Tintin

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Otorhinolaryngology –
Head & Neck Surgery
MASTOID SERIES (MaST – M[eyer]aS[chuller]Townes)
Towne’s View Meyer’s View Schuller’s View
Projection AP projection of the skull with
the beam source 30 above the
canthomeatal line
AP projection of the skull with the head
turned 45 toward the side one wishes
to examine & the beam source 45
above the canthomeatal line
Lateral projection of the skull with the
beam source 30 above the canthomeatal
line
View Clear view of the foramen,
comparison of the petrous
pyramid & mastoids
Provides axial view of the external
auditory meatus, mastoid, & petrous
bone
Shows extent of pneumatization of the
mastoid
(1) Pneumatic – well-developed mastoid
air cells
(2) Diploic – with few large air cells
(3) Sclerotic – with opacity due to
calcification
PARANASAL SINUS SERIES
Water’s View Caldwell View Skull Lateral Basal View
Occipitomental view or
chin-nose view
Occipitofrontal view
orforehead-nose view
Submentovertical view
Projection Patient’s head is tilted
with the nose & the chin
on the film,
orbitomeatal line is 37
from the film, x-rays are
directed horizontally
PA viewofthe skull with
the beam 15-20 from
the horizontal
Pt’s infraorbitomeatal
line is parallel to the film,
x-rays
perpendicular to the
infraorbitomeatal line
through the sella turcica
Best view Maxillary sinus
Open mouth Water’s
view – sphenoid sinus
Frontal sinus Sphenoid sinus Zygomatic arch
fractures
Also shows Frontal & anterior
ethmoid sinuses
Nasal bones, requested
if suspecting nasal
fractures together with
Nose STL
Anterior ethmoid &
sphenoid sinuses,
lamina papyracea
Posterior ethmoid,
frontal, & maxillary
sinues & sella turcica
Sphenoid, posterior
ethmoid, maxillary &
frontal sinuses
Panorex View
• Provides the best view of the mandible
• Requested when suspecting mandibular fractures (most common site being the angle, having the thinnest bone), dentoalveolar
abscess (DAA), ameloblastoma, & oseteomyelisis of the mandible
Neck soft tissue lateral (Neck STL)
• Requested when suspecting foreign body lodged in the neck, epiglottitis (seen as “thumb sign”), laryngotracheobronchitis (seen
as “steeple sign”)
CXR AP-L to include the neck and abdomen
• Requested when suspecting foreign body in the aerodigestive tract
• Possible for children, otherwise request for CXR AP-L to include the neck (or a separate STL when not possible), plain abdomen
Nose soft tissue lateral (Nose STL)
• Requested together with Water’s view when suspecting nasal bone fractures
IMPACTED CERUMEN
Signs and Symptoms
a. sense of ear fullness
b. otalgia (ear pain) – usually felt after getting water into the ear, because the cerumen swells, impinging on the pain receptors
in the external ear. May occur with secondary otitis externa because of the clumsy efforts to remove the cerumen.
c. Conductive hearing loss – usually not clinically significant. On Weber’s, there is lateralization to the affected ear (may not
be appreciated when impaction is not significant)
RADIOLOGY
THE EAR

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Treatment
Softening of cerumen with baby oil or commercially available ceruminolytics, such as Docusate Na (Otosol) 0.5% X 10mL (Lie on the
side, turning the head sideways, slightly towards the surface on which you are lying. Fill the ear canal & stay in this position for 5
minutes then insert a cotton wool plug. Repeat to the other ear if necessary. Max of 2 consecutive nights.). Have the pt come back
after 1 week for aural irrigation with clean lukewarm water. Aural irrigation is done with the stream directed behind the cerumen and
not directly at it, which may push it further down the canal.
OTITIS EXTERNA
• May result from ear manipulation (e.g. sharp metal objects) or the presence of foreign objects/foreign body (FB)
• Most common etiologic agent is Staphylococcus aureus, a normal flora of the external ear
Classification
a. Diffuse – swimmer’s ear. Swelling of the entire external auditory meatus (EAC)
b. Circumscribed – furunculosis. There is only a circumscribed swelling affecting the hairy portion of the EAC
Signs and Symptoms
a. otalgia
b. serous ear discharge
c. tenderness on manipulation of pinna or tragus
d. hearing loss if swelling occludes the external ear
e. swelling on otoscopy
Otitis Externa Otitis Media
Pain Severe Not as severe
Tenderness on pinna / tragus Present Absent
Fever Absent Present
History of URTI Usually none Usually present
History of ear manipulation Present Absent
Hearing Not impaired Impaired
Mastoid series Normal With evidence of mastoiditis
Treatment
a. Systemic oral antibiotic – treat the infection. For children: Cloxacillin 50 mg/kg/day in 4 divided doses X 7 days
(125mg/5mL preparation)
b. Topical steroid – reduce the swelling; usually prepared with antibiotic
1. Corticosporin: Hydrocortisone + Polymyxin B + Neomycin
2. Aplosyn: Fluocinilone + Polymyxin B + Neomycin
3. Synalar: Fluocinolone + Polymyxin B + Neomycin
c. Oral analgesic – for pain.
