ENT - Main

• ENT stands for Oto-rhino-laryngology
• Knowing about ENT can help you understand common conditions, overlaps with OS/OMFS, recognize Oro-facial differential diagnosis and can help with communication
• ENT knowledge is important for exams

The Ear

• The ear consists of three parts: the external, middle, and inner ear

History

• Important factors to be aware of when discussing ear issues with a patient

Earache (Otalgia)

• Ear pain that could be related to TMJ issues due to proximity

Deafness

• Refers to a loss of hearing

Discharge

• Drainage from the ear

Tinnitus

• It presents as a ringing sound - can be idiopathic

Vertigo

• Patients experiencing vertigo may feel sick and vomit
• It creates the sensation that "the external world revolving around the patient"

Examination

• Steps to examine the ear

External Examination

• Look for obvious malignancies and diseases
• It's important to Document this
• Focus on diagnosing TM joint injuries
• Otoscopy can assist in examination
• Perform a Visual examination into the Canal to check for Tears and Perforations

Tuning Fork Tests

• Two main types of tests are used - Rinne and Weber tests

Rinne Test

• Place the tuning fork on the Mastoid Process and see if the patient can hear it
• If patient can't hear it, move the fork to the Air to check if they can hear it
• The test compares Air vs Bone Conduction
• In a normal patient, Air Conduction is greater than Bone Conduction
• If Diseased Pt has Conductive Deafness, Bone conduction will be greater than the Air Condution
• Note: False Negatives may occur; test is not 100% reliable

WEBER

• Place the tuning fork in the Middle Of The Head
• Note if sound Lateralises to One Side or the other
• Ipsilateral lateralization indicates Conductive Deafness: The affected Ear will experience More Conduction through Bone
• Contralateral lateralization indicates Sensorineural Deafness

Deafness Types

• Two main types; Conduction and Sensorineural Deafness.

Conduction Deafness

• Occurs when Sound waves are blocked from reaching the Inner Ear

Sensorineural Deafness

• Nerve damage travels to the Brain Defect

Investigations

Pure Tone Audiometry

• Soundproof Booth with Headphones & various Pitches of Beeping Sounds are played→ to TEST SENSITIVITY (db)
• Both Air and Bone Conduction are Tested
• Requires Pt co-operation→ Very easy to skew results
• Assesses Sensitivity (db)

Electric Response Audiometry

• Assesses Brainstem or Cortical Function
• Co-operation is not needed making it→ More OBJECTIVE TEST

External Ear

• Remember the HELIX because it is important in terms of Malignancies & injuries since it is exposed to the Sun and has a high chance of Malignancy

Features

• Outer 2/3 cartilaginous
• Composed of Specialized Squamous Epithelium
• No Hair inside the Ear Canal because it is Devoid of Follicles
• No Flaking or Shedding because it Does not Desquamate
• The Outer Ceruminous Glands→ Ear Wax producing Glands are included
• Multiple Sensory Supply included

Common Disorders of the Outer Ear

• Can be Inflammatory, Traumatic, Neoplastic, Congenital, or Idiopathic

Inflammatory

• Otitis Externa
• Necrotising (Malignant) Otitis Externa

Otitis Externa

• General causes of Irritants, Skin Disorders, Necrotic Debris, Pre-Existing skin condition, Using Earbuds or Cleaners

Local Causes

• Trauma (e.g., earphones
• OM Infection - Infection of the Middle Ear
• Pathogens that arise are: Pseudomonas, S. aureus, HSV, Candida, Aspergillus

Symptoms

• Painful sensations
• Some (serous) Discharge presents as Watery and makes it feel like EAR is BLOCKED
• "Blocked Ear" sensation

Treatment

• Gentamicin-Steroid Ear Drops or Otamise Ear Drops commonly given Possible Antifungal Treatment prescribed Tends to be Fungal when patient is a Swimmer

