Author: S Forrington

Diseases of the Ear

Anatomy: The external ear is the auricle, canal and tympanic membrane. The middle ear has the 3
ossicles and is connected to the pharynx via the Eustachian tube. The inner ear comprises the cochlear
with the semi-circular canals, utricle and sacule relays signals to central auditory and vestibular
systems respectively.
Common presenting complaints: hearing loss, tinnitus, vertigo, aural discharge, otalgia
Inspection / examination: any surgical scars around the or in the ear? Cervical lymph nodes. Use
otoscope to examine canal and membrane. Perform Rinnes and Webers.
Hearing Tests: response to normal conversational voice: external + middle ear problems: conductive,
inner ear/auditory nerve: sensorineural loss. Rinnes Test is tuning fork lateral to ear then on mastoid
process air should be louder (positive test). Weber Test bone conduction in both ears from skull
midline. Tone Audiometry test over a range of frequencies.
Balance Tests: Hallpike Test: lower head rapidly over the end of the bed and check for nystagmus.
Fistula test: apply +ve pressure to canal with pneumatic otoscope nystagmus or vertigo is experienced
if a fistula to the inner ear is present.
External ear disease
Infection: otitis externa (swimmers ear) bacterial or fungal. Tx local debridement, drops.
Obstruction: from osteomas (benign bony tumours), foreign bodies, wax impaction
Middle ear disease
Otitis media: most often in young children H. influenzae usually preceded by URTI. Give Abx.
Membrane rupture usually heals spontaneously, if not then surgery (myringoplasty).
Glue ear: may present with developmental delay at school. Eustachian tube blockage leads to fluid
accumulation in middle ear. Usually self limiting if persistent then adenoidectomy or grommets.
Cholesteatoma: presents with chronic, smelly discharge due to keratinising squamous epithelium
invading underlying bone infection, labyrinthitis, facial nerve palsy. Tx: mastoid surgery.
Otosclerosis: autosomal dominant fixation of stapes and conductive deafness. Tx: hearing aid or
stapedotomy.
Inner ear disease
Presbycusis: hearing loss of old age (high freqs 1st) hearing aid usually helps.
Noise-induced: chronic exposure leads to irreversible damage.
Ototoxic drugs: aminoglycosides (permanent damage), quinine, aspirin (reversible)
Vestibula neuronitis : viral (viral labyrinthitis) or vascular damage to inner ear severe vertigo, nausea,
vomiting. May be temporary or permanent, may also present with sudden hearing loss
Acoustic neuroma: unilateral tinnitus+hearing loss, imbalance. Diagnosis: MRI. Surgical removal usually
possible with small tumours detected early.
Menieres disease: fluctuating sensory hearing loss, tinnitus, vertigo. Idiopathic, usually unilateral, no
evidence that medical intervention works. Destructive surgical procedures may control symptoms in
severe disease but cause hearing loss in the affected side.
Vertigo: BPV episodic vertigo when head is in a certain position, usually resolves in a few months.
Ramsay-Hunt syndrome: herpes zoster infection of inner ear gearing loss, vertigo, facial nerve palsy.
Tx: systemic anti-herpetic therapy. Recovery of facial nerve may be incomplete.
Refered otalagia: common. Teeth and TMJ are common sites exclude tongue+throat disease.

