SURGER

Y
Uthuman

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EAR, NOSE AND THROAT DISORDERS
Definition of Terms as used in Ear Anatomy
 Acoustic
This is pertaining to sound or the sense of hearing
 Cerumen
This is a yellow or brown, wax like secretion found in the
external auditory canal
 Cochlea

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This is the winding, snail-shaped bony tube that forms a portion
of the inner ear and contains the organ of Corti which is the
transducer for hearing
 Cochlear (acoustic) nerve
This is the division of the eighth cranial (vestibulocochlear)
nerve which goes to the cochlea
 Eustachian tube
This is a 3cm to 4cm tube that extends from the middle ear to
the nasopharynx
 External auditory canal
This is the canal leading from the external auditory meatus to
the tympanic membrane and its about 2.5 cm in length
 External ear
This is the portion of the ear that consists of the auricle and
external auditory canal
It is separated from the middle ear by the tympanic membrane
 Incus
This is the second ear bone of the three ossicles in the middle
ear
It articulates with the malleus, stapes and the anvil

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 Inner ear
This is the portion of the ear that consists of the cochlea,
vestibule, and semicircular canals
 Internal auditory canal
This is a canal in the petrous portion of the temporal bone which
houses the facial and vestibulocochlear nerves (cranial nerves
VII and VIII)
 Malleus
This is the first bone (most lateral) and largest of the three
ossicles in the middle ear
It is connected to the tympanic membrane laterally and
articulates with the incus and the hammer
 Middle ear
This is the small, air-filled cavity in the temporal bone that
contains the three ossicles
 Organ of Corti
This is the end organ of hearing located in the cochlea
 Ossicles
These are the three small bones within the middle ear ie malleus,
incus, and stapes

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 Oval window
This is a fenestra (aperture) between the vestibule of the inner
ear and the middle ear which is occupied by the base of the
stapes
 Pinna
This is the outer part of the external ear which collects and
directs sound waves into the external auditory canal and the
auricle
 Round window
This is a fenestra(aperture) between the middle ear and the inner
ear at the base of the cochlea which is occupied by the round
window membrane
 Semicircular canals
This is the superior, posterior, and lateral bony tubes that form
part of the inner ear which contain the receptor organs for
balance
 Stapes
This is the third (most medial) ossicle of the middle ear which
articulates with the incus, the stirrup and its footplate fits into
the oval window

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 Temporal bone
This is a bone on both sides of the skull at its base composed of
the squamous, mastoid, and petrous portions
 Tympanic membrane
This is the membrane that separates the middle ear from the
external auditory canal and is also referred to as the eardrum
 Vestibulocochlear nerve
This is a cranial nerve VIII containing the cochlear (acoustic)
nerve and vestibular nerve

DIAGNOSTIC EAR INVESTIGATIONS

 Audiometry
 This is a test used in detecting hearing loss and involves pure-
tone audiometry, where the sound stimulus consists of a
pure or musical tone and speech audiometry, where the
spoken word is used to determine the ability to hear and
discriminate sounds and words

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 When evaluating hearing, three characteristics are very
important ie frequency, pitch, and intensity.
 Frequency is the number of sound waves emanating/
orignating from a source per second and is measured as
cycles per second, or Hertz (Hz). Its ranges from 20 to 20,000
Hz
 Pitch is the term used to describe frequency ie a tone with
100 Hz is considered of low pitch and a tone of 10,000 Hz is
considered of high pitch.
 The unit for measuring loudness (ie, intensity of sound) is the
decibel (dB) which is the pressure exerted by sound.
 Hearing loss is measured in decibels, a logarithmic function
of intensity that is not easily converted into a percentage.
 Tympanogram or impedance audiometry
 This measures middle ear muscle reflex to sound stimulation
and compliance of the tympanic membrane by changing the
air pressure in a sealed ear canal. Compliance is impaired
with middle ear disease
 Electronystagmography

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 This is the measurement and graphic recording of the
changes in electrical potentials created by eye movements
during spontaneous, positional, or calorically evoked
nystagmus
 It is also used to assess the oculomotor and vestibular
systems and their corresponding interaction.
 It helps in diagnosing conditions such as Ménière’s disease
and tumors of the internal auditory canal or posterior fossa
 Platform posturography
 This is used to investigate postural control capabilities.
 Sinusoidal harmonic acceleration or a rotary chair
 This is used to assess the vestibulo-ocular system by
analyzing compensatory eye movements in response to the
clockwise and counterclockwise rotation of the chair
 Middle ear endoscopy
 This is performed to evaluate suspected perilymphatic fistula
and new-onset conductive hearing loss, the anatomy of the
round window before transtympanic treatment of Ménière’s

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 disease, and the tympanic cavity before ear surgery to treat
chronic middle ear and mastoid infections
HEARING IMPAIRMENT (HEARING LOSS)
 Hearing impairment and dizziness are major symptoms of
inner ear problem that can hinder communication with
others, limit social activities, and negatively impact
employment.
 Hearing loss diminishes the individual aesthetic enjoyment of
major aspects of daily living and can adversely affect quality
of life
Etiology
Hearing loss is a symptom rather than a specific disease or
disorder and can be as a result of mechanical, sensory or neural
problems due to;
 Trauma to the ear and head
 Infections or diseases of the ear
 Tumours to the ear and CNS
 Advancing age (52 years)
 Presence of wax in the ear
 Foreign bodies in the ear
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  Ear retraction
 Scarring or perforation of the tymphanic membrane
 Occupation eg carpentry, plumbing and coal mining
 CVA
Risk Factors for Hearing Loss
 Family history of sensorineural impairment
 Congenital malformations of the cranial structure (ear)
 Low birth weight (<1500 g)
 Use of ototoxic medications (eg, gentamicin, loop diuretics)
 Recurrent ear infections eg otitis media
 Bacterial meningitis
 Chronic exposure to loud noises
 Perforation of the tympanic membrane
Types of healing loss
Conducting Hearing Loss: Loss of the hearing from mechanical
problem
• Sensorineural Hearing Loss: Loss of hearing involving the
cochlea and auditory nerve; bone and air conduction equal but
diminished.

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• Neural Hearing Loss: A sensorineural hearing loss
originating in the nerve or brainstem.
• Fluctuating Hearing Loss: A sensorineural hearing loss that
varies with time.
• Sensory Hearing Loss: A sensory neural hearing loss
originating in the cochlea involving the hair cells and nerve
endings.
• Sudden Hearing Loss: A sensorineural hearing loss with a
sudden onset.
• Central Hearing Loss: Loss of hearing from damage to the
brain auditory pathways or auditory
center.
• Functional Hearing Loss: Loss of hearing for which no
organic lesion can be found.
• Mixed Hearing Loss: Elements of both conduction and
sensorineural hearing loss.
Pathophysiology
 Conductive Hearing Loss results from any interference with
the conduction of sound impulses through the external
auditory canal, the eardrum, or the middle ear.

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 Conductive hearing loss may be caused by anything that
blocks the external ear, such as wax, infection or a foreign
body, a chickening, retraction, scarring or perforation of the
tymphanic membrane; or any pathophysiological changes in
the middle ear affecting or fixing one or more of the ossicles.
 Sensorineural Hearing Loss results from disease or trauma to
the inner ear, neural structure, or nerve pathways leading to
the brainstem.
 Some of the causes of “nerve” deafness are infectious
diseases, (measles, mumps and meningitis), arteriosclerosis,
ototoxic drugs, neur of cranial nerve VIII, otospongiosis (form
of progressive deafness) caused by the formation of new
abnormal sponge bone in labyrinth, trauma to the head or
ear, or degeneration of the organ of corti occuring most
commonly from an advancing age (Presbycusis).
 Central deafness is also known as central auditory
dysfunction, results from the inability of the CNS to interpret
normal auditory stimuli and may be due to tumour or CVA.
Clinical Manifestations

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Early manifestations of hearing impairment and loss may
include
 Tinnitus
 Increasing inability to hear in groups and a need to turn up
the volume of the television
 Withdrawal , suspicion, loss of self-esteem and insecurity
following advanced hearing loss
 Hearing impairment can also trigger changes in attitude, the
ability to communicate, the awareness of surroundings, and
even the ability to protect oneself, affecting the person’s
quality of life.
 In a classroom, a student with impaired hearing may be
disinterested and inattentive and have failing grades.
 Isolation while at home and may miss part of the
conversations

EAR, NOSE AND THROAT DISORDERS

These are disorders or conditions which affects the ear, nose and
throat
DISORDERS OF THE EAR
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Conditions of the External Ear
These include the following
FOREIGN BODIES IN THE EAR
These are foreign objects which may be impacted into the ear
FBs are most common in children and mentally retarded persons
Causes
The cause is accidental ie
 Children may usually insert the FB themselves, or their
peers may do it
 Adults usually insects may penetrate into adjacent parts
and lodge in the middle ear
Predisposing factors
 Children often place items in their ears
 Mentally ill patients
 Adults leaving cotton tissue while cleaning their ears
Types of FBs
The most common foreign bodies (FB) include:
 Inanimate foreign bodies eg non vegetable foreign bodies
such as pieces of papers, beads, buttons, stones and

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 vegetable foreign bodies such as beans, maize and peas
which swell with water
 Animate foreign bodies eg insects such as flies, cockroaches,
ants, fleas etc
Clinical features
 Blockage of the ear and the FB may be seen
 Noise in the ear if the FB is a live for example insects
 Discomfort and irritation within the ear
 Hearing loss when the FB occludes the external canal
 Pain in the ear if the FB stays for so long in the ear
 Bleeding or discharge from the ear following attempts to
remove the FB
Management
 Syringe the ear with clean lukewarm water to remove the FB
if its smooth and round
 If FB cannot be removed by syringing, remove the FB with a
foreign body hook under general anaesthesia for children
and sensitive adults
• Do NOT use forceps to try to grasp round objects, as this
will only push the FB further in the ear
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 If there is an edge to grab the FB, remove it with Hartmann
(crocodile) forceps
 If the FB is an insect, kill it by inserting clean cooking oil or
water into the ear and then syringe it out with lukewarm
water
 If the FB is a cockroach remove it using a crocodile forceps
since they have hooks on their legs that makes removal by
syringing impossible
 If the FB is an impacted seed do not syringe the ear with
water as the seed may swell and block the ear but refer
immediately to ENT specialist if you cannot remove it with a
hook
 Suction of the ear may also be useful for certain FBs

Complications of FBs
 Hearing loss due to damage of the ear drum
 Otitis media or Otitis external
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  Injury to the ear canal, ear drum and or ossicles
IMPACTED CERUMEN
This is the accumulation of wax in the external ear
Wax in the ear is normal and usually comes out naturally from
time to time.
It may accumulate to form a wax plug and cause a problem for
the patient.
Causes
 Excessive and thick wax production
 Small, tortuous and hairy ear canal
 Use of ear pads
Clinical features
 Blockage of the ears
 Buzzing sound in the ears
 Sometimes there is mild ear pain
 Hearing loss due to blockage of the canal
 Tinnitus
 Vertigo
 Cough
Management

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General treatment measures
 Soften the wax by inserting drops of Vegetable oil or
Glycerine or Sodium bicarbonate into the ear 3 times a day
for a few days to allow the wax fall out of the ear on its own
 Syringe the ear carefully with clean Luke warm water after
insertion of cooking oil or sodium bicarbonate to soften the
wax
Cautions
 Advise the patient not to poke anything into the ear in an
attempt to clean it as this may damage the eardrums eg
sticks
 Do not syringe the ear if (a) there is history of ear discharge
and (b) if there is pain

OTITIS EXTERNA
 This is the infection of the external ear canal which may
either be localized (furunculosis) or generalised (diffuse).
Causes
These include;

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 Bacterial infections eg staphylococci aureus and
pseudomonas spps
 Fungal infections eg Aspergillus
 Viral infections
Predisposing factors
These include;
 Water in the ear canal (swimmer’s ear)
 Trauma to the skin of the ear canal permitting entrance of
organisms into the tissues
 Systemic conditions such as vitamin deficiency and endocrine
disorders eg diabetes mellitus
 Dermatosis such as psoriasis, eczema, or seborrheic
dermatitis.
 Allergic reactions to hair spray, hair dye
Clinical features
 Ear pain (otalgia)
 Swelling and tenderness on pulling the pinna (external ear)
 Itching of the ear (especially for fungal infections)
 Discharge from the external auditory canal which may be
yellow or green and foul smelling
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 Aural tenderness (usually not present in middle ear
infections)
 Pruritus
 Hearing loss or a feeling of fullness
 Fever
 Cellulitis
 On otoscopic examination, the ear canal is erythematous and
edematous
 In fungal infections, the hairlike black spores may even be
visible.
Investigations / diagnosis
 Good history and physical examination of the external ear
 Pus swab for microscopy to identify the status of the
discharge eg if the discharge is white or black it is fungal and
if yellow it is bacterial
 Pus swab for culture and sensitivity to indentify the causative
organisms
Management

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The principles of therapy are aimed at relieving the discomfort,
reducing the swelling of the ear canal, and eradicating the
infection.
The treatment options include;
 Thorough cleaning of the external ear canal
 Apply antibiotic ear drops, e.g. Chloramphenicol ear drops
0.5% 2 drops into the ear three times daily for 14 days
 Apply topical antibiotics on the area or the ear affected eg
Neomycin or chloramphenical cream
 Give analgesics to relieve ear pain e.g. NSAIDs such as
paracetamol 1g tds for 3 days
 If severe administer intravenous antibiotics eg cloxacillin 500
mg 6 hourly for 5 or 7 days and children 12.5 or 25 mg/kg per
dose.
If fungal ear infection is suspected;
 Syringe the ear to remove any crusting
 Apply Clotrimazole solution into the ear once a week for 4-8
weeks or
 Give capsules fluconazole 200 mg once daily for 10 days

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MALIGNANT EXTERNAL OTITIS
 This is a more serious external ear infection and is sometimes
called temporal bone osteomyelitis although its rare.
 Its a progressive, debilitating and fatal infection of the
external auditory canal, the surrounding tissue and the base
of the skull
 Its caused by Pseudomonas aeruginosa and mainly occurs in
patients with low resistance to infection eg patients with
diabetes
Clinical features
 Severe stabbing otalgia
 Purulent ear discharge
 Granulation tissue in the floor of the external canal, at the
junction of cartilaginous part with bony part.
Investigations

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  Pus swab for culture and sensitivity to identify the
causative organism
 CT scans of the temporal bone to detect and reveals skull
base destruction.
 Biopsy for histopathology to exclude malignancy
Management
 Successful treatment includes control of the diabetes,
administration of antibiotics (usually intravenously), and
aggressive local wound care by debridement, apply antibiotic
ear drops.
Complications
 Osteomyelitis of the skull base and temporal bones
 Cranial nerve palsy

OTITIS MEDIA
This is an acute or chronic infection of the middle ear
It occurs mostly in children
Acute otitis media
This is an acute infection of the middle ear, usually lasting less
than 6 weeks.

