Otolaryngology: Healthcare Team & Basic Rules

• The book's goals include making medical students into good clinicians and teaching the basics of Otolaryngology-Head and Neck Surgery
• Transitioning from second-year medical student to healthcare professional involves learning how to act as a professional
• Becoming a good clinician involves observing professors' demeanor, comments, and interactions with staff and patients

Active Healthcare Team Member

• Become an active member of the team.
• Medical students often have extra time to spend with patients and establish a true patient-physician relationship.
• Establishing a true patient-physician relationship establishes the medical student as an important part of healthcare team.

Basic Rules

• During the third year, conflicting responsibilities may arise so patient care should be the priority
• Two kinds of physicians exist: those who read and those who don't.
• Textbooks cover the basics and 90% of people do not know what is in them and articles are for later.
• If information is important, it will come up again in later reading and if it is unimportant, it will not come up very often.

Good Medical student

• Strive to uphold the highest ideals of professionalism with neat appearance and pleasant personality
• Complete thorough histories and physicals
• Compassionate to all patients and coworkers
• Always be willing and ready to learn

Honesty is a Prerequisite

• Enthusiasm is a student's secret weapon and having an enthusiastic student around makes a difference.
• Understand how to recognize potentially dangerous problems and how to manage uncomplicated problems

Otolaryngology History

• The ENT history begins with the chief complaint and a description of the location, duration, frequency, and quality of the presenting symptoms.
• Inquire about aggravating and relieving factors and ask about associated symptoms.

Exam Symptoms should include

• General/systemic symptoms (fever, chills, cough, heartburn, dizziness, etc).
• Otologic tinnitus, otalgia, otorrhea, aural fullness, hearing loss, vertigo
• Facial swelling, pain, numbness, nasal congestion, rhinorrhea, post-nasal drip, epistaxis, decreased smell
• Sinus pressure, pain, Throat soreness, odynophagia, dysphagia, globus sensation, throat clearing, Larynx vocal changes or weakness, hoarseness, stridor, dyspnea
• Neck symptoms pain, lymphadenopathy, torticollis, supine dyspnea
• Head and neck exam involves inspection (and palpation if practical) of all skin and mucosal surfaces of the head and neck
• Otolaryngologists use special equipment to assess the ears, nose, and throat.

Examining the ear

• Assess the external auricle for congenital deformities, such as microtia, promin auris, or preauricular pits.
• Examine external auditory canal by otoscopy after cleaning if cerumen is present, assessing for swelling, redness (erythema), narrowing (stenosis), discharge (otorrhea), and masses
• The tympanic membrane is normally pearly gray, shiny, translucent, and concave. White patches, called tympanosclerosis, often provide evidence of prior significant infection
• An erythematous, bulging, opacified tympanic membrane indicates acute bacterial otitis media.
• A dull, retracted, amber eardrum can be a sign of serous otitis, and middle ear lining may be viewed directly
• Perform pneumatic otoscopy to observe the mobility of the tympanic membrane with gentle insufflation of air.

Tuning forks

• Tuning forks can be used to grossly assess hearing and differentiate between conductive and sensorineural hearing loss.
• Weber test involves a tuning fork placed in the center of the skull which will normally be perceived in the midline
• If a sensorineural loss exists, the sound will be perceived in the better or normal hearing ear.
• Rinne's test of air conduction hearing involves placing the tuning fork just outside the external auditory canal. Placing the base of the tuning fork over the mastoid process assesses bone conduction hearing.

The Nose

• Perform anterior rhinoscopy utilizing a bivalve speculum. Evaluate the septum and anterior portions of the inferior turbinates.
• Assess turbinate response to decongestion with topical vasoconstriction with oxymetazoline and identify compromises to nasal patency that may be caused by swollen boggy turbinates, septal deviation, nasal polyps, or masses/tumors.
• The nasal cavity can be more carefully examined by performing flexible fiberoptic or rigid nasal endoscopy
• Ammonia fumes can be used to distinguish true anosmics from malingerers because ammonia will stimulate trigeminal endings.

The Mouth

• Systematically inspect all mucosal surfaces: gingivobuccal sulci, gums and alveolar ridge, hard palate, soft palate, tonsils, posterior oropharynx
• Observe buccal mucosa, dorsal and ventral tongue, lateral tongue, floor of mouth, and parotid duct orifice (Stenson's duct), and submandibular and sublingual glands which empty into the floor of the mouth.

