Ear, Nose and Throat (and Neck)

Transcription

1 Ear, Nose and Throat (and Neck)

2 EAR

3 Physical examination GENERAL Observation: Observation of child s gait. Speech should be noted for articulation and intensity. Assess the child s response to verbal instructions. Note any craniofacial anomalies, which potentially affect hearing and upper airway

4 Possible painful or serious skin conditions Squamous cell cancer on the ear com/data/images1/11a._scc_advancement_a.jpg&w=500&h=375&ei=- RWQUubwO4bikgWf24GABA&zoom=1&iact=hc&vpx=128&vpy=435&dur=2344&hovh=194&hovw=259&tx=163&ty=82&page= 7&tbnh=136&tbnw=180&ndsp=45&ved=1t:429,r:44,s:200,i:136

5 Mastoiditis

6 Possible incisions Endaural vw=128&tx=105&ty=108&page=1&tbnh=128&tbnw=81&start=0&ndsp=37&ved=1t:429,r:7,s:0,i:100

7 Possible incisions Postauricular w=1294&bih=815&tbm=isch&tbnid=e hvcuyo3w1fztm:&imgrefurl= ww.pedsent.com/surgery/tympanopla sty.htm&docid=4uqwybug9vjlm&imgurl= dsent.com/images/surg_postauricular.jpg&w=200&h=226&ei=- RiQUq7yFoWBkgWnq4DoCA&zoom=1 &iact=hc&vpx=2&vpy=108&dur=1172 &hovh=180&hovw=160&tx=41&ty=63 &page=1&tbnh=138&tbnw=133&start =0&ndsp=34&ved=1t:429,r:0,s:0,i:77

8 Foreign bodies

9 Fungal otitis externa Fungal infection resembles wet newspaper

10 Polyp from the middle ear Perforation of the tympanic membrane u6dokrqpm:&imgrefurl= ENT/Disease_of_ENT/hc htm&docid=ykJ9DWS1oA5y9M&imgurl= of-ent/disease_of_ent/r f004.jpg&w=800&h=349&ei=0rmqupkxcmmkkwwcsiggdq&zoom=1&iact=hc&vpx=69&vpy=246&dur=1000&hovh= 148&hovw=340&tx=144&ty=82&page=3&tbnh=129&tbnw=251&ndsp=34&ved=1t:429,r:0,s:100,i:4&biw=1294&bih=81 5

11 Otoscopy Ensure you have a bright light and a charged battery Use a clean speculum between ears if there is otitis externa Use the largest speculum that will fit into the ear canal comfortably Better view of the tympanic membrane Less painful

12 What not to do

13 Otoscopic examination

14 To see the TM straighten the EAC Pull up and back on the pinna for adults and older children Pull down and back for babies

15 Use the otoscope in the left hand for the left ear and the right hand for the right ear Hand should rest on the patient in case of sudden movements

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17 Developmental considerations MIDDLE EAR: Newborns: Tympanic membrane lies in a more horizontal plane Eustachian tube is shorter and wider and lies in a relatively horizontal plane until approximately age 8 years compared to the eustachian tube of an older child or adult

18 Malleus Incus Stapedius tendon Normal middle ear

19 Normal Injection when baby cries

20 Colour Red=infection Yellow=fluid

21 Contour of the TM Bulging in acute OM Retracted if middle ear effusion

22 Contents of the middle ear serous effusion

23 Contents of the middle ear - mucopus

24 Contents of the middle ear - congenital cholesteatoma

25 Central perforation

26 TM perforation - marginal Attic retraction Head of stapes Marginal perforation Cochlea Round window niche

27 Subtotal perforation

28 Attic disease Attic retraction Attic cholesteatoma

29 Presence of middle ear ventilation tubes

30 What are grommets?

31 Any tube with flanges

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33 Young surfers

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35 Middle ear ventilation tubes

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38 If ventilation tubes are in the tympanic membrane Look to see if: still in the TM or extruded patent otorrhoea or granulations

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40 Ear Tuning fork tests Rinne - Air conduction should be louder than bone conduction (Rinne +) Weber useful if hearing is different in the two ears - if SNHL, will lateralise to the better ear

41 Weber Test

42 Rinne test

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44 Development of the face In the newborn the cranium is very much larger than the face. Growth of the maxillary sinuses and of the alveolar bone around the teeth elongates the face.

45 Photographs of these two children from birth to adulthood show the changes that occur with the lengthening of the face.

