest an autoimmune or embolic aetiology.

EXAMINATION
A neuro-otological examination is required in saccades and latent squint and cerebellar signs.
every patient presenting with vertigo. Although Romberg test (on both floor and foam) and the
a working diagnosis may have been made, it is Fukuda stepping test should also be performed.
essential both to confirm and exclude possible Whilst the latter is generally regarded to
concurrent pathology. This includes ear and localize a peripheral vestibular deficit (rotation
cranial nerve examination, eye movement in occurs towards the weaker side), the Halmagyi
all four planes for nystagmus, smooth pursuit, head thrust test is a far more sensitive and

Vertigo and dizziness 153

specific clinical investigation (Table 32.2). pathology. It is essential to document the latency
Dix–Hallpike testing is also required in every and duration of any nystagmus seen and whether
case to demonstrate any form of nystagmus, the nystagmus settled completely.
but in particular geotropic torsional nystagmus
consistent with posterior semicircular canal A thorough assessment also includes lying and
BPPV. Vertical or horizontal nystagmus, or standing blood pressure recording and gait
nystagmus that does not fatigue, is unusual, and assessment.
patients require MRI scanning to exclude central

SPECIAL INVESTIGATIONS
All patients should undergo a pure tone audiogram Bithermal caloric testing remains a simple
and tympanometry. A sensorineural asymmetry and valuable method of comparing lateral
may suggest a cerebellopontine angle tumour, semicircular canal function. Eye movements
which must therefore be excluded with MRI may be recorded with electrodes attached to
internal auditory meatii. Vestibular testing is the face, electronystagmography (ENG) or by
required in the majority of subjects referred videoing pupil movement, videonystagmography
to a balance service (exceptions may include (VNG). Saccades, smooth pursuit and optokinetic
BPPV that settles completely following particle movement may also be assessed with this
repositioning manoeuvres). Not only do these recording method. Additional tests include
investigations support a working diagnosis, rotational chair and vestibular evoked myogenic
but in approximately 5%−10% of cases reveal potentials (VEMPs).
unexpected unilateral or bilateral peripheral
vestibular hypofunction and guide vestibular Patients with a history and assessment in keeping
rehabilitation. with central pathology should also undergo an
MRI scan to exclude a space-occupying lesion or
As it is not possible to directly access the demyelination. Patients with chronic ear disease or
peripheral vestibular organs, an indirect suspected superior semicircular canal dehiscence
assessment based on the vestibulo ocular reflex is require a fine-cut computed tomography scan of
generally used (Figure 32.2). the temporal bones.

COMMON VESTIBULAR PATHOLOGY

Listed below are common vestibular conditions to go about their normal daily activities. There is
amenable to treatment (Table 32.1). Management no associated hearing loss or tinnitus. Spells last
pathways are also illustrated in Figure 32.3. for days to weeks and usually settle spontaneously.
Patients often describe a previous head injury,
Benign paroxysmal positional episode of ‘labyrinthitis’ or a brief spell of
vertigo (BPPV) environmental tilting (‘the floor suddenly came up
to meet me’).
This is the commonest cause of vertigo in all
age groups. Patients classically describe rotatory Symptoms arise due to debris derived from the
vertigo when rising or turning over in bed. otoconial membrane of the utricle. Head rotation
Although the vertigo lasts for seconds, they feel results in this debris striking the delicate cupula
unsteady for a great deal longer, but are then able of the posterior semicircular canal, profoundly

154 ENT: An Introduction and Practical Guide

Lateral Medial
rectus rectus

Oculomotor nucleus
Abducens nucleus

Vestibular nucleus

Neural firing rate

Head turning

Figure 32.2. The vestibulo ocular reflex. As a result of head rotation, endolymph flow within the semicircular
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.

Table 32.1. Common causes of dizziness (in order stimulating the associated hair cells and causing
of frequency). vertigo (Figure 32.2). The mismatch in input
between each side that occurs may also result in
●● Benign paroxysmal positional vertigo (BPPV) nausea, vomiting and anxiety.
●● Acute peripheral vestibular deficit (labyrinthitis/
vestibular neuritis) The most common form affects the posterior
●● Vertiginous migraine semicircular canal. On Dix–Hallpike testing,
●● Multilevel vestibulopathy
following a short latency, geotropic (towards
●● Cholesteatoma (CSOM)
●● Hyperventilation syndrome
the ground) torsional nystagmus will gradually
●● Menière’s disease appear, increase in severity and gradually subside
●● Vestibular schwannoma completely. This will correlate well with the
●● Multiple sclerosis symptoms of vertigo experienced by the patient
●● Vertebrobasillar insufficiency during the test. Having confirmed the diagnosis,
●● Superior semicircular canal dehiscence an Epley manoeuvre should be performed. This

