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Pharyngitis (sore throat)
https://t.me/med1917
ACUTE: sudden onset sore throat
• Usually viral (rhinovirus, coronavirus, influenza, HSV, VZV)
• May be bacterial (group A strep)
CHRONIC: long-standing sore throat
• Specific (syphilis, TB, toxoplasmosis)
• Non-specific (GORD, tobacco)
Supraglottitis (adults) / epiglottitis (children)
→ H.influenzae B
SYMPTOMS
• Very sore throat + high fever
• Dysphagia, drooling
• Stridor – fast, noisy breathing, leans forward
• Altered/hoarse voice
Pharynx looks normal O/E
Chapter 8: Ear, nose and throat 247
General Mx advice for sore throat:
gargle warm salty water
fluids, analgesia,
MANAGEMENT: immediate admission
• Airway protection – intubation/tracheostomy
• IV ABX & steroids
compromise airway
Deep neck space infection
→ spread of throat infections (pus/abscess) via para- or retropharyngeal space
SYMPTOMS
• Sore throat + odynophagia
• Dysphagia, drooling
• Fever
• Trismus – if parapharyngeal
• ‘Hot potato’ (muffled) voice – if
parapharyngeal
SIGNS
• Poor head movement*
• Neck mass*
• Septic
INVESTIGATIONS
• CT – shows deep neck spaces
• OPG – dental X-ray
MANAGEMENT: emergency
(A→E)
• Airway protection
• IV ABX
• Surgical drainage
Other ENT symptoms
Complications of deep neck space infection
• Airway compromise
• Empyema
• Pneumonia
• Mediastinitis (50% mortality)
• Carotid artery erosion
• IJV thrombosis (Lemierre’s syndrome)
*signs that differentiate it from quinsy
Symptom Description Causes
Catarrh Build-up of mucus in the airway infection, allergy, emotions,
Cough Protective reflex to clear irritants/
Referred otalgia Ear pain caused by non-otologic
Globus pharyngeus Painless
secretions. Dry or productive.
source. Due to shared nerve supply
between ear & facial structures/ oro-/
laryngopharynx (CNV, VII, IX, X)
sensation of ‘sticking’ / lump in
throat even when not swallowing
cold/heat, hormones
aspiration, reflux, infection
dental pain, tonsillitis,
thyroiditis, GORD
LP reflux, stress/anxiety, minor
inflammation → must exclude
pathologies like cancer
Mx: treat underlying cause, avoid caffeine/smoking,
sip icy sparkling water, PPI, Gaviscon Advanced
248 Chapter 8: Ear, nose and throat
https://t.me/med1917
Airway obstruction
Stertor: noisy breathing due to partial obstruction ABOVE the larynx → tonsils,
Signs of severe airway obstruction
• Tracheal tug/recession
• Accessory muscle use
• Tachycardia
• Hypoxia
• Confusion
adenoids, tongue, angioedema
Stridor: noisy breathing due to partial obstruction BELOW the larynx
→ needs ENT REFERRAL for laryngoscopy, or ANAESTHETICS REFERRAL for
intubation (depends on severity)
Differentials of stridor
Congenital Acquired
• Laryngomalacia
• VC web / VC palsy
• Subglottic stenosis
Acute Chronic
• Laryngeal trauma
• Foreign body
• Croup
• Epiglottitis
• Allergic reaction
• Deep neck space infection
• VC palsy
• VC polyp/cyst
• Tumour
• Thyroid mass
• Subglottic stenosis
• Post radiotherapy
LARYNGEAL TRAUMA: usually the result of RTAs
Symptoms
→ stridor (may be delayed)
→ neck bruising
→ surgical emphysema (perforation)