The Pharynx

• The posterior wall of the oropharynx is easily visualized via the mouth by depressing the tongue
• Examine all mucosal surfaces; eustachian tube openings, adenoid, posterior aspect of the soft palate, tongue base, posterior and lateral pharyngeal walls, vallecula, epiglottis, arytenoid cartilages, vocal folds
• Assess vocal fold mobility by asking the patient to alternately phonate and sniff deeply, and observe that the glottis opens with inspiration (sniffing) and closes for phonation

Salivary Glands and the neck

• The parotid and submandibular glands should be inspected and palpated to detect enlargement, masses, and/or tenderness.
• The normal neck is supple, with the laryngotracheal apparatus easily palpable in the midline

Cranial nerves

• A complete head and neck exam includes testing of cranial nerves (CN) II-XII and vision (Optic - CN II) with a pocket eye chart
• Extraocular eye movements and pupillary response to light must be tested.
• The trigeminal nerve (CN V) can be tested by testing areas of the face using a pin and a wisp of cotton and test facial nerve (CN VII) by having the patient raise eyebrows, squeeze eyes shut, scrunch nose, pucker lips, and smile
• Assess swallowing, the gag reflex, and speech. Have the patient swallow and say “ah, ah, ah.”
• Assess spinal accessory nerve (CN XI) function by having the patient push his head laterally against resistance and shrug shoulders against resistance
• Assess hypoglossal nerve (CN XII) by having the patient stick out tongue, where deviation to one side indicates weakness/paralysis of the nerve on that side.

Managing patients on service

• A system based on disease categories represents a trick represented by an acronym: "Vitamin C"
• Vascular, Infectious, Traumatic, Autoimmune (or anatomic), Metabolic, Iatrogenic or idiopathic, Neoplastic, Congenital should be used to organize thoughts when confused or during high-stress rounds.
• Maintain a list of key information for each patient in a usable format: 3 x 5-inch note cards, Personal Digital Assistants (PDAs) or devices with commercial data software.
• Be aware that identifiable patient information is protected

Patient Presentation

• Patient presentations should be goal-directed with the following format
• "Mr. Jones is a 63-year-old man with a T3 cancer of the tonsil that failed radiation"

Last sentence for patient presentation

• "The plan is..."
• "The plan is to remove the drains today, continue the tube feedings, and start feeding the patient by mouth at one week post surgery, to cap his tracheostomy tube and remove it if he tolerates having it plugged

Post op fevers

• The five Ws of post-op fever: Wind, Water, Walking, Wound, and Wonder drugs
• POD 1-2, Wind, Atelectasis, inadequate sighs prevent deep breathing, incentive spirometry will assist
• POD 3-5, Water, Urinary tract infections Foley catheters in place
• POD 4-6, Walking, Deep venous thrombosis, subcutaneous, low-dose heparin Walking the patient on POD 1 prevents this
• POD 5-7,Wound, Wound, Most wound infections occur during this period
• POD 7+ Wonder drugs Drugs can cause fevers

Airway

• Airway emergencies depend on the caregiver's ability to recognize, access, and manage the airway. Patients are often in coma.
• If a tracheotomy is considered, it must be performed, as a scar on the neck is more comfortable than death.
• Cricothyrotomy is the preferred procedure, palpating the cricothyroid membrane immediately below the thyroid cartilage if an immediate surgical airway is needed for non-experienced surgeons

Choanal Atresia

• Choanal atresia is a congenital disorder in which the nasal choana is occluded by soft tissue, bone, or a combination of both.
• Unilateral, presents with unilateral mucopurulent discharge, bilateral, neonate unable to breathe

Difficult intubations and infections

• Anatomic characteristics of the upper airway, can lead to difficult laryngeal exposure
• Recognize Ludwig's angina which is an infection in the floor of the mouth causing airway obstruction.
• Treatment requires incision, drainage of the abscess
• Patients present with unilateral neck swelling, redness, pain, fever and antibiotic coverage to reduce oral cavity anaerobes

Acute Supraglottic Swelling and Peritonsillar abscess

• Angioneurotic edema can result in dramatic swelling of the tongue, pharyngeal tissues with medical treatment for swelling and airway maintenance
• Peritonsillar abscess is a collection of purulence reported as an untreated sore throat that has now gotten worse on one side. Hallmark signs are fullness of the anterior tonsillar pillar, deviation away from the side of the abscess, a hot potato voice

ENT Emergencies

Foreign Bodies

• Foreign bodies can be presented as airway emergencies, expelled or else no longer can be resuscitated.
• Foreign bodies can be extracted by Magill forceps after laryngeal exposure with laryngoscope
• "All that wheezes is not asthma".

Mucormycosis

• Fungal infection of the sinonasal cavity that occurs in immunocompromised hosts growing in acidic environments.
• Spreads to the nose, eye, palate, and brain so treatment involves quick correction of the patient and wide debridement consisting of a medial/radical maxillectomy and orbital exenteration.

Epistaxis

• Topical nose bleeds should be treated using oxymetazoline or phenylephrine nasal spray and digital pressure for 5-10 minutes including the nasal septum and digital trauma from fingernails. .
• Recurrent nosebleeds may warrant evaluation for coagulation.