Vertigo and dizziness 155

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
over in bed. nystagmus, not days associated History of poor infections’. state. Clinical and tinnitus. Hours hearing loss.
Torsional fatigable associated with with periods or, vision, peripheral Otoscopy examination, with nausea and Occasional
nystagmus on hearing loss nor previous history of neuropathy, demonstrates TM normal. vomiting. episodes of
Dix-Hallpike tinnitus. Nausea classic migraine osteoarthritis. retraction with Nystagmus during disequilibrium
testing. and vomiting. then subsequent keratin/debris. episodes. or vertigo.
spells lasting days.
Sensorineural
No associated
hearing loss, nor hearing loss.
tinnitus. Patients
prefer bed rest in
a quiet darkened
room.

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

156 ENT: An Introduction and Practical Guide

• 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 • Bendrofluazide assessment
those who fail • Antimigrainous therapy • Surgical • Surgical
to recover Tx intervention intervention

Figure 32.3. Management pathways for common vestibular pathology. (PTA – pure tone audiometry; FVT – formal vestibular testing)
is curative in approximately 90% of cases. A Patients may describe a recent flu-like illness.
repeat manoeuvre may on occasion be required. They classically wake up with severe continuous
Alternative particle repositioning manoeuvres rotatory vertigo that persists for 3−5 days.
for posterior semicircular canal BBPV include Initially, patients must lie still as any movement
Brandt–Daroff (9) and Semont manoeuvres (10). results in worsening symptoms. Thereafter,
Gans manoeuvre may be used if the anterior movements may be tolerated, but compensation
semicircular canal is involved (11). for normal activities may take weeks or months.
Prochlorperazine, a peripheral vestibular
Acute peripheral vestibular sedative, is indicated in this situation, but should
deficit (labyrinthitis/vestibular be limited to 7 days, as long-term use may limit
central compensation and, hence, functional
neuritis) recovery.
This relatively common cause of vertigo arises due
Clinical examination may reveal rotation on
to a sudden failure of one peripheral vestibular
Fukuda. More reliable is the head thrust test,
organ. This results in labyrinthine asymmetry, and
where a catch-up saccade may be evident (note
the sensory mismatch that occurs causes severe
Table 32.3).
persistent rotatory vertigo and profuse vomiting.

Table 32.2. Limitations of vestibular compensation.

Visual impairment Cataracts

Poor visual acuity
Eye movement disorders
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

Patients who do not compensate benefit from and visually stimulating environments (12).
generic or customized physiotherapy. Those with Those who fail to improve must be reassessed and
visual vertigo (over-reliance on visual input) possible limitations to compensation excluded
benefit from combining physiotherapy exercises (Table 32.2).

Vertigo and dizziness 157

Table 32.3. The sensitivity and specificity of clinical tests used to identify peripheral
vestibular hypofunction.

Clinical test Sensitivity (%) Specificity (%)

Gait assessment 23–86 38–92
Halmagyi head thrust test 34–100 64–100
Head shake test 35–95 62–92
Romberg test 61–79 58–80
Stepping tests 50 61
Dix–Hallpike testing for PC-BPPV 79 75

Vestibular migraine proprioceptive loss due to diabetes mellitus),

in addition to central changes within the
Also known as vertiginous migraine, this brain (e.g. ischaemic episodes) may result in
common cause of vertigo produces spells of multilevel vestibulopathy. Patients benefit from a
vertigo or disequilibrium that last for several combination of physiotherapy exercises (generic,
days and, in women, are frequently cyclical as customized or strength and balance exercises) and
they are hormone related. Patients often describe lifestyle changes (e.g. the use of a walking stick,
phonophobia or photophobia and prefer to rest glasses or cataract correction).
in a quiet, darkened room. This is not usually
associated with hearing loss or tinnitus. Cholesteatoma (CSOM)

Although no abnormalities are likely to be found Squamous epithelium within the middle ear may
on clinical examination, ENG/VNG testing may expand to erode into the inner ear. While most
support central changes. All patients should patients present with intermittent or chronic ear
undergo MRI scanning in order to exclude central discharge and hearing loss, some also experience
pathology. intermittent vertigo and unsteadiness.

