OT Otolaryngology – Head & Neck Surgery Peter Dixon and Ryan Figueroa, chapter editors Jieun Kim and Daniel Soong, associate editors Jef Martin, EBM editor Dr. Jonathan C. Irish and Dr. Evan J. Propst, staf editors Acronyms .............................. 2 Facial Nerve (CN VII) Paralysis ........... 21 Basic Anatomy Review ................... 2 Rhinitis ............................... 22 Ear Allergic Rhinitis (Hay Fever) Nose Vasomotor Rhinitis Throat Head and Neck Rhinosinusitis .......................... 24 Anatomical Triangles of the Neck Acute Bacterial Rhinosinusitis Chronic Rhinosinusitis Differential Diagnoses of Common Presenting Problems ..................... 5 Epistaxis ............................. 26 Dizziness Otalgia Hoarseness ........................... 27 Hearing Loss Acute Laryngitis Tinnitus Chronic Laryngitis Nasal Obstruction Vocal Cord Polyps Hoarseness Vocal Cord Nodules Neck Mass Benign Laryngeal Papillomas Laryngeal Carcinoma Hearing ............................... 9 Normal Hearing Physiology Salivary Glands ........................ 29 Types of Hearing Loss Sialadenitis Pure Tone Audiometry Sialolithiasis Speech Audiometry Salivary Gland Neoplasms Impedance Audiometry Parotid Gland Neoplasms Auditory Brainstem Response Otoacoustic Emissions Neck Masses .......................... 31 Aural Rehabilitation Approach to a Neck Mass Evaluation Vertigo ............................... 12 Evaluation of the Dizzy Patient Congenital Neck Masses ................ 32 Benign Paroxysmal Positional Vertigo Branchial Cleft Cysts/Fistula Menière’s Disease (Endolymphatic Hydrops) Thyroglossal Duct Cysts Vestibular Neuronitis Lymphatic Malformation Labyrinthitis Neoplasms of the Head and Neck ......... 34 Acoustic Neuroma (Vestibular Schwannoma) Thyroid Carcinoma Tinnitus .............................. 15 Pediatric Otolaryngology ................ 38 Diseases of the External Ear ............. 15 Acute Otitis Media (AOM) Cerumen Impaction Otitis Media with Effusion (OME) Exostoses Adenoid Hypertrophy Otitis Externa (OE) Adenoidectomy Malignant (Necrotizing) Otitis Externa Sleep-Disordered Breathing in Children (Skull Base Osteomyelitis) Acute Tonsillitis Peritonsillar Abscess (Quinsy) Diseases of the Middle Ear .............. 17 Tonsillectomy Acute Otitis Media and Otitis Media with Airway Problems in Children Effusion Signs of Airway Obstruction Cholesteatoma Acute Laryngotracheobronchitis (Croup) Mastoiditis Acute Epiglottitis Otosclerosis Subglottic Stenosis Laryngomalacia Diseases of the Inner Ear ................ 18 Foreign Body Congenital Sensorineural Hearing Loss Deep Neck Space Infection Presbycusis Sudden Sensorineural Hearing Loss Common Medications .................. 47 Autoimmune Inner Ear Disease Drug Ototoxicity References ............................ 48 Noise-Induced Sensorineural Hearing Loss Temporal Bone Fractures OT1 Otolaryngology Toronto Notes 2014 OT2 Otolaryngology Acronyms/Basic Anatomy Review Toronto Notes 2014 Acronyms ABR auditory brainstem response FAP familial adenomatous polyposis OSA obstructive sleep apnea AC air conduction FESS functional endoscopic sinus surgery RA rheumatoid arthritis AOM acute otitis media FNA fine needle aspiration SCC squamous cell carcinoma BAHA bone anchored hearing aid GERD gastroesophageal reflux disease SCM sternocleidomastoid BC bone conduction HL hearing loss SNHL sensorineural hearing loss CHL conductive hearing loss HPV human papilloma virus TEF tracheoesophageal fistula CPA cerebellopontine angle INCS intranasal corticosteroids TM tympanic membrane EAC external auditory canal OE otitis externa TNM tumour, node, metastases EBV Epstein-Barr virus OME otitis media with effusion URTI upper respiratory tract infection Basic Anatomy Review Ear External Middle Inner Temporalis fascia Auditory ossicles Semicircular canals and muscle Helix Malleus Incus Stapes Triangular fossa Vestibular Helical crus nerve Antihelix Vestibulocochlear nerve (CN VIII) Cochlear nerve Scapha Tragus Facial nerve (CN VII) Cochlea Antiragus Lobule External acoustic Tympanic Eustachian tube © Aarti Inamdar meatus membrane © Susan Park 2009 Figure 1. Surface anatomy of the external ear; anatomy of ear Tympanic membrane viewed View into tympanic cavity after through speculum removal of tympanic membrane Pars flaccida Neck of malleus Lateral process of malleus Incus long process Tensor tympani Stapes tendon Tensor tympani Tendon of muscle stapedius muscle Long process of malleus Umbo (Flat portion) Tympanic plexus Fossa of round (branch of CN IX) (cochlear) window Hypotympanum Cone of light Pars Annulus tensa © Diana Dai 2006 Figure 2. Normal appearance of right tympanic membrane on otoscopy OT3 Otolaryngology Basic Anatomy Review Toronto Notes 2014 Nose Adenoid Sphenoid sinus Superior