1. For the elderly or those with PUD: COX-2 Inhibitors
i. Etoricoxib (Arcoxia) 120 mg OD – preferred by ENT
ii. Celecoxib (Clebrex 200mg OD
iii. Rofecoxib (Vioxx) 25 mg OD
2. On a full stomach: Mefenamic Acid 500mg QID prn
3. For children: Paracetamol 10 mg/kg/day prn (125mg/5mL and 250mg/5mL preparations)
d. Aural toilette is done prior to application of Corticosporin.
If there is no response after 1 week, then suspect Pseudomonas infection and give a quinolone with anti-Pseudomonas activity
such as Ciprofloxacin 500 mg tab
ACUTE OTITIS MEDIA
• Infection of the middle ear <4 weeks
• Usually results from obstruction of the Eustachian Tube (ET), which serves as drainage of the middle ear. Sniffing too hard causes
a negative pressure in the middle ear, closing the ET tube; blowing the nose hard creates a positive pressure in the middle ear,
opening the ET tube
• Obstruction can be either
a. Mechanical – e.g. benign or malignant tumors
b. Functional – e.g. cleft palate
Sample Chart Entry
Apply 3 baby oil drops 3gtts TID X 7 days on affected ear
Avoid ear manipulation (AEM)
TCB after 7 days for aural irrigation
Sample Chart Entry
Cloxacillin 500mg/cap 1 cap PO QID X 7 days (adults)
Corticosporin Otic Drops 3gtts TID X 7 days
Etoricoxib 120 mg/tab 1 tab OD prn for pain (adults)
Aural toilette with H2O2 3 gtts TID X 7 days priorto application of Corticosporin
Avoid ear manipulation
TCB after after 7 days for reassessment.

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Predisposing factors
a. young age – ET is wider, shorter & more horizontal compared to adults
b. immunocompromised state – causes recurrent URTI
c. altitude changes
d. bottle feeding – greater risk than breastfeeding
e. congenital defects (cleft palate)
f. benign or malignant masses in the nasopharynx
Stages
a. Hyperemia – onset of disease; presents with otalgia, ear fullness, hearing loss, fever, (+) peripheral congestion of the ear
drum on otoscopy
b. Exudative – pouring of fluid in the middle ear; presents with increased otalgia, ear fullness, hearing loss and fever
c. Suppurative – rupture of TM with discharge; presents with mucupurulent discharge, decreased pain, decreased fever, but
increased hearing loss
d. Resolution / Complications – a surgical ear is those with complications
e. Coalescence – thickening of mucoperiosteum → drainage is blocked → venous stasis → local inflammation? →
decalcification → pus; nocturnal fever; simple mastoidectomy
Treatment
a. Antibiotic – to treat the infection
1. For children, give Amoxicillin 40 mg/kg/day divided in 3 doses X 14 days (125mg/5mL and 250mg/5mL
preparations available)
2. If with TM perforation, such as during the stage of suppuration, a topical antibiotic such as Corticosporin, may
be given because of perforation allows for the delivery of the drug into the ear.
3. If there is no response after 1 week, suspect Pseudomonas infection and give a quinolone with anti-
Pseudomonas activity like Ciprofloxacin
b. Aural toilette is done only if there is active discharge. It is done prior to application of corticosporin.
c. ET opening exercises are done to open the ET and thus provide drainage of middle earsecretions
1. Valsalva maneuver – Ask pt to blow nose against a closed mouth and nose → opens ET
2. Toynbee maneuver – Ask pt to swallow with mouth & nose closed → opens ET
3. Chewing gum
Complications
a. Extracranial complications (FLAPS)
Facial nerve paralysis
Labyrynthitis
Abscess
Subperiosteal abscess
Bezold’s abscess – abscess in the SCM
Cittelli’s abscess - digastric
Petrositis – Gradenigo’s syndrome (DRE)
Diplopia due to lateral rectus palsy
Retroorbital pain due to involvement of the optic nerve
Ear discharge
Sensorineural hearing loss
b. Intracranial complications (MATH)
Meningitis – most common
Abscess (epidural, subdural, cerebral)
Thrombophlebitis – picket-fence fever(caused by emboli of abscess)
Hydrocephalus
CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM)
• Infection of the middle ear >4 weeks; persistent ear discharge on a perforated ear >6weeks
• Fever not a constitutional sign
Classification
a. Active – (+) discharge
b. Inactive – (-) discharge > 3 months
c. Quiescent – (-) discharge < 3 months
Treatment
• Mastoid series is requested to assess pneumatization of the mastoid and aseess for cholesteatoma
• Pure tone audiometry and speech test to assess severity of hearing loss
• Tympanometry is requested if TM is retracted, dull or suspecting chronic infection of the middle ear
Sample Chart Entry
Amoxicillin 500mg/cap 1 cap TID X 14 days
Corticosporin otic 3 gtts TID X 14 days (only if suppurative)
Aural toilette with H2O2 3 gtts TID X 14 days (only if suppurative)
AEM, increase OFI, KED
Frequent ET opening exercises
TCB after 7 days for re-assessment

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Benign Dangerous
Perforation is central regardless of size or shape Perforation is total or located at the margin, attic (pars flaccida)
or postero-superior
Mucosa lining in the middle ear is edematous Mucosa around the perforation is replaced by stratified
squamous epithelium. Cholesteatomatous debris may be seen
around the perforation or in the attic
There may be granulation tissue or polyps arising from the
middle ear mucosa
Granulation or polyps are frequently seen in the canal obscuring
the drainage
Discharge is mucoid to purulent & non-foul smelling Discharge is purulent & foul-smelling
Hearing loss is conductive Hearing loss is conductive and sensorineural
Mastoid series show no cholesteatoma Mastoid series reveal cholesteatoma. On PE, there may be
posterior auricular or subperiosteal abscess or fistula.