Treatment consists of dietary changes (avoidance Hyperventilation syndrome

of chocolate, caffeine, red wine, cheese and
processed meat). The majority of patients benefit Hyperventilation associated with anxiety, may
from this approach alone, although some may also result in lightheadedness and dizziness. In some,
require tricyclic antidepressants, calcium channel anxiety may be the residual effect of a previous
blockers or beta-blockers. vestibular insult that the patient may have
compensated for. Asking a patient to breathe
Multilevel vestibulopathy rapidly through pursed lips can reproduce
symptoms. These patients benefit from cognitive
Dizziness and vertigo are common symptoms in behavioural therapy.
elderly patients.
Ménière’s disease
Unilateral decline in one sensory pathway may
be compensated for centrally, with little or no Often misdiagnosed, this very uncommon cause of
functional loss. A reduction in the quality and vertigo arises due to expansion of the scala media
quantity of sensory information from multiple compartment within the inner ear. As a result
sensory pathways (e.g. worsening vision, Reissner’s membrane may intermittently rupture

158 ENT: An Introduction and Practical Guide

resulting in mixing of perilymph and endolymph Treatment includes sublingual prochlorperazine
and toxic over excitation of the neuronal elements for acute episodes, and bendrofluazide or
within the inner ear. betahistine to reduce the frequency and severity of
attacks.
Attacks are unpredictable and severe. An initial
feeling of aural fullness is followed by hearing loss, For those not controlled medically, surgery
severe rotatory vertigo and tinnitus. A pure tone may be indicated. Procedures include grommet
audiogram will demonstrate a sensorineural hearing insertion, transtympanic gentamicin ablation,
loss, initially in the low frequencies in the affected labyrinthectomy and vestibular nerve section. Up
ear and then, as attacks continue, hearing loss across to 50% of patients may develop bilateral disease.
all frequencies. It is essential to exclude a central Bilateral vestibular hypofunction results in severe
pathology (e.g. a cerebellopontine angle tumour) oscillopsia, with patients wheelchair-bound and
and, hence, an MRI scan must be performed. unable to move their heads. Hence, vestibular
Bithermal calorics will reveal a peripheral vestibular destructive procedures should be avoided if
weakness. Attacks eventually subside but at the possible.
expense of the hearing in the affected ear.

OTHER CAUSES
Other relatively uncommon conditions that Superior semicircular canal dehiscence is a rare
may present with vertigo or dizziness include condition whereby a defect in the bony covering
multiple sclerosis, vestibular schwannoma of the superior semicircular canal results in a third
(Figure 32.4), and vertebrobasilar ischaemia. window through which a pressure wave may be
In each an MRI scan is required to establish a transmitted from and into the intracranial cavity.
diagnosis. This not only results in momentary vertigo in
response to loud sounds (Tullio’s phenomenon)
but also results in patients hearing their eyes moving.

KEY POINTS:
●●An understanding of the sensory
pathways and their central
interpretation provides a valuable
guide to the diagnosis and
management of patients who
complain of vertigo and dizziness.
●●While a number of conditions exist
that may result in vertiginous spells,
treatment is either curative or
enormously beneficial in the vast
majority of patients.
●●The commonest cause of vertigo,
BPPV, should be excluded in all cases
by Dix–Hallpike testing.
Figure 32.4. Right vestibular schwannoma.