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Causes
 Bacterial infection e.g. Streptococcus pneumoniae,
Haemophilus influenza etc
 The bacteria enter the middle ear after eustachian tube
dysfunction caused by obstruction related to upper
respiratory infections, inflammation of surrounding
structures (eg, sinusitis, adenoid hypertrophy), or allergic
reactions(eg, allergic rhinitis).
 Bacteria can also enter the eustachian tube from
contaminated secretions in the nasopharynx and the
middle ear from a tympanic membrane perforation.
Risk factors of acute otitis media
These include
 Young age
 Congenital abnormalities
 Immune deficiencies
 Passive smoke inhalation
 Eustachian tube damage from viral infections
 Family history of otitis media
 Recent upper respiratory infections
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 Gender mainly male
 Participation in day care
 Bottle feeding
 Allergic rhinitis.
Clinical features
Symptoms vary with the severity of the infection;
 Usually its unilateral in adults
 Pain in and about the ear (otalgia), which may be intense
and relieved only after spontaneous perforation of the
eardrum or after myringotomy.
 Fever
 Drainage from the ear (otorrhea)
 Hearing loss
 Tympanic membrane is erythematous and often bulging.
 Conductive hearing loss due to exudate in the middle ear.
 On otoscopic examination, the external auditory canal
appears normal and the patient reports no pain with
movement of the auricle
Differential diagnosis
 Foreign body in the ear
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  Otitis externa and media with effusion
 Referred ear pain, e.g. from toothache
Investigations
 Good history and physical examination of the ear
 Pus swab for culture and sensitivity to detect and reveal
the causative micro organism

Management
The outcome of acute otitis media depends on the efficacy of
therapy (ie, the prescribed dose of an oral antibiotic and the
duration of therapy), the virulence of the bacteria, and the
physical status of the patient.
The treatment options include;
 Medical treatment in case of acute infection
 Give capsules Amoxicillin 500 mg every 8 hours for 5 days
 Or erythromycin 500 mg every 6 hours in penicillin allergy
 Give analgesics, e.g. Paracetamol to relieve pain
 Apply antibiotic ear drops, 2 drops every 6 to 8 hours daily

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 Surgery mainly Myringotomy or Tympanotomy.
(Where an incision is made into the tympanic membrane to
relieve pressure and to drain serous or purulent fluid from the
middle ear)
Complications
 Perforation of the tympanic membrane
 Chronic otitis media.
 Mastoiditis
 Meningitis
 Brain abscess
CHRONIC OTITIS MEDIA
This is as result of repeated episodes of acute otitis media
causing irreversible tissue pathology / infection and persistent
perforation of the tympanic membrane.
Chronic infections of the middle ear damage the tympanic
membrane, destroy the ossicles, and involve the mastoid.
Clinical features
 Pus discharge from the ear (persistent or intermittent foul-
smelling otorrhea)
 Healing loss
 Pain in the ear in case it has involved the mastoid bone
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 Tenderness, swelling and edema of the post auricular area
 Perforation of the tympanic membrane
 Cholesteatoma (an in growth of the skin of the external layer
of the eardrum into the middle ear).
Management
 Medical treatment
 Surgery
 Medical Treatment
 Systemic antibiotics are NOT recommended because they
are not useful and can create resistance
 Aural irrigation using hydrogen peroxide mixed with clean
lukewarm water 2-3 times daily
 Drying of the ear by wicking 3 times daily until the ear is
dry
 Instillation of the ear antibiotics eg ciprofloxacin ear drops
0.5% or Caf ear drop 2 - 4 drops into the ear each time
after drying or
 Application of antibiotic powder in cases of otorrhea
 Surgery
Surgical procedures include;
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 Tympanoplasty, to prevent recurrent infection, re -
establishe middle ear function, close the perforation, and
improve hearing.
 Ossiculoplasty, to reconstruct the middle ear bones to
restore hearing.
 Mastoidectomy, to remove cholesteatoma, gain access to
diseased structures, and create a dry (noninfected) and
healthy ear
Note
Refer if complications occur, e.g., meningitis, mastoid abscess
(behind the ear), infection in adjacent areas, e.g. tonsils, nose
Complications of otitis media
Cranial complications (bony skull):
 Mastoiditis
 Otitic labyrinthitis
 Otitic facial paralysis
Intra-cranial complications (inside the intra cranial cavity):
 Extra-dural abscess
 Sub-dural empyema
 Lateral sinus thrombosis or thrombo-phlebitis
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  Meningitis
 Brain abscess (Temporal lobe or Cerebellum)
 Otitic hydrocephalus
Extra-cranial complications (in the soft tissues of the head and
neck):
 Otitis externa
 Retropharyngeal abscess

Prevention
 Health education of the public about Otitis media e.g. by
advising patients on recognizing the discharge of otitis media
(believed by some to be “milk in the ear”)
 Early diagnosis and treatment of acute otitis media and
upper respiratory tract infections

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 Treatment of infections in adjacent area, e.g. tonsillitis

Difference between acute otitis externa and otitis media

Acute otitis externa Acute otitis media
 Otorrhea may or may not  Otorrhea is present
be present and is profuse
 Otalgia is persistent and  Otalgia relieved if
may awaken patient at tympanic membrane
night ruptures
 Aural tenderness is  Aural tenderness is
present on palpation of usually absent
auricle  Systemic symptoms
 Systemic symptoms are are present eg fever,
absent upper respiratory
 Edema of external infection, rhinitis
auditory canal is present  Edema of external
 Tympanic membrane may auditory canal is
appear normal absent
 Hearing loss is a  Tympanic membrane
conductive type may appear
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 erythematous, bulged
and perforated
 Hearing loss is also a
Conductive type

MASTOIDITIS
This is the inflammation of the mastoid bone (bone behind the
ear) resulting from an infection of the middle ear (otitis media)
Chronic otitis media may cause chronic Mastoiditis and may
lead to the formation of cholesteatoma (ingrowth of the skin of
the external layer of the eardrum into the middle ear) and if
untreated, osteomyelitis may occur
Causes
Usually is a complication of otitis media
Clinical features
 Severe pain felt over the mastoid bone
 Tenderness behind the ear (postauricullar tenderness)
 Ear pain (otalgia)
 The mastoid area may be erythematous and edematous

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 Swelling in post auricular area (pinna is pushed down and
forward)
 Discharge from the middle ear (otorrhea)
 Fever
 Mental confusion is a grave sign of intracranial spread of
infection (Refer to ENT surgeon immediately)
 Headache

Investigations / diagnosis
 Diagnosis of mastoiditis is mainly by clinical features
 Mastoid x-ray to detect and reveal the extent and severity of
the condition on the mastoid bone and r/o cranial
complications
 Cranial CT scan to comfirm the diagnosis and r/o cranial
complications
 Full blood count (CBC) to r/o leucocytosis
 Pus swab for culture and sensitivity to detect and reveal the
causative agent
Management
This may be medical treatment and surgery
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Medical treatment
 Give analgesics to relieve pain eg tablets ibuprofen 400mg
tds for 5 days
 Give oral antibiotics if mild eg caps ampiclox 500mg or
flucloxacillin 500mg qid for 7 days
 In severe admit the patient and administer intravenous
antibiotics eg iv ceftriaxone 2g once daily and iv
metronidazole 500mg three times daily
Surgery mainly mastoidectomy to drain pus if the abscess has
formed

Complications of mastoiditis
 Dizziness or vertigo as it affects the vestibular system which
maintains body balance.

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 Destruction or erosion of the mastoid bone.
 Subperiosteal abscess (pus formation in the inner layer of the
bony tissue).
 Cranial nerve involvement. Gradenigo’s syndrome – Facial
nerve paralysis, deep facial pain and otitis media.
 Meningitis (inflammation of membranes of the brain).
 Brain abscess.
 Bezold abscess (collection of pus behind the muscle of the
neck)
 Moderate to severe hearing loss.

Benign Tumors / Masses of the Ear

These are harmless growth that does not spread or invade other
tissues that develops in the ear

These may develop in the ear canal, blocking it and causing a

buildup of wax and hearing loss

General characteristics of benign tumours in the ear

 They are slow growing

 They are usually encapsulated

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 They do not metastasize
 They do not recur after removal
 If completely excised they rarely endanger life.
 Their effects are due to size and site.
 They are well differentiated
 They have a low mitotic rate
 They resemble the tissues of origin
Examples of benign masses / tumors of the ear
These include;
 Exostoses
These are small, hard, bilateral bony protrusions found in the
lower posterior bony portion of the ear canal
If large, it leads to occlusion of the canal causing conductive
deafness.
 Cholesteatoma

This is an in growth of the skin of the external layer of the

eardrum into the middle ear.
It is generally caused by a chronic retraction pocket of the
tympanic membrane, creating a persistently high negative
pressure of the middle ear.
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The skin forms a sac that fills with degenerated skin and
sebaceous materials.
 Glomus jugulare
This is a tumor that arises from the jugular bulb.
 Glomus tympanicum
This is an identical tumor that arises from Jacobson’s nerve and
remains limited to the middle ear
 Facial nerve neuroma
This is a tumor that occur on cranial nerve VII, the facial Nerve
 Cholesterin granuloma
This is an immune system reaction to the byproducts of blood
(ie, cholesterol crystals) within the middle ear.
 Tympanosclerosis
This is a deposit of collagen and minerals within the middle ear
that can harden around the ossicles as a result of repeated
infections.
 Acoustic neuroma
This is a slow-growing, benign tumor of cranial nerve VIII,
usually arising from the Schwann cells of the vestibular portion
of the nerve.

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Complications of surgery for acoustic neuroma
These include;
• Facial nerve paralysis
• Cerebrospinal fluid leak
• Meningitis
• Cerebral edema
 Sebaceous cyst
These are small sac within the ear filled with skin secretions
mainly sebum
 Osteomas (bone tumors)
 Keloids
This growth of excessive scar tissues with in the ear after an
injury
Clinical features of benign tumors in the ear
Early symptoms include;
 Hearing loss
 Tinnitus
 Dizziness
 Unsteadiness

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 Other symptoms develop if the tumor enlarges and
compresses other parts of the brain, the facial and trigeminal
nerves
Diagnosis
 Early diagnosis is based on MRI scan and hearing test
Management
 The best treatment of these tumors is by surgical removal of
the tumor and after treatment hearing usually returns to
normal.
 Repeated injections of corticosteroid such as triamcinolone
or hydrocortisone for Keloids
Malignant tumours of the ear
These are harmful tumors capable of spreading and invading
other tissues far away from the site of origin (to distant areas)
Characteristics of Malignant tumours of the ear
 They expand and infiltrate locally
 They have no capsule or encapsulation is rare
 They metastasize to other organs via blood, lymphatics or
body spaces
 They endanger life if untreated.
40
 They have varying degrees of differentiation from tissue of
origin,
 They have a high mitotic rate.
Examples of malignant tumors of the ear
These include;
 Basal cell carcinomas on the pinna
 Squamous cell carcinomas in the ear canal.
 These are common skin cancer that often develop on the
external ear after repeated and prolonged exposure to the
sun
 They may also develop in or spread to the ear canal
 If untreated, squamous cell carcinoma may spread through
the temporal bone, causing facial nerve paralysis and
hearing loss.
 Ceruminoma
This is cancer of the cells that produce wax in the ear and
develops in the outer third of the ear.
Treatment is by surgical removal of the cancer and the
surrounding tissue
 Melanoma
41
This is also a more rapidly spreading form of skin cancer that
can also develop in the skin of the outer ear canal
Clinical features of malignant tumors of the ear
 Facial nerve paralysis
 Hearing loss
 Otalgia (severe ear pain)
 Swelling and tenderness of the ear
 Dizziness
 Headache
Management
 Surgery
 Radiation therapy
 Chemotherapy

DISORDERS OF THE NOSE

These include;
Foreign Body in the Nose
 These are foreign objects which have been inserted into the
nose

42
 Usually occurs in children <5 years and mentally retarded
persons/ adults
 Common foreign objects which may be put into the nose
include;
• Seeds, e.g. bean, peas, ground nut, maize
• Piece of paper
• Foam rubber (e.g. mattress foam)
• Beads
• Stones
• Buttons
• Metal objects eg ball bearing
Predisposing factors
 Curious children
 Mental ill patients
 Trauma
Clinical features
 Usually they are inserted by the child and are mostly found in
the right-hand nasal cavity
 Foreign body noticed by a child or parent may be visible or
felt
43
 Nasal bleeding if object is sharp
 Difficult breathing through the affected nostril
 Irritation or pain in the nose
 Unilateral foul-smelling discharge from the nose
Investigations
 Usually not required (Clinical diagnosis is enough)
 Nasal x-ray in case of metallic objects like wires or ball
bearings to r/o other nasal complications
Management
First aid
 Blow through the mouth while blocking the unaffected side
of the nose
 Grasp firmly and remove the paper or foam rubber with a
fine forceps e.g. Tilley’s forceps
 Other objects, carefully pass a blunt hook behind the object,
and then gently pull it out
 If the object is visible and round encourage the patient to
blow through the nose gently to allow the FB come out
 If the above fails refer to an ENT specialist
Prevention
44
 Always caution children about placing objects in mouth,
nose, and ears
Complications
 Sinusitis
 Otitis media
 Accidental migration of foreign body in the lower airway
 Nasal stone or Rhinolith

EPISTAXIS (nose bleeding)

 This is bleeding from the nostrils which may be arterial or

venous or
 This is hemorrhage from the nose caused by rupture of tiny,
distended vessels in the mucous membrane of any area of
the nasal passage.
 The most common site of bleeding is the anterior septum of
the nose.

Causes / predisposing / risk factors

Local causes
 Nose-picking
45
 Trauma (including vigorous nose blowing and nose picking)
 Nose infections eg acute sinusitis, rhinitis
 Nose tumours
 Low humidity
 Nasal inhalation of illicit drugs
 Nasal fracture and skull base fracture
General causes
 Hypertension
 Bleeding disorders eg thrombocytopenia
 Sickle-cell trait/disease
 Renal diseases eg renal failure
 Liver diseases eg hepatic failure
 Often familial
 It can also be a symptom of serious disease, e.g., typhoid,
malaria, viral fevers such as Ebola
 Drugs eg anticoagulants (heparin) and antiplatelets (aspirin)
Clinical features
 Bleeding from the nose
 On examination, site of bleeding from nose may be seen

46
 Signs and symptoms of shock if bleeding is severe such as
hypotension, cold clammy skin, severe pallor
 Signs and symptoms of predisposing cause eg hypertension
such as headache, dizziness, blurred vision, drowsiness etc
Investigations
 CBC to r/o anaemia and know the patients Hb level
 Blood clotting profile and platelet count to detect for blood
clotting time and platelet level
 Nasal endoscopy to detect and reveal the bleeding site and
r/o other nasal complications
 Nasal CT scan to r/o fractures and other complications
Management
First aid
 Sit the patient up (if patient not in shock) and tilt the head
forward to avoid pooling of blood into the posterior pharynx
or aspiration of blood
 Instruct patient to pinch the nose between the finger and the
thumb for 15 minutes, breathe through the mouth and spit
out any blood

47
 Alternatively, apply a cotton tampon into the nose to try to
stop the bleeding.
 Suction to remove excess blood and clots from the field of
inspection.
 Application of anesthetics and nasal decongestants
(phenylephrine, one or two sprays) to act as vasoconstrictors
 Cauterization of the visible bleeding sites with silver nitrate
or electrocautery/ diathermy
If bleeding continues:
 Pack the nose with gauze and tetracycline eye ointment
using a forcep and leave the gauze in place for 24-48 hours
 Administer antibiotics eg iv ceftriaxone 2g once daily
 Administer analgesics eg Diclofenac 75mg three times daily
 Give anti hypertensive’s if the cause is hypertension
 Give Anti malarial if the cause is malaria
 In case bleeding still continues refer the patient to the ENT
specialist
Prevention
 Avoid picking the nose
 Treat/control predisposing conditions
48
NASAL ALLERGY
 This is an abnormal reaction of the nasal tissues to certain
allergens which tends to start in childhood
 Vasomotor rhinitis starts in the 20s and 30s.21
Causes
Predisposing factors include;
 Hereditary: Family history of similar or allied complaints
 Infections may alter tissue permeability
 Psychological and emotional factors in vasomotor rhinitis
 Changes in humidity and temperature
 Dust mite, infections
 Certain foods
 Drugs e.g. acetylsalicylic acid
 Alcohol, aerosols, fumes
Clinical features
 Often present in school age children
 Sometimes preceded or followed by eczema or asthma. (Less
common in persons >50 years old)
 Paroxysmal sneezing
49
 Profuse watery nasal discharge
 Nasal obstruction, variable in intensity and may alternate
from side to side
 Postnasal drip (mucus dripping to the back of the nose)
Investigation
 Careful history is most important
 Large turbinates on examining the nose
Management
 Avoid precipitating factors (most important)
 Reassure the patient
 Give antihistamines, e.g. Chlorphenamine 4 mg every 12
hourly for 21 days, then as required thereafter if it recurs
 Apply nasal decongestants, e.g. Pseudoephedrine or
xylometazoline to relieve nasal congestion
 Surgery in case of obstruction of the nose