CHOLESTEATOMA
• Concurrent with CSOM
• Seen radiographically as an enlarged mastoid antrum (>1cm). It appears as a radiolucency surrounded by areas of sclerosis with
no trabeculations. Bony destruction or erosions may be seen. Clinically, there is pearly white ear discharge, very foul smelling with
TM perforation.
• Plain & contrast CT scan with 1mm temporal bone cuts is requested if clinically positive for cholesteatoma for OR planning prior to
possible tympanomastoidectomy
AURAL POLYP
• Squamous hypertrophy from the middle or external ear
PRESBYCUSIS
• Hearing loss related to aging process
• Normal otoscopy
SENSORINEURAL HEARING LOSS
• May be due to chronic exposure to loud noise, as a complication of CSOM, as a result of infection or tumor
• On Weber, there is lateralization to the unaffected ear
Sample Chart Entry
Mastoid series
PTA-ST
Amoxicillin 500mg/cap 1 cap TID X 14 days
Corticosporin otic 3 gtts TID X 14 days (only if active)
Aural toilette with H2O2 3 gtts TID X 14 days (only if active)
AEM, increase OFI, KED
Frequent ET opening exercises
TCB after 7 days for re-assessment
Sample Chart Entry
Mastoid series
PTA-ST
Cranial CT scan, plain & contrast, with 1mm temporal bone cuts
Pen G 4 million units IV LD ( ) ANST then 2 million units q6h
Clindamycin 600mg IV LD ( ) ANST then 300mg q6h
Corticosporin otic 3 gtts TID (only if suppurative)
Aural toilette with H2O2 3 gtts TID (only if active)
AEM, increase OFI, KED
Frequent ET opening exercises
TCB after 7 days for re-assessment
Sample Chart Entry
PTA-ST
For possible application of hearing aid
TCB once with results
Sample Chart Entry
PTA-ST
TCB once with results

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SPEECH DELAY SECONDARY TO HEARING IMPAIRMENT
• First, rule out other causes such as autism
EXTERNAL AUDITORY CANAL BLEEDING SECONDARY TO EAR MANIPULATION
• Rule out other causes
• Antibiotic is given due to damage to EAC mucosa predisposing to infection
SINUSITIS
• Most common etiologic agents: S. pneumonia, H. influenza, Moraxella catarrhalis, anaerobes
Signs and Symptoms
a. nasal obstruction
b. mucopurulent nasal discharge
c. paranasal pain
d. headache
e. paranasal tenderness
f. congested nasal mucosa on rhinoscopy
g. absent illumination(frontal / maxillary sinuses)
h. fever may be present
i. opacities on x-ray
Classification
a. Acute - < 3 months
Sample Chart Entry
Co-amoxiclav 625 mg/cap TID or 1g BID X 7 days
Increased OFI
TCB after 1 week for re-asessment
b. Chronic - > 3 months, most common cause is untreated acute sinusitis; usually mized flora
Treatment
Nasal douche is prepared by mixing 1 tsp rock salt, 1 tsp baking soda, and 1L of boiled tap water made to cool.
ALLERGIC RHINITIS
Signs and Symptoms
a. rhinorrhea
b. sneezing (>4x/day, usually in the morning)
c. nasal obstruction
d. nasal pruritus
e. congested nasal mucosa on rhinoscopy
f. allergic salute (crease near the tip of the nose due to frequent rubbing)
g. allergic shiners (skin hyperpigmentation below the lower eyelid)
h. triggers – may be present; most common allergens are household dust mite, cockroach, grass pollen, molds
i. family history of allergy
j. personal history of bronchial asthma or eczema
Sample Chart Entry
PTA-ST
Refer to Pedia for evaluation and co-management
TCB once with results
Sample Chart Entry
Suction
Cloxacillin 500 mg/cap 1 cap QID X 7 days
Etoricoxib 120 mg/tab 1 tab OD prn for pain
TCB after 1 week for re-assessment
THE NOSE
Sample Chart Entry
PNS series
Co-amoxiclav 625 mg/cap TID or 1g BID X 7 days
Increased OFI
Nasal douche BID on each nostril, increased OFI
TCB after 1 week for re-asessment

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Treatment
a. Topical steroid – relieve the inflammation
1. Fluticasone (Flixotide) Fluticasone nasal spray 2 puffs / nostril BID X 14 days & prn – Usually prescribed by
ENT
2. Budesonide (Budecort) nasal spray 64 mcg/dose [X 120 doses] Initially 2 puffs in each nostril daily.
Maintenance: 1 puff in each nostril daily.