Management: intubation ± tracheostomy
FOREIGN BODY
Symptoms
→ feel something ‘stick’ in throat
→ sharp pain
→ cannot eat/drink/swallow saliva
Investigations: lateral neck X-ray & CXR
Management: flexiscope ± theatre for removal
Management of stridor
1. Basic history & assess severity – cyanosis, RR, etc.
2. A→E first aid – ensure clear mouth
3. Secure airway
• Endotracheal tube: first-line → need trained staff & equipment
• Cricothyroidotomy → incision in midline of cricothyroid membrane &
insert ET tube + bag valve mask
• Tracheostomy → tube inserted between 2nd & 4th rings of cartilage
Tracheostomy complications
• Tube blockage
• Wound infection
• Pneumothorax
Tracheostomy indications
• Bypass obstruction
• Aspiration prevention
• Secretion management
• Respiratory failure
• ICU weaning
Sleep apnoea
https://t.me/med1917
Repeated upper airway obstruction whilst sleeping, resulting
in desaturation & awakening
↳ Obstructive: due to upper airway collapse ( O
slightly & taking deep breath)
↳ Central: fault with central respiratory drive e.g. cerebral palsy, cognitive defect
→ diagnosed in childhood
Symptoms
• Snoring/choking in sleep & witnessed apnoeas
• Restless/non-refreshing sleep
• Daytime sleepiness & concentration – assess risk, e.g. driving
• Irritability & libido
Investigations
• History – Epworth Sleepiness Scale5
• Examination – upper airway endoscopy
• Sleep studies
▶ measure pulse, ECG, O2 overnight
▶ audio/video recording of sleep
▶ polysomnography = gold standard version
→ EEG, chest expansion, etc.
Adult AHI Paediatric AHI
Mild OSA ≥5 to <15 events/h ≥1 to ≤5 events/h
Moderate OSA ≥15 to <30 events/h >5 to ≤10 events/h
Severe OSA ≥30 events/h >10 events/h
causes reflex of waking
2
Apnoea Hypoxia Index (AHI)
Chapter 8: Ear, nose and throat 249
Risk factors for sleep apnoea
• Older age • Obesity
• Male • Smoking/alcohol
• Sedatives • Neuromuscular disease
Apnoea Hypoxia Index: measures no. of episodes
to determine severity
Management
1. Lifestyle – weight loss, reduce smoking/alcohol
2. Conservative – nasal splints/tape & jaw advancers
3. Medical – CPAP via mask = noisy & uncomfortable
4. Surgery – adenotonsillectomy, polypectomy, uvulopalatopharyngoplasty
6
1 & 2 also for Mx of simple snoring
Sleep apnoea in children
SYMPTOMS
• Snoring/choking in sleep & witnessed apnoeas
• Restless/non-refreshing sleep
• Daytime sleepiness or hyperactivity
• concentration – poor school performance
• Failure to thrive
INVESTIGATIONS
• History often all that is needed
• Sleep studies if complex/syndromic child/very young or small / multiple
comorbidities
MANAGEMENT
• Clear clinical history with no
comorbidities = TONSILLECTOMY
3
If suspect more complex/central cause,
further investigations and management
may be required
Risk factors for childhood sleep apnoea
• Down syndrome
• Craniofacial abnormalities
• Neuromuscular disease
• Obesity
5
Johns NW (1990–97) Epworth Sleepiness Scale
6
NICE (2021) Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in
over 16s [NG202]
250 Chapter 8: Ear, nose and throat
Nasal cavit
Hard palate
s
https://t.me/med1917
The larynx & voice disorders
Normal voice production
VC = vocal cord
Due to VC vibration:
• Movement of air molecules
Fundamental frequency (F0) = PITCH (Hz)
• determined by density of vocal fold
• density altered by muscle contraction/
relaxation
• HIGHER DENSITY = LOWER FREQUENCY
e.g. males, Reinke oedema
Intensity/pressure level = LOUDNESS (dB)
• Determined by subglottic pressure
• Pressure depends on degree of VC
closure / length of closure
• LOWER PRESSURE = WEAKER VOICE
e.g. recurrent laryngeal nerve palsy
in larynx causes oscillation
of VC mucosa
• VCs drawn together, then
apart
• Oscillation causes sound
wave that resonates within
vocal tract
Vowel production: vibration
of OPEN VCs & mouth/tongue
position
Consonant production: force