ACUTE SINUSITIS
Inflammation of air sinuses of the skull
Causes
 Allergy
50
 Foreign body in the nose
 Viruses, e.g. rhinovirus, often as a complication of URTI
 Dental focal infection
 Bacteria, e.g., Streptococcus pneumoniae, Haemophilus
influenzae, Streptococcus pyogenes
Clinical features
 Rare in patients <5 years
 Pain over the cheek and radiating to frontal region or teeth,
increasing with straining or bending down
 Redness of nose, cheeks or eyelids
 Tenderness due to pressure over the floor of the frontal
sinus immediately above the inner canthus
 Referred pain to the vertex, temple or occiput
 Postnasal discharge
 A blocked nose/ Nasal blockage
 Persistent coughing or pharyngeal irritation
 Hyposmia
 Fever and malaise
Investigations

51
 C&S of the discharge to detect and reveal the causative
micro organism
 X -ray of sinuses to detect and reveal the extent and severity
of condition to the skull sinuses and r/o other complications.
 Nasal CT scan to comfirm the diagnosis and r/o other nasal
complications
Management
General measures
 Steam inhalation to clear the blocked nose
 Give analgesics to relieve pain eg NSAIDs
 Nasal irrigation with normal saline to remove discharge
 Give Antibiotics in case of infection such as Amoxicillin 500
mg 8 hourly for 7-10 days
 In case of dental infection, extract the tooth and give
antibiotics such as Amoxicillin 5 00mg Metronidazole 400mg
8 hourly for 7 to 14 days
 In case of FB refer immediately to the ENT specialist for
further management
Notes

52
Do NOT use antibiotics except if there are clear features of
bacterial sinusitis, e.g., persistent (> 1 week) purulent nasal
discharge, sinus tenderness, facial or periorbital swelling,
persistent fever
Complications
 Chronic sinusitis
 Osteomylitis
 Orbital cellulitis
 Orbital abscess
 Meningitis
 Brain abscess
 Thrombophlebitis of cavernous sinus
 Pharyngitis
 Tonsillitis
 Bronchitis and pneumonia
 Otitis media
 Septicemia
RHINITIS
 Rhinitis refers to inflammation of the mucous membrane
of the nose.
53
  It may be acute, chronic or allergic rhinitis.
 All forms of rhinitis cause sneezing, nasal discharge with
nasal obstruction and headache
Acute rhinitis
 This is an inflammatory condition of the mucous membrane
of the nose and accessory sinuses caused by a filterable virus.
 It is spread by airborne droplet sprays emitted by the
infected person while breathing, talking, sneezing or
coughing or by direct hand contact.
 Its frequency increases during winter months, when people
stay indoors and overcrowding
 Other factors such as chills, fatigue, physical and emotional
stress and patient compromised immune status, may
increase susceptibility
Predisposing factors
 Allergy
 Environmental pollution by dust, fumes
 Overuse of nasal decongestants (Rhinitis medicamentosa)
 Hormone imbalances : e.g. during pregnancy, puberty
Clinical features
54
 Tickling and irritation within the nose
 Sneezing or dryness of the nose or nasopharynx
 Copious nasal secretions
 Nasal obstruction
 Watery eyes
 Elevated temperature,
 General malaise, and
 Headache
 Thick and sticky mucus within a few days
Management:
 Bed rest
 Plenty of warm oral fluids intake
 Proper nutrition
 Use of home remedies such as steam, honey etc
 Use of antipyretics and analgesics such as tablets
paracetamol 1g three times daily
 Apply Xylometazoline 0.05% or 0.1% nose drops 2-3 drops
into each nostril 3 times daily

Complications of acute rhinitis

These include
55
 Pharyngitis
 Sinusitis
 Otitis media
 Tonsillitis
 Chest infection
Allergic rhinitis (hayfever)
 This is a type I hypersensitive reaction.
 It is the reaction of the nasal mucosa to a specific antigen
(allergen).

Causes
Its caused by allergens such as pollen of trees, grasses or weeds,
spores of molds, dustmites, and animal danders.
Clinical features
 Nasal congestion
 Sneezing
 Watery itchy eyes and nose,
 Altered sense of smell
 Thin watery nasal discharge
 Headache
56
 Cough
 Hoarseness or the recurrent need to clear throat
Management
 Avoidance of the causative agents mainly allergens such as
smoke, pollens, dust mites, mold spores
 Use of antihistamines such as chloropheniramine, cetrizine
or loratidine
 Apply xylometazoline 0.05 or 0.1% nasal drop 2 – 3 drops in
each nose daily
 Administer iv / im hydrocortisone 100- 200mg three times
daliy

Chronic rhinitis
This is a chronic inflammation of the mucous membrane with
increased nasal mucosa caused by repeated acute infections,
allergy and or vasomotor rhinitis.
ATROPHIC RHINITIS
This is a chronic infection of the nasal mucosa in which various
components become thinner (atrophy) due to fibrosis of the
terminal blood vessels
Cause
57
The cause is unknown but its associated with
 HIV/AIDS
 Poor socioeconomic status
 Syphilis
 Rhinoscleroma (early stages)
Clinical features
 Tends to affect both nasal cavities and affects females more
than males
 Foul stench not noticed by patient who cannot smell
 Crusts and bleeding points in the nose
 Epistaxis when crusts separate
 Sensation of obstruction in the nose
 Nasal airway very wide
Investigations
 C&S of smear of nasal material to identify the causative
micro organisms
 X-ray to detect for the extent and severity of the condition
along the nasal cavity and to r/o sinusitis
Management

58
 Clean nasal cavities twice daily to remove crusts
(most important)
 Syringe the nose or douche it with warm normal
saline Or sodium bicarbonate solution 5% (dissolve 1
teaspoon of powder in 100 ml cup of warm
water) then apply tetracycline eye ointment 1%
inside the nose twice daily
 Give amoxicillin 500 mg every 8 hours for 14
days and in case of rhinoscleroma: Give 1 g every
8 hours for 6 weeks
 In case symptoms persist refer to ENT specialist
Complications of rhinitis
 Otitis media
 Sinusitis
 Pharyngitis
 Laryngo-bronchitis
Adenoid Disease
 Enlargement or inflammation of nasopharyngeal tonsil.
 Common in small children.
Clinical features

59
May be due to enlargement, inflammation, or both;
 Obstruction of the nose leading to mouth breathing,
difficulty eating, snoring, jaw deformities
 Obstruction of Eustachian tube leading to hearing loss, which
fluctuates due to fluid in middle ear (”Glue ear”)
 Recurrent otitis
 Discharge from the nose
 Recurrent cough
 Physical and other developmental retardation, e.g. small size
for age
Investigations
 Diagnosis is usually based on history and physical
examination
 X-ray for neck soft tissue( lateral view) to detect and reveal
narrowing of the post-nasal space
Management
 In mild cases manage on conservative treatment with
chlorpheniramine 1-2 mg daily (depending on age) for 7 days
 Apply Topical nasal steroids if available
 If moderate or severe refer to the ENT specialist
60
 Adenoidectomy in cases of chronic nasal obstruction and
discharge, secretory Otitis media and sleep apnoea
Benign tumors of the nose
All areas of the nasal cavity and paranasal sinuses can be
affected, but the lateral wall, ethmoids and maxillary sinus are
the most common primary sites.
The frontal and sphenoid sinuses are rare primary sites for
reasons that are unknown.
Examples of benign tumors of the nose include;
 Inverted papilloma (IP)
This is a warty, slow-growing tumour that arises from the
epithelial lining of the nasal cavity nose.
Its more common in males more than females at the ratio of
(5:1).
Its similar to a nasal polyp and causes nasal blockage.
 Haemangioma
This is a soft reddish polyp on the anterior part of septum that
bleeds easily on touch and usually brings about nasal blockage.
The common types include the capillary haemangioma which is
a bleeding polypus of the nasal septum and the cavernous
haemangioma which occurs on the lateral nasal wall
 Osteoma

61
This is the most common benign tumour of the nose and sinuses
commonly in frontal sinus and followed by ethmoid
The common types include the compact (ivory) osteoma which
is common in the frontal sinus and the cancellous Osteoma
which is common in the ethmoid sinuses.
 Juvenile angiofibroma
This is a slow growing highly vascular tumour which arises
predominantly from the sphenopalatine region
Its common in adolescent and young adult males
The tumour is locally invasive and can cause life-threatening
epistaxis and nasal obstruction
 Nasal polyps
These are the most common non-cancerous tumour of the nasal
cavity and paranasal sinuses.
They are abnormal growths of the mucosal lining of the nose
and sinuses
Nasal polyps appear most frequently near the openings to the
sinuses in the nasal passage but they can also develop anywhere
throughout the nasal passages or sinuses.

62
Causes
The exact causes of nasal polyps are not known but can be due
to the following risk factors
 Sensitivity to aspirin (people with an allergic response to
aspirin or other NSAIDs (non-steroidal anti-inflammatory
drugs) are more likely to develop polyps).
 Asthma.
 Allergic fungal sinusitis (an allergy to airborne fungi).
 Rhinitis / Rhino sinusitis (an inflammation of the nasal
passage and sinuses)
 Cystic fibrosis (a chronic disease that affects organs such as
the liver, lungs, pancreas, and intestines).
 Churg-Strauss syndrome (a disease that results in the
inflammation of blood vessels).
 Age (occurs at any age, but young and middle-aged adults
are more at risk).
 Genetics (as it may run into families).

Clinical features of nasal polyps

These include;

63
  Stuffy, blocked or runny nose
 Loss of smell
 Loss of taste
 Headache
 Pressure in the head

 Pain in the face

 Snoring

 Itchiness around the eyes

 Obstructive sleep apnea (in severe cases)

 Double vision (in severe cases)

Investigations

 Nasal endoscopy to detect and locate the site and location of

the polyp.
 Nasal CT scan to locate the nasal polyps and r/oother
abnormalities linked to chronic inflammation within the
nose.
 Nasal x ray to r/o nasal obstruction and sinusitic opacities

64
 Skin prick allergy test to r/o or identify if the cause is an
allergy
 Nasal biopsy to r/o cancer

Management

Medical management

 Apply steroid nasal spray eg Avamys 2 sprays once daily to

relieve nasal congestion
 Give tablets prednisolone 20mg once daily for 3days then
10mg once daily for 7 days
 Give antibiotics if the cause is bacterial eg Chloraphenical
nasal drops 2 drops three times daily

Surgery mainly polypectomy (surgical excision of the polyp

from the nasal cavity)

Complications

 Chronic sinusitis
 Obstructive sleep apnea
 Facial deformity

65
Prevention

 Regular and thorough hand washing to reduce risk of

bacterial or viral infection which may result into
inflammation of the sinuses and nasal passages
 Avoidance of irritants, such as allergens, chemicals, and
airborne pollutants which may cause inflammation hence
reducing the risk of developing polyps
 Early management of asthma and allergies
 Rinsing of the nasal passage with saline spray to help
improve the flow of mucus and remove irritants and
allergens.
Other examples of benign tumors include;
 Haemangiopericytoma
 Schwannoma
 Pleomorphic adenoma and
 Meningioma
Malignant tumours of the nasal cavity and paranasal sinuses
These include
Squamous cell carcinoma

66
This is the most common type of nasal cavity and paranasal
sinus cancer
Its most common in males above 40 years and
It commonly affects the lateral nasal wall, the maxillary and the
ethmoidal sinuses.

Adenocarcinoma

This is the second most common type of nasal cavity and

paranasal sinus cancer. It begins in gland cells.

Malignant melanoma

This develops from cells called melanocytes that give the skin
its color and is an invasive, fast-growing cancer accounting for
about 1%

Inverting papilloma

These are benign, wart-like growths that may develop into

squamous cell carcinoma.

Esthesioneuroblastoma

67
This type of cancer is related to the nerves that control the
sense of smell.

It occurs on the roof of the nasal cavity and involves a structure

called the cribriform plate.

Midline granuloma

This refers to a group of several unrelated conditions that cause

the breakdown of healthy tissues of the nose, sinuses, and
nearby tissues

Lymphoma

This is cancer of the lymphatic system supplying the nasal cavity

and paranasal sinuses.

Sarcoma

This is a type of cancer that begins in muscle, connective tissue,

or bone eg chondrosarcoma and rhabdomyosarcoma and
haemoproliferative tumours

Others include

68
  Olfactory neuroblastoma
 Adenoid cystic carcinoma

Risk factors for nasal cancer and paranasal sinus cancer

 Active or passive tobacco use

 Alcohol consumption

 Age (common at the age of 45 to 85)

 Gender (as its more common in men than women)

 Human papilloma viruses (HPV)

 Occupation leading to frequent inhalation of irritants eg

dust from wood, textile and leather industry etc

 Exposure to air pollution

 Use of marijuana

Clinical features of malignant tumors of the nasal cavity and

sinuses
 Nasal obstruction or persistent nasal congestion and
stuffiness
69
 Chronic sinus infections that do not go away with antibiotic
treatment

 Frequent headaches or pain in the sinus region

 Pain or swelling in the face, eyes, or ears

 Persistent tearing of the eyes

 Bulging of the eyes and loss of vision

 Decreased sense of smell

 Pain or numbness in the teeth

 Loosening of the teeth

 A lump on the face, nose, or inside the mouth

 Frequent runny nose

 Frequent nose bleeding

 Difficulty opening the mouth

 A lump or sore inside the nose that does not heal

 Fatigue

 Unexplained weight loss

70
  A lump in the neck

Investigations / diagnosis
 Good physical examination
 Nasal biopsy to confirm the diagnosis
 Nasal x ray to r/o nasal blockage and other nasal
complications
 CT / MRI scan to detect the size of the tumor, the extent of
the disease on the nasal cavity (metastases)and r/o other
nasal complications

Management
 Surgery eg excision, maxillectomy, neck dissection and
craniofacial resection
 Radiation therapy
 Chemotherapy
 Palliation

Staging of the nasal cavity and paranasal sinus cancer

This is based on the TNM system and is used to describe the
size and location of the tumor thus

71
T – Tumor, N – nodes and M- metastasis.
Primary tumor (T) in the nasal cavity and ethmoid sinus

 TX: The primary tumor cannot be evaluated.

 Tis: This is also called carcinoma (cancer) in situ and cancer
cells are found only in one layer of tissue.

 T1: The tumor is limited to the inside of the sinus.

 T2: The tumor extends into the nasal cavity.

 T3: The tumor extends into the maxillary sinus or to the bone
surrounding the eye.

 T4a: The tumor has spread throughout the facial bones or

into the base of the skull.

 T4b: The tumor invades any of the following: the back of the
eye, the brain area, or the back of the head.

N (Nodes)

 NX: The regional lymph nodes cannot be evaluated.

72
 N0 (N plus zero): There is no evidence of cancer in the
regional lymph nodes.

 N1: The cancer has spread to 1 lymph node on the same side
as the primary tumor. The cancer found is 3 centimeters (cm)
or smaller. It does not extend into the tissue beyond the
involved lymph node, called extranodal extension (ENE).

 N2a: The cancer has spread to 1 lymph node on the same

side as the primary tumor. It is between 3 cm and 6 cm in
size. There is no ENE.

 N2b: The cancer has spread to more than 1 lymph node on

the same side as the primary tumor, and all are smaller than
6 cm. There is no ENE.

 N2c: The cancer has spread to more than 1 lymph node on

either side of the body, and all are smaller than 6 cm. There
is no ENE.

 N3a: The cancer is found in at least 1 nearby lymph node and

is larger than 6 cm. There is no ENE.

73
 N3b: The cancer has spread to any node, and it has spread to
the tissue surrounding the lymph node (ENE).

M (metastasis)
This indicates that the cancer has spread to other parts of the
body, called distant metastasis.