b. Oral anti-pruritus
1. Cetirizine (Virlix) 10 mg/tab 1tab OD at HS X 14 days & prn
2. Loratidine (Claritin) 10 mg/tab 1tab OD at HS X 14 days & prn
c. Decongestant are not of proven benefit and may cause rebound rhinitis (rhinitis medicamentosa) if used for more than 5
days
NASAL POLYPOSIS
• Usually arises from the osteomeatal complex (MIM HUBAd: Middle meatus, Infundibulum, Maxillary sinus ostium, Hiatus
semilunaris, Uncinate process, Bulla ethmoidalis, Agger nasi)
Signs and Symptoms
a. Nasal obstruction – may cause sinusitis due to obstruction of the drainage of frontal and maxillarysinuses
b. Anosmia
c. Rhinorrhea (watery to mucoid)
d. Smooth, gelatinous, semitransparent to pale white mass on anterior rhinoscopy
Grading
0 No polyps
I Polyps do not prolapse beyond the middle turbinate & may require endoscopy for visualization
II Polyps extend below the middle turbinate. Visible with nasal speculum.
III Polyps touching the nasal floor. May occlude the entire nasal cavity. May be seen through the vestibule without the aid of a
nasal speculum
Comparison of Nasal Polyp & Turbinates
Nasal Polyps Turbinates
Color “skinned grapes” Pink to red
Decongestant effect (-) (+)
Mobility Mobile Fixed
Sensation (-) (+)
Location Usually at osteomeatal complex Along entire lateral nasal wall
Consistency Soft Hard
Treatment
a. Surgery: (PEA) Polypectomy, Ethmoidectomy, Anthrostomy. Done under LA if middle-aged. Done under GA in children &
elderly.
b. Steroids – given 1 week prior to OR to decrease the swelling & minimize bleeding intraop
1. Prednisone 10mg/kg OD X 1 week prior to OR
2. Methylprednisolone 16 mg 2 tab OD every other day for 1 week
c. SAPOD clearance: CBC with PC & DC, BUN/Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR
NASAL FOREIGN BODY
• Usually presents as a unilateral, foul-smelling, purulent nasal discharge, usually in children & handicapped
• Removal may be done with theuse of Hartmann forceps, alligator forceps, or a blunt right-angled hook. Done in office setting with
the use of restraints for uncooperative patients, especially children.
INVERTING PAPILLOMA
• Most common benign neoplasm in the nose & sinuses
• Pre-malignant lesion usually unilateral
• 10% develops SCCA
• Complete excision
Sample Chart Entry
Fluticasone nasal spray 2 puffs / nostril BID X 14 days & prn
Cetirizine (Virlix) 10 mg/tab 1tab OD at HS X 14 days & prn
Avoid exposure to allergen
Refer to Allergy Clinic Re: Skin testing
TCB after 2 weeks for re-assessment
Sample Chart Entry
PEA/LA c/o minor OR
Prednisone 10mg/kg OD X 1 week prior to OR
SAPOD clearance: CBC with PC & DC, BUN/Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR
TCB once with results for OR scheduling

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Hyperthyroidism Hypothyroidism
Nervousness Fatigue, lethargy
Weight loss Weight gain
Excessive sweating Cool, dry, coarse skin; loss of hair
Warm, smooth, moist skin Swelling of the face, hands, legs, non-pitting edema
Heat intolerance Cold intolerance
Muscular weakness, tremor Weakness, muscle cramps, arthralgia, paresthesia
Lid lag, exophthalmos, stare Peri-orbital puffiness
Palpitations, hyperdynamic cardiac pulsations, accentuated S1 Decreased intensity of heart sounds
Tachycardia Bradycardia
 SBP,  DBP  SBP,  DBP
Frequent bowel movements Constipation
Toxic SSx: Heat intolerance, palpitations, dysphagia/dyspnea, finger tremors
NODULAR NON-TOXIC GOITER (NTNG)
• Present as an asymmetric anterior neck mass (ANM) that moves with deglutition and usually nodular on palpation; no or minimal
symptoms of hypo/hyperthyroidism
DIFFUSE TOXIC GOITER (DTG)
• Presents as symmetric ANM which moves with deglutition and smooth on palpation; with symptoms of hyperthyroidism
• FT4 is requested and not total T4 because it is the active form. Free T3 is only requested when both FT4 & TSH are normal and
the pt is clinically hyperthyroid. Between the two, TSH is more diagnostic of hyperthyroidism.