Vertigo and dizziness 159

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

160 ENT: An Introduction and Practical Guide

INDEX
A aetiology of airway B
obstruction, 138
ABC, see Airway, Breathing, BAHA, see Bone-anchored
airway, breathing,
Circulation hearing aid
circulation, 137
ABG, see Air–bone gap Balancing function, 152–153
compromised airway
ABR, see Auditory brainstem BC, see Bone conduction
management, 137–139
responses Behavioural audiometry, 50;
Absorbable packs, 42 Airway obstruction see also Audiology
AC, see Air conduction aetiology, 138 air conduction thresholds, 50
Action potential (AP), 55 Anterior nasal packing, 44–45 audiogram interpretation,
Acute mastoiditis, 28; see also Anterior posterior (AP), 36 52–53
ENT pathology AOM, see Acute otitis media bone conduction, 51
Acute otitis media (AOM), AP, see Action potential; conductive hearing loss, 51
27; see also ENT Anterior posterior left conductive hearing
pathology Arterial blood supply to nose, 9, loss, 52
Acute peripheral vestibular 41; see also Epistaxis left sensorineural hearing
deficit, 155, 157 ASOM, see Acute suppurative loss, 52
Acute sinusitis, 32; see also ENT otitis media normal hearing, 52
pathology ASSR, see Auditory steady state pure tone audiometry,
Acute suppurative otitis media responses 50–51
(ASOM), 29–30; Attico antrostomy, 93, 94 right mixed hearing loss, 52
see also Facial nerve Audiology, 49, 57 rules of masking, 51
palsy auditory brainstem response symbols used in pure tone
Adenoidal curettage, in waves, 55 audiometry, 50
62–63; see also auditory evoked potentials, transcranial attenuation
Adenoidectomy 55–56 through air, 51
Adenoidectomy, 62 behavioural audiometry, Bells palsy, 29; see also Facial
adenoidal curettage, 62–63 50–53 nerve palsy
indications, 62 hearing loss, 49 Benign paroxysmal positional
operative technique, 62 objective audiometry, 54–55 vertigo (BPPV),
preoperative review, 62 otoacoustic emissions, 56 152, 154–156
suction diathermy, 63–64 speech audiometry, 53 BIPP ribbon gauze packing of
Advanced trauma life support tests of hearing, 49 nasal cavity, 45
(ATLS), 31 Auditory brainstem responses Bone-anchored hearing aid
AEPs, see Auditory evoked (ABR), 55 (BAHA), 103
potentials Auditory canal, 1–2 complication, 105
Air–bone gap (ABG), 51 Auditory evoked potentials indications, 103
Air conduction (AC), 20 (AEPs), 55–56; see also operative procedure, 103–105
Airway, Breathing, Circulation Audiology postoperative review, 105
(ABC), 137 Auditory steady state responses preoperative review, 103
Airway management, 137 (ASSR), 56 Bone conduction (BC), 20

Index 161
BPPV, see Benign paroxysmal of sinuses, 144 wax, 26
positional vertigo of temporal bone, 143–144 EBV, see Epstein–Barr virus
Branchial cyst, 150–151 Continuous positive airway ECochG, see
pressure (CPAP), 69 Electrocochleogram
C Contrast swallow, 141 Electrocochleogram
Coronal section of paranasal (ECochG), 55
CAEPs, see Cortical auditory sinuses, 10 Electronystagmography
evoked potentials Cortical auditory evoked (ENG), 154
Canal, 2 potentials (CAEPs), 56 Embolization, 46
wall up mastoidectomy, 93 CPAP, see Continuous positive Endoscopic sinus surgery
CAT, see Combined approach airway pressure (ESS), 80
tympanoplasty Cricothyroidotomy, 126 to access middle meatus, 81
Cauliflower ear, see CSF, see Cerebrospinal fluid along anterior attachment of
Pinna—haematoma CSOM, see Chronic secretory uncinate process., 82
Cautery, 43–44 otitis media complication, 83
Cerebrospinal fluid (CSF), 31, Cuffed tubes, 129 indications, 80
71, 81 Cupula, 5
Cervical lymph nodes, 16 middle meatal antrostomy and
CXR, see Chest x-ray ethmoid bulla, 82
Chest x-ray (CXR), 115
Cholesteatoma, 158 opening of left anterior
D ethmoid, 82
surgery, 92
Chronic secretory otitis media Deep neck spaces, 17 operative procedure, 80–82
(CSOM), 92 Direct-and microlaryngoscopy, postoperative review, 83
Clinical anatomy, 1 107 preoperative review, 80
cervical lymph nodes, 16 complication, 108 removal of left uncinate, 82
deep neck spaces, 17 indications, 107 Endotracheal tube (ET), 58
ear, 1–5 operative procedure, 107 ENG, see Electronystagmography
facial nerve, 5–7 postoperative review, 108 ENT examination, 18; see also
larynx, 14–15 Distortion product OAEs Rinne and Weber
nose, 7–11 (DPOAEs), 56 tuning fork testing
oral cavity, 11–12 DPOAEs, see Distortion product otoscopy, 18–19
pharynx, 12–14 OAEs pinna and postaural region
salivary glands, 15–16 examination, 18
E right tympanic membrane
sensory distribution of
face, 17 EAC, see External auditory canal examination, 19
thyroid and parathyroid Ear, 1 ENT pathology, 26
glands, 15 canal, 2 acute mastoiditis, 28
CM, see Cochlear microphonic cochlea, 5 acute otitis media, 27
Cochlea, 5 coronal section of ossicles, 3 acute sinusitis, 32
Cochlear microphonic (CM), 55 cupula, 5 ear wax, 26
Combined approach Eustachian tube dysfunction, 3 epiglottitis, 35
tympanoplasty (CAT), external auditory canal, 1–2 facial nerve palsy, 29–30
93, 96–98 inner ear, 4, 5 foreign bodies removal, 30,
Complication, 113 maculae, 5 31, 36
Compromised airway microsuction, 21–22 impacted wax, 26–27
management, 137–139 middle, 3 leakage or loss of
Computed tomography pinna, 1 tracheoesophageal
axial views of neck, 142 right tympanic membrane, 2 voice prosthesis, 37