M0 (M plus zero): The cancer has not spread to other parts of

the body.
M1: The cancer has spread to another part(s) of the body

DISORDERS OF THE THROAT

FOREIGN BODIES (FB)
 Foreign Body (FB) in the Airway
 This is a foreign object stuck in the air way
 Mostly occurs in children <5 years
Cause
 Inhalation from the mouth while the child is chewing,
laughing, or crying or there is a sudden disturbance, which
opens the vocal cords so the object is inhaled
Types of FBs
These include;
74
 Seeds (groundnuts, beans, maize)
 Plastics
 Rubber
 Metal wires
 Ball bearing etc

Clinical features
 Sudden onset of choking followed by stridor (noisy
breathing) or
 Cough
 Difficulty in breathing,
 Wheezing
 Hoarseness of voice if FB is stuck at the vocal cords
 Symptoms start suddenly, some symptoms may be transient
(may disappear after a short period), but complications may
present few days later such as sudden death, intractable
pneumonia, branchiectasis, atelectasis, pneumothorax, lung
abscess

75
 Upper airway obstruction as shown by flaring of the nostrils,
recession of the chest inlet and or below the ribs, rapid chest
movements and reduced air entry (usually on the right side)
Investigations
 Once the history and examination are suggestive,
investigations can be omitted to save time
 Chest x-ray may show lung collapse, hyperinflation,
mediastinal shift, shift of heart shadow
Management
Child
 In case the child is chocking, attempt to dislodge the FB by 3
cycles of 5 back slaps or 5 chest compressions for infants or
Heimlich manoeuvre for children
 Do not do blind finger sweeps
 In case the foreign body is visible in the mouth, remove it
with a Magill forceps
 In case the child has severe respiratory distress, refer to
higher level for airway visualization to the ENT specialist but
give oxygen if necessary
Adult
76
 Dislodge large FB, e.g. chunk of meat from the pharynx by
cycles of 5 back slaps and Heimlich manoeuvre while
standing behind the patient with both arms around the
upper abdomen and give 5 thrusts. If the patient is pregnant
or very obese, perform 6-10chest thrusts while the patient is
lying on the back
 In case you still suspect any FB, refer for airway visualization
to the ENT specialist for Endoscopy and extraction of the FB
under general anesthesia
Prevention
 Do not give groundnuts or other small hard food items to
children <2 years
 If a child is found with objects in the mouth, leave the child
alone to chew and swallow or gently persuade the child to
spit out the object (Do not struggle with/force the child)
Complications of FBs in the airway
 Sudden death
 Pneumonia
 Branchiectasis
 Atelectasis
77
  Pneumothorax
 Lung abscess
 Foreign Body in the Food Passage / Oesophogus
This is any foreign object impacted into the oesophogus or
food passage
Causes
 Accidental mainly in children and unconscious patients
 Large food bolus ingestion
Types of FBs commonly involved
These include:
 Fish or chicken bones often lodging in the tonsils, behind the
tongue, or in the pharynx
 Coins in the esophagus especially in children.
 Disc battery (is particularly dangerous and requires
immediate referral)
Clinical features
 Difficulty in swallowing ( the patient winces as he attempts to
swallow)
 Pain in swallowing
 Drooling of saliva
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 Pointing sign (patient may point to the site where aforeign
body is stuck with a finger)
 FB may be seen, e.g., in tonsil, pharynx
Investigations
 Chest x-ray may reveal radio-opaque FB eg coins, fish bone
and confirm the diagnosis
Management
 The approach depends upon the type of object ingested, the
location of the object, and the patient’s clinical status.
 If the x – ray is negative, no symptoms and the FB does not
belong to any dangerous category (magnets, disc batteries,
sharp long objects, etc), expectant management is advised.
 If the patient is symptomatic and or the object is dangerous,
immediately refer for further management by the ENT
specialist
First Aid management
 Allow the patient to take only clear fluids mainly water if able
to swallow

79
 Do NOT try to dislodge or move the FB with solid food as it
may push the FB into the wall of the oesophagus causing
infection and sometimes death
 Give IV infusion if unable to swallow the liquids or if oral fluid
intake is poor
 If FB is visible in the pharynx or tonsil grasp and remove it
with a long forceps
 If patient tried to push FB with solid food and sustained an
injury give broad-spectrum antibiotic eg capsules Amoxicillin
500 mg and tablets metronidazole 400mg three times daily
for 5 days
Prevention
 Keep potential FBs out of children’s reach
 Advise children to take care while eating by not taking in too
large pieces of food and chewing of food thoroughly before
swallowing
 Advise the patient once a FB is stuck in the esophagus to
avoid trying to “push” it down with solid food as this may
sometimes be fatal

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PHARYNGITIS (SORE THROAT)
This is the inflammation of the throat
Causes
 Most cases are viral
 Bacteria mainly Group A haemolytic Streptococci
 Diphtheria in non-immunized children
 Gonorrhoea (usually from oral sex)
 Ingestion of undiluted spirits
 Candida albicans in the immunosuppressed
Clinical features
 Onset is abrupt
 Throat pain
 Pain on swallowing
 Mild fever
 Loss of appetite
 General malaise
 Nausea and vomiting, and diarrhoea in children
 If the cause is viral there is presence of runny nose,
hoarseness, cough, conjunctivitis, viral rash and diarrhea

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 If cause is bacterial there is presence of tonsilar exudates,
tenderness of neck glands, high fever, and absence of cough
Differential diagnosis
 Tonsillitis, epiglottitis, laryngitis
 Otitis media if there is referred pain
Investigations
 Throat examination with torch and tongue depressor to
reveal if inflamed
 Throat swab for microscopy to reveal presence or absence of
pus
 Throat swab for C&S to reveal and identify the causautive
micro organisms
 CBC to r/o leukocytosis
 Serological test for haemolytic streptococci (ASOT) to r/o or
confirm the causative agent
Management
Most cases are viral and do not require use of antibiotics
therefore supportive treatment include;
 Keep the patient warm

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 Give the patient plenty of warm oral fluids e.g. tea or lemon
tea
 Give analgesics to relieve pain e.g. tablets Paracetamol 1g 8
hourly for 3 days
 Review the patient for progress after care
If the case is bacterial give antibiotics like;
 Capsules Amoxyl or Ampiclox 500mg 8 hourly for 10 days or
Augmentin 625mg twice daily for 5 - 10 days if mild or
moderate
 If severe admit the patient and give iv ceftriaxone 1g or 2g
once daily and injectable analgesics
Complications
 Blockage of the airway (in severe cases)
 Middle ear infections
 Peritonsillar abscess (quinsy)
 Retropharyngeal and parapharyngeal abscesses
 Sinusitis
 Rheumatic fever
 Acute glomerulonephritis
 Septicemia
83
 Bronchitis
 Pneumonia
 Rheumatic heart disease
 Septic arthritis
Notes
If not properly treated, streptococcal pharyngitis may lead to
acute rheumatic fever and retropharyngeal or peritonsillar
abscess, therefore ensure a full 10-day course of antibiotics is
completed where applicable
PHARYNGO-TONSILLITIS (tonsillitis)
This is the inflammation of the tonsils
Causes
 Streptococcal infection (most common)
 Viral infection (less common)
Clinical features
 Onset is sudden and is most common in children
 Sore throat
 Fever
 Shivering
 Headache

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 Vomiting
 Enlargement of Tonsils with exudate
 Enlargement of cervical lymph nodes
Investigations
 Throat swab for C&S to reveal and confirm the causative
micro organism
 CBC to r/o leukocytosis
Management
Medical management
 If bacterial and mild or moderate give broad spectrum
antibiotics such as capsules ampiclox 500mg 4 hourly and
analgesics such as ibuprofen 400mg 8 hourly fro 5 days
 If severe admit patient and give iv ceftriaxone 1- 2g once
daily for 5 days
 If patient is allergic to penicillin give Erythromycin 500 mg
every 6 hours for 10 days
 If the cause is viral give analgesics mainly paracetamol 1g
three times daily and increase oral fluids
Surgery management is mainly by tonsillectomy (in cases of
chronic repetitive tonsillitis)
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Complications
Local complications
 Peritonsilar abscess (quinsy)
 Cellulitis
Systemic complications
 Bacterial endocarditis
 Glomerulonephritis
 Rheumatic fever

PERITONSILLAR ABSCESS (QUINSY)

This is an abscess formed between the tonsil capsule and the
lateral wall of the pharynx
Cause
Follows (often mild) tonsillitis attack
Clinical features
 Severe throat pain
 Fever
 Headache
 Malaise
 Rigors

86
 Inability to open the mouth
 Salivation and dribbling
 Bad mouth odour
 Thickened muffled (unclear) speech
 Ear pain
 Enlarged cervical lymph nodes
 Tonsil and soft palate reddish and oedematous
 Swelling pushing the uvula to opposite side (bulging
collection of pus)
Differential diagnosis
 Tumour
 Tonsillitis
 Abscess in the pharynx
Investigations
C&S of pus if present or after drainage to identify the causative
microorganism
Management
 Medical /Conservative management
 Bed rest
 Oral hygiene
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 Use of antibiotics ie
• If mild, Benzyl penicillin 2 MU IV or IM every 6 hours for 48
hours then switch to amoxicillin 500 mg every 8 hours to
complete a total of 7 days
• If moderate or severe, Ceftriaxone 1 g IV once daily for 7
days, Child: 50 mg/kg IV Plus metronidazole 500 mg IV
every 8 hours Child: 10 mg/kg IV every 8 hours
 Use of analgesics ie Im Diclofenac 75mg every 8 hourly daily
to relieve pain
 Surgery mainly I&D to drain out pus from the abscess

TRACHEOSTOMY
Key facts
 This is a surgical procedure in which an opening is made into
the trachea to relieve sudden laryngeal obstruction or for the
purpose of establishing an airway
 The indwelling tube which is inserted into the trachea is
called a tracheostomy tube
 Its either temporary or permanent
Indications of tracheostomy
88
 To bypass an upper airway obstruction
 To facilitate removal of secretions along the trachea and
bronchial or allow removal of tracheobrachial secretions
 To permit long-term use of mechanical ventilation
 To prevent aspiration of oral or gastric secretions in
unconscious or paralyzed patient
 To replace an endotracheal tube
 To Permit oral intake and speech in the patient who requires
long-term mechanical ventilation
 To establish and maintain patent airway
Causes of upper air way obstruction
Upper airway obstruction is due to the following
 Foreign bodies and vomitus imparted in the larynx
 Acute or chronic laryngitis
 Trauma
 Burns of the mouth or larynx
 Laryngeal edema
 Laryngeal paralysis
 Acute edema of the glottis
 Laryngeal carcinoma
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 Peritonsillar abscess
 Retrosternal goiter
 Enlarged mediastinal lymph nodes
 Hematoma around the upper airway
 Thoracic aneurysm
Complications of tracheostomy
Complications may occur early or late in the course of
tracheostomy tube management or years after the tube has been
removed.
Early complications include
 Bleeding / haemorrhage
 Pneumothorax
 Air embolism
 Aspiration of secretions
 Subcutaneous or mediastinal emphysema
 Recurrent laryngeal nerve damage
 Posterior tracheal wall penetration
Long-term complications include
 Airway obstruction from accumulation of secretions or
protrusion of the cuff over the opening of the tube,
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 Infection
 Rupture of the innominate artery
 Dysphagia
 Tracheoesophageal fistula,
 Tracheal dilation
 Tracheal ischemia and necrosis.
 Tracheal stenosis after removal of the tube
Prevention of complications associated with endotracheal
and tracheostomy tubes
Complications of tracheostomy may be prevented by;
 Administering adequate warmed humidity.
 Maintaining the cuff around the tube.
 Suction to remove secretions and prevent aspiration.
 Maintaining the skin integrity by changing the tapes and
dressing prn
 Auscultating the lungs for the lung sounds.
 Monitoring for signs and symptoms of infection including
temperature and white blood cell count.
 Administering prescribed oxygen and monitoring of the
oxygen saturation.
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  Monitoring the patient for cyanosis.
 Maintaining adequate hydration of the patient.
 Using sterile technique when suctioning and performing
tracheostomy care.

Post operative management of the patient after

tracheostomy
Aims
 To treat and relieve symptoms
 To treat and prevent complications that may occur post
operatively
 To restore normal function of the upper air way
On Ward

 After the patient has been transferred and handed over to

the theatre team for operation, a post operative bed is made
ready for the management of the patient during the post
operative period together with an observation tray,
functional suction machine, drip stand, emergency tray with
emergency drugs, oxygen cylinder / concentrator properly

92
 assembled, tracheostomy tray, pen, piece of paper, bell,
screen and table at the bed side.

Collection of the patient after operation

 After the operation, the ward nursing team is informed and

two nurses will go to theatre to collect the patient and while
in theatre they will;
 Receive a verbal report from the anesthetist regarding the
general condition of the patient, any post medication and the
type of anesthesia given.
 Also receive post operative instructions from the ENT
surgeon concerning the general management of the patient
during the post operative period and the type of
tracheostomy tube used (cuffed or none cuffed).
 Observe the patient for breathing by checking for the chest
movement and other accessory muscles.
 Observe the wound dressing for bleeding and ensure its
maintained in position by strapping

93
 Observe the tracheostomy tube to ensure its in and is held
in position by tapes tied around the patients neck and if
cuffed is inflated
 Observe the NGT and urinary catheter to ensure its in
position and is continiously draining out the bladder
 Take vital observations and maintain an observation chart
and thereafter they will transfer the patient from theatre to
the ward for post operative management with one nurse in
front and other behind ensuring a patent air way, privacy and
warmth respectively.

In ward

 On reaching ward the patient is taken near the post

operative bed, more help is called for, privacy is maintained,
and is transferred to the post operative bed gently for
management throughout the post operative period.

Immediate nursing care

These will include;

94
 Proper positioning the patient in a recumbent position to
ensure a patent air way, breathing and circulation
 Proper positioning of the urinary catheter and the urine bag
to ensure proper and continuous drainage.
 Proper positioning of the NGT to avoid the patient from
sleeping on it and irritation of the gut
 Observation of the tracheostomy tube to ensure its in situ
and properly held in position by the tapes tied around the
patients neck and its not tight.
 Observation of the wound dressing for bleeding and to
ensure its in situ
 Inflation of the tracheostomy tube if cuffed to minimize
pressure on tracheal wall
 Oxygen therapy in case patient has difficulty in breathing to
ease breathing and maintain the SPO2 above 95%
 Suction of mouth secretions present to ensure a patent air
way, ease breathing, and avoid blockage of the air way or
aspiration.

95
 Administration of iv fluids (Normal saline / 5% Dextrose) as
prescribed and maintain afluid balance chart
 Administration of analgesics as prescribed eg im pethidine
100mg to control pain
 Taking vital observations as ordered and maintain an
observation chart

Recovery from the effect of anesthesia

 After recovery, the patient is welcomed back, propped up,

counseled and reassured to allay anxiety, lips, tongue and
oral cavity is inspected, oral cavity is cleaned with swabs
soaked in saline, moisturizing agent is applied to cracked lips
and soiled bed linen and gown is changed with clean ones to
ensure comfort in bed.
 The patient is also offered a pen, bell and piece of papers on
the table at the bed side to aid his or her communication
with the health care team and relative’s prn.

General nursing care

Post Medication / Drugs

96
These will be administered to the patient as prescribed by the
ENT surgeon and a treatment chart is maintained and they
include;

 IV ceftriaxone 1g or 2g once daily for 7 days

 IV flagyl 500mg three times daily for 5 days
 IM pethidine 100mg three times x 3 doses alternating with iv
paracetamol 1g three times daily for 3 days
 IV fluids, Normal saline alternating with 5% Dextrose 3 litres
in 24 hours.
 Blood transfusion with 2 units of whole blood slowly over
4hours each under iv lasix 20mg
 Oxygen therapy 4 – 6 litres

Care of the Wound and tracheostomy tube

 The wound dressing is observed for bleeding and in case of

bleeding more sterile gauze is applied to arrest bleeding and
is maintained in situ by strapping.
 The wound is cleaned using anti septic solution prn or as
ordered by the ENT surgeon to promote healing and avoid
wound sepsis.
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 The tracheostomy tubes is continuously observed to ensure
that its in situ and is held in position by the tapes tied around
the patients neck
 The tapes holding the tracheostomy tube in position are
observed regularly to ensure that they are not too tight and
in case, they are loosened
 The tapes holding the tracheostomy tube in position are
changed whenever soiled with clean ones to avoid skin
irritation
 The tracheostomy tube is sucked prn to clear out the
secretions present along the air way to maintain a patent air
way.
 The inner tube is removed regularly or prn, cleaned with
sodium bicarbonate or savlon and reinserted back into the
tracheostomy tube.
 In case a cuffed tracheostomy tube is used, its observed
regularly , released and inflated prn
 The tracheostomy tube is removed prn as ordered by the
ENT surgeon when the cause of the obstruction has subsided

98
 or in case of carcinoma the tracheostomy will be permanent
and will not be removed.