air through NARROWED VCs
y
Tongue
Nasopharynx
Oropharynx Laryngopharynx
Fig. 8.4
Soft palate
Epiglottis
Larynx
(voice box)
Oesophagu
Trachea
Abnormal speech
Dysphonia: any voice impairment
Dysarthria: reduced voice muscle coordination
Dysphasia: receptive or comprehensive
Voice disorders
STRUCTURAL/NEOPLASTIC
Malignant Benign
Laryngeal carcinoma Polyp Reinke’s oedema
Causes
Symptoms Progressive hoarseness
Signs
Treatment
INFLAMMATORY
• Smoking
• Genetics (FHx, male, black)
• (+ alcohol >8units/d)
± stridor, dysphagia
± referred otalgia
± cervical lymphadenopathy
• Irregular mass
• Leukoplakia/erythroplakia
• Radiotherapy
• Surgical excision
collection of fluid in Reinke’s pouch
• Shouting
• Voice abuse
• Professional voice users
• Smoking
• Voice overuse
• LP reflux
Husky (deeper) voice Deep, gravelly voice
• Smooth, grey swelling
→ usually UNILATERAL
• Surgical excision
± medical Tx
± voice therapy
• Grey/red swelling
→ usually BILATERAL
• Stop smoking / Tx
reflux
• Surgical reduction
• Voice therapy
Infectious Non-infectious
Laryngitis (bacterial,
Laryngopharyngeal (silent) reflux
fungal, HPV)
Symptoms
• Hoarse/croaky/voice loss
• Sore throat, odynophagia
• URTI symptoms
• Strained voice + pitch range
• Dysphagia & globus sensation
• Cough & constant throat clearing
• NO HEARTBURN unless concurrent GORD
(often have both)
Signs
Treatment • Voice rest, analgesia, fluids
• Erythematous, sloughy VCs • General erythema & oedema
• Gaviscon + PPI
• Steam inhalations
→ self-limiting
• Vocal hygiene
• Dietary advice – avoid fatty/fried food & caffeine
NEUROMUSCULAR – RECURRENT LARYNGEAL NERVE PALSY
https://t.me/med1917
Causes
• Miscellaneous
• Surgical trauma – e.g. thyroidectomy
• Malignancy – of bronchus, thyroid, oesophagus, larynx
• Idiopathic
• Neurological disorders
Symptoms
• Weak, higher-pitched voice
• Tires with prolonged use
• Choking on fluids
• Weak ‘bovine’ cough
• Diplophonia – 2-tone voice
Investigations
1. Examination – listen to voice, head & neck exam, cranial nerves, flexible
nasendoscopy
2. CXR – exclude mediastinal mass
3. CT (skull base to mid thorax) – check for lesions along nerve
4. Barium swallow – if suspect oesophageal lesion
Chapter 8: Ear, nose and throat 251
Approximate incidence of VC palsy7:
65% = LEFT VC*
25% = RIGHT VC
10% = BOTH VCs
↳ *longer course of left recurrent
laryngeal nerve leaves it more
vulnerable to damage
Management → may just wait for spontaneous recovery
• Voice therapy
• VC medialisation – inject collagen or surgery
MUSCLE TENSION IMBALANCE = excessive tension of laryngeal muscles
Causes
• Stress/anxiety
• Following URTI
• Long-term ineffective voice use
• Compensation for underlying VC problem e.g. cyst
Symptoms
• Husky voice – worse with use
• Deeper or higher-pitched than expected
• Unstable voice
• Sore throat
Management
• Vocal hygiene – steam inhalations
• Lifestyle advice – avoid irritants (smoke, caffeine, spicy food), drink plenty of
water
• Voice therapy – practise projecting voice, relaxed posture, breathing control
Voice therapy
Aims: restore voice, eliminate benign nodules & avoid further vocal problems
Indications
• LP reflux
• Nodules, cysts, polyps
• Muscle tension imbalance
• Psychological voice problems
7
Yamada M, Hirano M, Ohkubo H (1983) Recurrent laryngeal nerve paralysis. A 10-year review of
564 patients. Auris Nasus Larynx, 10, S1–15.
Components
• Semi-occluded airflow exercises – reduce
muscle straining
• Efficient respiration
• Voice resonance & projection
• Advice on vocal hygiene – steam
inhalations, avoid irritants etc.
252 Chapter 8: Ear, nose and throat
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Outer ear problems
Excess wax
→ Wax-softening drops e.g. sodium bicarbonate / olive oil
→ Ear syringing → contraindicated if grommets, or perforation
Foreign bodies
Fig. 8.5 Cauliflower ear.