Dr R Clarke

www.askdoctorclarke.com

Author: S Forrington
Disease of the Nose and Paranasal Sinuses
A+P nose: upper 1/3 is bony, lower 2/3 is cartilage. Nasal cavities have respiratory epithelium. Rich
blood supply from internal and external carotids. Olfaction and warms+humifies inspired air, traps
particles on hairs.
Paranasal sinuses are in pairs: Anterior frontal, maxillary, anterior ethmoid sinuses drain to middle
meatus in nasal cavity. Posterior posterior ethmoid, sphenoid sinuses drain to sphenoethmoidal recess
in the nasal cavity. No known function in humans.
Clinical features
Obstruction: most common problem uni/bilateral. May be structural (e.g. septum) problem or mucosal
swelling (rhinitis), nasal polyps.
Discharge: clear or coloured, uni/bilateral. Posterior discharge is catarrh.
Sneezing: due to mucosal irritation, often in allergic rhinitis.
Anosmia: lack of smell obstruction or more rarely, disease of anterior cranial fossa.
Pain: 2ndary to inflammation and sinus obstruction.
Investigations: inspect for deviation, examination of nasal cavity, nasopharynx with endoscope.
Supplement with CT/MRI, allergy testing with skin-prick. Mucociliary clearance testing (velocity of mucus
over epithelium) and rhinomanometry (air flow and pressure).
Diseases
Rhinitis: inflam of mucous membrane - most commonly the common cold (viral) obstruction, discharge,
sneezing. Self limiting 4-5 days, may be complicated by bacterial infection. More severe in smokers who
have impaired mucociliary function.
Sinusitis: pain over affected sinus. May be a complication of common cold. Steam inhalation +
decongestants may reduce symptoms, May be added bacterial infection or infection of premolar and
molar teeth. Consider antibiotics. Occasionally a surgical drain is required now done endoscopically.
Allergic rhinitis: seasonally from tree + grass pollen, perennially from house dust mite, animal shit,
feathers. Affects up to 1/5 of population. Type 1 HS reaction with IgE/allergen complex.
Non-specific / vasomotor rhinitis: Nasal mucosa may also react to temperature, humidity, stress,
hormones of puberty + pregnancy. Tx for both is steroid nasal sprays and in allergic rhinitis antihistamines.
Trauma to Septum: look for other injuries. Drain any nasal haematoma (due to risk of abcess formation),
pack to prevent re-accumulation, give Abx. Correct deformity by nsal manipulation within 10-14 days
otherwise bones heal and will require rhinoplasty surgery.
Septal perforation: may be trauma, iatrogenic, cocaine abuse if symptomatic (bleeding, whistling) small
perforations may be repaired surgically.
Epistaxis: usually disruption of blood vessels in anterior septum (Littles Area) rich vascular
anastomosis. Tx: head slightly forwards + pinch nose. Local anaesthesia and cautery if necess. More
serious posterior bleeds in elderly, hypertensive pts may be large blood loss (often a lot swallowed)
assess for shock. Mostly controlled by anteriorly-placed packing (with Abx of more than 48 hrs) or
endoscopic cautery. Check for coag disorder. Arterial ligation may be required in severe refractive cases.
Polyps: redundant oedematous mucosa, most commonly in ethmoid sinuses and bilateral, causing nasal
obstruction. Look like skinned green grapes, insensitive to probing. Regard unilateral polyps with
suspicion. Large ones surgical removal, small ones local steroid sprays.

Dr R Clarke

www.askdoctorclarke.com

Author: S Forrington
Diseases of the Throat
Common symptoms: sore throat, difficulty in swallowing, changes in voice, airway obstruction.
Examination: use pen torch and tongue depressor. Inspect and examine whole neck. Endoscopy, CT
and MRI are adjuncts.
Diseases
Pharyngitis: usually viral. Bacterial (usually strep) may be primary or secondary. Give oral soothing
medication. Abx only bacterial cause is suspected. Candida may occur in diabetic or
immunocompromised pts and sometimes with steroid inhalers for asthma. Tx antifungals.
Tonsillitis: bacterial tonsillitis sore throat for a week, difficulty and pain on swallowing, fever, cervical
lymphadenopathy, malaise. If recurrent attacks interfere with school/work, consider tonsillectomy.
Complications reactionary haemorrhage (in 1st 24hrs), 2ndry haemorrhage a week after surgery.
Swallowing disorders
Progressive dysphagia to solids then liquids - ?oesophageal ca, dysphagia with aspiration of liquids
suggests neuromuscular disease (e.g. MND, myasthenia gravis). May be extrinsic cause e.g. goitre and
medistinal masses.
Suggestion of a lump in the throat without dysphagia globus pharyngis. Need to swallow twice,
associated with regurgitation of food suggests a pharyngeal pouch. Investigations: barium swallow,
endoscopy.
Changes in the voice
Dysphonia altered quality of voice. Most commonly due to self-limiting viral laryngitis. Exacerbated by
smoking, alcohol may cause chronic laryngitis. Voice abuse may lead to vocal cord nodules
(singers/screamers nodules) and polyps. May require speech therapy and surgery to remove nodules.
Hoarseness may be the result of neoplasia and a 3 week hx should be examined via laryngoscopy.
Vocal cord palsy may be idiopathic or due to laryngeal nerve supply damage anywhere from brainstem to
mediastinum.
Airway obstruction