162 Index
nasal trauma, 32 treatment, 42 H
otitis externa, 26 treatment algorithm for, 43
Haemorrhagic polyp, 135
otitis media with effusion, 27 vessel ligation, 46
Heliox, 34; see also ENT
parapharyngeal abscess, 35 Epstein–Barr virus (EBV), 33
pathology
perichondritis, 28 ESS, see Endoscopic sinus
Hemi-and total
periorbital cellulitis, 32–33 surgery
thyroidectomy, 119
peritonsillar abscess, 34 ET, see Endotracheal tube
complication, 119
pinna cellulitis, 28 Eustachian tube dysfunction, 3;
indications, 119
pinna haematoma, 28 see also Ear
operative procedure, 119–121
retropharyngeal abscess, External auditory canal (EAC),
postoperative review, 121
36–37 1–2, 122; see also Ear
preoperative review, 119
septal haematoma/abscess, 32
F Hereditary haemorrhagic
smoke inhalation, 35
telangiectasia (HHT),
sudden sensorineural hearing Facial nerve, 5 40, 47
loss, 28–29 external branches of, 7 HHT, see Hereditary
supraglottitis, 34 function examination, 25 haemorrhagic
temporal bone fractures, intratemporal course, 6 telangiectasia
30–31 Facial nerve palsy, 29; see also HPV, see Human papilloma
tonsillitis, 33 ENT pathology virus
tympanic membrane acute suppurative otitis Human papilloma virus (HPV),
trauma, 30 media, 29–30 135
Epiglottitis, 35; see also ENT Bells palsy, 29 Hyperventilation syndrome, 158
pathology foreign bodies removal, 30,
Epistaxis, 40 31, 36 I
aetiology, 40 Ramsay Hunt syndrome, 29
anatomy, 40 trauma, 30 Impacted wax, 26–27; see also
anterior nasal packing, 44–45 Fenestrated tubes, 130 ENT pathology
arterial blood supply to Fine needle aspiration Inflated epistaxis balloon in
nose, 41 (FNA), 141 situ, 45
BIPP ribbon gauze packing of Fine needle aspiration cytology Inner ear, 4, 5
nasal cavity, 45 (FNAC), 119 Intensive therapy unit (ITU), 126
cautery, 43–44 FNA, see Fine needle ITU, see Intensive therapy unit
embolization, 46 aspiration
examination, 42 FNAC, see Fine needle K
hereditary haemorrhagic aspiration cytology
Kiesselbach’s plexus, 40; see also
telangiectasia, 47
G Epistaxis
history, 41–42
KTP, see Potassium titanyl
inflated epistaxis balloon in Glue ear, see Otitis media with phosphate
situ, 45 effusion
insertion of nasal pack, 44 Grommet insertion, 65 L
local and systemic causes complications, 66
of, 41 indications, 65 Laryngeal cancer, 134
management, 42 operative procedure, 65 Laryngeal papillomatosis, 135
nasal pack in situ, 44 patient information and Larynx, 14–15
posterior nasal packing, consent, 65 Lateral soft tissue film, 140–141
45–46 postoperative review and Lateral surface of nasal cavity, 9
surgical intervention, 46 follow-up, 67 Lazy-S incision, 123