Fig. 8.6 Acute otitis externa.
Risk factors for AOE
• Immunocompromised/DM
• Atopies & skin conditions
• Swimmers
Differentials/complications of AOE
• Necrotising otitis externa
• Mastoiditis
• Pinna perichondritis
• Pinna cellulitis
• Middle ear infection (discharge but no canal
swelling)
→ Wax hook/forceps/suction
→ GA if uncooperative / deep into canal
often in children
Pinna haematoma
→ blood collects between cartilage & perichondrium
→ Cause: trauma
→ Complications: avascular necrosis & infection → ‘Cauliflower ear’
→ Management: IMMEDIATE DRAINAGE
Neoplasm
→ Benign: papilloma or adenoma → Malignant: BCC or SCC
Acute otitis externa (AOE)
AETIOLOGY: inflammation of the ear canal
CAUSES
• Skin conditions e.g. eczema, psoriasis
• Generalised skin infections e.g. impetigo
• Localised skin infections e.g. Pseudomonas, S. aureus, candida
• Trauma / foreign bodies (cotton buds)
• Water exposure
SYMPTOMS
• Pain & swelling
• Itching
• Hearing loss
• ± discharge (exudate build-up)
MANAGEMENT
1. Mild/simple (TM visible)
• Analgesia & keep dry
• Topical ABX ± steroid
2. Severe/complex (TM not visible / Tx-resistant)
• Microsuction
• Pope wick & topical antibiotic drops
• PO ABX if pinna cellulitis
8
SIGNS
• Tender pinna/tragus
• Swollen/red canal
• TM not visible
Needs ENT referral
Necrotising/malignant otitis externa
AETIOLOGY: Complication of AOE → infection spreads to skull base
SYMPTOMS
• Severe, often deep pain – worse at night & when chewing
• Nerve palsies – CN VII, IX, X, XI
• Canal granulations
Pathogen: Pseudomonas aeruginosa
INVESTIGATIONS: CT/MRI
MANAGEMENT: → ENT referral
• High dose IV ABX (6w course)
• ± topical treatment
8
NICE (2021) CKS Management Scenario: Acute otitis externa
• Microsuction (twice weekly)
• Analgesia
Chapter 8: Ear, nose and throat 253
A
VIII)
Stapes
https://t.me/med1917
Middle ear problems
Acute otitis media with effusion (OME)
→ ‘glue ear’
AETIOLOGY: build-up of fluid within the middle ear
SYMPTOMS
• Middle ear fluid with NO SX OF INFECTION
(painless)
• CHL 20–30dB = speech delay / school
problems
CAUSES: Eustachian tube dysfunction
• Nasal/sinus infection
• Allergic response
• Ciliary dysfunction
MANAGEMENT9: 50% spontaneous resolution
• If persists >3m:
▶ grommets – ventilate middle ear
→ pop out in 18m
▶ hearing aids
External
auditory
canal
→ Cause conductive hearing loss
Eustachian tube aerates middle ear & equalises pressure
Risk factors for OME
• Child
• Smoking
Malleus
Incus
Tympanic
membrane
Fig. 8.7 Middle ear anatomy.
• Large adenoids
• Nasal abnormalities
Semicircular
canals
0.5 kHz
6 kHz
Cochlear
nerve (
Cochlea
16 kHz
Acute suppurative otitis media (ASOM)
AETIOLOGY: acute infection of middle ear
SYMPTOMS
• PAIN! = crying/screaming child
• Fever / systemic upset
• Conductive hearing loss
• Otorrhoea (pus ± blood) if TM perforated →→ relieves pain
∙ H. influenzae
∙ S. pneumoniae
↳
∙ M. catarrhalis
∙ RSV/rhinovirus
Complications of ASOM: refer to middle ear
anatomy, Fig. 8.7
∙ Residual perforation/ effusion (CSOM)
∙ Ossicle necrosis
∙ Tympanosclerosis
∙ Intracranial sepsis/meningitis
∙ Facial palsy
∙ Labyrinthitis
∙ Mastoiditis
SIGNS
• Bulging TM OR
• TM perforation & pus/blood
MANAGEMENT10: by GP
1. Analgesia & wait for resolution in 3–7d
2. Antibiotic ear drops – if TM perforation & ongoing infection
3. PO amoxicillin ONLY IF:
• Aged <6m
• Risk of complications
• Otorrhoea
• Aged <2y with bilateral Sx
• Systemically very unwell
• Non-resolving infection (3d)
Mastoiditis: pus in air cells → bone necrosis &
abscess
Symptoms
∙ Otalgia
∙ Hearing loss
∙ Malaise/pyrexia
∙ Post-auricular swelling
∙ Pinna down & forwards
Management: ABX ± surgery (ENT referral)
9
NICE (2008) Otitis media with eusion in under 12s [CG60]
10
NICE (2018, updated 2022) Otitis media (acute) [NG91] Fig. 8.8 Bulging TM.