Continued Vital Observations

 Vitals such as temperature, pulse, respiration and blood

pressure are continuously monitored a hourly or 2 hourly
and a temperature chart is maintained or as ordered and
any abnormality detected is noted and reported to the ENT
surgeon throughout the post operative period

Elimination

 Bladder care
 A urinary catheter present is maintained in situ for
continuous bladder drainage throughout the recovery period
and urine in the urine bag is observed for color and amount
and a fluid balance chart is maintained and any abnormality
detected is noted and reported to the ENT surgeon or doctor
on duty. After recovery a urinary catheter is removed as
ordered by the doctor and the patient is offered a bed pan

99
 (female) or urinal ( male) prn to open the bladder throughout
the post operative period.
 Bowel care
 After recovery, the patient is offered a bed pan prn to open
the bowel and stool is observed for colour and amount and
any abnormality detected is and noted reported to the ENT
surgeon throughout the post operative period.

Diet

 The NGT present is maintained in position and patient is

maintained on NIL per mouth until recovery and after
recovery is fed on a light diet through the NGT until is able to
feed by mouth and the NGT is removed and is fed on a well
balanced die to promote quick healing process throughout
the post operative period.

Hygiene

The patients hygiene is ensured by the following throughout the

post operative period;

100
 Daily bed bath and bed making to ensure patients comfort in
bed
 4 hourly treatments of pressure areas to prevent
development of pressure sores.
 Daily oral care to prevent oral complications such as halitosis,
stomatitis, gingivitis and to stimulate the appetite

Physiotherapy

 The patient is offered passive exercises and speech therapy

throughout the recovery period and is encouraged and
supported to do active exercises like ambulation, deep
breathing exercises and neck or head rotation and shoulder
exercises to prevent respiratory, circulatory complications
and neck muscle rigidity.

Rest and Sleep

The patients time to rest and sleep is ensured by the following

throughout the post operative period;

 Avoiding noise on the ward by restricting visitors and

allowing them only at visiting hours

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 Administering post medication in time and prn
 Continued psychotherapy to alley anxiety

When the patient is fully improved following the post

operative management the Doctor will consider his or her
discharge

Advice on Discharge

After discharge, the patient is advised on the following

 To take drugs as prescribed by the ENT surgeon and to

ensure that he / she complete the dose
 To come back for review on the date noted on the discharge
form.
 To always eat a well balanced diet
 To come back as early as possible in cases of any early neck
complications.
 To avoid heavy lifting on the head until fully recovered
 To continue caring for the trachestomy tube and the stoma
 To continue with regular exercises
 To avoid alcohol consumption and smoking

102
 To always to go or come for radiation therapy and
chemotherapy prn

TUMORS OF THE EAR, NOSE AND THROAT

TUMORS OF THE THROAT

Examples of benign tumors of the vocal cord include;
• Vocal cord polyps
 These are non cancerous growth on the vocal cord that
develop from abuse of voice, chronic allergic reactions
affecting the larynx or chronic inhalation of irritants eg
industrial fumes or cigarette smoke
 Symptoms include; hoarseness and breathy sounds
 Diagnosis is by examination of the vocal cord with the
mirror and biopsy
 Treatment if by surgical removal of the polyp and
speech therapy
• Vocal cord nodules
 These are non cancerous scar like growth on the vocal
cord similar to vocal cord polyp but firmer and do not
disappear by rest.

103
  These are caused by chronic abuse of the voice such as,
repeated yelling, shouting and strenuous singing
 Symptoms include hoarseness and breathy sounds
 Treatment is by surgical removal of the nodules and in
childrens it disappears with voice therapy alone
 Prevetion is by stopping abusing the voice
• Laryngoceles
 These are out pouching of the mucous membrane of part
of the voice box (larynx)
 They may bulge inwards resulting into hoarseness and air
way obstruction or out wards producing a visual lump in
the neck
 They are filled up with air and can be expanded when a
person breathes out forcefully with the mouth open and
nostril pinched shut
 Treatment is by surgery
Other Benign laryngeal tumors include
 Juvenile papillomas
 Hemangiomas
 Fibromas
104
  Chondromas
 Myxomas and
 Neurofibromas
 These may appear in any part of the larynx but Papillomas
and neurofibromas can become malignant
 Symptoms of benign laryngeal tumors include;
 Hoarseness
 Breathy voice
 Dyspnea
 Aspiration
 Dysphagia
 Otalgia (ear pain), and
 Hemoptysis
Examples of malignant throat tumors
Cancer of the larynx
Cancer of the larynx accounts for approximately half of all head
and neck cancers.
Almost all malignant tumors of the larynx arise from the surface
epithelium and are classified as squamous cell carcinoma.

105
Laryngeal carcinoma mainly affects the glottic region
accounting for 60%, supraglottic 35% and the subglottic 5%.
Its mode of spread is mainly by direct spread and lymphatic
spread according to the regions ie supraglottic, glottic and
subglottic
Risk factors of cancer of larynx
These include
 Male gender
 Age 60 to 70 years
 Tobacco use (including smokeless
 Excessive alcohol use
 Vocal straining
 Chronic laryngitis
 Occupational exposure to carcinogens
 Nutritional deficiencies (riboflavin), and
 Family predisposition.
Clinical Manifestations
 Early symptoms include;
 Hoarseness (Dysphonia) with cancer in glottic area
 Harsh, raspy, low-pitched voice

106
 Persistent cough
 Pain and burning in the throat when drinking hot liquids
 Lump is felt in the neck.
 After metastasis symptoms include:
 Dysphagia
 Dyspnea
 Unilateral nasal obstruction or discharge
 Persistent hoarseness or ulceration
 Foul breath
 Enlarged cervical node
 Weight loss
 General debilitated state
 Pain radiating to the ear
 Haemoptysis
Investigations / diagnosis
 History and physical examination of the head and neck to r/o
neck lumps

 Direct laryngoscopic examination under local or general

anesthesia to reveal the extent of the condition on the
larynx

107
  Laryngeal biopsy to confirm the diagnosis
 Neck CT scan to confirm the diagnosis r/o laryngeal
complications and neck involvement
 Plain chest x ray to r/o chest involvement
Management
The goals of treatment of laryngeal cancer include cure,
preservation of safe effective swallowing, preservation of useful
voice, and avoidance of permanent tracheostoma.
Treatment options include;
 Surgery
 Radiation therapy
 Chemotherapy
 Combination therapy
 Speech therapy eg esophageal speech, artificial larynx
(electrolarynx), or tracheoesophageal puncture.
Surgery
Depending on the location and staging of the tumor, four
different types of laryngectomy (surgical removal of part or all
of the larynx and surrounding structures) are considered:
 Partial laryngectomy

108
This is recommended in the early stages of cancer in the glottic
area when only one vocal cord is involved
 Supraglottic laryngectomy
This is indicated in the management of early (stage I)
supraglottic and stage II lesions, and the hyoid bone, glottis, and
false cords are removed.
 Hemilaryngectomy
This is performed when the tumor extends beyond the vocal
cord but is less than 1 cm in size and is limited to the subglottic
area.
 Total laryngectomy plus tracheostomy
This is performed in the most advanced stage IV laryngeal
cancer, when the tumor extends beyond the vocal cords, or for
recurrent or persistent cancer following radiation therapy.
In total laryngectomy, laryngeal structures are removed,
including the hyoid bone, epiglottis, cricoids cartilage, and two
or three rings of the trachea.
Staging of the tumours:
This is mainly based on TNM classification, to standardize
treatment method and to report the treatment results.
• Primary Tumours (T):
109
  Tx: Primary tumour can't be assessed.
 T0: No evidence of primary tumour.
 T is: Carcinoma in situ
 T1: Tumour limited to one site with normal vocal cord
mobility.
 T2: Tumour extending to more than one site with normal
vocal cord mobility.
 T3: Tumour limited to larynx with vocal cord fixation.
 T4: Tumour extending beyond the larynx.
• Lymph Nodes (N):
 N0: No clinically positive nodes.
 N1: Single clinically positive ipsilateral node 3 cm or less in
diameter.
 N2: Single clinically positive ipsilateral node more than 3
cm but less than 6 cm in diameter.
 N3: Ipsilateral nodes equal to 6cm in diameter or bilateral
or contralateral nodes. (of any size).
• Distant Metastasis (M):
 M0: No evidence of distant metastasis.
 M1: Tumour with distant metastasis.
110
Post operative management of the patient after total
laryngectomy and permanent tracheostomy
Aims
 To relieve symptoms that may occur during the post
operative period
 To prevent complications that may occur during the post
operative period
 To promote quick recovery of the patient
On Ward

 After transferring and handing over the patient to the

theatre team, a post operative bed is made ready for the
management of the patient during the post operative period
together with an observation tray, functional suction
machine and oxygen concentrator, drip stand, emergency
tray with emergency drugs, tracheostomy tray, pen, piece of
paper, bell, screen and table at the bed side.

Collection of the patient

111
 After operation, the ward nursing team is informed and two
nurses go to theatre to collect the patient and while in
theatre they will;
 Receive a verbal report from the anesthetist concerning the
general condition of the patient, any post medication and the
type of anesthesia given.
 Also receive post operative instructions from the ENT
surgeon concerning the general management of the patient
during the post operative period and the type of
tracheostomy tube used (either cuffed or non cuffed).
 Observe the patient for breathing by passing the back of the
palm near the patient’s nose and also the chest movement.
 Observe the urinary catheter if present for drainage and the
drainage for colour and amount and maintain a temperature
chart
 Observe the tracheostomy tube to ensure that its in situ and
is held in position by tapes tied at the sides of the patients
neck and the cuff is inflated
 Observe the NGT to ensure that its in situ

112
 Take vital observations and maintain an observation chart
and when satisfied, they will then transfer the patient to the
ward for further management post operatively with one
nurse in front ensuring a patent air way while the other
behind maintaining privacy and warmth.

In ward

 On reaching ward the patient is taken near the post

operative bed, privacy is maintained; more help is called for
and is transferred to the post operative bed gently for
management throughout the post operative period.

Immediate nursing care

This will include;

 Proper positioning the patient in a recumbent or semi prone

position with the head turned on one side to ensure a patent
air way, breathing and circulation
 Proper positioning of the urinary catheter and the urine bag
to ensure proper and continuous bladder drainage.

113
 Proper positioning of the NGT to avoid the patient from
sleeping on it and irritation of the gut
 Observation of the tracheostomy tube to ensure that its in
situ and properly held in position by the tapes tied around
the patients neck to ensure its not tied too tight.
 Observation of the wound dressing for bleeding and in case
more sterile gauze is added to arrest bleeding and
maintained in situ by strapping
 Inflation of the tracheostomy tube if cuffed to minimize
pressure on tracheal wall
 Administration of oxygen to ensure a patent air way and ease
breathing
 Suction of secretions if present to ensure a patent air way,
ease breathing, and avoid blockage of the air way and
aspiration.
 Administration of iv fluids (Normal saline / 5% Dextrose) as
prescribed to ensure fluid and electrolyte balance
 Administration of analgesics as prescribed to relieve pain
such as pethidine 100mg and maintain treatment chart

114
 Taking of vital observations as ordered and maintain a
temperature chart

Recovery from anesthesia

 After recovery, the patient is welcomed back, propped up,

counseled and reassured to allay anxiety, soiled bed linen
and gown is changed with clean ones to ensure comfort in
bed.
 The patient is also offered a pen, bell and piece of papers on
the table at the bed side to aid his or her communication
with the health care team and relative’s prn.

General nursing care

Post Medications / drugs

Drugs will be administered to the patient as prescribed by the

ENT surgeon and a treatment chart is maintained and these
include;

 IV ceftriaxone 2g once daily for 7 days

 IV flagyl 500mg three times daily for 5days

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 IM pethidine 100mg alternating with iv paracetamol 1g three
times daily for 3days
 IV fluids, Normal saline alternating with 5% Dextrose 3 litres
in 24 hours.
 Oxygen therapy 4 – 6 litres

Care of the Wound and tracheostomy tube

 The wound dressing present is observed for bleeding and in

case more sterile gauze is applied to arrest bleeding and is
maintained in situ by strapping.
 The wound is cleaned prn with anti septic solution as ordered
by the ENT surgeon to promote quick wound healing and
avoid sepsis.
 The tracheostomy tubes is continuously observed to ensure
that its in position and is held by the tapes tied around the
patients neck
 The tapes holding the tracheostomy tube in position are
observed regularly to ensure that they are not too tight and
in case, they are loosened to promote circulation

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 The tapes holding the tracheostomy tube in position are
changed whenever soiled with clean ones to avoid skin
irritation and sepsis or as ordered by the ENT surgeon
 The tracheostomy tube is sucked as ordered to clear out the
secretions present along the air way to ensure a patent air
way and ease patient breathing.
 The inner tube is removed prn or as ordered, cleaned with
sodium bicarbonate or savlon and reinserted back into the
tracheostomy tube properly.
 If the tracheostomy tube is cuffed, its observed regularly ,
released and inflated prn as ordered by the surgeon
 The tracheostomy tube is permanently maintain in position
as ordered by the ENT surgeon

Continued Vital Observations

 Vital observations are continuously taken as ordered by the

ENT surgeon or 2 hourly and an observation chart is
maintained and any abnormality detected is noted and
reported to the surgeon throughout the post operative
period

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Elimination

 Bladder care
 A urinary catheter present is maintained in situ for
continuous bladder drainage throughout the recovery period
and urine in the urine bag is observed for color, smell and
amount and a fluid balance chart is maintained. After
recovery a urinary catheter is removed as ordered by the
ENT surgeon and is offered a bed pan (female) or urinal
(male) prn to open the bladder and any abnormality
detected is noted and reported throughout the post
operative period.
 Bowel care
 After recovery, the patient is offered a bed pan prn to open
the bowel and stool is observed for colour, smell, texture and
amount and any abnormality detected is noted reported to
the ENT surgeon throughout the post operative period.

Diet

 The NGT present is maintained in situ and the patient is

maintained on NIL per mouth until recovery and is fed
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 through the NGT on a light diet until is able to feed by
mouth. After recovery the NGT is removed and is fed on a
well balanced diet throughout the post operative period

Hygiene

The patient’s hygiene will be ensured by the following

throughout the post operative period;

 Daily bed bath and bed making to ensure patients comfort in

bed
 4 hourly treatments of pressure areas to prevent
development of pressure sores.
 Daily oral care to prevent oral complications such as halitosis,
stomatitis, gingivitis and to stimulate the appetite
 2 hourly turning of the patient to relieve pressure from
pressure areas to prevent development of pressure soers

Physiotherapy

 The patient is offered passive exercises and speech therapy

throughout the recovery period and thereafter is encouraged
to do active exercises like ambulation, deep breathing

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 exercises and neck and head rotation, shoulder exercises to
prevent respiratory, circulatory complications and neck
muscle rigidity.

Rest and Sleep

The patients time to rest and sleep will be ensured by the

following throughout the post operative period;

 Avoiding noise on the ward by restricting visitors and

allowing them only at visiting hours
 Administering post medication in time and prn
 Continued psychotherapy to alley anxiety

When the patient is fully improved following post operative

management the ENT surgeoan will consider his or her
discharge

Advice on Discharge

After discharge, the patient will be advised on the following

 To take drugs as prescribed by the ENT surgeon and to

ensure that he / she complete the dose

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 To come back for review on the date prescribed on the
discharge form.
 To always eat a light well balanced diet
 To come back as early as possible in cases of any early neck
complication.
 To avoid heavy lifting on the head until fully recovered
 To continue caring for the trachestomy tube and the stoma
to avoid sepsis
 To continue with regular exercises
 To avoid alcohol consumption and smoking
 To always to go or come back for radiation therapy and
chemotherapy prn

Complications of total laryngectomy

 Voice loss
 Dyphagia
 Parathyroid insufficiency / hypoparathyroidism
 Hypothyroidism
 Stromal recurrence
 Pharyngocuteneous fistula

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  Tracheal crusting
Staging of cancer of larynx
This is mainly based on the TNM system
T – Tumor
There are 5 main T stages for cancer of the larynx and these
include;

 Tis – Tumour in situ, cancer is contained in mucosa and has

not spread into any surrounding tissue.
 T1 – Tumour is only in one part of the larynx and the vocal
cords are able to move normally.