46 The Nose

47 Paranasal sinuses

48 Nasal crease Allergic salute Allergic Rhinitis Allen, P. Common Nose and Throat Problems. Normal mucosa Allergic mucosa

49 Inspect and Palpate Inspect the external nose for symmetry and abnormalities/proportion to face (consider the family) Test patency and smell one side at a time Use an otoscope to inspect the nasal cavity (with a speculum) or can push the tip of nose up instead Look for the inferior and middle turbinate

50 Nose examination test for patency Check for patency on each side

51 Deviated nasal septum - often the mucosa is dry and crusty

52 Nasal septal haematoma Check for septal haematoma Blocked nose with pain Needs urgent drainage and antibiotics Complications are damage to cartilage and cavernous sinus thrombosis

53 Can use an otoscope to see into the middle meatus

54 Endoscopy Middle turbinate Pus from under the turbinate Nasal septum

55 Not to be confused with nasal polyps Allergic mucosa Bull P & Clarke R. Diseases of the Ear, Nose and Throat. Blackwell Publishing 2007.

56 Endoscopic view of the adenoids

57 Unilateral rhinitis foreign body unilateral choanal atresia antrochoanal polyp malignancy Bull P & Clarke R. Diseases of the Ear, Nose and Throat. Blackwell Publishing 2007.

58 Nasal foreign bodies Beker W et al. Atlas of Ear, Nose and Throat Diseases, 1984, Thieme.

59 Unilateral symptoms Unilateral Obstruction Blood-stained rhinorrhoea Eye symptoms

60 The oral cavity Alveolar ridges Buccal mucosa Vestibule

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66 Floor of the mouth The epithelium on the floor of the mouth is smooth There are three important landmarks: 1. Many blood vessels (medication under the tongue is quickly absorbed) 2. Lingual frenulum joins the tongue to the mandible 3. Sublingual folds mark the ducts for the submandibular salivary glands The openings for the ducts are either side of the lingual frenulum

67 (Palatine) tonsils Anterior pillar=palatoglossus muscle Posterior pillar =palatopharyngeus muscle The tonsil lies in the triangular recess between the two pillars mgrefurl= rfiles.freewebs.com/39/84/ /photos/mouth/uvula,%252520dr%252520sonia%252520,ent%252520specialist%252520bangal ore.jpg&w=375&h=382&ei=ihfqucwnec- ZlQWyxYGIBg&zoom=1&iact=hc&vpx=889&vpy=460&dur=3313&hovh=227&hovw=222&tx=121&ty=118&page=3&tbnh=143&tbnw=13 7&ndsp=33&ved=1t:429,r:0,s:100,i:4

68 Tonsil size grading classification based on the ratio of the tonsils to the oropharynx measured between the anterior pillars

69 Grade 0 tonsil in fossa 1=<25%

70 Grade 2<50% 3<75%

71 Grade 4>75%

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74 Bifid uvula Submucous cleft palate

75 Tonsillitis

76 The salivary glands There are three paired salivary glands: Parotid Submandibular Sublingual

77 Parotid gland=para-otic

78 Vocal cord nodules

79 Laryngeal papillomata

80 Thyroglossal duct cyst Thyroid enlargement

81 Thyroid cartilage of the larynx Thyroid gland

82 Neck Systematic to examine each area mastoid tip, pre- and post-auricular lymph nodes parotid gland submandibular midline laryngeal crepitus thyroid - palpate both lobes and isthmus -ask patient to swallow anterior border of sternomastoid posterior border of sternomastoid posterior triangle occipital lymph nodes

83 Neck Systematic to examine each area

84 Hearing Pathways

85 Central connections Sound crosses over within the brainstem

86 Hearing Loss There are three main types of hearing loss depending on which part of the hearing system is affected: Conductive Hearing Loss outer ear and middle ear Sensorineural Hearing Loss cochlea +/- cochlear nerve Mixed Hearing Loss both

87 The audiogram

88 Reference for audiology Audiology. Rose E: Aust Fam Physician; 2011 May;40(5): %5Bpmid%5D&cmpgn83301=TED2 045Tl1fSuEPNM&xpclps3=Matches

89 The audiogram Low pitched soft High pitched The speech banana Level of normal conversation loud

90 Degrees of hearing loss/impairment

91 Degree of hearing loss Normal (20 db +) mild moderate severe profound

92 Symbols on the audiogram O X [ ]

93 Symbols on the audiogram O right ear X left ear - air conduction - air conduction [ right ear - bone conduction ] left ear - bone conduction

94 Normal hearing Air and bone conduction are similar XO [ ] O [ X ] X O X [] [ O ] OX [ ] O X Hearing threshold is 20 db or better

95 Mild hearing loss (20-40 db) If not aided: Manage in quiet situations with clear voices Difficult to hear soft speech and conversation Difficult to hear in background noise OX OX OX X O O X OX

96 Moderate hearing loss (41-60 db) If not aided: Will miss most of the conversation Pronunciation is not clear Difficulty in background noise Limited vocabulary X O X X O O X O XO O X

97 Severe hearing loss (61-90 db) If not aided: Will not hear most conversational speech Speech and language do not develop spontaneously Very limited vocabulary Pronunciation is not clear O X O X XO X O X O O X

98 Severe hearing loss (61-90 db) Hearing aids will greatly assist the child to develop speech Should develop good speech if wears aids consistently from an early age Visual cues usually assist in understanding speech O X O X XO X O X O O X

