The nose and sinuses condition (septal perforation)

Septal perforation

There are several reasons why a patients's septum may be perforated.
These include:

• Trauma or accident
• Post septal surgery
• Nose picking
• Granulomatous disease- must be excluded before treating perforation.

1. wegener's
2. sarcoidosis
3. TB
4. syphilis

• Cocaine addiction

Signs and symptoms

• whistling - if there is a small anterior perforation.
• bleeding from the nose
• crusting of the nose at the site of the perforation.

Treatment

• apply vaseline to the edge of the perforation
• treat epistaxis expectantly.
• septal button- this is a plastic prosthesis fitted into the hole in the septum. only half the patients find it tolerable and continue using it long term.
• surgical septum repair- the results of surgery are variable even in experienced hands.

The Mouth, Tonsils, and Adenoids Condition (Glandular fever)

What is Glandular fever?

Glandular fever is also known as infectious mononucleosis or EpsteinBarr virus infection. It is common in teenagers and young adults. Patients with glandular fever may present a similar picture to patients with acute bacterial tonsillities, but with a slightly longer of symtoms. Diagnosis relies upon a positive monospot or Paul-Bunnell blood test, but early in the course of the disease this test can still show up negative.

Signs and Symptoms

- Sore throat
- Pyrexia
- Cervical Lymphadenopathy
- White slough on tonsils
- Petechial haemorrhages on the palate
- Marked widespread lymphadenopathy
- Hepatosplenomegaly

Treatment

This is self limiting condition for which there is no cure as such. Treatment is largely supportive with painkillers, although patients may appreciate a short course of corticosteroids to decrease swelling. IV fluids may be necessary if they cannot drink enough.

Complications

Patients should be advised to refrain from contact sports for six weeks because of the risk of a ruptured spleen. This can lead to life threatening internal bleeding.

The Mouth, Tonsils, and Adenoids Condition (Tonsillectomy)

What is Tonsillectomy?

Tonsillectomy is one of the most commonly performed operations. Patients usually stay in the hospital for one night, so that bleeding may be recognized and treated appropriately. Tonsils are removed by dissection under general anaesthetic. Haemostasis is achieved with diathermy or ties.

What is going to happen after your surgery? (Post op)

Tonsillectomy is very painful and regular simple analgesia is always required afterwards. Patients should be advised that referred pain to the ear is common. Until the tonsillar fossae are completely healed, eating is very uncomfortable. The traditional jelly and ice cream has now been replaced with crisps, biscuits, and toast, since chewing and swallowing after tonsillectomy is very important for recovery and in helping to prevent infection.
In the immediate postoperative period the tonsillar fossae become coated with a white exudate, which can be mistaken as a sign of infection.

Complications

Postoperative haemorrhage is a serious complication for between 5-15% of patients after a tonsillectomy.

A reactive haemorrhage can occur in the first few hours after the operation, this will frequently necessitate a return trip to the operating theatre (OT).

A secondary haemorrhage can occur any time within two weeks of the operation. It occur less than 10% of cases and may result from an infection of the tonsillar fossa.

Neck Condition (Neck Hernias)

What is Neck hernias?

Laryngocoele
This is caused by expansion of the saccule of the larynx. The saccule is a blind-ending sac arising from the anterior end of the laryngeal ventricle. A laryngocoele is an air-filled herniation of this structure. This can expand, and either remains within the laryngeal framework (internal laryngocoele), or part of it may extend outside the larynx (external laryngocoele). It escapes through a point of weakness in the thyrohyoid membrane.
There is a rare association with a laryngeal cancer of the saccule, and all patients should have this area examined and biopsied.
There is little evidence to support the supposition that this condition is more frequent in trumpet players and glass blowers.

Sign and symptoms
- Lump in the neck which may vay in size
- Hoarseness
- A feeling of something in the throat FOSIT
- Swallowing difficulties
- Airway problems
If the laryngocoele become infected and full of pus ( laryngo-pyo-coele) then they may rapidly increase in size and cause additional pain.

Neck Condition (Neoplastic Lymphadenopathy)

What is neoplastic lymphadenopathy?

Lymphoma
This is a primary malignant tumour of the lymphatic tissues.

Sign and Symptoms

Multiple nodes of a rubbery consistency. The patient may or may not experience night sweats, weight loss, axillary or groin nodes, and lethargy.

Investigations

FNAC may be suspicious but an excision biopsy is often required to confirm the diagnosis and allow for sub typing. A CXR and/or a chest CT scan may be done, or, for staging, a CT scan of the abdomen or pelvis. Bone marrow may be needed for staging.

