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ENT AN INTRODUCTION AND PRACTICAL GUIDE This page intentionally left blank ENT

ENT AN INTRODUCTION AND PRACTICAL GUIDE This page intentionally left blank ENT AN INTRODUCTION AND PRACTICAL GUIDE EDITED BY James Russell Tysome MA PhD FRCS (ORL-HNS) Senior Clinical Fellow in Neurotology and Skull Base Surgery Cambridge University Hospitals NHS Foundation Trust AND Rahul Govind Kanegaonkar FRCS (ORL-HNS) Consultant ENT Surgeon Medway NHS Foundation Trust Guy’s and St Thomas’ NHS Foundation Trust First published in Great Britain in 2012 by Hodder Arnold, an imprint of Hodder Education, Hodder and Stoughton Ltd, a division of Hachette UK 338 Euston Road, London NW1 3BH http://www.hodderarnold.com © 2012 Hodder & Stoughton Ltd All rights reserved. Apart from any use permitted under UK copyright law, this publication may only be reproduced, stored or transmitted, in any form, or by any means with prior permission in writing of the publishers or in the case of reprographic production in accordance with the terms of licences issued by the Copyright Licensing Agency. In the United Kingdom such licences are issued by the Copyright Licensing Agency: Saffron House, 6–10 Kirby Street, London EC1N 8TS. Hachette UK’s policy is to use papers that are natural, renewable and recyclable products and made from wood grown in sustainable forests. The logging and manufacturing processes are expected to conform to the environmental regulations of the country of origin. Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular, (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug companies’ printed instructions, and their websites, before administering any of the drugs recommended in this book. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN-13 978-1-444-14908-1 1 2 3 4 5 6 7 8 9 10 Commissioning Editor: Francesca Naish Production Controller: Joanna Walker Cover Design: Helen Townson Project management provided by Naughton Project Management Typeset in 10/12 pt Minion Regular by Datapage Printed and bound in Spain by Graphycems What do you think about this book? Or any other Hodder Arnold title? Please visit our website: www.hodderarnold.com Dedication This book is dedicated to Dipalee, Amee and Deven and to Laura, George and Henry This page intentionally left blank CONTENTS Contributors 8 Foreword 9 Preface 10 Introduction 11 1 Clinical anatomy 12 2 ENT examination 29 3 Common ENT pathology 37 4 Epistaxis 50 5 Audiology 59 6 Tonsillectomy 68 7 Adenoidectomy 72 8 Grommet insertion 75 9 Septoplasty 78 10 Septorhinoplasty 84 11 Turbinate surgery 87 12 Antral washout 90 13 Endoscopic sinus surgery 92 14 Nasal polypectomy 96 15 Tympanoplasty 98 16 Mastoidectomy 104 17 Stapedectomy 111 18 Bone-anchored hearing aid 115 19 Panendoscopy 118 20 Direct- and micro-laryngoscopy 119 21 Pharyngoscopy 121 22 Rigid oesophagoscopy 124 23 Examination of the postnasal space (PNS) 125 24 Rigid bronchoscopy 126 25 Submandibular gland excision 128 26 Hemi- and total thyroidectomy 131 27 Superﬁ cial parotidectomy 134 28 Tracheostomy 138 29 Voice 145 30 Airway management 149 31 Radiology 152 32 Management of neck lumps 157 33 Vertigo and dizziness 161 Index 169 Mr Ketan Desai FRCS Associate Specialist in Otorhinolaryngology Royal Sussex County Hospital, Brighton Mr Neil Donnelly MSc (Hons) FRCS (ORL-HNS) Consultant Otoneurological and Skull Base Surgeon Cambridge University Hospitals NHS Foundation Trust Dr Dipalee Vijay Durve MRCPCH FRCR Consultant Radiologist Guy’s and St Thomas’ NHS Foundation Trust Mr Steven Frampton MA MRCS DOHNS ENT Specialist Trainee Registrar Wessex Region Mr Jonathan Hughes MRCS DOHNS Specialist Registrar in Otolaryngology North Thames rotation/Royal National Throat Nose and Ear Hospital Mr Ram Moorthy FRCS (ORL-HNS) Consultant ENT Surgeon Heatherwood and Wexham Park Hospitals NHS Foundation Trust and Honorary Consultant ENT Surgeon, Northwick Park Hospital Ms Joanne Rimmer FRCS (ORL-HNS) Specialist Registrar in Otolaryngology North Thames rotation/Royal National Throat Nose and Ear Hospital Mr Francis Vaz FRCS (ORL-HNS) Consultant ENT/Head and Neck Surgeon University College London Hospital CONTRIBUTORS 8 9 FOREWORD The ‘Introduction to ENT’ course has now become an established and must attend course for the novice ENT practitioner. The synergistic blend of didactic teaching and practical skills training has allowed many junior trainees to raise the standard of care they deliver to their ENT patients. The course