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PRIMARY EAR, NOSE & THROAT CARE

A TRAINING MANUAL FOR


PRIMARY HEALTH CARE WORKERS AND PRESCRIBERS
DR. DANIEL ASARE MD,MA,DLOWACS MEDICAL SUPERINTENDENT ENT SURGEON REGIONAL HOSPITAL SUNYANI

OUTLINE OF LECTURES
LECTURE 1
Anatomy, physiology,

Signs and symptoms of ear disease


Management of common ear diseases

LECTURE 2
Hearing is a Public Health and a social issue

Prevention of deafness
Causes of hearing Treatment of hearing loss

LECTURE 3
Anatomy physiology of nose and paranasal sinuses Signs and symptoms of nose and paranasal diseases Sinusitis, rhinitis, epistaxis Treatment of common nasal diseases

LECTURE 4
1.Practical session Otoscopy Rhinoscopy Technique of syringing Examination of buccal cavity 2.Radiology Interpretation of x-rays of common ENT emergencies 3.Quiz end of session exams on E.N.T Disease

LECTURE 1

INTRODUCTION TO

OTORHINOLARYNGOLOGY
FOR NURSES

THE FIELD OF OTORHINOLARYNGOLOGY COVERS DISEASES OF THE

1. Ear
2. Nose

3. larynx
4. Pharynx

5. Buccal cavity
6. Oesophagus (upper)

Most of the Ear, Nose Throat (ENT) area is


accessible to direct visualization and a good part can be examined normally and digitally. Certain structures such as pharynx larynx nasopharynx requires light for clear visualization, head lamp. Both hands are needed to expose and visualize these

structures with appropriate instruments. For


these reason a reflected light using the head

mirror and light source is used.

INSTRUMENTS
Examination of the ear can be done with otoscope

ROUTINE EXAMS
A routine examination covers the following regions: Oral and buccal cavily and oropharynx nasophrynx and posterior part of nose Hypopharynx and larynx. Nose Ears Neck

Examine as well adjacent structures. Tongue depressors are used in the buccal cavity the pharynx and posterior nasal pharynx

Nasal speculum Ear specula Nasopharyngeal and laryngeal mirrors

Cotton applicators
Tuning fork

THE EAR
A brief outline of the anatomy and physiology

ANATOMY
The ear can be divided into the following 3 parts: 1. External Ear Consisting of the pinna (Auricle),Tragus, Antetragus, External Auditory Canal/Meatus 2. Middle Ear 3 Ossicles - Incus - Malleus - Stapes

Eustachian Tube Connects The


Middle Ear To Pharynx Mastoid Air Cells

Facial Nerve
Muscles (Stapedius/Tensor Tympani)

3. INNER EAR:
Consisting of the three semi circular canals The Cochlea The vestibula containing the utricle and saccule

Nerves connecting the inner ear to the central


nervous system.

THE EXTERNAL EAR


Pinna External Auditory Canal The outer third of the external auditory canal is cartilagenous and the medial 2/3 bony. Average length (31m and 25mm respectively). The canal has a slight curve, directed forward and a bit downward in the Adult.

In a child the curve is more in a


forward direction. Hence to visualize

the ear drum one must pull the pinna


upward and a bit backward in the adults whereas in the child the pinna

needs to be pulled backward and


slightly downward.

The Cartilagenous part of the ear canal contains hair follicles and sebacious and ceruminous glands and hence is a site for furunculosis and other skin disease. WAX is an essential part of the ceruminous glands.

It has Bacteriocidal - Anti fungal

- Water proof properties


And also serves as a fly paper for flies. Dont enthusiastically clean

your ear you will be predisposing the


ear to infections and insection.

QUESTION In case insects enter some ones


ear what will you do at home?

The pinna is highly visualized. So


if it is cut off it can survive when sutured back even after 48 hours.

THE MIDDLE EAR Starts with the Tympanic membrane which reflects the situation in the middle ear cavity. The three ossicles
Incus Malleus Stapes

Are joined in an ossicular chain. The


stapes footplate covers the oval

window. The tympanic membrane


has two parts the parts tensa and flaccida.

Attached to the tympanic


membrane is the handle of malleus.

Flaccida has two layers one


devoid of fibrous layer. Tensa has three layers.

The middle ear is connected to the


Nasopharynx by way of the Eustachian

tube approximately 38mm in length


consist of lateral third which is bony and

medial two thirds which Cartilaginous.