External Ear Trauma

• Auricular Haematoma occurs between the Skin & Cartilage
• Can develop Perichondritis which is inflammation of the Perichondrium
• Can lead Can lead to Cauliflower Ear or Aesthetic issues
• Closes the External Acoustic Meatus which Affects Hearing and Can lead to Necrosis of the Tissues

Auricular Haematoma

• The Patient should be shown which to Identify this & Signpost to get it DRAINED
• Advise them on the Risks of Necrosis when draining Blood
• Blood is drained from the Ear using a needle

External Ear Neoplasia

• Neoplasms are either: Benign or Malignant
• The non cancerous types include osteomas (Bone Tumour), Keloid

Keloid

• Soft tissue extends beyond the Margin of the Trauma which may be Hyperplastic/Trophic Scar

Basal Cell Carcinoma

• Diagnosed via Incisional Biopsy
• The area of skin around it appears More Nibbled Away with Eroded Ulcer Appearance, also known as Rodent Ulcer

SQUAMOUS CELL CARCINOMA

• Usually located on the HELIX
• Presents superficially with Keratinised Appearance which is WHITISH

Disorders Of The Middle Ear

• 2nd & 3rd most common types.

Common ones to remember

• Acute Suppurative Otitis Media
• Otitis Media with Effusion ("Glue Ear")
• Cholesteatoma
• Acute Mastoiditis - If starts affecting Mastoid, might be affecting Middle Ear and may need Antibiotics
• Tympanosclerosis
• Otosclerosis

Measurement of Infection Progression

• How much the Disease has progressed is shown through Investigation of either spreads into the Cranium or down into the Mastoid
• Often infection presents either spreads into the Cranium or down into the Mastoid

Acute Suppurative Otitis Media

• Bacterial or Viral Infection, often Occurring in Children
• Pus to build up behind the Eardrum results in:
  • Severe Early Pain
  • Fever
  • Hearing Loss

Common Symptoms

• Irritable behaviour
• Pain
• Pyrexia
• Hearing loss
• Discharge
• Systemic Illness where Ascending URTI causes ACUTE SUPPURATIVE MEDIA and the common bacteria associated are St. pneumoniae and H. influenzae

Treatment for Otitis Media

• Antipyretics like Calpol + Paracetamol can be very effective
• Antibiotics
• Decongestants
• Surgical Incision made in the Tympanic Membrane to drain it using a Myringotomy

Common Complications

• Otitis Externa can occur when its Spreading outwards
• Recurrent Otitis Media can lead to glue ear
• Perforation/Chronic Otitis Media → Perforates the Ear Drum
• Once infected the infection spreads up into the Cranium or down into the Mastoid leading to Mastoiditis

Mastoiditis

• Can arise from both Bacteria and viral infections and occurs more often in children
• The Pus builds up behind the Eardrum resulting in Severe Ear Pain, Fever, and Hearing Loss

Chronic Otitis Media with Effusion ("Glue Ear")

• Known as Endemic in under 5s
• Causes Conductive Hearing Loss because Pus stops the Ossicles resulting in no Vibration

Multifactorial Causes

• Eustachian insufficiency can arise
• Build-up of secretions in the middle ear causes infections
• Can also arise from various Environmental factors; Immunity, Social class and Allergies

Testing procedures

• Childhood Screening is conducted where School Nurses perform Hearing Tests by Pure Tone Audiometry

Acute Otitis Media Effect on childhood

• Can result in: Language Delay and Behavioural Issues
• Child is Bored & Misbehaving because they Can't Hear: recurrent infections and may exhibit poor School Performance

Management

• Conserve with Medicine where possible
• Myringotomy alone
• Auto-Inflation where Puffing of Ears Out can Make them Pop Aids Drainage of Pus

Insertion Of Grommets

• Myringotomy is conducted before Grommets are placed in where ear is kept open
• These are Typically placed in C/L & C/P pts
• It Creates a Surgical Drainage Pathway