Index 163
Leakage or loss of N osteomeatal complex, 11
tracheoesophageal principal function, 7
Nasal
voice prosthesis, skeleton of nasal septum, 8
cavities, 8
37; see also ENT
landmarks and external nasal
pathology O
skeleton, 7
Ludwig’s angina, 12; see also
pack insertion, 44 OAEs, see Otoacoustic emissions
Oral cavity
pack in situ, 44 Objective audiometry, 54–55;
Lymphadenopathy, 149–150
skeleton, 8 see also Audiology
Lymph nodes in neck, 142
trauma, 32; see also ENT Obstructive sleep apnoea
CT axial views of neck, 142
pathology (OSA), 69
CT of sinuses, 144
Nasal polypectomy, 84 Oesophagogastroduodenoscopy
CT of temporal bone,
complication, 85 (OGD), 36
143–144
indications, 84 OGD, see Oesophagogastro
magnetic resonance
operative procedure, 84–85 duodenoscopy
imaging, 145
postoperative review, 85 Olfactory mucosa, 9
PET-CT, 146–147
preoperative review, 84 OME, see Otitis media with
Nasolaryngoscopy, flexible, 22 effusion
M National Institute for Health Operative procedure, 113
Maculae, 5 and Clinical Oral cavity, 11
Magnetic resonance imaging Excellence (NICE), 65 examination, 23–24
(MRI), 56 Neck and facial nerve function floor of mouth, 12
Mastoidectomy, 92 examination, 24–25 tongue, 11
aims of surgery, 94 Neck lump management, 148 OSA, see Obstructive sleep
alternatives to surgery, 94 branchial cyst, 150–151 apnoea
assessment, 92–94 examination, 148–149 Osteomeatal complex, 11
Attico antrostomy, 93, 94 history, 148 Otitis externa, 26; see also ENT
canal wall up lymphadenopathy, 149–150 pathology
mastoidectomy, 93 salivary gland tumours, 151 Otitis media with effusion
cholesteatoma surgery, 92 special investigations, 149 (OME), 27, 65; see also
chronic secretory otitis thyroglossal duct cyst, 150 ENT pathology
media, 92 thyroid masses, 151 Otoacoustic emissions (OAEs),
combined approach treatment, 149 56; see also Audiology
tympanoplasty, 96–98 NICE, see National Institute for Otoscopy, 18–19; see also ENT
complication, 94 Health and Clinical examination
indications, 92 Excellence Outfracture of inferior
modified radical Nose, 7 turbinate, 77
mastoidectomy, 93 arterial blood supply to, 9
operative procedure, 94 coronal section of paranasal
sinuses, 10 P
Mastoiditis, acute, 28
Ménière’s disease, 158–159 lateral surface of nasal Panendoscopy, 106
Microlaryngoscopy, 136 cavity, 9 Parapharyngeal abscess,
Modified radical lateral wall of nasal cavity, 10 35; see also ENT
mastoidectomy, 93 nasal cavities, 8 pathology
MRI, see Magnetic resonance nasal landmarks and external Parathyroid glands, 15
imaging nasal skeleton, 7 Parent’s kiss, 31
Multilevel vestibulopathy, 158 nasal skeleton, 8 Parotid gland, 15
Myringoplasty, 87 olfactory mucosa, 9 Percutaneus tracheostomy, 126

164 Index
Perichondritis, 28; see also ENT CT of sinuses, 144 Rinne’s test, 20
pathology lateral soft tissue film, Weber’s test, 20
Periorbital cellulitis, 32–33; 140–141 Rinne’s test, 20
see also ENT pathology magnetic resonance RLN, see Recurrent laryngeal
Peritonsillar abscess, 34; see also imaging, 145 nerve
ENT pathology morphology of lymph nodes
Perpendicular plate of the in neck, 142 S
ethmoid (PPE), 71 PET-CT, 146–147
Salivary glands, 15–16
Pharyngoscopy, 109 ultrasound neck, 141
tumours, 151
complication, 110 Ramsay Hunt syndrome, 29;
Scottish Intercollegiate
indications, 109 see also Facial nerve
Guidelines Network
operative procedure, 109–110 palsy
(SIGN), 58
postoperative review, 110 Recurrent laryngeal nerve
Sensory distribution of face, 17
Pharynx, 12 (RLN), 120
Septal haematoma/abscess,
right postnasal space, 13 Reinke’s oedema, 133 32; see also ENT
sagittal section through head Retropharyngeal abscess,
and neck, 13 pathology
36–37; see also ENT Septoplasty, 68
stacked muscular bands, 12 pathology
Pinna, 1; see also Ear; ENT continuous quilting suture of
Rhinoscopy, anterior, 20 nasal septum, 72
pathology Right tympanic membrane, 2; freer elevator, 71
cellulitis, 28 see also Ear
examination of, 18 incisions for septoplasty, 70
examination of, 19 incision Through septal
haematoma, 28 Rigid bronchoscopy, 114
PNS, see Postnasal space cartilage, 71
complication, 115 indications, 68
Posterior nasal packing, 45–46 indications, 114 infiltration of septal
Postnasal space (PNS), 106 operative procedure, 114 mucosa, 70
Post nasal space examination, 113 postoperative review, 115 nasal septum, 68
Potassium titanyl phosphate ventilating bronchoscope, 115 operative procedure, 69–72
(KTP), 47 Rigid oesophagoscopy, 111 postoperative review, 72
PPE, see Perpendicular plate of complication, 112 septal deviation to left, 69
the ethmoid indications, 111 Septorhinoplasty, 74
Pure tone audiometry, 50–51; operative procedure, 111–112 complications, 76
see also Audiology postoperative review, 112 dorsal hump removal, 75
Rinne and Weber tuning fork indications, 74
Q testing, 19; see also intercartilaginous incision, 75
Quinsy, see Peritonsillar abscess ENT examination medial and lateral
anterior rhinoscopy, 20 osteotomy, 75
ear microsuction, 21–22 operative procedure, 74–75
R facial nerve function postoperative review, 76
Radiofrequency turbinoplasty, 78 examination, 25 preoperative review, 74
Radiology, 140 flexible nasolaryngoscopy, 22 SIGN, see Scottish Intercollegiate
computed tomography axial interpretation, 20, 21 Guidelines Network
views of neck, 142 neck and facial nerve function Singer’s nodules, 133
computed tomography examination, 24–25 Skeleton of nasal septum, 8
of temporal bone, oral cavity examination, Smoke inhalation, 35; see also
143–144 23–24 ENT pathology
contrast swallow, 141 rigid endoscopy, 23 SMR, see Submucous resection

