HNO

Thema 1: Einführung

Introduction
Patient History

 Chief complaint: Ear? Nose? Throat? Neck?

 Onset, Frequency, Duration
 Symptoms
 What have you already tried?
 Malignancy?  Smoking? Alcohol?
 Previous work
 Medical history

Epistaxis

 Rhinitis sicca
 Cocain, other drugs
 Bilateral?
 Mostly from Little´s area or Kiesselbachi anteriorly
 Posterior more in adults, can be fatal
 Causes
o Idiopathic, nose picking, trauma, infection, iatrogen, tumors
o Hypertension
o Anticoagulants
o NSAIDS
o Coagulopathy
o Heredetary haemmorhagic teleangiectasia
 Lean forward! Don´t swallow, pinch for 10 minutes, ice
 Airway! Asses blood loss, pulse, RR, IV, stop bleeding
 Cauterization
o First aid first
o Local anesthesia
o Light source and nasal speculum, suction
o Anterior: silver nitrate sticks or bipolar cautery, nasal tampon
o Posterior: difficult to cauterize, epistaxis balloon or urinary catheter, always
secure at nasal vestibule (it slips back otherwise)
o Failure: interventional radiology
Septal deviation

 Congenital, idiopathic or traumatic

 Rhinoscopy
 Endoscopy
 Treatment
o Depens on symptoms
o 3 months of local steroids, then sub mucus resection
o Nose will be blocked for a week afterwards

Septoplasty

 30 min OP time
 Deviated cartilage and septal bone party removed
 Day case
 Complications
o Bleeding
o Septal perforation
o Infection
o Change in nasal shape

Nasal bone fracture

 Compilcations
o Exclude other injuries and medical issues
o May involve structures other than nose
o Septal hematoma: must be drained, otherwise: infection
o May be infection if bone open
 Examination
o Deviation of external nose – nasal bones
o Crepitation
o Haematoma – swelling
o Pain
o Endoscopy
o Open fractures?
o Epistaxis
 Important
o Orbital wall  fractures?
o Ocular anatomy
o Nasolacrimal duct
o Infection  serious complications
o Cribriform plate  leakage of CSF, drainage of clear rhinorrhea after trauma
and up to several days later possible
 o Head injury, cervical spine injury
o Outpatient appointment in 5 days bc of soft tissue swelling
o Tetanus vaccination?

Foreign bodies in the nose

 Unilaeral nasal obstruction, foul smelling discharge, vestibulitis, epistaxis

 Otoscope, patient blows nose
 Wax hook
 Uncoorperative child  sedation

Nose furuncles

 Folliculitis
 S. aureus
 Swelling and redness at vestibule
 Painful
 Treatment
o Antibiotics
o If redness and swelling on the walls + anticoagulants:
 Thrombophlebitis of angular veins
 Opthalmic veins
 Meningitis

 Recurrent nosebleeds:
o Maybe vascular knuckle that can erupt or superficial vessles for dripping
nosebleed
o anesthesia, cauterization (silver nitric stick or electricity when deeper)
o heals within two weeks
o CAVE: coagulation disorders (Haemophilia A and B, Leukemia, bleeding
diathesis)

 Older patients with high blood pressure:

o Emergency medication to sink RR (nitro spray)
o Nasal endoscopy with suction
o Anteriorly: cauterization
o Posteriorly: cauterization, nasal tampons, interdisciplinary, inflating tampons,
CT scan of sinuses if hemodynamic stable  OR, Hb control and transfusion,
interventional radiology
  Allergy:
o Treatment:
 Antihistaminika
 Topical steroids
 Nasal douche
 Avoid allergens
 Allergy tests
o Symptoms persist: Conchotomy or ablation of inferior nasal conchae
 Complications:
 Bleeding
 Infection
 Prolonged healing process
 Dry nose syndrome
 Recurence of nasal conchae hypertrophy
 Kakosmia (qualitative Riechstörung) especially if dry nose
syndrome occurs

 Chronic nasal obstruction:

o Septal deviation and conchae hypertrophy
o Septoplasty:
 1% Lidocain
 Bleeding
 Infection
 Adhesions
 Abscess

Smell

 Hyposmia: decreased
 Parosmia: strange
 Cacosmia: bad

Cranial nerves

 Nervus facialis: CN VII, muscles of facial expression

 Nervus trigeminus: CN V, bilateral sensation
 Nervus vestibulocochlearis: CN VIII, hearing
 Nervus glossopharyngeus: CN X, voice, palate rise
 Nervus accessorius: CN XI, shoulder, head turn
 Nervus hypoglossus: CN XII: tongue protrusion
 Nervus oculomotorius, trochlearis, abducens: extraocular muscles
Paranasal sinuses