The Eustachian tube is normally closed and opens only during swallowing and yawing or pronouncing koka, kuku etc

THE INNER EAR


Situated in the petrous part of the temporal bone and consist of three semicircular canals One horizontal Two vertical The vestibule containing the utricle and saccule and the cochlea. The Cochlea contains the organ of corti which is the organ of hearing. The semicircular canals is responsible for signal charges in position of the head balancing.

THE FINAL PART


Nerves connecting the central nervous
system from the inner ear through the internal auditory canal. The Center of

Hearing is the Auditory Cortex.

PHYSIOLOGY
THE PHYSIOLOGY OF HEARING

Sound is conducted through the Ear

Canal, the tympanic membrane and the


ossicles to the cochlea. From here

impulses are carried in the Cochlear nerve


and its Central Connections.

The Ear Canal the tympanic membrane


and the ossicles form the conductive

component of hearing and the cochlea


and its neural connections from the

sensory neural mechanism of hearing.


Conductive hearing loss

Sensoneural hearing loss


Mixed hearing loss

THE PHYSIOLOGY OF BALANCE


The sense of position is obtained from several sensory mechanisms: visual, vestibular and proprioceptive. The three are important for maintenance of balance. Loss of one can be compatible with adequate maintenance of posture. Loss of two greatly impairs posture and locomotion. The cerebellum is closely related to the vestibular system. Vertigo spinning result from loss of vestibular function.

SIGNS AND SYMPTOMS OF EAR DISEASE

Otalgia - Primary - Secondary Otorrhea/Otorrhagia Tinitus Hearing loss Vertigo Facial paralysis Itch Congenital deformities

Otalgia or painful ear, results from

Involvement of ear structures or


In the absence of ear disease, pain referred from other structures (referred otalgia)

REFERRED OTALGIA
Parts of the ear and several structures on the head and neck have a common source of sensory supply GTVF C2, C3 The commonest sources of referred otalgia are:

1. The teeth
2. The temperas mandibular joint 3. The tongue 4. The pharynx 5. The Nasopharynx and the hypophaynx and neck.

Otalgia due to disease of the ear primary otalgia are due to

Trauma/Foreign Bodies
WAX Obstruction Otitis Externa

Otitis Media Acute


CA of Ear Canal

WAX OBSTRUCTION
The Ear Canal may be occluded with WAX and cause pain. Small amount

of wax can be easily removed with


WAX curette under direct vision. No

maneuver should be carried out


blindly in the Ear.

WAX can be syringed with tap water at body temperature. Cold or hot water will cause caloric stimulation vertigo.
Technique of syringing syringing that causes pain must be stopped. Drape patient Direct stream posteriorly

INDICATION FOR SYRINGING


WAX Obstruction

FB in Ear (inanimate objects)


Debris in Ear CONTRAINDICATION Perforation of T.M Acute Ottitis Media Chronic Ear Discharge

Sometimes WAX needs to be


softened with olive oil or glycerine warm to body temperature 3x daily for 3 days after which syringing is repeated.

Acute ottis external is the inflammation of the skin linning the external auditory canal it can be acute or chronic. Acute external ottis usually presents as a very painful ear while chronic external ottis is often characterized by itchness and discharge.

AOE
May be localized (circumserbed ottis ext. furuncle. Or diffuse otitis ext.

PREDISPOSING FACTORS
Wet ears swimmers ear Ear trauma caused by pricking of the ear

Or by use of cotton swabs or features


Or somehow as a result of systematic diseases eg. Diabetes mellitus.

ORGANISMS
1. Bacteria eg. Staphylococci Steptococci Pseudomanas

Fungi otomycosis due to


aspergillus Niger or Canada Herpetic eruptions Herpes zooster oticus Ramsay-hunt-disease

Clinical features commonest symptoms

Pain in the ear Swelling of the ear

There may be hearing loss.


Pre-or-post auricular lymph needs enlargement. Fever may be present.

ON EXAMINATION
Movement of pinna painful, tragal
tenderness, stenotic canal.

Tympanic, membrane normal, canal


red or with pus/erythema.There may be a discharge.

COMPLICATION
Extension to perichondrium as
gabbage ear in older people or

diabetic may lead to malignant


ottis, ext. destruction of bone sets in.