turbinate Drainage into Nasal Cavity Middle turbinate • Superior meatus: sphenoid (via sphenoethmoidal recess), posterior Middle meatus ethmoid sinuses • Middle meatus: frontal, maxillary, Inferior turbinate anterior ethmoid sinuses Inferior meatus • Inferior meatus: nasolacrimal duct Speculum View of Right Nostril Palatine process of maxilla ine 2003 Ra Soft palate Opening for Eustachian tube © Jason Figure 3. Nasal anatomy Anterior ethmoid a. Frontal sinus Posterior ethmoid a. Sphenoid sinus Kiesselbach’s plexus Septal branch of sphenopalatine a. Branch of superior labial a. Internal carotid a. Greater palatine a. External carotid a. Common carotid a. © Barbara Brehovsky 2012 Figure 4. Nasal septum and its arterial supply (see Epistaxis section for detailed blood supply) Frontal sinus Orbit Ethmoid • Nasopharynx: skull base to soft sinus palate Lamina • Oropharynx: soft palate to hyoid bone papyracea • Laryngopharynx: hyoid bone to Osteomeatal inferior cricoid cartilage complex Maxillary sinus Nasal cavity Teeth Figure 5. Anatomy of the four paranasal sinuses: maxillary, ethmoid, sphenoid, and frontal Reprinted from Dhillon R.S, and East CA. Ear, Nose and Throat and Head and Neck Surgery, 2nd ed. Copyright 1999, with permission from Elsevier. Throat Coronal Section Superior View Valeculla Epiglottis Anterior Vestibule Thyroid cartilage Vestibular folds (false cords) Vocal folds (true cords) Trachea Posterior Pyriform fossa Arytenoid cartilage Posterior View © Glen Oomen 2002 Figure 6. Anatomy of a normal larynx; superior view of larynx on indirect laryngoscopy OT4 Otolaryngology Basic Anatomy Review Toronto Notes 2014 Head and Neck Temporal branch Zygomatic branch Buccal branch Superficial temporal a. Styloid process Maxillary a. Mastoid process Angular a. Stylomastoid foramen Occipital a. Lateral nasal a. Facial n. (VII) Posterior auricular a. Posterior belly of Ascending pharyngeal a. digastric m. Parotid gland Superior labial a. Mandibular branch Internal carotid a. Marginal mandibular Inferior labial a. branch External carotid a. Cervical branch Facial a. ng 2007 Common carotid a. Wa Lingual a. Superior thyroid a. © Sean © M. Romanova 2010 © M. Romanova Figure 7. Extratemporal segment of facial nerve Figure 8. Blood supply to the face Branches of facial nerve (in order from superior to inferior) Branches of the external carotid artery (in order from inferior to superior) Ten Zebras Broke My Car Some Angry Lady Figured Out PMS Hyoid bone External Thyrohyoid membrane carotid a. Thyroid cartilage Post. belly Common digastric m. carotid a. bifurcation Common carotid Median cricothyroid ligament Ant. belly a. bifurcation Internal digastric m. jugular v. Sternocleidomastoid m. Hyoid bone Ant. belly Sternocleidomastoid m. omohyoid m. Sternohyoid m. Posterior triangle Omohyoid m. Trapezius m. Anterior triangle Cricoid cartilage Post. belly omohyoid m. Thyroid gland Sternohyoid m. Trachea Clavicle © Inessa Stanishevskaya 2012 after Figure 9. Anatomy of the neck Anatomical Triangles of the Neck Anterior triangle: Paired Parasympathetic Ganglia of the Head and Neck • bounded by anterior border of SCM, midline of neck, and lower border of mandible • Ciliary: pupillary constriction • divided into: • Pterygopalatine: lacrimal gland, nasal submental triangle: bounded by both anterior bellies of digastric and hyoid bone mucosa • Submandibular: submandibular, digastric triangle: bounded by anterior and posterior bellies of digastric, and inferior border sublingual glands of mandible • Otic: parotid gland carotid triangle: bounded by sternocleidomastoid, anterior belly of omohyoid, and posterior belly of digastric contains: tail of parotid, submandibular gland, hypoglossal nerve, carotid bifurcation, and lymph nodes Function of Facial Nerve Posterior triangle: “Ears, Tears, Face, Taste” • bounded by posterior border of sternocleidomastoid, anterior border of trapezius, and middle Ears: stapedius muscle third of clavicle Tears: lacrimation (lacrimal gland) and • divided into: salivation (parotid) occipital triangle: superior to posterior belly of the omohyoid Face: muscles of facial expression Taste: sensory anterior 2/3 of tongue subclavian triangle: inferior to posterior belly of omohyoid (via chorda tympani) • contains: spinal accessory nerve and lymph nodes OT5 Otolaryngology Basic Anatomy Review/Diferential Diagnoses of Presenting Problems Toronto Notes 2014 Table 1. Lymphatic Drainage of Nodal Groups and Anatomical Triangles of Neck Nodal Group/Level Location Drainage 1. Suboccipital (S) Base of skull, posterior Posterior scalp • Left-sided enlargement of a 2. Retroauricular (R) Superficial to mastoid process Scalp, temporal region, external auditory meatus, supraclavicular node (Virchow’s posterior pinna node) may