Treatment

May involve chemotherapy and/or radiotherapy. The patient may need a lymphoma multi-Disciplinary Team review.

What is squamous cell carcinoma

This a primary muco-cutaneous malignancy which commonly spreads to local lymph nodes. It can affect single or multiple nodes.

Signs and Symptoms

The patient may have ENT-related symptoms such as a sore throat, a hoarse voice or otalgia. The nodes may have a firm or hard consistency. The patient may have a history of smoking.

Investigations

These may include FNAC , ENT examination looking for ENT primary carcinoma, a CT or MRI scan of the neck, a CT scan of the chest and/or CXR (metatases), a liver USS (metatases), a panendoscopy and biopsy.
Where no ENT primary is seen on examination, a rigorous search should be done for a silent tumor. This will usually involve imaging as above with ipsilateral tonsillectomy, biopsy of the tongue base, post nasal space and piriform fossa as a minimum.

Treatment

This depends on the stage, the size and the site of the primary. Options for treatment include:
Radiotherapy: this involves 4-6 weeks of daily treatment with a total dose of 50-60Gy.

Radical neck dissection: this involves removing the affected nodes as well as all the other nodal groups and lymph-bearing structures on that side od the neck. This includes the lymph nodes at level 1, 2, 3, 4, and 5, the internal jugular vein (IJV), the Sternomastoid and the accessory nerve.

Modified radical neck dissection: this takes all the nodal levels (1, 2, 3, 4, 5) but preserves one or all of the IJV, the sternomastoid and the accessory nerve.

Selective neck dissection: Instead of all the nodal groups being removed, those groups thought to be at most risk are selectively dissected and removed. All other structures are preserved.


N staging of the neck

N1 - a single node< 3cm
N2a - a single node>3cm but <6cm
N2b - >1 ipsilateral node <6cm
N2c - Bilateral or contralateral nodes <6cm
N3 - Any node >6cm

Neck Condition (Lymph node enlargement)

What is lymph node enlargement?

-The majority of neck nodes in children are benign
-The majority of neck nodes in adults are malignant
-Neck nodes may be involved secondarily in an infection of any part of the ENT system.

Infective lymphadenopathy
This secondary lymphadenopathy is extremely common in children. An example is jugulo-digastric node enlargement during or following tonsillitis. A single node or a group of nodes may be enlarged. There may be tenderness and symptoms related to the primary infection.

Specific infections presenting with lymph node enlargement (priamary lymphadenopathy) include:
- Glandular fever
- TB
- Toxoplasmosis
- Brucellosis
- Cat- scratch fever
- HIV
The diagnosis in these cases will often be made following the appropriate screening blood test and CXR. FNAC and even excision biopsy may be needed to exclude malignancy

Neck Condition (Neck infections)

Parapharyngeal abscess

This is a deep seated infection of the parapharyngeal space. It often results from a primary infection in the tonsil or is an extension from a parapharyngel abscess (or quinsy). It is more common in children than in adult.

Signs and symptoms

Include pyrexia, neck swelling deep to sternomastoid muscle and a patient who seems unwell. There may be trismus, or a reduced range of neck movements. The tonsil and the lateral pharyngeal wall may be pushed medially. Airway compromise is a late and ominous sign.
If the diagnosis is in doubt, a CT scan will often distinguish between lymphadenitis and an abscess.

Treatment

This will involve a high dose of IV broadspectrum antibiotics (Augmentin), in addition to surgical drainage via a lateral neck approach.

Retropharyngeal abscess

This is a very rare infection of the retropharyngeal space. It is much more common in children and infants than in adults.

Signs and symptoms

An unwell patient, with pyrexia, often with preceding URTI or swallowing difficulty. There may be shortness of breath or stridor, or torticollis-due to prevertebral muscle irritation.

Treatment

A high dose of IV broad spectrum antibiotics (Augmentin). Where necessary the airway will be secured and surgical incision and drainage may be performed via the mouth.

Lugwig's angina

This is a rare infection of the submandibular space, it usually occurs as a result of dental infection. It is more common in adults than in children.

Signs and symptoms

These include pyrexia, drooling, trismus, airway compromise due to backward displacement of the tongue. There may be firm thickening of the tissues of the floor of mouth-best appreciated on bi-manual palpation.

Treatment

High doses of IV broad spectrum antibiotics (Augmentin). Secure the airway (try a naso-pharyngeal airway first since this will often suffice, but were necessary consider a tracheostomy). Surgical incision is often unsatisfying since little pus may drain away.