NODULAR TOXIC GOITER
• Not very common; presents as an asymmetric ANM which moves with deglutition and nodular on palpation, but presents with
symptoms of hyperthyroidism
Treatment
FNAB is done because of higher rate of occurrence of CA in nodular goiter
DIFFUSE NONTOXIC GOITER
• Not very common, presents with symmetric ANM which moves with deglutition and smooth on palpation but has no symptoms of
hyperthyroidism
Treatment
FNAB is not done due to low incidence of CA in DNTG. Thyroid scan is requested to determine the size and activity of the ANM.
THE THYROID GLAND
Sample Chart Entry
FNAB
FT4, TSH
TCB once with results
Sample Chart Entry
FT4, TSH
CBC with PC & DC
12L ECG
PTU 50mg/tab 2 tabs TID (Maximum of 600mg/day)
Propranolol 10mg/tab 1 tab BID (for tachycardia, palpitations, and anxiety)
Refer to ENDO re: DTG
Sample Chart Entry
FNAB
FT4, TSH
PTU 50mg/tab 2 tabs TID (Maximum of 600mg/day)
Propranolol 10mg/tab 1 tab BID (for tachycardia, palpitations, and anxiety)
Refer to ENDO re: NTG
Sample Chart Entry
Thyroid scan
FT4. TSH
TCB once with results

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Most common complications of thyroid surgery
a. Hemorrhage – if this occurs post-op, remove the sutures immediately to protect the airway
b. Hypocalcemia – occurs if all parathyroid glands are inadvertently removed or if ischemia occurs
c. Recurrent laryngeal nerve transaction – Pt would present with hoarseness
BELL’S PALSY
• Facial nerve paralysis (CN VII) usually following viral infection
Grading of Facial Nerve Involvement
1-2 risorius involved; can’t smile
3-4 cheeks involved
5 orbicularis involved; can’t close eyes
6 frontalis involved; can’t wrinkle forehead
TEMPOROMANDIBULAR JOINT DYSFUNCTION
• Most common: Myofascial pain and dysfunction, usually the result of bruxism or jaw clenching, related to stress/ anxiety/
depression/ chronic pain.
• Less commonly due to mechanical problem or OA. Or primary internal derangement of joint (has clicking during open/close)
leading to disc displacement, due to many causes.
Etiology
a. Traumatic (OA, condylar fx, TMJ subluxation, whiplash, capsulitis synovitis)
b. Dental (malocclusion, reconstruction, poor fitting prosthesis/ dentures/ orthodontics)
c. Iatrogenic (ETT intubation, surgical)
d. Systemic (RA, gout, Pagets, psoriasis)
e. Infectious (GC, syphilis, TB, actinomycosis, RF, Lyme dz --> cyclic pain q1-3mo lasting 7-14d)
f. Congenital (aplasia, hyperplasia, hypoplasia, bifid condyle)
g. Others: stress, bruxism, idiopathic, myofascial pain.
3 Cardinal features
a. orofacial pain – Classic: pain in front of tragus with radiation to ear/ lower jaw/ cheek/ temple. Preauricular, temporal, ear that
may radiates to head/face/eye. Pt also may c/o pain in the neck/ shoulder, tinnitus, H-A, insomnia. Pain worse in AM, may occur
in cyclical episodes
b. restricted jaw function - Jaw movement is described as a tightness/ sticking/ catching/locking.
c. noise in the joint (crunch-pop-grind).
Physical Examination
a. Clicking TMJ
b. Check ROM
1. Open & close, <30mm between teeth is abnormal. Should be able to insert your digits 2,3,4 in between pt’s incisor
teeth.
2. Check the lateral excursion of mandible, ask pt to move his jaw from side to side. Palpate masseter and temporalis m.
Note any excessive occlusal wear, tooth mobility, buccal mucosal ridging, lateral tongue scalloping.
Treatment
a. Conservative effective for 80%: education, stress reduction/ relaxation therapy, modify chewing and other habit that cause
excessive jaw movement. Massage, local moist heat and aerobic exercise. NSAIDs & restricted opening, soft diet to reduce
painful loads.
b. Silicone Night Guard = Interocclusional Appliance/ splint → stabilize an occlusion & dec the load on the inflamed joint X 4-
6 week trial
c. Closed reduction and Barton’s Manuever
TONSILLITIS
• Most commonly caused by Streptococcus sp.
• Treated with Clindamycin 150mg/tab (children) or 300mg/tab (adults) a tab TID X 1 week
THE UPPER AERODIGESTIVE TRACT
Sample Chart Entry
EMG-NCV
Prednisone 5mg/tab 4 tabs AM, 3 tabs lunch, 2 tabs PM X 2 weeks
Etoricoxib 120 mg/tab for pain
Refer to Neuro
Refer to Ophtha re: Exposure keratitis
Sample Chart Entry
Soft diet X 1 week
Etoricoxib 120 mg/tab 1 tab OD X 1 week for pain
Wear dentures all the time except during sleep

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TONSILOPHARYNGITIS
• Treated with Roxithromycin 150mg/tab BID X 1 week
CHRONIC HYPERTROPHIC TONSILS
• Treated with tonsillectomy if with indications:
Absolute indications:
a. Malignancy
b. Obstructive sleep apnea
c. Dysphagia leading to significant weight loss
Relative indication: Recurrent tonsillitis (>6x/year)
LARYNGITIS
• Acute if <4 weeks; Chronic if >4 weeks.