 Communicate with nasal cavities

 All present embryo except sphenoid sinus
 Frontal, maxillary sinus, anterior ethmoic cells  middle meatus  below middle
turbinate
 Posterior ehtmoid cells  superior meatus
 Sphenoid sinus  anterior wall above choanae
 Ostiomeatal Unit
o Anatomic area on lateral nasal wall
o Paranasal sinuses open in nasal cavity (except sphenoid)
o Narrow: Ostium of maxillary sinus  Sinusitis if blocked
o After 12 weeks: chronic  surgery
 Iatrogenic trauma
o Ethmoid roof and cribiform plate are thin
o Easily injured (e.g. Polyp removal)
 Imaging
o CT scan for chronic diseases: because we need to see the bone structure
o MRI only for children and tumors, encephaloceles (differentiate polyps vs.
Tumors) but CT obligatory for surgery, then child also gets CT scan
o Sphenoid sinus if optic nerve issue, optic nerve through sphenoid sinus
(Blindness!)
o Internal carotid artery + posterior wall of sphenoid sinus checked (Bleeding!)
Functional Endoscopic Sinus Surgery
 Enlarge the tight passages in the middle meatus and ostiomeatal unit
 Septoplasty might be needed with severe septal deviation
 First: CT scan of the sinuses
 Causes:
o Polyps
o With Aspirinintolerance: Samter-Trias
o Fungus
o Accessorial windows with chronic mucus production
 Complications:
o Bleeding
o Skull base trauma and CSF-leak
o Trauma (orbita, optic nerve, internal carotid artery)
 Lamina papyracea traumatised:
o 1: Soft eyelids, emphysema, bulbus motility normal
o 2: hard eyelids, mydriasis, no light reflex, cannot see seconds after extubation

Rhinitis
 Inflammation of nasal lining
 Blocked nose, rhinorrhea, postnasal drip, sneezing
 1 in 6 adults
 History is importnant: Asthma, already using nasal spray?  Rhinitis medicamentosa
 Mostly allergic (Prick test!) or infectous
 Sometimes neoplastic, idiopathic, autonomic, atrophic, drugs, NARES
 Can be part of systemic condition
 Search for polyps
 Treatment
o Avoid allergen
o Topical steroids (only dryness)
o Antihistamines
o Nasal decongestants (risky, max 7 days)
o (Ipratropium bromide)
o (Sodium cromoglycate)
o Oral steroids can be added
o Nasal douche (important)
 Surgical
o Turbinate reduction
o Septoplasty
o FESS

Anterior Skull Base Olfactory Schwannoma

 Schwannoma: coming from Schwann-cells
  Compression
 Excision

Rhynophyma
 Untreated Rosacea Stadium III
 Men 50-60 years
 Operation: CO2 laser ablation, grinding (sharp instrument)
 Granulomatous infiltration
 Hypertrophy of sebaceous glands of nose tip

Osler-Weber-Rendu disease

 Rare autosomal dominant

 Vascular dysplasia  tendency for bleeding
 Hereditary hemorrhagic telangiectasia
 YAG-Laser for haemostasis and symptomatic

Acute Sinusitis

 Etiopathogenesis
o Children: ethmoidal cells (incomplete pneumatisation of others)
o Adults: maxillary > ethmoid > frontal > sphenoid
o Rhinogenic sinusitis most common cause
 Anatomy, immune status, virulence
o H. influenzae + Str. pneumoniae
o Dentogenic sinusitis, nosocomial, baro (diving, landing), swimmers
 Symptoms
o Congestion, rhinorrhea, sneezing
o Headache
o Pain over sinus
o Exacerbation when bending over
 Diagnosis
o Purulent secretion
o Anterior rhinoscopy
o CT scan
 One filled with air, one with fluid  sinusitis
o Pregnancy: only life-threatening CT, B-mode sonography not any more, so no
imaging
 Therapy
o Decongestans (xylometazolin, hypertonic salt spray)
o Cotton pack with xylometazolin in middle meatus
 o Antibiotics (fever, severe)
o Heat therapy (not suggestable)
o Inhale chamomile
o FESS