Obstructive sleep apnoea

Large tonsils in young children (tonsillectomy)
EBV infection can produce tonsillar hypertrophy and require tonsillectomy
Epiglottitis H. influezae in young kids (rare since vaccine) causes stridor and is an emergency which
may require intubation. Cf. croup viral causae, usually self-limiting.
Ca larynx occasionally presents with airway obstruction

Dr R Clarke

www.askdoctorclarke.com

Author: S Forrington
Head and Neck Neoplasia
Most are squamous cell and due to smoking or excessive alcohol. Adenocarcinoma and lymphoma less
common. Spread locally to cervical lymph nodes. May disrupt breathing, swallowing, speech. Epstein-Barr
virus: nasopharyngeal carcinoma, Burkitts lymphoma and possibly others. Most are treated by surgery,
radiotherapy or both.
Pre malignant: leucoplakia, erthroplakia (mucosal patches), erosive lichen planus.
Inspect the tongue and mouth and use a laryngeal mirror. Palpate the neck nodes. Flexible
rhinolaryngoscope for examination and biopsy for diagnosis. Also CT and MRI.
Squamous Cell Carcinoma of the Larynx
Most common site: glottis (vocal cords) presents with hoarseness. Hoarseness > 3/52: investigate with
laryngoscope. In early disease, 85% can be cured by radical radiotherapy. Cancers above or below the
cords have a poorer prognosis they present later. Total laryngectomy reserved for v large tumours.
Oral Cavity
Mostly squamous cell anterior ones have better prognosis due to early detection. Causes: smoking,
alcohol, poor dental hygiene. Small malignancies do well with surgery or radiotherapy, larger tumours have
poor prognosis. All will need SALT support. Metastatic lymph node disease is dissected out or treated with
radiotherapy (small nodes).
The Pharynx
Pharyngeal tumours often present late with cervical lymph node involvement.
Referred otalgia may be presenting complaint in oropharynx tumours. Pt is usually a heavy smoker and
drinker. Management surgery, radiotherapy or both. The oropharnx is also the most common site of
presentation of extra-nodal lymphoma usually non-Hodgkins.
Carcinoma of the nasopharynx has highest incidence in SE Asia: EBV is implicated as the cause.
Presentation is often late and may include Horners syndrome, facial pain, otitis media. Treated by
radiotherapy poor prognosis.
Nose and Paranasal Sinuses
Squamous cell is again the most common site is most commonly the maxillary sinus. Presentation with
nasal obstruction or diplopia with orbital involvement. A bleeding polyp in an elderly pt should be regarded
suspiciously. Tx is radical radiotherapy followed by surgery. Poor prognosis.
Salivary Glands
Most are in the parotids (80%) and are benign. In the other glands they are more likely to be malignant.
Pleomorphic adenoma slowly growing and painless lump behind and just below earlobe. Do not mistake
for a node. Treat by removal of the gland. Warthins Tumour: bilateral parotid tumour of lymphoid tissue,
usually in older men.
Malignant tumours generally grow rapidly, invade the facial nerve and are often painful. Adenoid cystic
carcinoma is the most common. Tx is parotidectomy +/- facial nerve excision.

Note
The original notes on these topics were written by S Forrington when a final year medical student in 2006. They are presented in good faith and
every effort has been taken to ensure their accuracy. Nevertheless, medical practice changes over time and it is always important to check the
information with your clinical teachers and with other reliable sources. Disclaimer: no responsibility can be taken by either the author or publisher
for any loss, damage or injury occasioned to any person acting or refraining from action as a result of this information

Dr R Clarke

www.askdoctorclarke.com