Index 165
Sound pressure level (SPL), 50 TEP, see Tracheoesophageal Turbinate surgery, 77
SP, see Summating potential puncture complication, 79
SPA, see Sphenopalatine artery Thyroglossal duct cyst, 150 indications, 77
Speech audiometry, 53; see also Thyroid, 15 operative procedure, 77–79
Audiology and parathyroid glands, 15 outfracture of inferior
roll-over, 53 masses, 151 turbinate, 77
Sphenopalatine artery (SPA), 46 Tongue, 11; see also Oral cavity postoperative review, 79
SPL, see Sound pressure level Tonsillectomy, 58 radiofrequency
SSHL, see Sudden sensorineural bipolar tonsillectomy, 59 turbinoplasty, 78
hearing loss operative procedure, 58, 60 turbinectomy, 78, 79
Stapedectomy, 99, 101 postoperative review and Turbinectomy, 78, 79
aims of surgery, 100 follow-up, 60 Tympanic membrane trauma,
alternatives to surgery, 100 post-tonsillectomy 30; see also ENT
assessment, 99-100 haemorrhage, 61 pathology
complication, 100 preoperative review, 58 Tympanogram, 54
operation, 101–102 Tonsillitis, 33; see also ENT Tympanometry, 54
postoperative review, 102 pathology Tympanoplasty, 86
Submandibular gland excision, Tracheoesophageal puncture alternatives to surgery, 87
116, 117 (TEP), 37 complication, 87
complication, 116 Tracheoesophageal voice indications, 86
indications, 116 prosthesis leakage or myringoplasty, 87
operative procedure, 116–118 loss, 37 operative procedure, 88–90
postoperative review, 118 Tracheostomy, 125 postoperative review, 91
preoperative review, 116 changing tracheostomy tube, preoperative review, 87
Submucous resection (SMR), 68 130–131 types of, 86
Suction diathermy, 63–64; cleaning inner tubes, 130
see also Adenoidectomy complication, 127–128 U
Sudden sensorineural hearing contraindictions, 131
loss (SSHL), 28–29; UADT, see Upper aerodigestive
cricothyroidotomy, 126
see also ENT pathology tract
cuffed tubes, 129
Summating potential (SP), 55 Ultrasound neck, 141
dressings, 130
Superficial parotidectomy, 122 Uncuffed tubes, 129–130
fenestrated tubes, 130
complication, 122 Upper aerodigestive tract
generating voice with, 131
external auditory canal, 122 (UADT), 132
indications, 125
indications, 122 Upper respiratory tract infection
percutaneus tracheostomy, 126 (URTI), 132
Lazy-S incision, 123
surgical tracheostomy, URTI, see Upper respiratory
operative procedure, 122–124
126–127 tract infection
postoperative review, 124
transtracheal needle, 126
preoperative review, 122
tube care and speaking
Supraglottitis, 34; see also ENT V
valves, 128
pathology
tube with adjustable flange, 130 Ventilating bronchoscope, 115
Surgical tracheostomy, 126–127
uncuffed tubes, 129–130 Vertigo and dizziness, 152
Transcranial attenuation acute peripheral vestibular
T through air, 51 deficit, 155, 157
Temporal bone fractures, 30–31 Transient evoked OAEs balance function, 152–153
TEOAEs, see Transient evoked (TEOAEs), 56 benign paroxysmal positional
OAEs Transtracheal needle, 126 vertigo, 152, 154–156