 T2 – Tumour which may have started on the vocal cords

(glottis), above the vocal cords (supraglottis) or below the
vocal cords (subglottis) has grown into another part of the
larynx.

 T3 – Tumour has grown into nearby areas such as the tissue

in front of the epiglottis or the inner part of the thyroid
cartilage.

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 T4 – Tumour has grown into body tissues outside the larynx
and has spread to the thyroid gland, windpipe (trachea) or
food pipe (oesophagus).

N – Nodes

There are 4 main N stages for cancer of the larynx and these
include;

 N0 – Lymph nodes don't contain cancer cells.

 N1 – Cancer cells have spread in one lymph node on the
same side of the neck as the cancer and the node is less than
3cm across.

 N2a – Cancer cells have spread in one lymph node on the

same side of the neck as the cancer and the node is between
3cm and 6cm across.

 N2b – Cancer cells have spread in more than one lymph node
on the same side of the neck as the cancer and all are smaller
than 6cm across.

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 N2c – Cancer cells have spread to the lymph nodes on both
side of the neck from the cancer and all are less than 6cm
across.

 N3 – Cancer cells have spread to at least one lymph node and

are larger than 6cm across.

M – Metastasis

There are 2 stages of metastasis

 M0 – No cancer spread to any part of the body

 M1 - Cancer has spread to other parts of the body, such as
the lungs

TUMORS OF NASOPHARYNX
These are tumors which affects the lower part of the nasal cavity
and the upper part of the pharynx
These may either be benign or malignant tumors
Benign tumor in the nasopharynx
 Nosapharayngeal Angiofibroma
This is the commonest benign tumour of the nasopharynx
common in males only at the age 10-20 years originating from
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the periosteum of the roof of nasopharynx or margin of the
sphenopalatine foramen in the posterior part of lateral nasal
wall.

Nasopharyngeal Angiofibroma
Clinical features
 Nasal obstruction
 Epistaxis
 Tinnitus
 Hearing loss
 Facial swelling
 Diplopia( double vision)
 Proptosis (down ward displacement of the eye ball resulting
into amass within the orbital cavity)
Investigations / diagnosis
 CT scan or MRI to detect and reveal the nature and size of
the tumor in the nasopharynx and to r/o complications

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 Management
 Surgery mainly excision to remove the tumor, Transnasal
endoscopic excision, transpalatal, lateral rhinotomy or
mid-facial degloving approach,
Malignant tumors of the nasopharynx
These include;
 Nasopharyngeal carcinoma
 Lymphomas mainly non - Hodgkin lymphoma
 Chondroma
Risk factors for nasopharyngeal carcinoma
 Ingestion of salted fish
 Excessive alcohol consumption
 Cigarette smoking
 Inhalation of industrial smoke and chemicals
 Virus eg Epstain barr virus and HPV
Clinical features
 Epistaxis
 Nasal obstruction
 Discharge from the nose
 Hearing loss
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 Tinnitus
 Otitis media
 Horseness
 Facial pain
 Altered sensation of the face
Diagnosis / investigations
 Facial CT scan / MRI to confirm the diagnosis
Management
 Surgery
 Radiation therapy
 Chemotherapy
Tumors of the Laryngopharynx (Hypopharyngeal Tumors)
Benign tumors in this region are rare and the malignant tumor
which is very common is the squamous cell carcinoma
Risk factors of hypopharyngeal tumors
These include;
 Cigarette smoking
 Excessive alcohol consumption
 Viruses eg Epstein Barr virus and HPV infection.
Clinical features

127
These include;
 Dysphagia
 Disphonia / hoarseness
 Reffered ear pain (otalgia)
 Weight loss
 Enlarged neck nodes
 Airway obstruction
Investigations
These include;
 Barium swallow to r/ o any obstruction along the
laryngopharynx
 Neck and chest x – ray to detect and reveal the size of the
heart and paratracheal regions due metastasis
 Neck CT MRI scan to confirm the diagnosis and r/o neck
complications due to metastasis
Management
 Surgery
 Radiation therapy
 Chemotherapy

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DISORDERS OF THE EYE
Terms used in ophthalmology
Accommodation
This is a process by which the eye adjusts for near distance (eg,
reading) by changing the curvature of the lens to focus a clear
image on the retina
Anterior chamber:
This is a space in the eye bordered anteriorly by the cornea and
posteriorly by the iris and pupil
Aphakia
This is absence of the natural lens
Astigmatism
This is a refractive error in which light rays are spread over a
diffuse area rather than sharply focused on the retina caused by
differences in the curvature of the cornea and lens
Binocular vision
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This is normal ability of both eyes to focus on one object fusing
the two images into one
Blindness
This is inability to see defined by a corrected visual acuity of
20/400 or less, or a visual field of not more than 20 degrees in
the better eye
Chemosis
This is edema of the conjunctiva
Cones
These are retinal photoreceptor cells essential for visual acuity
and color discrimination
Diplopia
This is seeing one object as two or double vision
Emmetropia
This is absence of refractive error
Enucleation
This is the complete removal of the eye ball and part of the optic
nerve
Exenteration
This is the surgical removal of the entire contents of the orbit,
including the eyeball and lids
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Evisceration
This is the removal of the intraocular contents through a corneal
or scleral incision but the optic nerve, sclera, extraocular
muscles, and the cornea are left intact
Hyperemia
This is red eye resulting from dilation of the vasculature of the
conjunctiva
Hyperopia
This means far sightedness (a refractive error in which the focus
of light rays from a distant object is behind the retina)
Hyphema
This means blood in the anterior chamber
Hypopyon
This is collection of inflammatory cells that has the appearance
of a pale layer in the inferior anterior chamber of the eye
Injection
This means congestion of blood vessels
Keratoconus
This is cone-shaped deformity of the cornea
Limbus
This is a junction of the cornea and sclera
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Myopia
This means near sightedness (a refractive error in which the
focus of light rays from a distant object is anterior to the retina)
Nystagmus
This is involuntary oscillation of the eyeball
Papilledema
This is swelling of the optic disc due to increased intracranial
pressure
Photophobia
This is ocular pain on exposure to light
Posterior chamber
This is a space between the iris and vitreous
Proptosis
This is downward displacement of the eyeball resulting from an
inflammatory condition of the orbit or a mass within the orbital
cavity
Ptosis
This is drooping of the eyelid
Rods
This is a retinal photoreceptor cells essential for bright and dim
light
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Scotomas
These are blind or partially blind areas in the visual field
Strabismus
This is a condition in which there is deviation from perfect
ocular alignment
Trachoma
This is a bilateral chronic follicular conjunctivitis of childhood
that leads to blindness during adulthood, if left untreated
Vitreous humor
These are gelatinous material (transparent and colorless) that
fills the eyeball behind the lens

DISORDERS OF THE EYE

These include;
CONJUNCTIVITIS
Key facts
 This is the inflammation of the conjunctiva of the eye.
 It is the most common ocular disease worldwide
characterized by a pink appearance (hence the common term

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 pink eye) because of the sub conjunctival blood vessel
hemorrhages
 Conjunctivitis may be unilateral or bilateral, but the infection
usually starts in one eye and then spreads to the other eye
by hand contact
Causes
Its caused by;
 Bacteria eg chlamydia
 Virus
 Fungi and parasites
 Eye trauma by chemicals or foreign bodies
 Smoke or irritating toxic stimuli into the eye
 Allergy
 Pre existing ocular infection
Clinical features of conjunctivitis
 Watery discharge from the eye (viral or chemicals)
 Pus discharge from the eye (bacteria)
 Cornea is clear and does not stain with fluorescein
 Visual acuity is normal

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 Redness (usually both eyes but may start/be worse in one
usually reddest at outer edge of the eye)
 Swelling and itching of the eye
 Photophobia
 Scratching or burning sensation of the eye

Types of conjunctivitis
Conjunctivitis is classified according to its cause and these
include;
Bacterial conjunctivitis
• This is commonly caused by bacteria eg staphylococcus
aureus, streptococcus pneumonia and Hemophilic
influenza and may be acute or chronic
• Staphylococcus aureus is the most common cause in
adults
• Its highly contagious from secretions or with contaminated
objects and surfaces.

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 • It lasts for 1 - 2 weeks and then it usually resolves
spontaneously
Signs and symptoms / clinical features of bacterial
conjunctivitis
• Eye redness and discharge which may be bilateral.
• The affected eye often is “stuck shut” in the morning
• Purulent eye discharge throughout the day
• Thick eye discharge which may be yellow, white or green
• Eye irritation, itching and discomfort
• Normal eye vision
• Purulent discharge at the lid margins and in the corners of
the eye
• Eye redness due to dilatation of superficial blood vessels
• Edema of the conjunctiva (chemosis)
• Swelling of the eyelids
• Corneal opacity if the cornea is involved
Viral conjunctivitis
• This is a highly contagious type of conjuctivitis spread by
direct contact with the patient and his or her secretions or
with contaminated objects & surface

136
 • The common causative organisms are adenovirus and
herpes simplex virus
• It usually presents with extreme tearing, watering or
watery discharge, photophobia, eye irritation, lid edema,
ptosis conjunctival hyperemia and foreign body sensation

that can involve one or both eyes.

• These signs and symptoms vary from mild to severe and

may last for 2 weeks and may also be acute or chronic
• The condition is usually preceded by symptoms of upper
respiratory infection.

Conjunctival hyperemia in viral conjunctivitis.

Allergic conjunctivitis
• This is a type of conjunctivitis caused by air borne allergy
contacting the eye.

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 • It is common in patients with history of an allergy to
pollens and other environmental allergens.
• It is more common in children and young adults and the
most affected individuals have a history of asthma or
eczema.
Signs and symptoms / clinical features include;
• Epiphora (ie, excessive secretion of tears)
• Severe photophobia
• Reddening of the eye
• Severe and persistent itching of both eyes
• Stringlike mucoid eye discharge
• No visual reduction
• Visual Acuity is normal
Chemical conjunctivitis
This is a type of conjunctivitis that may result from medications,
chlorine from swimming pools, exposure to toxic fumes among
industrial workers, or exposure to other irritants such as smoke,
hair sprays, acids, and alkalis.
Neonatal Conjunctivitis (Ophthalmia Neonatorum)

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  This is conjunctivitis in a newborn within the first 28 days
of life
Etiology / causes
 Its caused by bacteria mainly gonococcus and chlamydia
resulting into profuse thin to thick purulent eye discharge
Clinical presentations
• Purulent eye discharge
• Swelling of the eye lids
• Ulcer and scarring of the eye if cornea is involved
Prevention
• Clean the eye lids with saline swabs as soon as the head is
born and before the infant‘s eyes open.
• Apply Tetracycline eye ointment routinely whenever there
is a risk that the mother had these infections during
pregnancy.
Investigations
 Clinical features are diagnostic
 Pus swab for culture and sensitivity to identify and confirm
the causative micro oraganism
Management
139
Infective conjunctivitis
 Instill chloramphenicol or gentamicin eye drops 2 or 3 hourly
for 2 days then reduce to 1 drop every 6 hours for 5 days
 Change treatment as indicated by results of culture and
sensitivity where possible
Allergic conjunctivitis
 Apply cold compresses to the eyes
 Facial hygiene by thorough face washing with clean water
and soap
 Instill betamethasone or hydrocortisone eye drops every 1-2
hours until inflammation is controlled then apply 2 times
daily
Viral conjunctivitis
 Viral conjunctivitis is not responsive to any treatment but
may be managed by
 Applying cold compresses to the eye to alleviate some
symptoms
 Proper hand hygiene mainly handwashing
 Avoiding sharing hand towels, face cloths, and eye drops.
Chemical conjunctivitis
140
 For conjunctivitis caused by chemical irritants, the eye must
be irrigated immediately and profusely with saline or sterile
water.
Note
 NB. Gonococcal conjunctivitis should be treated aggressively
and in line with management of Sexually Transmitted
Infections
Prevention
 Proper personal hygiene by daily face washing using clean
water
 Avoid irritants and allergen
STYE (HORDEOLUM)
This is a localized infection of the hair follicle of the eyelids
Cause
 Bacteria mainly staphylococcus aureus
Clinical features
 Eye itching in the early stages
 Swelling of the eye
 Eye pain
 Eye tenderness
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 Pus formation
 May burst spontaneously

Differential diagnosis
 Other infections of the eyelids
 Blepharitis
Management
 Usually it heal spontaneously
 Avoid rubbing the eye as this might spread the infection
 Apply a warm / hot compress to the eye
 Apply tetracycline eye ointment 1% 2-4 times daily until
symptoms disappear
 Remove the eye lash when it is loose
 Give analgesics to relieve pain eg tablets ibuprofen 400mg
tds for 5 days

142
 Give oral antibiotic if severe eg caps flucamox 500mg qid for
5 days
 I &D of pus if present
Prevention
 Remove any loose eyelashes
 Good personal hygiene
 Early detection and medical intervation
Common ocular surgeries
These include
• Enucleation
• Exeteration
• Evisceration
Enucleation
 This is the removal of the entire eye and part of the optic
nerve.
 It may be performed for the following conditions:
• Severe injury resulting in prolapse of uveal tissue or loss of
light projection or perception

143
 • An irritated, blind, painful, deformed, or disfigured
eye,usually caused by glaucoma, retinal detachment, or
chronic inflammation
• An eye without useful vision that is producing or has
produced sympathetic ophthalmia in the other eye
• Intraocular tumors that are untreatable by other means
Evisceration
• This is the surgical removal of the intraocular contents
through an incision or opening in the cornea or sclera.
• The optic nerve, sclera, extraocular muscles, and
sometimes, the cornea are left intact.
• The main advantage of evisceration over enucleation is
that the final cosmetic result and motility after fitting the
ocular prosthesis are enhanced
• Its main disadvantage is the high risk of sympathetic
ophthalmia
Exenteration
• This is the removal of the eyelids, the eye, and various
amounts of orbital contents.

144
 • It is indicated in malignancies in the orbit that are life
threatening or when more conservative modalities of
treatment have failed or are inappropriate.
• An example is squamous cell carcinoma of the paranasal
sinuses, skin, and conjunctiva with deep orbital
involvement.
• In its most extensive form, exenteration may include the
removal of all orbital tissues and resection of the orbital
bones.

TRACHOMA
 This is a chronic infection of the outer eye caused by
Chlamydia trachomatis
 It is transmitted through direct personal contact, shared
towels and cloths, and flies that have come into contact with
the eyes or nose of an infected person.
 It’s a disease of poor hygiene and poverty
 It is a common cause of blindness if not treated
Cause of trachoma
 Its caused by bacteria mainly chlamydia trachomatis
Clinical features

145
In early stages symptoms include;
 Reddening of eye
 Discharge from the eye
 Itching of the eye
 Photophobia
 Ocular pain
 Follicles (grain-like growth) on conjunctival
 Decreased visual acuity
In case of repeated untreated infections or late symptoms
include;
 Scar formation on eyelids causing the upper eyelid to turn
inwards (entropion) and the eyelashes to scratch the cornea
 Scarring of the cornea leading to blindness
 Corneal opacities in older children and adults
Investigations
No investigation is required and done
WHO grading of trachoma
TF – At least five follicles in the upper tarsal conjunctiva,
Indicates active disease and need for treatment
TI – Intense inflammation, need for urgent treatment

146
TS – Scarring stage, old infection now inactive
TT –Trachoma trichiasis, needs surgical treatment
CO – Corneal opacities. Visual loss from previous infection
Differential diagnosis
 Allergic conjunctivitis (chronic)
 Other chronic infections of the eye
Management
 Apply tetracycline eye ointment 1% twice daily for 4-6 weeks
(until the infection / inflammation has disappeared)
 Give erythromycin 500 mg every 6 hours for 14 days or
azithromycin 500mg once daily for 3 – 5 days.
 Regular washing of the face
 Good water and sanitation
 If there is any complications refer for specialist management
and surgery of the entropion

GLAUCOMA
Key facts

147
 Glaucoma is a group of disorders characterized by loss of
visual field associated with cupping of the optic disc and
optic nerve damage. or
 Its a group of ocular conditions characterized by optic nerve
damage related to IOP caused by congestion of aqueous
humor in the eye.
 In the past, it was seen more as a condition of elevated
intraocular pressure (IOP) than of optic neuropathy.
 Glaucoma is the second leading causes of blindness among
adults
 There is no cure for glaucoma, but the disease can be
controlled.
 It is not one disease but rather group of disorders
characterized by; increased intraocular pressure and the
consequences of elevated pressure, optic nerve atrophy and
peripheral visual
 The term glaucoma refers to a group of disorders such as:
 Primary open angle glaucoma (POAG): Is chronic or simple
usually caused by obstruction in the trabecular meshwork.