Chronic sinusitis

 Recurrent or longer 12 weeks

 Etiopathogenesis
o Impaired ventilation of ostiomeatal unit (stenosis or obstruction)
o Frontal, maxillar, anterior ethmoidal cells affected
o Swelling of mucosa  vicious cycle
 Symptoms
o Headaches
o Pain, feeling of pressure
o Hyposmia (polyposis), anosmia (never reaches cribiform plate)
o Obstruction nasal breathing
o Postnasal drip
 Diagnosis
o CT
o Rhinoscopy, endoscopy
 Treatment
o Decongestans
o Nasal douche
o Steroids
o Antibiotics
o Conservative treatment does not eliminate cause  definite only surgical
o FESS

Nasal polyposis

 Edematous polypoid hyperplasia of sinus and nasal mucosa

 Usually ethmoid cells, maxillary sinus
 Complex condition
 Response to diverse noxious stimuli
 Etiology
o Genetic
o Chronic inflammation
o Aspirin intolerance
o Anatomic factors
o Cystic fibrosis (in children)
 Symptoms
 o Obstruction
o Headache, snoring, rhinophonia clausa, postnasal drip
o Laryngitis, bronchitis (sinobronchial syndrome)
o Hyposmia
 Diagnosis
o Same as chronic
 Treatment
o Same as chronic
o Removal of polyps
o Recurrence of polyposis (rarely definite cure) > 50% (when genetic
predisposition)
o Prophylaxis: topical steroids
o FESS: surgical treatment

Mucoceles and Pyoceles

 During chronic inflammation

 Mucocele: cystlike mucus containing sac in paranasal sinus, after trauma/ fracture/
surgery (pressure  frontal bone becomes thin and Mucocele protrudes)
o Surgical removal and reconstruct
o Pressure to anatomical structures
o CT or MRI (if invasion suspected intracranially)
 Pyocele: mucocele with purulent material due to infection

Complications of Sinusitis

 Orbital:
o Mostly children < 6 years
o From ethmoid cells/ frontal sinus
o 1. Orbital edema (erythema, swelling, normal ocular mobility)
o 2. Periosteitis (pain at the medial canthus, conservative)
o 3. Subperiostal abscess (drain! Emergency, separation of orbital periosteum
from lamina papyracea  limitation of ocular mobility and proptosis 
urgent drainage) 
o 4. Orbital cellulitis limited ocular mobility, pain, chemosis, visual
desorientation/ blindness  life threatening (if not drained)  immediate
surgical decompression
o Rare because of antibiotics and earlier symptoms
 Orbital apex syndrome
o Inflammation to cranial nerves II-VI, ophthalmic artery, vein
o Progressive thrombophlebitis  cavernous sinus thrombosis
 Osteitis and Osteomyelitis
o Mainly bc of frontal sinusitis
 o Tender, doughy, erythematous swelling over forehead
o CT scan
o Treatment: surgical resection of bone and antibiotics
 Intracranial:
o Epidural, subdural, intracerebral abscesses (CT, drainage)
o Meningitis (CSF sampling, CT, drainage of sinus, antibiotics)
 Sinus thrombosis and thrombophlebitis
o Can be fatal if diagnosed late
o Orbital edema
o Chemosis
o Optic fundus – venous congestion (ophthalmologist)
o MRI
o Surgical drainage, antibiotics

Differential diagnosis nasal obstruction

Basal cell carcinoma

 Most common form of skin cancer
 Slow growth
 Appearance: like open wounds, Wucherungen
 Sun damage
 Kürretage, excision, kryosurgery, laser, radiotherapy

Septal perforation
 Complication after surgery
 Septal buttong to close it
 No risk for recurrence
  Improves nasal breathing and whistling
 Custom-made and easily removed

Aspergillosis
 Feeling of pressure, pain, kakosmia, obstruction
 CT scan required
 Voriconazol

Physical examination
Ear

 External auditory canal:

o Erythema, stenosis, debris, discharge
 Tympanic membrane:
o Normal (shiny, transclucent, visible light reflex)
o Tympanosclerosis (white)
o Erythema, bulging, dull, retractions
o Perforations
o Handle of the Malleus, cartilagous annulus, Incus may be seen
 Pneumatic otoscopy:
o Determination of mobility of tympanic membrane
o In response to pressure
 Microscopy 3D image
 Tuning fork exam:
o Rinne´s Test:
 First against mastoid bone vs. 1 cm next to ear
 Normal: air conduction louder than bone conduction
o Weber´s Test:
 Does the sound lateralise?