TREATMENT
Antibiotic Local treatment wick ribbon gauze

Topical ear drops (neomyxin


polyxin)

Not CED/Gentamycin Ear drops


Anti inflammatory drugs

Ear drops should not be kept in a


refrigerator. Some of the topical preparations have steroid base anti inflammatory Properties. In otomycosis use antifungal drugs - Thorough cleaning of the ear

In chronic otis ext the skin involvement is pronounced eg. Eczematous or seborrheic

dermatitis from irritation by the


discharge. The causative agent is pseudomonas aeruginosa.

TREATMENT
Local treatment Swabs for C/S Tropical ear, ear drops polymyxin Neomycin Cream of these topical drugs and steroid base for the skin condition. Surgery for canal stenosis

TRAUMA
Haematoma - Bony - Blow - Dress Foreign Bodies

Cutlass Cut/Bite
Suture

ACUTE OTITIS MEDIA AOM


Acute infection of the middle ear include acute viral otitis media,

acute supurative Otitis media (ASOM) acute serous


otitis media.

ETIOLOGY
Children by virtue of shortness of Eustachian tube, feeding cultures, cold Blockage of the eustachian tube exudation of serous fluid in middle ear bulging of tympanic membrane Resolution or natural spontaneous rupture discharging blood and mucous or chronic otitis media hearing loss other complications.

SYMPTOMS
Fever Pyrexia Chills Convulsion Ottalgia Cattarrh Discharging Ear Mucoid General Malaise

- All signs of Malaria except few.

OTOSCOPIC FINDINGS
Reddened Tympanic Membrane Bulging and injected tympanic

membrane
Ruptured T.M with perforation

Canal normal
In ASOM Mucopurulent discharge

TREATMENT
Depending on stage

Myringotomy
Antibiotic Nasal decongestant Analgesics Clean pus

Treat other diseases adenoids sinusitis.

CHRONIC OTITIS MEDIA/CSOM


Persistent of discharge on/off from 6

weeks onwards to years


SYMPTOMS Tinitus

Hearing loss
Discharge off/off

FINDINGS
Perforation in T.M central or peripheral with or without pus. Very difficult to treat Antibiotics Antihistamines Keep ear dry Clean ear of discharge Tympanoplasty reconstructive surgery

COMPLICATIONS OF AOM/COM
Meningitis Otitis hydrocyphalus Chronic otitis media Serous otitis media Deafness Facial nerve paralysis Cerebellar asscess Lateral sinus thrombophlebitis Temporal lobe abscess larbyrinthitis

LECTURE 2

HEARING LOSS
May be a symptom of its own
or associated with tinitus, vertigo (triad of symptoms meneres).

A.

TYPES OF HEARING LOSS

Conductive Sensomanual Mixed hearing loss The auditory and vestibular nerves (VIII) are intimately related to CN VII. In the internal auditory meatus

B.
Acquired Congenital H.L

The following can cause hearing loss


Lesions of the external auditory canal

Congenital atresia
WAX, foreign body

Otitis ext
Trauma Tumours Stenosis Exostosis

LESION OF THE MIDDLE EAR


AOM, COM, CSOM, ASOM Trauma

Tumors
Glue ear The above two produces conductive H.C

The following lesions produce sensoneural hearing loss

Familial

Congenital
Presbycusis

Noise induced H.L


Ototoxic drugs Head injury labyrinthitis

Commonness infectious disease cause hearing loss leading cause in Ghana


Meningitis CSM Measles Febrile Convulsion

Parotitis unilateral H.L


CSOM

MANAGEMENT OF H.L
Examine ext, middle ear

Text of hearing turning fork test.


Audiometry Treat disease

Rehabilitation. Hearing Aid


Cochlea implant

OTOTOXIC DRUGS
Aminoglycosides antibiotic Quinine Salicylates With some drugs the damage is corrected if withdrawn early others progresses. A patient with renal failure on Aminoglycoside is susceptible to ototoxicity Hearing loss is usually bilateral and symmetrical.

NOISE INDUCED H.L


Acoustic trauma sudden exposure Nose induced H.L gradual over a long period in a noisy environment.

Noise damages the cochlea hair cells can be due to


sudden, sharp, laud noise or from prolonged exposure to noise. Eg. Rifle fire, expolosion or blast. Prolonged noise occurs in industrial setting Airports, Sawmills, Dickos

PREVENTION OF DEAFNESS/TREATMENT
EPI Primary prevention Secondary prevention Use of ear protection

Minimizing industrial and domestic noise


Screening with hearing test for all such workers

School screening to detect early treatable causes


New born screening

Hearing AIDS are valuable in the


treatment of many types of Hearing loss

Surgical treatment for many types

Hearing AID has a Microphone, an amplifier, and receiver.