LARYNGOPHARYNGEAL REFLUX
• Characterized by foreign body sensation in the throat
• Treated with Omeprazole 20mg/tab 1 tab OD X 2 weeks
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
• Characterized by retrosternal chest pain
• Treated with Omeprazole 20mg/tab 1 tab OD X 2 weeks
• Diet modification: No spicy & sour food, eat small-portioned meals
• Sleep at 30 angle and rest the voice
FOREIGN BODY INGESTION
• Pt may feel pain on the anatomic location where the FB was lodged (cricopharynx, notch on esophagus, arch of the aorta, L
bronchus, lower esophageal sphincter)
• Diagnostics is through radiographic studies which may be repeated every 12 hours. FB appears slit-like when in the esophagus on
lateral x-rays. If FB is in the stomach, refer to Surgery. If it is in the airway but beyond the main bronchi, refer to TCVS. ENT
manages FB in the esophagus and upper airway (trachea & main bronchi)
• Barium swallow is done when plain radiographs are non-diagnostics. It is not requested if FB is metallic.
CELLULITIS
ABSCESSES
Sample Chart Entry
Cloxacillin 500mg/cap 1 cap QID X 7 days
Etoricoxib 120 mg/tab 1 tab OD prn for pain
TCB after 1 week for re-assessment
Sample Chart Entry
For tonsillectomy/GA
SAPOD clearance: CBC with PC & DC, BUN/Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR
TCB once with results for OR scheduling
Sample Chart Entry
Lonazolac 200mg/tab 1 tab BID X 2 weeks
Voice rest
Increased OFI
Warm saline gargle
TCB after 2 weeks once with results
Sample Chart Entry
NPO now
IVF: D5 0.9 NaCl 1L X 8
CXR-APL to include neck and abdomen (in children)
CXR-APL to include the neck, plain abdomen (in adults, a separate neck STL may be requested when not possible)
SOFT TISSUE INFECTIONS

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• Include dentoalveolar abscess (DAA), tonsillar abscess, parotid abscess, and parapharyngeal abscess
Treatment
a. Incision and Drainage. Local analgesic is not used since it is not effective in the presence of an abscess.
b. Antibiotics. To cover for G (+) & (-), Pen G is given. To cover for anaerobes, Clindamycin or Metronidazole.
1. For adults:
i. Pen G 4 million units IV LD ( ) ANST then 2 million units q6h
ii. Clindamycin 600mg IV LD ( ) ANST then 300 mg q6h OR
Metronidazole 500mg IV LD ( ) ANST then 250 mg q6h
2. For children:
i. PenG 50,000 units/kg IV LD ( )ANST then 25,000 units/kg q6h
ii. Clindamycin 20 mg/kg IV LD ( ) ANST then 10 mg/kg q6h OR
Metronidazole 15 mg/kg IV LD ( ) ANST then 7.5 mg/kg q6h
3. Preparations
i. Pen G is available in 1 million units/amp preparation
ii. Clindamycin is available in 1,600 mg/amp preparation
4. After IV loading and I&D, the pt may be sent home with the followingmeds:
i. Pen G 250 mg/tab 1 tab QID to complete 7days (40,000 units =250mg)
ii. Clindamycin 300mg/tab 1 tab QID to complete 7 days
LUDWIG’S ANGINA
• Abscess dissecting the muscle planes of the chin which pushes the floor of the mouth upwards
• Palpated as a board-like mass in the floor of the mouth
• Usually originates forma DAA
• Commonly caused by Borrelia or spirochete which is responsive to Pen G / Metronidazole / Clindamycin
REACTIVE LYMPHADENOPATHY
• Usually has a focus of infection
• Commonly due to dental carries, hair lice, skin infection in the head and neck
• Should rule out TB adenitis
TB ADENITIS
• May or may not present with chronic cough (>2 weeks), weight loss, failure to gain weight, anorexia
• Should rule out reactive LAD
PAROTIDITS
Sample Chart Entry
S/P I & D
Pen G 4 million units IV LD ( ) ANST then 2 million units q6h
Clindamycin 600mg IV LD ( ) ANST then 300 mg q6h OR
Etoricoxib 120mg/tab 1 tab OD prn for pain
MGH
Advised
Sample Chart Entry
S/P I & D
Pen G 4 million units IV LD ( ) ANST then 2 million units q6h
Clindamycin 600mg IV LD ( ) ANST then 300 mg q6h OR
Etoricoxib 120mg/tab 1 tab OD prn for pain
MGH
Advised
TCB after 1 week for re-assessment
Sample Chart Entry
FNAB
Co-amoxiclav 625 mg/tab TID or 1 g/tab BID X 7 days
TCB after 1 week for re-assessment
Sample Chart Entry
FNAB
CXR AP-L
Sputum AFB X 3
TCB once with results

11. 11 | P a g e
• If viral (mumps), treatment is supportive with Etoricoxib 120 mg/tab 1 tab OD prin for pain, bed rest, increased OFI, and
avoidance of close contact with household members
• If bacterial, treat with Co-amoxiclav 625 mg/tab TID or 1 g/tab BID X 7 days
NASAL BONE FRACTURE
• Common due to its midline location on the face
• Most common mechanism of injury is mauling, followed by vehicular accidents
• Usually associated with a history of impact to the midfacial area
• Said to be “neglected” if fracture >14 days post-injury
Signs and Symptoms
a. crepitation
b. step-down deformity
c. nasal speculum deviation
d. shortening of the nose
e. increased mobility of the nose
f. anosmia
g. epistaxis
h. CSF rhinorrhea
Treatment
a. Imaging – Radiographic studies cannot distinguish between recent and old fractures. Therefore, these are not useful for
medico-legal cases, with a high rate of false negatives and false positives.