Nose

 External exam:
o Deformities, symmetry, size/ patency of nares
  Nasal speculum (anterior rhinoscopy):
o Septum, inferior turbinates
o Septal deviation, boggy/ pale
turbinates (Nasenmuscheln),
mucosa, hypertrophy of inferior
turbinates, rhinorrhea, masses,
prominent vessels
 Turbinates:
o Enlarged: mistaken for polyp
o Erythematous: inflammation
o Pale blue: allergy
 Mucosa:
o Crust: infection
o Normal: moist and clear
o Purulent drainage: infection
 Middle meatus:
o Drainage of maxillary and most oft he ethmoid sinuses
 Rigid or flexible nasal endoscopy:
o Exam of sinus openings, mucosa, middle turbinates
o Rasining 30°: middle turbinate, middle meatus, inferior turbinate, here most
polyps
o Continue: eustachian tube laterally (Fossa of Rosenmuller) and superior
turbinate
o Flexible better for nasopharynx, pediatric: adenoids, older: nasopharyngeal
carcinoma when unilateral
 Polyps:
o Pale: allergic or infectious
o Red or firm: tumor
 X-Ray only for bone fracture

Oral cavity

 Tongue blades!
 Teeth, gums, alveolar ridge, mucosa
 Retromolar trigone
 Tongue surface (bulk/ atrophy, fasciculations, strength)
 Palpation

Salivary glands
  Salivary duct patency (Durchgänigkeit)
o Stenson´s duct (parotid gland opening on buccal mucosa)
o Wharton´s duct (submandibular and sublingual gland, floor of mouth)

Oropharynx

 Tongue blades!
 Palate, uvula
 Tonsils:
o 1+ fills <25% of oropharynx between tonsillar pillars
o 2+ 25-50%
o 3+ 50-75%
o 4+ >75%
 Posterior pharyngeal wall: erythema, drainage, purulence, exudates
 MALT
 Palatine tonsil hyperplasia during childhood  normal, only treatment when
disturbing

Neck

 External exam, lymphadenopathy, thyroid, range of motion, larynx, trachea

 Masses (exact location, depth, tenderness, texture, firmness, flucutance, mobility)

Fiberoptic Nasopharyngoscopy and Laryngoscopy

 Xylometazoline and local anesthetic (spray) before exam to decongest, vasoconstrict,
provide local anesthesia
 Nasal passage, nasopharynx, oropharyanx, hypopharynx, larynx
 Indications:
o Voice changes
o Neck masses
o Shortness of breath/ noisy breathing
o Concern for mass along the aerodigestive tract (nose to larynx)
Thema 2: Salivary Glands

Classification
 Parotid gland
o Duct: 6 cm over masseter, through buccinator to 2nd upper molar
o Facial nerve enters parotid divides into superficial and deep portion
 Submandibular gland
o Submandibular trigone (between mandible and digastric muscle)
o Duct: 5 cm anterior floor of mouth, with sublingual process of gland  anterior floor
of mouth  over lingual nerve  sublingual caruncle
o Facial a.  facial v., jugular v.
 Sublingual gland
o Duct: submucous part on mylohyoid muscle lateral to submandibular duct to
submandibular duct or as small ducts
o Or directly via minor salivary glands

Physiology
 500-1000 ml daily volume
 Glandular acini: primary saliva
o Serous (parotid)
o Mucous (palatine)
o Mixed (sublingual, submandibular)

Diagnosis and management of Salivary Gland Swelling

Benign tumor:

 Slow growth
 Painless
 No infiltration
 No additional symptoms
 Not fixed nodule

Malignant tumor:

 Rapid growth
 Painful
 Infiltration (facial nerve palsy)
 Lymph-node enlargement
 Fixed nodule
Clinical examination
 Submandibular gland: bimanual (inside and outside)
 Parotid gland: only outside, asymmetries?
 Function of facial nerve
 Imaging
o US sometimes not enough
o MRI or CT
o Sialendoscopy (Sialolithiasis)
o Biopsy

Sialolithiasis
 Stone formation in excretory duct system of salivary gland
 3rd, 4th decade, males
 70-80% submandibular, 20% parotid
 Organic salivary contents  calcification of plugs
 Symptoms:
o Swelling of affected gland
o Severe pain
o Infection
o During meals
 Diagnosis:
o History
 Smoking
 Poor oral hygiene
o Clinical examination
o Ultrasound
 Diff. Diagnosis:
o Infection
o Abscess
 Treatment:
o Conservative sometimes
o Sialoendoscopy
o Surgical removal of stone or gland

Sialadenosis
 Noninflammatory symmetrical swelling of major salivary glands
 Systemic: cause often unknown, no pain
 Secretory disorder, large acinar cells
 Mostly parotid
 Pathogenesis:
o Alcohol
o Vitamin/ protein deficiencies
o Diabetes
 o Anorexia nervosa
 Diagnosis:
o History
o Clinical examination
o Symmetrical painless swelling: CT, MRI, FNAB (Feinnadelbiopsie)
 Diff. Diagnosis:
o Chronic sialadenitis
o Masseter hyperplasia
o Obesity with fatty hypertrophy of the gland
 Treatment:
o Underlying cause