148
 Secondary open angle glaucoma (SOAG): Occur from an
abnormality in the trabecular meshwork or an increase in
venous pressure.
 Primary angle-closure glaucoma (PACG): Narrow angle,
acute PACG outflow impaired as a result of narrowing or
closing of angle between iris and cornea.
 Secondary angle-closure: results from ocular inflammations,
blood vessel changes and trauma.
 Congenital glaucoma: Is an abnormal development of
filtration angle, can occur secondary to other systemic eye
disorders.
NB: The normal balance of production and drainage of aqueous
humor allows IOP to remain relatively constant within the
normal range of 10 to 21 mm Hg with a mean pressure of 16
mm Hg.
Etiology or causes of glaucoma
 Blockage and poor drainage of aqueous humuor from the
anterior chamber of the eye

149
 Raised or elevated intraocular pressure (IOP) inside the eye.
(It can also occur when this pressure is within the normal
range)20
A proper balance between the rate of aqueous production
(inflow) and the rate of aqueous reabsorption (outflow) is
essential to maintain the IOP within the normal limits.
Risk factors for glaucoma
 Family history of glaucoma
 Race (African American race)
 Older age above 40 years
 Diabetes
 Cardiovascular disease
 Migraine syndromes
 Near or short sightedness (myopia)
 Eye trauma
 Prolonged use of topical and systemic corticosteroids
 Raised intra-ocular pressure
 Central corneal thickness
Classification of Glaucoma
 Open angle glaucoma
150
  Angle closure glaucoma (also called pupillary block)
 Congenital glaucoma and glaucoma associated with other
conditions.
• Glaucoma can be primary or secondary, depending on
whether associated factors contribute to the rise in IOP.
• The two common clinical forms of glaucoma encountered in
adults are primary open angle glaucoma (POAG) and angle-
closure glaucoma, which are differentiated by the
mechanisms that cause impaired aqueous outflow.
• Primary open-angle glaucoma is the most common.
Types of glaucoma
 Open angle glaucoma
This is usually bilateral, but one eye may be more severely
affected than the other.
In all the three types of open-angle glaucoma, the anterior
chamber angle is open and appears normal
Types of open angle glaucoma
These include;
 Chronic open-angle glaucoma (COAG)
 Normal tension glaucoma
151
  Ocular hypertension
 Closed angle glaucoma
This is due to obstruction in aqueous humor outflow due to
complete or partial closure of the angle from the forward shift of
the peripheral iris to the trabecula which results into an
increased IOP
Types of angle closure glaucoma
These include;
 Acute angle-closure glaucoma (AACG)
 Sub acute angle-closure glaucoma
 Chronic angle-closure glaucoma
 Congenital glaucoma
This is an abnormal development of filtration angle.It can occur
secondary to other systemic eye disorders.
Stages of glaucoma
Regardless of the cause of damage, glaucomatous changes
typically evolve through clearly discernible stages:
 Initiating events

152
This is the first stage of glaucoma and its precipitating factors
include illness, emotional stress, congenital narrow angles, drugs
(ie long-term use of corticosteroids.
These events lead to the second stage.
 Structural alterations in the aqueous outflow system
During this stage tissue and cellular changes caused by factors
that affect aqueous humor dynamics lead to structural and
functional alterations.
 Functional alterations
During this stage conditions such as increased IOP or impaired
blood flow create functional changes that lead to optic nerve
damage.
 Optic nerve damage
This is characterized by loss of nerve fibers and blood supply
hence visual loss
 Visual loss
This is characterized by visual field defects.
Clinical features of glaucoma
Open angle glaucoma
 Mostly asymptomatic

153
  History of gradual loss of vision in affected eye or loss of
visual field
 Often suspected after seeing cupping of optic disc on
routine fundoscopy or finding elevated intra-ocular
pressure on screening
Angle-closure glaucoma
 Sudden onset of severe eye pain and redness, associated
with nausea, vomiting and headache
 Difficulty adjusting of the eyes in low lighting
 Loss of vision in the affected eye
 Coloured halos or bright rings around lights
 Hazy-looking cornea
 Fixed or semi-dilated pupil
 Shallow anterior chamber
 Severely elevated IOP. (When palpated with a finger, the
affected eye feels hard, compared to the other eye)
 If IOP rises more slowly, the patient may be asymptomatic
with gradual loss of vision
 Permanent blindness due to marked increase in IOP for 24
to 48 hours.
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Congenital Glaucoma
 Enlargement of the eye
 Lacrimation
 Photophobia
 Blepharospasm
Investigations
These include:
 Visual acuity measurement with the snellens chart
 Tonometry to measure IOP of the eye
 Tonography to estimate the resistance in the outflow
channels by continuously recording the IOP for over 2 to 4
minutes
 Ophthalmoscopy to evaluate the color and configuration
of the optic cup or to inspect the optic nerve
 Visual field permietry to measure the visual function in the
central field of vision or for visual field assessment.
 Gonicoscopy: to examine the angle structures of the eye,
where the iris, ciliary body and cornea meet.
Management

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 The aim of treatment is to arrest / delay progress of the
disease rather than visual improvement ie to prevent optic
nerve damage and therapy is usually life long
 Angle-closure glaucoma is a medical emergency that requires
urgent reduction of intra ocular pressure
 Management is both medical and surgery
Medical Treatment
Open-angle glaucoma
 Instill Timolol 0.5% eye drops 1 drop to the eye12 hourly
daily for 7 days
Angle-closure glaucoma (acute)
 Administer mannitol 20% IV to reduce raised IOP
 Give tablets acetazolamide 500 mg single dose followed by
250 mg every 6 hours to decrease aqueous humor
production and reduce intraocular pressure
 Instill timolol 0.5% eye drops 1 drop 12 hourly daily on the
eye to decrease aqueous humor production
Surgical management
This is indicated when conservative treatments fail to control the
IOP and they include;
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 Argon laser trabeculoplasty (ALT) or laser trabeculoplasty
 Here laser burns are applied to the inner surface of the
trabecular meshwork to open the intratrabecular spaces
and widen the canal of Schlemm, thereby promoting
outflow of aqueous humor hence decreasing the IOP
 The procedure is indicated when IOP is inadequately
controlled by medications
 It is contraindicated when the trabecular meshwork
cannot be fully visualized because of narrow angles.
 its complication is a transient rise in IOP (usually 2 hours
after surgery) that may become persistent.
 Trabeculectomy with or without filtering implant.
This is a standard filtering technique used to remove part of the
trabecular meshwork.
Its complications include
 Hemorrhage
 An extremely low (hypotony) or elevated IOP
 Uveitis
 Cataracts
 Bleb failure
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  Bleb leakage
 Endophthalmitis
 Laser iridotomy for pupillary block glaucoma
This is an opening made in the iris to eliminate the pupillary
blockage
It is contraindicated in patients with corneal edema, which
interferes with laser targeting and strength.
Its potential complications include;
 Burns to the cornea, lens, or retina
 Transient elevated IOP
 Closure of the iridotomy (Pilocarpine is usually prescribed to
prevent closure of the iridotomy)
 Uveitis and blurring.
 Cyclocryotherapy; to destroy the ciliary body.
 Filtering procedures for chronic glaucoma
 These are used to create an opening or fistula in the
trabecular meshwork to drain aqueous humor from the
anterior chamber to the subconjunctival space into a bleb,
thereby bypassing the usual drainage structures.

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  This allows the aqueous humor to flow and exit by
different routes (ie, absorption by the conjunctival vessels
or mixing with tears).
 Drainage implants or shunts
 These are open tubes implanted in the anterior chamber
to shunt aqueous humor to an attached plate in the
conjunctival space.
 A fibrous capsule develops around the episcleral plate and
filters the aqueous humor, thereby regulating the outflow
and controlling IOP.
Caution
Avoid timolol eye drops in patients with asthma, heart block
and uncontrolled heart failure

EYE TRAUMA AND INJURY

 An injury to the eye may result in vision loss.
 Ocular injuries can involve the ocular adnexa, the superficial
structures and or the deeper ocular structures.
 Eye injuries can result in permanent blindness though most
injuries are preventable.
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 It is important to recognize serious eye injuries and give
appropriate treatment or refer to a specialist immediately .
Causes
 Blunt injury from a blunt object like a ball or a fist
 A perforating injury from a sharp object, like, a knife, high
velocity projectiles from explosives
 Exposure to chemicals
 Thermal injuries
General Clinical Manifestation of eye trauma and injury
After the injury or trauma, the following signs and symptoms
are found depending upon the extent of injury or trauma.
 Eye pain
 Absent eye movement
 Photophobia
 Fluid drainage from the eye (e.g. blood, CSF, aqueous
tumor).
 Eye redness which may be diffuse
 Abnormal or decreased vision or localized vision
 Swelling of the eye (conjunctival swelling)
 Visible foreign body in the eye.
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  Ecchymosis within the eye (sub conjuctival haemorrhage)
 Prolapse of the bleb
 Tearing of the eye (lacrimation)
 Abnormal intraocular pressure.
 Presence of blood in the anterior chamber.
Types of eye trauma and injuries
 Blunt Injuries
 A blunt object striking the eye with great force may result in
minor or severe injury to the eye without a full thickness
wound to the eye ball.
 Examples of the blunt eye injuries sustained include
contusion and lamellar laceration
 Different structures of the eye may be involved and may
include;
Anatomical structure Clinical features
involved
Lids, cornea, and  Mild to severe swelling of
the conjunctiva eyelid
 Subcutaneous bleeding.

161
  Corneal abrasions
 Conjunctival swelling
 Sub conjunctival
haemorrhages
Anterior chamber,  Decreased visual acuity (this
lens, vitreous or is an indication that the
retina injury involved either the
anterior chamber, lens,
vitreous, or retina).
 Poor vision
 Blindness
Orbital bones  Orbital bone fractures.
(Commonest is a fracture of
the ethmoid bone).
 Swelling of the eye
 Sunken or retracted eyeball
(depending on the site of
the fracture)
 Double vision (Diplopia)

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  Proptosis if there is
haemorrhage in the orbit

Management
 Assess the visual acuity, and if this is normal and there are no
signs / symptoms of orbital bone fracture;
• Instill or apply antibiotic eye drops or ointments eg
Gentamicin or chloramphenicol eye drops or tetracycline
eye ointment
• Give tablets Paracetamol 1g tds to relieve pain for 3-5 days
• Apply cold compress to avoid lid swelling
 If the visual acuity is poor, pad the eye, give a pain reliever
and refer urgently the patient to a specialist as this is an
indication of injury to deeper structures
Complications of blunt eye injuries
 Hyphema
• This is presence of blood in the anterior chamber.
• Its treated by putting the patient in a semi sitting up
position and early referral to the ophthalmologist for
specialized management

163
 Rupture of suspensory ligaments. (This leads to the
dislocation of lens)
 Delayed cataract (due to concussion damage of lens cells)
 Concealed eyeball rupture

 Penetrating Eye Injuries

Penetrating eye injuries are common in children and adults and
results from injuries by sharp objects eg pieces of glass, metal,
wood, knife, stick or other large objects.
Examples of penetrating eye injuries
Eyelid Injuries
 This is an injury involving the eyelid margin caused by any
sharp object
 A cut involving the lid margin requires appropriate repair
under magnification so that its well approximated, otherwise
if not well repaired it may heal with a coloboma effect
• A cut involving the eye lids may injure the lacrimal system
if located in the medial aspect of the lid
Corneal and Scleral Perforations

164
 All perforations of the cornea or sclera are serious injuries
and may lead to blindness.
 Apply an eye shield to protect the eye from direct light
 Give a pain reliever eg tablets paracetamol 1g or im
Diclofenac 75mg to control pain and refer the patient
immediately to an Ophthalmologist
 At secondary or tertiary level, treatment of corneal / scleral
lacerations is immediate repair with 10/0 sutures under an
operating microscope, or if the laceration is extensive, an
immediate evisceration of the eye is performed
Complication of penetrating eye injuries
 Corneal scar
 Cataract
 Endophthalmitis (intra ocular infection)
 Chemical Injuries to the Eye
 Various chemicals may injure the eye when they come into
contact with the eyes or face.
 The commonest are acidic and alkaline chemical products.
 Acidic and Alkaline chemical products cause serious injuries
to the eye lids, cornea, and conjunctivae.
165
Management
First aid
 On exposure to acid or chemical products, immediately
irrigate the eyes with copious amounts of water to reduce
its effect on the eye
At health facility
 On arrival at a medical centre, continue irrigation of the eye
with normal saline to wash out the entire chemical
 After irrigating of the eye, apply tetracycline eye ointment,
pad the eye, and refer to an ophthalmologist immediately
for further management
 In case of tear gas, irrigate the eyes with plenty of water
since tear gas injury is usually short lived and does not
usually require treatment
 Thermal injury
 This is either due to direct burn from curling iron, or other
hot surface or indirect burn from ultraviolet light (e.g.
welding), sun ultraviolet burns from excessive sun exposure
(eg skiing, outdoor work, or sunbathing) or and use of heat
lamps and tanning beds.
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 Foreign Body in the Eye
This is the presence of an external object or substance in the eye.
FB in the eye is the most common eye injury and can be on the
conjunctiva or cornea
Conjunctival foreign body
 Its mostly found on the upper tarsal conjunctiva
 It is good to check for FB by everting the upper eye lid
 Needs illumination and remove it by a cotton tip from the
eye
 Irrigate the eye with normal saline or tap water if foreign
body cannot be traced in the eye
Corneal foreign body
 It can be on the surface or embedded in the cornea of the
eye
 Patient complains of pain and foreign body sensation within
the eye
 Use adequate light to visualize it on the cornea
Causes
 It may be accidental and the FB may be;
 Solids such as dust, insects, metal or wood particles
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  Liquids such as splashes of irritating fluids or chemical
Clinical features
 Severe eye pain
 Eye tearing
 Eye redness
 Foreign body (FB) may be visible
 Inability to open the eye
 Feeling of something in the eye which may be irritating
 Photophobia
 Irregular pupil
 Sub conjunctival haemorrhage
Differential diagnosis
 Other injury or trauma
Management
 Make a thin ‘finger’ of moistened cotton wool, move eyelid
out of the way, and gently remove FB from the eye if visible
 If this fails, apply tetracycline eye ointment 1%, pad the eye
and refer to the Eye Specialist for further management
 In case of irritating fluids in the eye, wash the eye with plenty
of clean water or normal saline
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 If the cornea is damaged, apply tetracycline eye ointment
1%, cover or pad the eye, and refer to the Eye Specialist for
further management
 Give tablets paracetamol 1g three times daily to relieve pain
Prevention of eye injuries
In the hospital
This is by;
 Reading instructions carefully before using cleaning fluids,
detergents, ammonia, or harsh chemicals and wash hands
thoroughly after use.
 Wearing special goggles to shield your eyes from fumes and
splashes when using powerful chemicals.
 Use of opaque goggles to avoid burns from sunlamps
 Avoiding praying with sharp objects such as surgical blades,
needles, used syringes etc
In and Around the House
This is by;
 Making sure that all spray nozzles are directed away from
you before you press down on the handle.