1. Water’s view – information regarding lateral displacement
2. Nose STL – demonstrates fracture in the anterior nasal bone
b. Packing – control bleeding using antibiotic impregnated nasal pack for 2-5 days. Antibiotics are given as prophylaxis
because nasal bone fractures are usually associated with lacerations of the nasal mucosa or skin.
c. Antibiotics – Penicillin (Cloxacillin) and first generation cephalosporin (Cefalexin – Cefalexin 500mg cap or 125mg/5mL
suspension) are usually given as prophylactic antibiotics.
d. Pain Medications
e. Closed reduction is done when swelling has subsided to allow for better assessment of the deformity. In children, swelling
usually subsides in <3 days while in adults, it takes 3-5 days. If with airway compromise, don’t wait for the swelling to
subside.
f. Open reduction with internal fixation (ORIF) is done only if the fracture is comminuted.
Complications
a. septal hematoma – irreversible damage to the underlying cartilage can occur within 3-4 days if not drained
b. infection
c. CSF leak
MAXILLARY FRACTURE
Classification
Lefort I (Guerin fracture) Lefort II (Pyramidal fracture) Lefort III (Craniofacial dysjunction)
Horizontal separation. The palate is
separated form the rest of the maxilla.
Midfacial fracture. The palate with the
maxilla is separated from the zygoma &
ethmoids.
The maxilla and the zygoma are separated
from the cranium passing through the
fronto-ethmoid and the fronto- zygomatic
sutures.
Imaging: Water’s view, Caldwell view, Lateral view. CT scan
MAXILLO-FACIAL TRAUMA
Sample Chart Entry
Water’s View
Nose STL
Cloxacillin 500mg/cap 1 cap QID X 7 days
Etoricoxib 120 mg/tab 1 tab OD prn for pain
Cold compress X 15 min TID for the 1st
24 hours then warm compress thereafter
TCB after

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MANDIBULAR FRACTURE
Types of muscles acting on Fracture Segments
a. Posterior group – upward, forward movement; stronger group. Masseter, lateral & medial pterygoids, & temporalis
b. Anterior group – down, backward movement. Geniohyoid, digastric, mylohyoid, genioglossus
Types of mandibular fracture
a. Favorable – muscle forces tend to keep fragments together
b. Unfavorable – muscle forces tend to pull fragments apart
Imaging studies
a. Panorex view – single best radiograph
b. AP- oblique, modified Towne’s
ZYGOMATIC FRACTURE
Types
a. simple fracture of the arch
b. trimolar or tripod fracture – involves all 3 suture lines
c. quadripod fracture – maxillary-zygomatic buttress considered
Imaging: Water’s, axial or submentovertical views.
CLEFT LIP
• May be unilateral or bilateral
Classification
a. Complete – cleft reaches the vestibule
b. Incomplete – does not reach the vestibule
Rule of Ten: Pt should be at least 10 lbs, 10 weeks, and has 10 mg/dL Hgb
CLEFT PALATE
• Reconstruction is performed before 2 years of age to aid in normal speech development. Early attention to nutrition is important
because sucking is impaired.