Injuries
 Facial nerve injuries: immediate treatment
 Penetrating or blunt trauma

Pneumoparotid
 Retrograde entry of air into Stensen (parotid) duct during:
o Forcible mask ventilation
o Blowing a musical instrument
o Inflating a balloon
 Symptoms:
o Transient pain
o Cutaneous emphysema rarely
 Treatment unnecessary

Sialadenitis (viral)
 Viruses:
o Mumps
o CMV
o Coxsackie
o Echo
o Parainfluenza
o Influenza
 Symptoms:
o Diffuse, painful acute swelling of parotid
o Swelling of cervical lymph nodes
o Non purulent
o Mild fever, 30% afebril
 Diagnosis:
 o Clinical presentation
o Serologic testing
 Diff. Diagnosis:
o Sialolithiasis
o Bacterial Sialadenitis
o Tumor
o Abscess
 Complications:
o Meningoencephalitis
o Orchitis
o Labyrinthitis
o Deafness
o Pancreas and ovaries maybe involved
 Treatment:
o Supportive
o Salivary stimulation
 Prophylaxis via vaccination

Sialadenitits (bacterial)
 Etiology
o Dehydration
o Sialolithiasis
o S. aureus, Streptococci, Haemophilus
 Symptoms:
o Diffuse, painful acute swelling of affected gland
o Purulent
o Trismus
o Redness over the skin above
 Diagnosis
o Clinical presentation
o Physical examination
o Ultrasound (exclude abscess, sialilithiasis, tumor)
 Diff. Diagnosis
o Sialolithiasis
o Tumor
o Abscess
 Complications
o Abscess
o Sepsis
 Treatment
o Supportive
o Salivary stimulation
o Antibiotic
o Hydration
 Abscess = drainage
Sialadenitis (chronic recurrent Parotitis)
 Pathogenesis
o Recurrent bacterial infections
o Usually childhood, unknown (congenital ductectasia?)
 Symptoms
o Diffuse, painful acute swelling of affected gland
o Purulent
o Trismus
o Redness over the skin above
 Diagnosis
o Clinical presentation
o Physical examination
o Ultrasound (exclude abscess, sialilithiasis, tumor)
 Diff diagnosis
o Sialolithiasis
o Tumor
o Abscess
o Immune sialadenitis
 Complications:
o Abscess
o Sepsis
 Treatment:
o Supportive
o Salivary stimulation
o Antibiotic
o Hydration
 Abscess = drainage

Sialadenitis (chronic sclerosing)

 Most common form of chronic inflammatory
 Sialolithiasis  permanent tumor like swelling
 Pathogenesis:
o Altered composition of saliva
 Symptoms
o Firm swelling of submandibular gland
o Acute enlargement during eating at beginning
o Firm constant painless swelling of gland
o Can not be distinguished from tumor
 Diagnosis
o Clinical presentation
o Physical examination
o Ultrasound
 o Maybe MRI (abscess, tumor, sialolithiasis)
 Diff. Diagnosis:
o Tumor
o Immune sialadenitis
 Treatment
o Submandibulectomy

Sjögren Syndrome
 Autoimmune form of chronic sialadenitis
 Gradual decline saliva production  sicca-syndrome
 Myoepithelial sialadenitis with keratoconjunctivitis
 Mostly females
 Pathogenesis
o Myoepithelial sialadenitis
o AB against salicary duct epithelium
 Symptoms
o Both parotid glands swollen
o Little pain
o Atrophy of glands
o Xerostomia
o Keratoconjunctivitis sicca
 Primary or secondary
 Exclusion criteria
o past head and neck radiation treatment
o Hepatitis C infection
o AIDS
o Pre-existing lymphoma
o Sarcoidosis
o GvHD
o Anticholinergic drug use
 Complications
o Recurrent parotitis
o Mucositis
o Dental caries
o Decreased lacrimation: keratoconjunctivitis, NHL incidence +
 Treatment
o Immunosuppressant therapy only in rheumatic setting
o Supportive
o Pilocarpine
Radiation sialadenitis
 Pathogenesis
o External irradiation
o Radioiodine therapy over 15 Gy
o Irreversible injury to salivary glands
 Symptoms
o Xerostomia
o Tongue burning
o Hypogeusia/ ageusia
o Sicca syndrome
 Treatment
o Symptomatic  stimulating production of saliva
o Saliva substitution
o Frequent hydration
 Prophylaxis
o Amiofistine during combined treatment with cisplatin and external irradiation helps
protect