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 Reading instructions carefully before using cleaning fluids,
detergents, ammonia, or harsh chemicals and wash hands
thoroughly after use.
 Using grease shields on frying pans to decrease spattering.
 Wearing special goggles to shield your eyes from fumes and
splashes when using powerful chemicals.
 Using opaque goggles to avoid burns from sunlamps.
In the Workshop
This is by;
 Protecting your eyes from flying fragments, fumes, dust
particles, sparks, and splashed chemicals by wearing safety
glasses
 Reading instructions thoroughly before using tools and
chemicals, and follow precautions for their use
Around Children
This is by;
 Paying attention to the age and maturity level of a child
when selecting toys and games by avoiding projectile toys,
such as darts and pellet guns

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 Supervising children when they are playing with toys or
games that are dangerous
 Teaching children the correct way to handle potentially
dangerous items, such as scissors and pencils
In Sports
This is by;
 Wearing protective safety glasses, especially for sports
such as racquetball, squash, tennis, baseball, and
basketball
 Wearing protective caps, helmets, or face protectors
especially during sports such as ice hockey.
Around Fireworks
This is by;
 Wearing eye glasses or safety goggles
 Not using explosive fireworks.
 Not allowing children to ignite fireworks.
 Not standing near others when lighting fireworks.

CATARACT
Key facts
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 This is the opacity or cloudiness of the lens inside the eye
 Cataracts can develop in one or both eyes and at any age.
 It is the most common cause of blindness in Uganda.
Causes of cataract
These include:
 Overproduction of oxidants, which are oxygen molecules
that have been chemically altered due to normal daily life
 Smoking
 Long-term use of steroids and other medication
 Certain diseases, such as diabetes, hypoparathyroidism etc
 Trauma to the eye
 Radiation therapy and Ultraviolet radiation
 Congenital
 Other eye disorders eg uveitis, glaucoma, retinitis
pigmentosa, or detached retina.
Risk factors
 Old age
 Sex (slightly common in female than male)
 Diabetes (high blood sugar)
 Certain drugs e.g. corticosteroids
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 Eye injuries eg blunt and penetrating trauma
 Cigarette smoking
 Ultraviolet light and ionizing radiation exposure
 Obesity
 Family history of cataract
 Heavy use of alcohol
Types of Cataracts
There are different types of cataracts and are classified basing on
where and how they develop in the eye
Nuclear cataract
 This forms in the middle of the lens and causes the nucleus
or the center to become yellow or brown.
Cortical cataract
 These are wedge-shaped and form around the edges of the
nucleus.
Posterior capsular cataract
 This form is faster than th e other two types and affects the
back of the lens.
Congenital cataract

173
 This is present at birth, where some babies are born with
cataract or develop it in childhood and often affects both
eyes.
 They may be so small that they do not affect vision but if
they do, the lenses may need to be removed.
Secondary cataract
 This is caused by disease or medications such as glaucoma,
diabetes and uveitis, use of the steroid eg prednisone
Traumatic cataract
 This develops after an injury to the eye eg foreign body allow
aqueous or vitreous humor to enter the lens capsule..
Radiation cataract
 This occurs after radiation treatment for cancer or exposure
to some types of radiation.
Clinical features
 Reduced vision
 Pupil is not a normal black colour but is grey, white,
brown, or reddish in colour
 Condition is not painful unless caused by trauma
 Eye is not red unless condition is caused by trauma
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  Light scattering leading to reduced contrast sensitivity,
sensitivity to glare, and reduced visual acuity.
 Myopic shift (return of ability to do close work [eg, reading
fine print] without eye glasses)
 Astigmatism
 Monocular diplopia (double vision)
 Brunescens (ie, color values shift to yellow-brown)
 Reduced light transmission.

Investigations
The diagnostic tests of cataract include the following:
 Visual acuity test using an eye chart to measures how well a
patient see at various distances
 Ophthalmoscopy (direct or indirect).
 Snellen visual acuity test
 Slit lamp biomicroscopic examination (are used to establish
the degree of cataract formation)
Management
Management may involve both medical and surgical
management
Medical management

175
 No non surgical treatment cures cataracts or prevents age-
related cataracts thus therefore refer the patient to the eye
specialist(ophthalmologist) for further management
 Use of glasses or contact, bifocal, or magnifying lenses which
may improve vision.
 Reassurance of the client
Surgical Management
 In general, if reduced vision from cataract does not interfere
with normal activities, surgery may not be needed.
 In deciding when cataract surgery is to be performed, the
patient’s functional and visual status should be a primary
consideration.
 Surgical options include;
• Phacoemulsification (method of extracapsular cataract
surgery and removal of the lens)
This method of extracapsular surgery uses an ultrasonic device
that liquefies the nucleus and cortex, which are then suctioned
out through a tube but the posterior capsule is left intact.

176
• Lens replacement eg (aphakic eyeglasses, contact lenses, and
intraocular lens implants). After removal of the crystalline
lens, the patient is referred to as aphakic (ie, without lens)

 Cataracts are removed under local anesthesia on an

outpatient basis.
 When both eyes have cataracts, one eye is treated first, with
at least several weeks, preferably months, separating the
two procedures.
Potential complications of cataract surgery
Immediate Preoperative
 Retrobulbar hemorrhage:
This results into increased IOP, proptosis, lid tightness, and
subconjunctival hemorrhage with or without edema
Intraoperative Complications
 Rupture of the posterior capsule
 Suprachoroidal (expulsive) hemorrhage: profuse bleeding
into the suprachoroidal space

Early Postoperative Complications

177
  Acute bacterial endophthalmitis: caused by Staphylococcus
epidermitus, S. aureus, Pseudomonas and Proteus species
 This is characterized by marked visual loss, pain, lid
edema, hypopyon, corneal haze, and chemosis
Late Postoperative Complications
 Suture-related problems
 Malposition of the IOL(intraocular lens)
 Chronic endophthalmitis (severe chronic inflammation
involving both the anterior and posterior segments of the
eye after intraocular surgery)
 Opacification of the posterior capsule (most common late
complication of extracapsular cataract extraction)
These may result from toxic reactions or mechanical injury from
broken or loose sutures, results in astigmatism, sensitivity to
glare, or appearance of halos, persistent, low-grade inflammation
and granuloma and visual acuity is diminished.

PAEDIATRIC CATARACT
Cataract in children is unique as it may interfere with the normal
development of vision resulting in lazy eye (amblyopia).

178
Causes
 Hereditary/genetic disorders
 Intrauterine infections (TORCHES)
 Drugs
 Trauma
 Metabolic diseases e.g. Diabetes
 Unknown
Symptoms
 A white pupil
 Older children may complain of poor vision
 “Dancing eyes” (nystagmus), squints
Investigations
If at HC2 or HC3 reassure patient and refer to hospital
Management
 Condition is managed surgically under general anaesthesia
 Surgery can be done as early as one month of age
 Patching/occlusion therapy in case of lazy eyes (amblyopia)
 Aphakic children /those less than one year who are not
implanted should be given aphakic glasses or contact lenses
Prevention
179
 Wear protective goggles when hammering, sawing,
chopping, grinding, etc.
 Caution children playing with sticks about risk of eye injuries
Pre and post operative management after cataract surgery
(brain storm)
CORNEAL ULCERS
This is the pitting of the cornea caused by bacteria, viruses,
fungi and or protozoan or sometimes from injury
This is an emergency
Causes
 Bacteria eg staphylococci, pneumococci
 Viruses
 Fungi
 Foreign body lodged in the eye
 Vitamin A and protein deficiency
Clinical features
 Eye pain
 Sensitivity to light / photophobia
 Reduced vision
 Increased tear production / lacrimation

180
 Pus discharge may appear on the cornea
 Reddening of the eye
Complications of corneal ulcers
 Impaired vision and scaring
 Perforation of the cornea
 Displacement of the iris
 Destruction of the eye
 Deep seated infection
Management
 Apply eye drops
 Use antibiotics
 Surgery

KERATITIS
This is the inflammation of the cornea.
Causes
 Infection eg bacterial, viral, or fungal infections leading to
corneal ulceration
 Trauma by Chemical, foreign bodies
Clinical features
181
 Redness and tearing of the eye
 Fear of light / photophobia
 Cornea is not clear and will stain with fluorescein in the case
of corneal ulcer (pattern of staining depends on the causative
agent, for example dendritic in viral keratitis)
 Visual acuity is usually reduced
 Condition is often unilateral
 The eye is painful
Investigations (where facilities are available)
 Full ocular examination to r/o ocular abnormality
 Fluorescein stain to confirm diagnosis
 Pus swab for gram stain, culture and sensitivity to identify
and confirm the causative micro organisms
 Corneal scraping for microscopy, culture and sensitivity to
detect for and confirm the causative micro oraganism
Management
 Admit the patient on eye ward
 If the cause is bacterial, apply gentamicin eye drops
alternately with chloramphenicol eye drops 1–2 hourly until
infection is controlled
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 If viral, acyclovir eye ointment 5 times daily for herpes
simplex and viral keratitis
 If fungal, natamycin ophthalmic suspension 5% or econazole
eye drops
 Apply Atropine eye drops to relieve pain
 Give Vitamin A capsules for children
 Surgery i.e. conjunctival flap and tarsorrhaphy
 Debridement (chemical/ mechanical)
Orbital Cellulitis
This is a sudden acute inflammation of the tissues around the
eye.
Causes
The cause is mainly bacteria by haemophilus influenza in
children leading to post sinus infection and Staphylococcus
aureus, Streptococcus pneumonia in adults
Risk factors
 Sinus infection
 Tooth extraction
 Orbital trauma
Clinical features

183
 Painful swelling of the eye
 Pain in the eye especially on eye movements
 Decreased vision
 Fever and headache
Investigations
 Good history and physical examination
Management
 This is an emergency and needs immediate referral to the
ophthalmologist
Prevention
 Prompt treatment of sinus and dental infections
 Complete immunization schedule for children, more
especially Hib vaccine (included in the pentavalent DPT/
HepB/Hib vaccine)

CANCER OF THE OESOPHOGUS

 This is cancer that affects the esophagus

 Tumor cells may involve the esophageal mucosa and
muscle layers and can spread to the lymphatics, obstruct

184
 the esophagus, perforate the mediastinum, or erode into
the great vessels in later stages.
Causes of Ca esophagus

The actual cause is unknown but it can be due to the following

risk factors

 Gender (male).
 Race (African American).
 Age (greater risk in fifth decade of life).
 Geographic locale (much higher incidence in China and
northern Iran).
 Chronic esophageal irritation.
 Use of alcohol and tobacco.
 Gastroesophageal reflux disease (GERD).
 Chronic ingestion of hot liquids or foods
 Nutritional deficiencies,
 Poor oral hygiene
 Exposure to nitrosamines in the environment or food

Clinical presentations of Ca esophagus

185
  Ca esophagus in early stages is largely asymptomatic
 Patient usually presents with an advanced ulcerated lesion
of the esophagus
 Dysphagia
 Odynophagia (steady, dull, substernal pain)
 Regurgitation first with solid foods and eventually liquids.
 Feeling of a lump in the throat and painful swallowing
 Heartburn
 Anorexia
 Hemorrhage
 Weight loss.
Types of Ca esophagus

These include the following

Adenocarcinoma

 It occurs in the lower third of the oesophagus and is

associated with dietary nitrosamines, GERD etc

Squamous cell carcinoma

186
 It occurs anywhere in the oesophagus and is associated with
smoking, alcohol intake, diet poor in fresh fruit and
vegetables, chronic achalasia etc
Investigations

 Barium swallow with fluoroscopy to detect for any

esophageal narrowing at the site of the tumor
 Esophagoscopy with biopsy to confirm the diagnosis of
carcinoma by identification of malignant cells
 Endoscopy to detect for tumor invasion to muscle layer.
 Bronchoscopic examination to detect for malignant
involvements of the trachea.
 Computerized tomography scanning (esophageal CT scan)
to assess the extent of the disease along the esophogas
and the surrounding organs
Management
Treatment of esophageal cancer is based on the location and size
of the tumor, degree of metastasis and the individual health
status and involves the following;
 Surgery (eg, esophagectomy)

187
  Radiotherapy
 Chemotherapy
 Palliative therapy to maintain esophageal patency by
dilation of the esophagus using a stent, balloon etc
Complications of Ca esophagus
 Hemorrhage (may occur if the cancer erodes through the
esophagus and into the aorta.
 Esophageal perforation with fistula formation into the lung
or trachea
 Esophageal obstruction due to enlargement of the tumor.
CANCER OF THE CERVIX

 This is the commonest type of cancer in women that affects

the cervix
 It is a cancer which is spread predominantly through sexual
contact
 It’s the type of cancer found in prostitutes

Causes of Ca cervix

The actual cause is unknown but it can be due to the following

risk factors
188
 Low socioeconomic status (poverty)
 Early age at first coitus
 Multiple sexual partners
 History of STD
 Short interval between menarche and first coitus
 Sexual contact with men whose partners have had cervical
cancer,
 Exposure to Human Papilloma Virus (sexually transmitted)
 Early age at first pregnancy ( early child bearing)
 Prostitution
 Multiparity
 Lack of regular pap smear screening
 Cigarette smoking
 Use of oral contraceptives
 Nulliparity
 Frequent douching
 Nutritional deficiencies (folate, beta-carotene, and vitamin C
levels are lower in women with cervical cancer than in
women without it)

189
 Chronic cervical infection
 HIV infection
Clinical Manifestations
 Cervical cancer is often asymptomatic in early stages
 Irregular or intermittent vaginal bleeding after sexual
intercourse or douching
 Watery, dark and foul smelling vaginal discharge because of
necrosis and infection of the tumor
 Irregular vaginal bleeding between periods or after
menopause after mild trauma ie (intercourse, douching, or
defecation)
 Lower abdominal pain on palpation
 Enlargement of the uterus on bimanual examination
 Cervical lesions like cervical ulcerations or necrotic tissues or
polypoid mass on speculum examination
 Thick, hard and irregular septum on rectovaginal
examination
 Rectal bleeding following rectal involvement
 Edema of the extremities following metastasis

190
 Excruciating pain in the back and legs due to nerve
involvement
 Anemia following
Investigations

 CBC r/o anaemia and any bacterial infections

 LFT to r/o liver involvement
 Urinalysis to r/o hematuria and bladder involvement
 Abdominal CT scan to r/o distant metastasis
 Proctoscopy to r/o rectal involvement
 Cervical biopsy to confirm the cancer

Management of cervical cancer

 Surgery ( hysterectomy ie total or radical)

 Radio therapy
 Chemotherapy

Complications of cervical cancer

 Ureteral stricture
 Bladder dysfunction
 Constipation

191
  Altered sexual function secondary to a shortened vagina
 Dyspareunia
 Psychological factors eg depression
 Vaginal stenosis
 Fistula formation

Preventive Measures of cervical cancer

 Regular pelvic examinations and Pap tests for all women,
especially older women past childbearing age
 Education related to reproductive health and safer sex
 Smoking cessation

Clinical staging of cervical cancer

Clinical Stages of Cervical Cancer (FIGO, Revised 1994)

Stage Characteristics
0 Carcinoma in situ, cervical intraepithelial lesion (CIN) 3
I Carcinoma is strictly confined to cervix (extension to
corpus should be disregarded)

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Stage Characteristics
IA Invasion is limited to measured stromal invasion with a
maximum depth of 5 mm and no wider than 7mm
IA1 Measured invasion of stroma no greater than 3 mm in
depth and no wider than 7 mm
IA2 Measured invasion of stroma greater than 3 mm and no
greater than 5 mm in depth and no wider than 7mm
IB Clinical lesions confined to the cervix or preclinical
lesions greater than IA
IB1 Clinical lesions not greater than 4 cm in size
IB2 Clinical lesions greater than 4 cm in size
II Carcinoma extends beyond cervix but has not extended to
pelvic wall; it involves vagina, but not as far as the lower
third
IIA No obvious parametrial involvement
IIB Obvious parametrial involvement
III Carcinoma has extended to the pelvic wall; on rectal
examination there is no cancer-free space between tumor
and pelvic wall; tumor involves lower third of vagina; all

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Stage Characteristics
cases with hydronephrosis or nonfunctioning kidney
should be included, unless they are known to be due to
another cause
IIIA No extension to pelvic wall, but involvement of lower
third of vagina
IIIB Extension to pelvic wall, or hydronephrosis or
nonfunctioning kidney due to tumor
IV Carcinoma has extended beyond true pelvis or has
clinically involved mucosa of bladder or rectum
IVA Spread of growth to adjacent pelvic organs
IVB Spread to distant organs

FIGO = International Federation of Obstetricians and

Gynecologists.

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