Necrotiziting Otitis Externa

• Severe infection of the external auditory canal caused by Pseudomonas, patients presents with deep ear pain, temporal headaches, drainage and granulation tissue.
• Diagnosis must include CT scan or bone therapy includes glucose control, frequent ear cleaning and antibiotics

Otitis Media

• Complications consists of the Meningitis, sigmoid sinus thrombosis, subperiosteal abscess of the mastoid, brain abscess, and facial nerve paralysis

Hearing loss

• Sensorineural hearing loss (SSHL) is an idiopathic hearing loss and viral infection to reduce vasodilatation

Otitis Media

• Simply defined as inflammation of the middle ear space.
• Classified by duration, patient symptoms, and physical exam findings.
• Diagnosed into variants: acute otitis media and otitis media with effusion (OME)
• Common bacteria that cause acute otitis media in children are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
• High-dose amoxicillin-clavulanate is a therapy for acute otitis media. Breastfeeding, pneumococcal may vaccination may help as well.
• Insertion involves placing small tubes in the eardrum to ventilate the middle ear and prevent the negative pressure and fluid buildup.

Otitis Physical Examination

• May be an air-fluid level behind the eardrum and decreased mobility of the eardrum.
• Patients may have up to a 30 to 40-decibel conductive hearing loss, but is not usually indicated for children.
• Exam must be done to examine the nasopharynx due to disease OME can also become present resulting bleeding and fluids inside

Otits Complications/Definition

• The most severe complications from acute media can include perforation of the eardrum, and timpanosclerosis (firm submucosal scaring).

Otits Media in Adults

• Examination is needed to determine whether tumor from nasal cavity may protrude through
• Fluid collection near the side of the ear in mastoid must resolve all fluid, requires tube operation and antibiotic use.

Hearing Loss basics

• Hearing loss can be caused by a wide variety of factors

• May have complaint of difficulties in understanding or being unable to hear. Tinnitus, which may be described as ringing, buzzing or as “crickets” in ear. Children: Harder to notice Conductive vs Sensrineuro

Causes

Conductive

• cerumen impaction
• inner ear or eighth cranial
• swelling of extenal auditory canal

Sensorineuro/Nerve

• persistent noise, age, genetic. Infection

Pure Tone Audiometry

• Requires ability and willingness to cooperate

0-db levels are “normal levels”

Dizziness Symptoms must include

• Disequilibrium, lightheadedness, syncope, ataxia, and vertigo
• Focus on true vertigo caused by disease balances in inner ear, known as peripheral vestibular disorders

Vestibular Testing

• Determines problems relating to inner or outer ear, which has an audiogram

• For test includes calibration, tracking, positron and caloric

BPPV

• benign paroxysmal positional vertigo,
• Causes and Treatment for BPPV
• dislodged fee flowing autolith repositions into vertible.

Neuritis, and Meniere Treatment

• Commonly caused by second infection that will treat with vestibular suprametisans
• Medical and Surgical treatment used to treat medical dizziness:

Facial Nerve Paralysis

• Can occur spontaneously following and results to malignant tumors where paralysis is peripheral
• Bell's Palsy, facial with onset in less than 172 hours and critical physical exam to prevent misdiagnosis

Bell's Palsy

• Gradual onset, often when noticing symptoms upon waking and spontaneously recover
• Medical therapy through steroids helps increase recovery while antiviral remains unclear

ENT facial fractures

• Can impact the ability for face nerves to properly occur because the facial nerve often becomes bruising resulting medical procedures to be done early

General facial laceration and care

The treatment for facial nerve provides is useful for eye lid to give maintenance to the cornea, giving protection and prevention

Rhinology

• Rhinorrhea and drainage can result from allergic nonallergic rhinitis
• Nasal instruction that has anatomical defection causes by mucosal edema and the undying cause

Vasocontriction

• Vasomotor rhinitis and non allergenic rhinitis can mimic allergic, but are all sensitive and must be relieved by food, temperature

The "Common Cold"

• Frequently attributes to one or many rehoviruses that increase mucus production, which must be relieved with anytiprotics. Spontaneous resolution occur within 7 -10 days

Rhinosinusitis

Prolonged mucosal edema from obstructs and retention to have obstructed sinus - Several patient may exhibit the major symptoms, where studies differ from both. It happens from a viral upper tract which must give a time resultion to have time to resolve within 7 to 10 days Acute is under 1 and Sub is between 1 to 3 months while treatment requires 10 day course either amosicillin In addition it may include decongestan

Sinusitis

The sinuses include frontal ethmoid and all which need treatment to not be a further consequence, as well as surgery where: The most diagnosis requires to see And if those symptoms must be shown immediately

Deviated Septum

• A deviated septum requires a deviated process by an elevated nasal septum They have been shown to improve continuous airway with little to no cure

Nasal Polyps

• Localized sinus mucus where are full, The treatment to treat: Intranasal are also possible when given to aid airways after surgical treatment.

Nasal masses

May includes symptoms for a nasal which includes: inflammatory etiologies and neoplastic primary

Skin Cancer

• Skin often appears and is followed up through treatment of tumor and melanoma.
• Early excision is critical often in the lips Morpheaform Basa Carcimoma is most difficult with a lack of tissue

Key facts

• A patient complains of fatigue, low-grade fever, purulent rhinorrhea, and headache in relation to sinus and the flu should be tested, while is If is less ,a side view must be placed for the child the airways must be open due to the small airways.