Benign tumors
 70%
 Pleomorphic adenoma: 30%  carcinoma
 Cystadenolymphoma (Whartin´s tumor): 90% males
 Diagnosis:
o Ultrasound
o FNA possible (risk of recurrence)
 Treatment:
o Surgical removal
o Laterofacial/ total parotidectomy/ enucleation of tumor
 Others:
o Lipoma
o Hemangioma
o Lymphangioma
o Adenoma of salivary duct

Malignant tumors
 (Mucoepidermoid
 Acinar cell, adenoid cell, adenoid cystic, adenocarcinoma
 Carcinoma in pleomorphic adenoma
 Squamous cell carcinoma
  Undifferentiated)
 Diagnosis
o Clinical presentation
o Imaging
o Biopsy
 Treatment:
o Surgical removal
o Chemo
o Radiotherapy

Superficial parotidectomy

 Tumor: mostly benign (pleomorphic adenoma)

 EMG (nerve feedback)
 Complications
o Peripheral facial nerve paralysis
o Fistula
o Scar
o Hypesthesia oft he auricule (great auricular nerve)
o Frey Syndrome
o Recurrence of tumor
o Second operation

Submandibulectomy

 Complications
o Fistula
o Scar
o Remains of sialolith in the duct
o Infection, abscess
o Hypoglossal nerve paralysis
o Paralysis of the oral branch of the facial nerve
o Trauma to lingual nerve and fibers of chorda tympani  hypesthesia, loss of taste
anterior 2/3 ipsilaterally
Thema 3: Oraly cavity and Pharynx

Lymphdrainage Tongue
 Bilateral submental
 Sublingual
 Upper jugual lymph nodes
o Metastasis! Possibly bilateral

Ultrasound
 Not most reliable

HSV I + II
 Primary infection in childhood: Gingivostomatitis
 Reactivation physical stress, UV, febrile infections, pregnancy
 Mostly herpes labialis
 History, clinical examination
 Complications
o Bacterial superinfection (aureus, streptococci)
 Treatment
o Topical antiseptics, topical aciclovir
o Ab when superinfection

Herpes zoster
 Primary infection (chickenpox)
 Reactivation, reinfection
 Segmental, cutaneous and mucosa lesions
 History, clinical examination
 Complications
o Menigngitis
o Enzephalitis
o Superinfections
o Postherpetic neuralgia
 Treatment
o Topical antiseptics
o Topical ointment
o Systemic: Aciclovir
o Carbamazepin (pain)
Recurrent aphthous stomatitis
 Etiology unclear
 Emotional stress, minor trauma, Fe, Folic acid, B12 deficiency
 Symptomatic treatment
 Diff. Diagnosis
o Adamantiades Behcet´s disease
o Herpes simplex
o Hand-food-mouth disease
 Candiadiasis
 Weakend host resistens, oral steroids
 Whitish, firmly adherent plaques
 Can be scarpes from mucosa (DD: Leukoplakia)
 Treatment
o Topical antifungal agents (Nystatin, Amphotericin B)

Tumors
 Benign
o Papillomas: extremly common (of Uvula, Tonsils), easily removed
o Pleomorphic adenomas: salivary glands
o Fibromas
o Lipomas
o Rhabdomyomas
o Leiomyomas
o Lymphangiomas
 Rare
 Precancerous lesions
o Leukoplakia
 Most common
 Asymptomatic
 biopsy
o Bowen´s disease
 Intraepidermal carcinoma
 Removal
 Radiotherapy
 Rare

 Malignant
o Squamous cell carcinoma (90%)
o Pipe smokers, UV, alcohol
o Ulverations, exophytic lesions
 o Biopsy, staging
o Diff. Diagnosis
 Keratocanthoma
 Basal cell carcinoma
 Primary syphillis oft he lips
o Treatment
 Surgical removal
 Neck dissection
 Radiotherapy, chemo
o Symptoms depend on location and extent

Pharynx – Anatomy
 Kilian triangle: weak point, Constrictor pharyngis inferior, Esophageal musculature, in
between: weak triangle,
 Swallowing: triangle  diverticle
 Laimer´s triangle
 Zenker diverticle
 Parapharyngeal space
o Abscess development
o Life threatening
o Edema of upper respiratory tract  dyspnea
o In contact with neck fascia  infection can spread  mediastinum
o Def.: petrous bone and lesser horn of hyoid bone