Cholesteatoma

• Arises From Complication of Eustachian dysfunction at Attic Position
• Starts growth in the Retraction Pocket of the Tympanic Membrane and Can arise From Misshapen Part of the Eardrum

Common Symptoms Include

• Bad retraction pocket
• Foul smell
• Conductive hearing loss
• Discharge and Facial palsy from where Facial nerve is in close proximity

Late Stage Symptoms Include

• Vertigoand Intra-cranial extension

Management

• Agressive and can be very destrictive which requires intervention
• Surgery is used to remove build up

Inner Ear

• Referred to as the Labyrinth

Inner Ear Labyrinth

• Semicircular canals, Ampulla, and is Responsible for angular acceleration

Disorders of the Inner Ear Include

• Acoustic Neuroma, Meniere's Disease, Vestibular Neuronitis
• [Benign Paroxysmal Positional Vertigo (BPPV)] which if Manipulations can realign

Acoustic Neuroma

• Occurs Rarely at approximately 6% of Brain Tumours
• Typically Benign & Locally Compressive
• Develops from Vestibular Schwannoma which is Growth of the Vestibulocochlear Nerve (tumour)

Symptoms

• Early progressive Unilateral Deafness has a potentially brain tumour where it can't be reversed
• Vertigo, Unsteadiness, Facial Palsy

Acoustic Neuroma Management

• Conservative strategy with Yearly MRI Scans is used to size is increasing and determine whether to remove it
• Gamma Knife surgery at 14% recurrence rate is Very expensive while Surgical intervention has a Significant risk of Nerve Damage with some possible 3% recurrence

Meniere's Disease

• Can have Episodic fullness, fluctuating deafness, tinnitus, vertigo., Nausea, vomiting, and "drop attacks" lasting 2-4 hours
• Note that Episode comes without warning and can be very Debilitating
• Common causes include Secondary results from things like a Head Injury

Meniere's Disease Management

• Generally is Self-limiting but unpredictable
• Various Conservative, medical, or surgical treatment options are available Medical
• Attempts to relieve nausea & dizziness
• Surgical
• To cut the cranial nerves to eliminate the dizziness sensation

Hoarseness

• Main Concern if there is Persistent hoarseness - Consider referral
• Look for Pain (especially when NOT TALKING) Earache
• Dysphagia which indicates a Problem with the Vocal Cords from possible Expiratory Problem Stridor that indicates Inflammation of the Vocal Cords from possible Inspiratory Problem
• Other Voice Changes: include Lingual/oral from Tongue interFering with voice or Oropharyngeal and possible Any Voice Changes or Issues with Airflow

Hoarseness

• Requires a 2 Week Rule and should be treated As a Dental Practitioner by Signposting this information to the GP

Sore Throat and Dysphagia

• Requires medical attention if the Patient has Persistent symptoms
• Look for Localised/unilateral pain because pain is likely unilateral Be aware of Possible Associated symptoms of Earache and Stridor as well as Bleeding, Foetor smell and Weight loss if present

Lump In The Throat Sensation

• Sensation that arises from a Lump in the Throat may be either BENIGN or MALIGNANT

Possible Causes Include Either

• May be a Psychological Problem because If it fluctuates or the lump is not likely to be a Physical Issue

If the Growth is Benign

• Symptoms could be due to Stable or Fluctuates of from being Food or Drink Unaffected
• Other causes from Patient feeling Anxiety, Stress or possible Reflux

If The Growth Is Malignant

• Symptoms could be from Progressive impairment of Problem Swallowing which causes solids and possible Liquids from possible Painful sensations Neck mass and possible Hoarseness and Weight loss

General Summary

• Do not ignore Dysphagia nor Odynophagia
• Be aware of the effects that Unilateral Symptoms have and be suspicious until Proven Otherwise

Key Take Aways

• It is essential to Have A Working Knowledge of ENT
• ENT and Oro-Facial Signs and Symptoms often overlap
• You must work closely with specialists within the OMFS Teams