manual is now a ‘Bible’ for juniors in nursing and medicine caring for patients on the wards, clinics or in emergency room. The Royal College of Surgeons has endorsed this course in the past and it continues to maintain a high standard of post graduate training. I would strongly recommend this course to any trainee embarking on a career in ENT. Khalid Ghufoor Otolaryngology Tutor Raven Department of Education The Royal College of Surgeons of England 10 This book has been written for trainees in otorhinolaryngology and to update general practitioners. Common and signiﬁ cant pathology that might present itself is described. Included also are relevant supporting specialties such as audiology and radiology. A signiﬁ cant proportion of this text has been devoted to common surgical procedures, their indications and operative techniques, as well as the management of their complications. We do hope that the text will facilitate and encourage junior trainees to embark on a career in this diverse and rewarding specialty. Writing this book would not have been possible had it not been for the encouragement of our many friends and colleagues, and the unfaltering support of our families. We would, however, like to make a special mention of some extraordinary and gifted tutors without whom we may not have initiated the popular ‘Introduction to ENT’ course nor written the course manual from which this text originates. Ghassan Alusi, Alec Fitzgerald O’Connor, Khalid Ghufoor, Govind Kanegaonkar, Robert Tranter and the late Roger Parker instilled in us a passion for teaching, nurtured our curiosity for all things medical and encouraged us to undertake the research that has served us so well. PREFACE 11 Otorhinolaryngology (ENT) is a diverse and challen ging specialty which is poorly represented on the busy Medical School curriculum. Although an estimated 20% of cases seen in primary care are ENT-related, many general practitioners have little or no direct clinical training in this ﬁ eld. This book has evolved from the Introduction to ENT course manual which has served so many of us so well. Over 1200 doctors have attended this course and its Essential Guide partner over the last eight years. This book covers both common and the life-threatening emergencies that may present in primary care. It not only describes the common management pathways for conditions, but also lists possible complications of procedures and their treatment and provides a basis for referral if there is doubt. The updated colour illustrations concisely depict relevant clinical anatomy without unduly simplifying the topic in question. I am certain this text will prove to be as, if not more, popular and relevant to general practitioners than the Introduction to ENT text from which it is derived. Dr Junaid Bajwa June 2011 INTRODUCTION 12 ENT: AN INTRODUCTION AND PRACTICAL GUIDE THE EAR CLINICAL ANATOMY 1 The ear is divided into three separate but related subunits. The outer ear consists of the pinna and external auditory canal bounded medially by the lateral surface of the tympanic membrane. The middle ear contains the ossicular chain, which spans the middle ear cleft and allows acoustic energy to be transferred from the tympanic membrane to the oval window and hence the cochlea of the inner ear. This elaborate mechanism has evolved to overcome the loss of acoustic energy that occurs when transferring sound from one medium to another (impedance mismatch), in this case from air to ﬂ uid. ❚❘ The outer ear The pinna consists largely of elastic cartilage over which the skin is tightly adherent (Figure 1.1). The cartilage is dependent on the overlying perichon- drium for its nutritional support; hence separation of this layer from the cartilage by a haematoma, abscess or inﬂ ammation secondary to piercing may result in cartilage necrosis resulting in permanent deformity (cauliﬂ ower ear). The lobule, in contrast, is a ﬁ bro-fatty skin tag. The pinna develops from six mesodermal conden- sations, the hillocks of His, during the sixth week of embryological development. Three arise from each of the ﬁ rst and second branchial arches on either side of the ﬁ rst pharyngeal groove. These fuse and rotate to produce an elaborate but surprisingly con- sistent structure. Failure of fusion may result in an accessory auricle or preauricular sinus, while failure of development of the antihelix (from the fourth hillock) in a protruding (‘bat’) ear. The external auditory canal uploads/Management/ ent-practical-guide.pdf