Adenoids
 Hyperplasia of pharyngeal tonsil
 Open mouth breating, nose congested
 Recurring infections of respiratory tract and middle ear
 Delay of speech development, dental malalignment, maxilary deformity
 Clinical diagnosis
 Treatment
o >3 years: nasal steroid spray, 3 months, then surgery
o Younger: surgery with tonsillotomy (if indication)

Tumors
 Benign
o Juvenile angiofibroma
o Exclusively young boys
o Symptoms
  Obstructed nasal breathing
 Epistaxis
 Headache
 Impaired eustachian tube ventilation
 Conductive hearing loss

o Treatment
 Removal, endoscopic
o Diagnosis
 No biopsy, bleeding can be dangerous
 MRI and MRA enough
 Malignant
o Usually squamous cell carcinoma
o Lymphoepithelial carcinomas (EBV)
o Symptoms
 Unilateral middle ear effusion
 Conductive hearing loss
 Obstruction of nasal breathing
 Kakosmia
 Cervical lymph node metastasis
 Headaches
 Cranial nerve palsies
o Not surgical, cannot remove tumor with clear margin to other structures
o Only chemo and radiotherapy
o Endoscopy, biopsy, imaging

Acute Tonsillitis
 Etiology
o Streptococci
o Rarely staphylococci
o Pneumococci
o H. influenzae
 Symptoms
o High fever
o Severe pain on swallowing
o Swollen tonsillar lymph nodes
o Muffling of speech
 Treatment
o AB for 10 days
o Penicillin V
o Cephalosporine
 Diagnosis
o Strep-A-test
o serology
 Complications
o Lingual tonsillitis
 o Streptococcal gingivostomatitis
o Acute GN
o Acute rheumatic fever
o Rheumatic endocarditis
o Chorea minor
o Peritonsillar abscess, pharyngeal abscess
o Tonsillogenic sepsis

Scarlet fever
 Exotoxin A β-hemolytic streptococci
 Rash on trunk
 Triangle
 Raspberry-like pperance
 Diagnosis
o Clinical picture
o Strep-a-test
o Bacterial culture
 Treatment
o Penicillin V

Mononucleosis
 EBV infection
 Symptoms
o Tonsillitis: cardinal, lot larger
o Lymphadenitis
o Anorexia
o Fever
o Pain on swallowing
o Limp pains
 History, clinical examination, hepatosplenomegalie, leukocytosis, positive EBV-serology
 Always US of abdomen: Hepatosplenomegalie, males should stop sports bc of spleen
 Treatment
o Symptomatic
o No penicillin and Cephalosporine (pseudoallergic rash)
o Tonsillectomy
o Maybe AB to prevent superinfection

Chronic pharyngitis
 Etiology
o Longterm exposure to noxious agents
o Chronic mouth breathing
o Chronic sinusitis
o Laryngopharyngeal reflux
 Symptoms
 o Dry-throat sensation
o Frequent throat clearing
o Dry cough
o Foreign body sensation

 Diagnosis
o History
o Mirror examination
o Endoscopy
o Nasal examination (exclude nasal airwy obstruction)
 Treatment
o Avoid causative agents
o Herbal extract (sage, chamomille)
o Correct nasal obstruction
o Treat reflux

Chronic tonsillitis
 Recurrent inflammations  scarring
 Bacteria grow on debris in poorly drained crypts
 Can be asymptomatic
 >5 episodes / year with AB  removal
 <5 episodes / year with AB  subtotal tonsillotomy (lateral part left, less pain, less bleeding)
 Complications
o Bleeding  aspiration
o Post-operative bleeding  obstruction upper airway
o Stopped with local anesthesia but when uncoorperative  intubation!

Tumors
 Malignant
o squamous cell carcinoma
 smoking, C2, HPV
 depends on location, trismus (infiltration of masseter), foetor ex ore,
dysphagia
 biopsy, staging
 surgical, adjuvant chemo, radiotherapy or primary chemoradiotherapy
(when functional loss, big area, but risk of recurrence then)

Diverticula
 Zenker´s diverticula
o Most older patients
 o Pathogenesis
 Herniation of esophageal mucosa
o Symptoms
 Dysphagia
 Foetor ex ore
 Regurgitation  weight loss
 Inflammation when food gets stuck

o Diagnosis
 Oral contrast study of esophagus
 Esophagoscopy
o Treatment
 Endoscopic laser surgery

Tumors
 Squamous cell carcinoma
 But of hypopharynx no early symptoms
 Mostly metastasis: extended surgerys and large flaps, primary chemo and radiotherapy