FACIAL PARALYSIS
LMN paralysis of all half of face UMN intact emotional movements

Bells palsy
CSOM as a complication Ramsay hunt disease

TINITUS
Noise

Ototoxic
Laribynthitis

WAX
Treat cause

Prevent offending cause


Maskers of noise

PRESBYCUSIS Sensoneural H.L due to the aging


process is referred to a

presbycusis.

LECTURE
3

THE NOSE AND PARANASAL SINUSES


The nose and the paranasal sinuses lie in the

upper part of the upper respiratory tract. The


paranasal sinuses connect with the nose

through various ostia. The nose is continuous


posteriorly with the nasopharynx and is

connected to the eustachian tube and the


middle er by way of the nasopharynx.

The anterior and middle cranial


fossa, the orbit and the roof of the mouth together with the

teeth are closely related to


certain parts of the nose and the sinuses.

The function of nose and paranasal sinuses are


Cosmetic
Upper part of respiration

Makes (the sinuses) the head lighter


Take part in resonance Nose filters, warm air Olfaction

THE NOSE
The external nose it formed by bones and cartilages. The anterior and posterior apertures of the nose are called anterior and posterior choans, respectively. The lateral wall of the nose contains the opening of the paranesal sinuses. It is marked by three turbinates. The interior (independent bone), the middle and superior conchae or turbiantes.

The area below the turbinate is called


meatus. The nasolacrimal duct opens into the inferior meatus. The middle

meatus contains the openings of the


frontal, maxillary and anterior enthmoid sinuses.

The superior meatus contains the


opening of the posterior ethmoid

cells. The sphenoid sinus opens


posteriorly in an area called the splenoethmoidal recess. The

mose contains olfectory cells and


nerve.

BLOOD SUPPLY
The turbinates are erectile tissues. The nasal septum contains many blood vessels and is called littles area a

frequent spot for epistaxis.

There is an area around the nose


known as the danger zone. Where internal carotid and external carotid branches meet and any small infection can result in

extension of infection to the brain


or cavernous sinus.

SYMPTOMS DUE TO NOSE INVOLVEMENT


Nasal obstruction

Nasal discharge increased


Loss of smell anosmia Sneezing excessively

Symptoms due alteration of the nasonator of the nose NASAL

speech.
Dryness to crust formation Pain in the nose

Nose bleeding
Trauma: Fracture Nasal Bone

SINUSE SYMPTOMS
Halitosis Sinus headache Tumours of sinus Symptoms of nose and sinus disease can be a part or a manifestation of systematic disease. For example epistaxis can be due to a bleeding diatesis nasal and sinus allergy may occur on a patient with bronchial asthma.

Polyp formation in a child may be due to cystic fibrosis: facial


and nasal deformity and asymmetry may be to congenital or familial.

Read about common cold/coryza


Pharyngitis Acute chronic pluritis

Unilateral offensive smell in a child is a foreign body in the


nose unless proven otherwise.

EPISTAXIS
Nose bleed is common. Minor instances are easily treatable or

controlled at home.
Bleeding is unilateral, or bilateral anterior or posterior.

CAUSES
Local and systemic causes local attributable to nose and its structures Trauma Nose prick to littles area

FB
Tumors

Infection Rhinitis, Sinusitis


Vicarious Menstruation Congenital - teleangioectasia

GENERAL CAUSES
SCD
Bleeding diathesis Leukemia Arterial hypertension Climatic condition such as harmattan

Altitude
The common cause is nose prick at littles area.

MANAGEMENT
At home pinch nose for 5 mins, sit upright apply ice pack. IN THE HOSPITAL FIND CAUSE Canterize bleeding part littles area
- Chemical

- Electrical Cantery

Anterior Nasal Packs with Gauze


Treated BIPP (Vaseline Gauze)

Posterior Packing
Catheter in Posterior Nasal Space Sedation + Rest

Replacement of Blood Loss


Ligation of Vessels

ACUTE/CHRONIC SINUSITIS
Acute sinusitis can involve all the sinuses in one or both sides pansinusitis all. Abology often 20 nasal infection following acute viral infection. catarrh