254 Chapter 8: Ear, nose and throat
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Chronic suppurative otitis media (CSOM)
AETIOLOGY: repeated ASOM (>6w) → non-healing TM perforation
Fig. 8.9 Cholesteatoma.
Risk factor for cholesteatoma:
Retraction pockets (weaker areas of TM)
→ dead cells accumulate in pockets
Complications of cholesteatoma: due to
erosion of bone & nearby structures
→ facial nerve palsy
→ vertigo
→ intracranial sepsis
→ CHL (ossicle erosion)
TEMPORAL BONE FRACTURE → Need CT
20% = transverse = SNHL
80% = longitudinal = CHL
Other complications: CSF leak, bleed, FN palsy
SYMPTOMS
• Repeated otorrhoea
• CHL 10–20dB or more
MANAGEMENT: ENT referral to assess
possible complications
• Regular aural toilet
• ABX + steroid ear drops
Cholesteatoma
AETIOLOGY: accumulation of keratinising squamous epithelium attracting
anaerobic bacteria
SYMPTOMS
• Foul-smelling otorrhoea
• Attic retraction & squamous debris
• Conductive hearing loss
INVESTIGATION: Fine cut CT temporal bones / diffusion weighted MRI
MANAGEMENT
• Surgical removal of sac
• Mastoidectomy if advanced disease
11
Foul otorrhoea + FN palsy needs ENT referral
Pseudomonas aeruginosa
Tympanic membrane perforation
CAUSES
SYMPTOMS
• Conductive HL (10–20dB)
± pain, tinnitus, vertigo
MANAGEMENT: heals in 6w
• Keep dry & wait
• GP follow-up in 6w → not healed = ENT
↳
• AOM
• Foreign bodies
• Head injury – temporal bone fracture
• Barotrauma
• Sudden air pressure e.g. loud
noise/slap
Tympanosclerosis
AETIOLOGY: calcification of scar tissue* on TM
SYMPTOMS: if large = conductive HL (50+dB)
*from previous infection, trauma
or grommet insertion
Otosclerosis
AETIOLOGY: spongy bone forms around oval window = fusion with stapes →
familial condition
SYMPTOMS: progressive, bilateral conductive HL ± tinnitus
MANAGEMENT: hearing aid / stapedectomy
Middle ear neoplasms
SQUAMOUS CELL CARCINOMAS = malignant
Sx: bloody otorrhoea & deep pain
→ may cause facial nerve palsy
GLOMUS TUMOURS PARAGANGLIONIC CELLS = slow growing
& benign
Sx: pulsatile tinnitus & CHL + pulsatile red mass behind eardrum
→ may cause facial nerve palsy or CN IX/XII paralysis
11
NICE (2020) CKS Management Scenario: Cholesteatoma
Chapter 8: Ear, nose and throat 255
https://t.me/med1917
Inner ear problems
How we hear
1. Sound waves vibrate TM → transmits to ossicles
2. Ossicles amplify & transmit to oval window
3. Pressure waves through perilymph vibrate tectorial membrane
4. Hair cells are moved against organ of Corti & stimulate cochlear nerve
5. Signals carried to cortex
Tinnitus
DEFINITION: perception of noise with no external stimuli
CAUSES
Subjective/intrinsic
= only heard by patient
• Idiopathic
• Drugs
• Trauma
• Presbycusis
MANAGEMENT OF TINNITUS
• Labyrinthitis
• Ménière’s
• Vestibular schwannoma
• Otosclerosis
12
1. Explain:
• Incorrect info reaching brain OR
• Incorrect processing in brain
2. Masking:
• Radio/television in background
• ‘Tinnitus maskers’ – play noise into
other ear
3. Counselling:
• CBT, mindfulness
• Tinnitus therapy – techniques to avoid stress response
• Support groups
4. Hearing aids: if associated SNHL
Objective/extrinsic
= heard by others as well
• Palatal myoclonus
• Insect in EAM
• Vascular
Treatment generally focuses on
symptom control & acclimatisation
rather than cure
→ Cause Sx of: tinnitus, SNHL, vertigo
The Internal Ear
Semicircular ducts
Anterior
Lateral
Posterior
Vestibular duct
Bony labyrinth
Membranous labyrinth
Cochlear duct
Tympanic duct
Cochlea
Fig. 8.10 Inner ear anatomy.