166 Index
causes, 159 Vestibular compensation, history, 132–133
cholesteatoma, 158 limitations of, 157 laryngeal cancer, 134
examination, 153–154 Vestibular migraine, 158 laryngeal papillomatosis, 135
history, 152–153 Vestibular pathology, 155 microlaryngoscopy, 136
hyperventilation management pathways pathology, 133
syndrome, 158 for, 156 Reinke’s oedema, 133
limitations of vestibular Vestibulo ocular reflex, 154 upper aerodigestive tract, 132
compensation, 157 Videonystagmography upper respiratory tract
management pathways (VNG), 154 infection, 132
for vestibular VNG, see Videonystagmography vocal cord cysts, 136
pathology, 156 Vocal cord vocal cord granuloma, 135–136
Ménière’s disease, 158–159 cysts, 136 vocal fold nodules, 133
multilevel vestibulopathy, 158 granuloma, 135–136 vocal fold palsy, 134
sensitivity and specificity of Vocal fold
clinical tests, 158 nodules, 133
W
special investigations, 154 palsy, 134
vestibular migraine, 158 Voice, 132 Weber’s test, 20
vestibular pathology, 155 examination, 133 Woodruff’s plexus, 40; see also
vestibulo ocular reflex, 154 haemorrhagic polyp, 135 Epistaxis

Index 167

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ENT

Visiting Professor in Otorhinolaryngology

© 2018 by Taylor & Francis Group, LLC

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-1-138-19823-4 (Paperback)

Library of Congress Cataloging‑in‑Publication Data

Names: Tysome, James Russell, author. | Kanegaonkar, Rahul Govind, author.

Visit the Taylor & Francis Web site at

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

James R Tysome and Rahul G Kanegaonkar

This book covers both common and uncommon, including life-threatening

The updated colour illustrations concisely depict relevant clinical anatomy

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

Dr Dipalee Durve MRCPCH and FRCR

Mr James Tysome MA PhD FRCS (ORL-HNS)

Professor Rahul Kanegaonkar FRCS (ORL-HNS)

Ms Sonia Kumar FRCS (ORL-HNS)

Mr Ram Moorthy FRCS (ORL-HNS)

Professor Francis Vaz FRCS (ORL-HNS)

Mr Max Whittaker FRCS (ORL-HNS)

Chorda tympani Lateral process of

Figure 1.2. Right tympanic membrane.

2 ENT: An Introduction and Practical Guide

Malleus Facial n. (CN VII) in

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

4 ENT: An Introduction and Practical Guide

Time Time Time

THE FACIAL NERVE

6 ENT: An Introduction and Practical Guide

The facial nerve exits the skull base at the

Nasion Nasal bone

Figure 1.7. Nasal landmarks and external nasal skeleton.

Figure 1.8. The skeleton of the nasal septum.

8 ENT: An Introduction and Practical Guide

Eustachian tube cushion

Figure 1.9. The lateral surface of the nasal cavity.

Anterior ethmoidal artery (I)

Posterior ethmoidal artery (I)

Sphenopalatine artery (E)

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

Posterior ethmoid ostia

Maxillary sinus ostia

Anterior ethmoid sinus

Figure 1.12. Coronal section of the paranasal sinuses.

10 ENT: An Introduction and Practical Guide

Posterior tonsillar pillar

Figure 1.13. The oral cavity.

12 ENT: An Introduction and Practical Guide

Eustachian tube cushion Posterior margin

Figure 1.15. Endoscopic view of the right postnasal space.

Interarytenoid bar Posterior

Cricoid cartilage Left pyriform

Median Lingual tonsil

Figure 1.16. Endoscopic view of the larynx.

14 ENT: An Introduction and Practical Guide

THE THYROID AND PARATHYROID GLANDS

THE MAJOR SALIVARY GLANDS

The parotid gland is a large, serous salivary gland

CERVICAL LYMPH NODES

16 ENT: An Introduction and Practical Guide

External nasal lacrimal

Figure 1.20. Sensory distribution of the face.

DEEP NECK SPACES

18 ENT: An Introduction and Practical Guide

Chorda tympani Lateral process of

RINNE AND WEBER TUNING FORK TESTING

Rinne’s test Anterior rhinoscopy

Interpretation Swing your middle finger to one side of the

20 ENT: An Introduction and Practical Guide

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

Figure 2.3. Interpretation of tuning fork tests.

In children, especially if a foreign body is experience temporary dizziness following the

22 ENT: An Introduction and Practical Guide

(d) (e) (f)

24 ENT: An Introduction and Practical Guide