Thema 3: Facial Nerve

Anatomy

 Temporal bone  middle ear  parotid gland

 Components of frontal branch of facial nerve from left and right corticonuclear tract
o A central facial nerve lesion causing facial nerve paralysis (still movement of frontal
branch of facial nerve because lesion unilateral but from both sides innervated)
o If peripheral: no components of facial nerve will function (motoric)
 Segments:
o Intrameatal, together with vestibocochlear nerve, narrowest point: fallopian canal
(facial canal)
o Labyrinthine: fibers to lacrimal glands and nasal mucosa glands
o Tympanic
o Mastoid (chorda tympani)
o Extracranial

Function

 Motoric: muscles of face

 Secretory: lacrimal glands, nasal mucosa glands; chorda tympani (submandibular, sublingual)
 Sensory: anterior 2/3 of tongue taste
Clinical examination

 Ask for borreliosis and other infections

 Systemic diseases: autoimmune, sarcoidosis, dm, cancer

Symptoms

 Paralysis or weakness of facial muscles

 Hyperakusis (paralysis of stapedis muscle)
 Otalgia (irritation of sensory fibers)
 Gustatory disturbances
 Lacrimal disturbances (dryness, crocodile tears- gustatory lacrimation due to faulty neural
regulation)
 Other cranial nerve deficits: exclude idiopathic paralysis of facial nerve
 Any changes in parotid gland should be noted!
 Motoric function:
o Frontal branch:
 Wrinkle forehead, look upwards
 If movement normal: central, supranuclear lesion
 If complete paresis: peripheral
o Ophthalmic branch: rapid blinking (slowed, weakend, none) or incomplete lid closure
o Oral branch: smiling, inflating cheeks: air will escape even when mild
 Synkinesis:
o Involuntary associated movement of mimetic muscles accompanying voluntary
movements of other muscles
o Additional tests:
 1. Laboratory: infectious diseases
 2. Audiometry

Diagnostic

 MRI of brain (gadolinium contrast)

 CT of temporal bone (for trauma or infection suspected)

Differential diagnosis
Cholesteatoma, can be treated surgically

Flow chart diagnosis

 Traumatic
o Extracranial injury: surgical exploration when penetrating,
otherwise observation
o Temporal bone fracture with paralysis: surgical exploration
 Nontraumatic: look for symptomatic or idiopathic, corticosteroids
 Central: neurologist

Idiopathic facial nerve paralysis

 Bell´s palsy
 Unilateral peripheral, acute onset
 No other cranical nerves
 20/ 100.000
 Theories:
o Infection
 o Inflammation
o Ischemia
o Diabetic, pregnant
 Symptoms:
o Retroauricular pain
o Peripheral facial nerve paralysis (including frontal branch)
o Partial or complete (70%9
o Dysgeusia
o Hyperacusis
o Lacrimation –
 Diagnosis:
o Exclusion
 Diff diagnosis:
o Otogenic and infectious causes
 Prognosis
o Partial: usually few weeks
o Complete: recovery in months, only 60-70% complete, 15%
residual paralysis and synkinesis
 Complications
o Corneal damage (lagophthalmos, ectropion, lacrimation)
 Treatment
o Systemic steroids
o Moisturizing
o Tarsorrhaphy
o Gold or titanium weight  upper lid

Inflammatory otogenic facial paralysis

 spread of infectious/ inflammatory process in temporal bone and middle
ear
o chronic otitis media
o necrotizing otitis externa
 damage cause of toxic agents, edema, pressure
 Symptoms
o Mostly otologic
 Diagnosis
o Ostoscopy and diagnosis of infectious or inflammatory process
  Complications, Treatment and Prognosis depend on cause

Facial nerve paralysis secondary to infection (viruses)

1. Herpes zoster
2. Borreliosis
3. HIV
4. Syphilis
5. Mumps
6. Poliomyelitis
7. Guillain Barré syndrome

Traumatic facial paralysis

 Pathogenesis
o Temporal bone fracture
o Surgical trauma (parotid)
o Obstetric trauma
 Symptoms
o Related to trauma
 Diagnosis
o Clinical manifestation
o CT, MRI
 Prognosis
o Extend of injury, location
 Complication
o Same as Bell´s palsy + complications of trauma
 Treatment
o Every immediate paresis should be surgically explored
o Delayed with steroids

Normal function of frontal branch: central

All branches affected: peripheral
Frontal branch is bilateral innervated
Frontal branch controls forehead muscles
Tonsillotomy
 Other indication for children:
o Massive hypertrophy of tonsils or adenoids
o Obstruct upper airway
o Develop sleep apnea, CPAP not for children