PREDISPOSAL
Dusty environ
Excessive dryness Instillation of concussion

BACTERIAL INFECTION
Henophilis

Influenza
Stephylococci

Sometimes fungi

SYMPTOMS
Feeling of fullness on the side of face Dull headache

FINDINGS
Tenderness

Hyperemia over affected sinus


Pus under the meatus in the nose X-ray shows opacity in the sinus

TREATMENT
Treat infection
Decongest nose Most will resolve if note

Anthral lavage - AWO is scheduled six


weeks later

Frontal Trephination Chronic sinusitis from


1. Unresolved Acute Sinusitis or recurrent Sinusitis. Duration 6 weeks or more.

SYMPTOMS
Nasal obstruction Halitosis

Post nasal drip


Headache

FINDING
Polyps Caries tooth (if chronic maxillary sinusitis)

Allergy
X-ray - opacity

TREATMENT
Antibiotic Decongestant

Antilustamine
Anthral Lavege

Intranasal Anthrotomy
Coldwell Luc Operation

COMPLICATION OF SINUSITIS Can come from acute of chronic sinusitis 1. Orbit involvement leads to proptasis,
Ostcitis Osteomylitis

Mucocele
Orbital Cellulitis Oroanthral Fistula Intracranial Spread Cavenous Sinus Thrombosis Chronic Pharyngitis, Laryngitis

LECTURE 4
LARYNX AND

PHARYNX

LARYNX
The Larynx forms the lower part of the upper respiratory tract. Apart from the gradual increase in size as childhood progresses, the major change in the Larynx during adolescence the anterior posterior length of the glottis increases by approximately 1cm in males and 3mm to 4mm in females.

The former increase accounts for the voice change in adolescent males. The thyroid cartilage forms the central and anterior walls of the larynx and produces the prominence in the neck referred to as the Adams Apple. Paired cartilages Thyorid Cricoid, Epiglotis. Form the framework of the larynx.

THE NERVE SUPPLY OF THE LARYNX


Significant nerve supply of the

larynx is derived from the


superior and recurrent laryngeal nerve.

FUNCTIONS OF THE LARYNX


Sphincter action: prevents entry of food and drink into trachea during deglutation

Passage for air


Voice production defecation and parturation

SYMPTOMS OF LARYNGEAL PATHOLOGY


Hoarseness Stridor Nerve Paralysis Asphyxia

Causes Inflammation
Acute Laryngitis

Ltb
Acute Epigloltitis Laryngeal Dyptheria

CHRONIC
Non specific Polyp Singers node

Chronic laryngitis

Hoarseness of voice in an adult of more than 4 weeks is cancer until proven otherwise.
Laryngea paralysis can give rise to Hoarseness of voice respectively difficulty and aspiration of liquids or solids into the trachea and bronchial tree.

Opening into upper trachea as a result of airway obstruction. INDICATION respiratory obstruction

TRACHEOSTOMY

To bypass obstruction
Lung toileting Reasons accumulation of secretion in tetanus Ventilation for assisted respiration in coma Poisoning

TYPES
Emergency Elective Intubation

THE PHARYNX 3 PARTS


Oro, Naso, Hypo Pharynx Tonsils Adenoids disappear in adolescents Waldeyers ring formed by palatine tonsils adenoid (pharyngeal tonsil) ligual tonsils and submuscosal follicles

FUNCTIONS OF PHARYNX Deglutition


Speech Airway

Taste

SYMPTOMS
Sore Throat FB throat Tonsillitis Common cold

Leukemia and tumour


diptheria

DYSPHAGIA CAUSES
FB Tumour

Infection
Trauma Ulceration

SORE
Tonsillitis Inflammation of tonsils Bacterial infection

Beta haenolytic streptoco

SYMPTOMS
Fever, Malaise, Odynophagia, Ottalgia

TREATMENT
Antibiotic Analgesic

COMPLICATIONS
Peritonsillar Abscess (Quinsy) Parapharyngeal Space Infection Chronic Tonsillitis Aom Glomerulonephritis Pericarditis Rheumatic Fever

SURGERY
TONSILECTOMY
Absolute indications Repeated attack 3 x a year Rec. tonsillitis Huge tonsils causing airway obstruction Snoring History of quinsy

ADENOIDECTOMY
If adenoids so hypertophied, that causing airway obstruction or feeding problems. Snoring and sleeping apnea.

1. Practical Exercises
Otoscopy

Radiology Interpretation
Turning Fork Test Discussion

2. Quiz