99 Profound hearing loss (91dB or worse) Cannot hear speech sounds Speech will not develop without a hearing aid or cochlear implant Will need manual communication for language X O X O O X XO XO O X

100 Profound hearing loss (91dB or worse) There is a plateau in reading ability at about the 8-10 years of age level i.e. Poor language development X O X O O X XO XO O X

101 Often the hearing is asymmetrical Right profound hearing loss Left moderate to severe hearing loss X X X X X X O O O O O O

102 Types of hearing loss/impairment

103 Normal hearing Air and bone conduction are similar XO [] O [] X[] [] X [] O X O OX O X Hearing threshold is 20 db or better

104 Sensorineural hearing loss Air and bone conduction are similar Hearing threshold is worse than 20 db O[ X] ] [ OX ] [ O X ] O[ X] [ O] X O X

105 Air and bone conduction are different Conductive hearing loss X O [] [] [] [] X O X O X O [] X O X O Hearing threshold is 20 db or better for bone conduction Hearing threshold is worse than 20 db for air conduction

106 Mixed hearing loss Air and bone conduction are different [ ] X O [ ] OX X O [] [ ] O X [ ] O X X O Hearing threshold is worse than 20 db for bone conduction Hearing threshold is worse than 20 db for air conduction

107 Audiogram What are these boxes on the side?

108 Audiogram X

109 Acoustic reflex X

110 Acoustic reflex can be abnormal if problems in: Middle ear Cochlea Cochlear nerve (e.g. acoustic neuroma) Facial nerve Brainstem Superseded by an MRI scan

111 Tympanograms A Pressure between +100 and No hearing loss B No measureable pressure Conductive hearing loss Consistent with fluid in the middle ear C Pressure between -150 and -400 Consistent with Eustachian tube dysfunction High B Low B

112 Speech testing Very useful for determining how much the patient understands and whether there will be benefit from amplification

113 Speech testing Right ear 30% at 50 db 75% at 70 db 85% at 90 db Left ear 25% at 50 db 85% at 70 db 100% at 90 db

114 Types of Hearing Assessments It is (usually) possible to assess hearing even in infants, or in children who have developmental delays

115 Types of Hearing Assessments The child needs to respond to the sound stimulus Visual reinforcement audiometry (VRA) Pure tone audiometry (PTA) The child does not need to respond Objective hearing tests

116 Visual reinforcement audiometry Free field no headphones Age Range: Response: 7 months to 2 years Response Level: Thresholdd Conditioned head turn; reinforced with a puppet The child is distracted with a toy He turns to a sound and is rewarded by a puppet moving

117 Play audiometry Age Range: Response: 2 years and older Response Level: Threshold Conditioned play child responds to the sound by a play activity, e.g. with blocks When the child hears a sound she places a sailor into the boat

118 Pure tone audiometry children and adults Head phones for air conduction Audiometer Bone conductor sound goes through the bone to the cochlea and bypasses the external and middle ear

119 Objective testing Victorian Infant Hearing Screening Programme Automated ABR at 35 db Pass or Refer result

120 Objective testing For infants and babies Also for children who are not able to perform audiograms because of physical or developmental problems sound stimulus into the ear scalp electrodes

121 Objective testing Several tests available For infants and babies Also for children who are not able to perform audiograms because of physical or developmental problems These are not a substitute for a formal hearing evaluation When possible the results should be compared with behavioural audiometry

122 Other objective hearing tests Otoacoustic emissions Detect outer hair cell function Child can be awake Auditory steady state responses Gives frequency specificity Cortical evoked responses Demonstrates if child can hear sounds in the auditory cortex Child is awake

123 A series of waveforms from the hearing nerve and lower brainstem are recorded Auditory Brainstem Response (ABR)

124 Auditory Brainstem Response (ABR) Used for measuring thresholds The waveform pattern is interpreted by the audiologist, and the baby s hearing threshold in each ear is determined The response is not affected by sleep, sedatives or anaesthetic agents Robust signals

125 Air Conduction - Normal ABR clear responses at 50 db responses still present at 20 db

126 ASSR auditory steady state responses hearing thresholds, but more accurate with moderate or worse hearing less accurate if near normal hearing frequency specific

127 ASSR An electrophysiological response Stimuli are pure tones, frequency specific ASSR is detected automatically

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129 Otoacoustic emissions (OAE) outer hair cells (OHC) motility generates mechanical energy in the cochlea propagates outward through ME and TM vibration of the TM generates an acoustic signal (OAE) recorded from a microphone in the EAC

130 OAE not accurate if... Wax/vernix in outer ear Middle ear effusion If hearing worse than 40dB then the OAE is absent and the baby needs full audiology Not a substitute for behavioual audiology

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132 OAE Normal response No response

133 Cortical Auditory Evoked Potentials (CAEP) Useful for infant/child hearing aid evaluation Speech sounds m, g, t

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