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ENT Undergraduate Lecture. Mr Rejali ENT Consultant University Hospital, Coventry. Plan. 3 lecture: Otology Rhinology Head and Neck Practical session. Otology. Anatomy / Physiology History Examination Outer ear problems Middle Ear Problems Inner Ear Problems.

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ENT Undergraduate Lecture


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    1. ENT Undergraduate Lecture Mr Rejali ENT Consultant University Hospital, Coventry

    2. Plan • 3 lecture: • Otology • Rhinology • Head and Neck • Practical session

    3. Otology • Anatomy / Physiology • History • Examination • Outer ear problems • Middle Ear Problems • Inner Ear Problems

    4. Otology Anatomy External Ear 1 • External • Pinna • Skin • Cartilage • External audiotary meatus (canal) • Lateral/Outer 1/3 in cartilages and produce wax • Medial 2/3 in bone and wax free • Skin migration

    5. Otology Anatomy External Ear 2 • External auditory meatus/canal • Ear wax (and hair) produced in outer 1/3 of ear canal • Ear wax (cerumen) more soluble in water • Rare cause of hearing loss unless impacted on to tympanic membrane or blocking canal completely and with a thickness of >2-m mm

    6. Otology Anatomy Middle Ear 1 • Air containing space in temporal bone. • Three ossicles (Mallus, incus and stapes) transfer sound from air to inner ear fluids • Common site of pathology

    7. Otology Anatomy Middle Ear 2 • Tympanic membrane • Right ear • Attic • Handle of malleus • Light reflex

    8. Otology Anatomy Middle Ear 3 • Eustachian tube equalises pressure between middle ear and atmosphere

    9. Otology Anatomy Inner Ear 1 • Cochlea – Hearing • Semicircular canal – Angular acceleration • Vestibule – Linear acceleration

    10. Otology Physiology Cochlea • Sound transmission through middle ear • Oval - Round Window travelling wave. • Tonotopic distribution of organ of corti

    11. Otology Physiology Vestibular Function • Macula in saccule and utricle - linear acceleration • Crista in semi-circular canal – angular acceleration

    12. Otology History • Middle ear: • Hearing loss (conductive) • Discharge: moderate mucoid • Pain • In acute otitis media until tympanic membrane perforates • Chronic otitis media only if complicated e.g. otitis externa or intracranial complications • Outer ear: • Pain • Discharge: scant, serous • Hearing loss, late

    13. Otology History • Inner ear: • Hearing loss (sensoneural) • Vertigo • Tinnitus

    14. Otology Examination • Wash hands (MRSA) • Intro • Ask about tenderness • Which is better ear • Inspect pinna, mastoid area • Otoscopy • External auditory canal • Tympanic membrane • Hearing test • Other test: cranial nerve (esp VII), co-ordination and romberg

    15. Tuning Fork Test • Rinne • Air conduction louder than bone conduction • Weber • Lateralises to side of conductive loss and away from sensoneural hearing loss • Clinical hearing test

    16. Otology Diagnosis • Surgical Sieve • Outer ear • Middle Ear • Inner Ear • Hearing loss • Conductive • Sensoneural

    17. Otology Investigations • Pure Tone Audiogram • Tympanogram • CT • MRI

    18. Otology Management • Explanation • Advice • Medical • Surgical

    19. Haematoma/Seroma of Pinna • Aspirate x2 (sterile conditions) • Compression bandage • Review in 24hrs • If re-accumulate proceed to formal drainage and quilting stitch

    20. Otology External • Pinna skin tumour

    21. Otitis Externa • Otitis Externa • Acute • Painful • Serous discharge • Moist swollen canal • Tympanic membrane intact • Pseudomonas aeroginosa • Treat topical toilet and antibiotics • Chronic • Eczema • Topical toilet and steroids

    22. Otitis Externa • Furuncle localised infection and pain • put wick with 10% icthamol/glycerine • Or incise and drain under local anaesthetic Furuncle/Abscess of Hair Follicle

    23. Otology External • Exostoses • Cold water swimmers • Osteomas • Bening neoplasia

    24. Otology Middle • Tympanosclerosis • Previous infection or trauma. • Usually of no significance

    25. Otology Middle • Retracted tympanic mebrane • Often no treatment needed • Differentiate from perforation • Occasionally progress to cholesteatoma

    26. Otology Middle • TM perforation • If dry may need no treatment • If recurrent infection can be repaired.

    27. Otology Middle • Acute otitis media • Pain • Hearing loss • Later otorrhea

    28. Acute Mastoiditis • IV antibiotics • Surgery

    29. Otology Middle • Otitis media with effusion – glue ear • Middle ear fluide • Common in children • Hearing loss • Infection starts process • Treatment conservative, Grommets

    30. Otology Middle • Cholesteatoma

    31. Otology Middle Ear • Mastoid cavity

    32. Otology Inner Ear • Balance:  Balance is determined by a complex combination of inputs into the brain.   • These inputs are: • Vision • Proprioception (sensation of position of joints)   • Inner ear • Integration by brain

    33. Otology Inner Ear • Vertigo illusion of movement • Hallmark of vestibular dysfunction • Rotary • Linear

    34. Otology Inner Ear • Benign Paroxysmal Positional Vertigo • Vestibular Neuronitis • Meniere's Disease • Recurrent vestibulopathy • Differentiate from central vestibular causes.

    35. Vestibular signal balance Normal balanced input Pathological Left ear in this case Reduced or no signal Increased signal Increased signal Vestibular Neuronitis Menieres BPPV Brain will get used to new situation but not to a frequently changing one.

    36. Otology Inner Ear • Presbyacusis • Congenital Hearing Loss

    37. Otology Inner Ear • Tinnitus • Acoustic neuroma

    38. Facial Palsy • Upper vs Lower motor neurone pattern.

    39. Facial Palsy • Not all are Idiopathic (Bells Palsy) • Assess other cranial nerves • Ear • Parotid • Symptoms/signs which suggest other aetiology • Above exam +VE • Slow onset • Little, no or incomplete recovery

    40. Facial Palsy • Eye care. If concern d/w Ophthalmic team. • Tape eye closed at night after Lacrilube • Hypomellose eye drops PRN during day • Steroids (Prednisolone 40mg od for one week) are indicated early in the course of the disease (less than 3 days) if there are no contraindications. • Acyclovir if signs of herpes zoster infection (vesicles in TM or pharynx or palate. (400mg five times a day for 10 days)

    41. The End of Otology Section

    42. Rhinology • Anatomy • Physiology • History • Examination • Pathology

    43. Rhinology Anatomy 1 • External • Internal • Lateral wall • Medial wall

    44. Rhinology Anatomy 2 • Nasal septum • Little’s area • Epistaxis

    45. Rhinology Anatomy 3 • Paranasal Sinuses • Frontal • Maxillary • Ethmoid • Sphenoid

    46. Rhinology Physiology • Nose • Warms, moisten • Filter • Mucociliary • Sinuses • Function unknown

    47. Rhinology History • Nasal obstruction • Anterior rhinorrhoea • Olfaction • Facial pain • Sneezing • Epistaxis

    48. Rhinology Examination • Examination • Inspect external nose • Palpate external nose • Evaluate nasal airway • Steam pattern on metal tongue depressor • Inspect nasal mucosa • Use otoscope • Lateral, medial • Inspect palpate over sinuses • Endoscopy • Olfaction

    49. Rhinology Investigation • Allergy testing • IgE levels • RAST (Blood test) • Skin Prick Testing • Plain X ray – inaccurate • CT