Cristae within ampullae
Vestibulocochlear
Utricle
nerve
Saccule
Vascular tinnitus = PULSATILE
→ AVM/glomus jugular tumour
→ Need CT/MR angiogram
Sensorineural hearing loss (SNHL)
→ General Mx: hearing aid, cochlear implant, hearing tactics
SUDDEN ONSET SNHL
Causes
• Ménière’s
• Viral infection
• Ototoxic drugs
• Temporal bone fracture
• Tumour → exclude acoustic
neuroma with CT/MRI
Management: emergency → ENT referral
→ PO steroids ASAP! (prednisolone)
Prognosis: worse if severe vertigo as well
12
NICE (2020) Tinnitus [NG155]
Unilateral SNHL Bilateral SNHL
• Vestibular neuroma
• Trauma
• Vascular insult
• Post-labyrinthitis
• Otosclerosis
• Congenital
• Presbycusis
• Noise-induced
• Metabolic
• Otosclerosis
• Congenital
256 Chapter 8: Ear, nose and throat
Frequency (Hz)
Hearing Level (dB)
Frequency (Hz)
Hearing Level (dB)
https://t.me/med1917
Must investigate ALL cases of UNILATERAL SNHL
Risks of surgical excision:
• damage to facial nerve
• intracranial sepsis
• hearing loss
• impaired balance
NON-ORGANIC HL = feigned loss to get compensation
VESTIBULAR SCHWANNOMA (ACOUSTIC NEUROMA)
Symptoms: caused by compression of CN VIII
UNILATERAL SNHL, tinnitus, vertigo ± neuro symptoms
Investigations
• Pure tone audiometry
• CT/MRI
Management
13
→ 6-monthly monitoring + yearly MRI (most are small and slow-growing)
→ Surgical excision
→ Highly focused radiotherapy (gamma knife)
NOISE-INDUCED HEARING LOSS
Aetiology: chronic loud noise exposure (initially reversible but eventually =
permanent)
Features
SYMMETRICAL SNHL & tinnitus
→ dip at 4kHz on tympanogram (Fig. 8.11)
Management: Prevention is key
• Tinnitus counselling
• Hearing aid
123456
Left ear
Right ear
Fig. 8.11
PRESBYCUSIS
Aetiology: SNHL due to ageing (>50y) due
to loss of outer hair cells of cochlea
Features
BILATERAL high frequency SNHL (Fig. 8.12)
±tinnitus → worse if background noise
Investigation
• Hx & otoscopy
• PTA / tympanogram
Left ear
Right ear
Fig. 8.12
Management
• Reassure: stress that low/mid frequency hearing is good & decline is gradual
• Hearing aid
• Hearing tactics e.g. facing speaker, background noise
OTOTOXICITY
Causes
• Aminoglycosides: gentamicin
• Diuretics: furosemide
• Salicylates
• Chemotherapy agents
Management
IRREVERSIBLE so prevention is crucial (careful monitoring of serum levels & PTA)
13
NHS Clinical Commissioning Policy (2013) Vestibular Schwannoma and Other Cranial Nerve
Neuromas – NHSCB/D5/P/a
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