Thallwitz classification: L_A_H_S_H_A_L_
Divide the key areas of the face (Lip, Alveolus, Hard palate & Soft palate) into thirds. LAH – right, HAL - left
LEVELS OF LYMPH NODES
IA – submental
IB – submandibular
II, III, IV – along SCM
V – posterior triangle
VI – pre-tracheal
VII - paratracheal
NASOPHARYNGEAL CARCINOMA
• Presents with epistaxis, nasal obstrucstion, anosmia, constitutional SSx of malignancy
• On rhinoscopy, (+) for fungating mass in the nasopharynx
Staging
Primary tumor stage
T1 Tumor confined to nasopharynx
T2 Tumor extends to soft tissues of oropharynx or nasal fossa
T2a Without parapharyngeal extension
T2b With parapharyngeal extension
T3 Tumor invades bony structures or paranasal sinuses
T4 Tumor with intracranial extension or involvement of cranial nerves, infratemporal fossa, hypopharynx, or orbit
Stage groupings
CLEFT LIP AND PALATE
HEAD & NECK TUMORS
Sample Chart Entry
Punch Biopsy /LA
SAPOD Clearance: CBC with DC & PC, BUN, Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR
TCB once with results

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I T1 N0 M0
IIA T2a N0 M0
IIB T1,2a N1 M0; T2b N0, N1 M0
III T1,2 N2 M0; T3 N0,1,2 M0
IVA T4 N0,1,2 M0
IVB Any T N3 M0
IVC Any T Any N M1
Treatment
Primary tumors: RT alone (bilateral) is used for both the primary tumor and the regional nodal metastases. Surgery is not feasible
because of the inadequacy of the surgical margins at the base of the skull and the frequent involvement of the retropharyngeal and
cervical nodes bilaterally.
PAROTID TUMOR
• Benign tumors are more common than malignant ones
• If bilateral, probably Warthin’s tumor
• Most common histologic types are
1. Benign mixed tumor – major salivary gland; with pseudopods so remove mass with margins; with 1% malignant
transformation.
2. Malignant adenoid cystic CA – more common in minor salivary glands.
3. Mucoepidermoid cyst - malignant
Staging of Salivary Gland Carcinoma
Primary tumor stage
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 Tumor <2 cm without extraparenchymal extension
T2 Tumor >2 cm but <4 cm extraparenchymal extension
T3 Tumor >4 cm but <6 cm or having extraparenchymal extension without seventh cranial nerve involvement
T4 Tumor invades base of skull or seventh nerve or is >6 cm
Stage groupings for major salivary gland carcinomas
I T1,2,3 N0 M0
II T3 N0 M0
III T1,2 N1 M0
IV T4 N0 M0; T3,4 N1 M0; any T N2,3 M0; any T any N M1
MAXILLARY CARCINOMA
• Most common type is SCCA, followed by adenoid cystic CA
MUCOUS RETENTION CYST
• Originates from the maxillary sinuses
• Usually not touched, but may do puncture via Caldwell-luc if hard enough
LARYNGEAL CARCINOMA
• Presents with hoarseness (other causes included VC mass, VC inflammation, VC paralysis)
• Involvement of the cricoid cartilage indicates a subglottic extension which has a poorer prognosis
• Pt is sent to the ER if with dyspnea for emergency tracheostomy and then possible admission for furtherwork-up
• Total laryngectomy with next dissection is done for proven laryngeal CA
Staging
Primary Tumor
Sample Chart Entry
FNAB
SAPOD Clearance: CBC with DC & PC, BUN, Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR
TCB once with results
Sample Chart Entry
FNAB
SAPOD Clearance: CBC with DC & PC, BUN, Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR
TCB once with results
Sample Chart Entry
Direct laryngoscopy with biopsy of laryngeal mass/LA
SAPOD Clearance: CBC with DC & PC, BUN, Crea, RBS/FBS, Na, K, Cl, U/A, 12L ECG, CXR
TCB once with results

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Supraglottis Glottic Subglottic
Tis Carcinoma-in-situ Carcinoma-in-situ
T1 Tumor confined to site of origin with normal
mobility
Tumor confined to vocal cord(s) with
normal vocal cord mobility
T1a – limited to one vocal cord
T1b – with involvement of anterior
commisure
Tumor confined to subglottic
area
T2 Tumor involves adjacent supraglottic sites or
glottis without fixation
Supraglottic or subglottic extensionof
tumor with normal or impaired mobility
Tumor extension to vocal cords
with normal or impaired cord
mobility
T3 Tumor limited to larynx with fixation or extension
to involve postcricoid area, medial wall of
pyriform sinus or pre-epiglottic space
Tumor confined to larynx with cord
fixation
Tumor confined to larynx with
cord fixation
T4 Massive tumor extending beyond the larynx to
oropharynx, skin or soft tissues of neck, or
destruction of thyroid cartilage
Massive tumor with thyroid cartilage
destruction or extension beyond
confines of larynx or both
Massive tumor with cartilage
destruction or extension beyond
confines of larynx
Nodal Involvement
Nx – minimum requirements to assess the regional nodes cannot be met
NO – no clinically positive nodes
N1 – clinically positive homolateral nodes
N2 – contralateral or bilateral nodes not fixed
N3 – fixed nodes
Distant Metastasis
Mx – minimum requirements for assessment of distant metastasis cannot be met
MO – no distant metastasis
M1 – distant metastasis present
Staging
I T1 NO MO
II T2 NO MO
III T3 NO MO; T1, T2, T3 N1 MO
IV T4 NO MO; T4 NO MO; Any T N2, N3 MO; Any N M1
Indications for Emergency Tracheostomy
a. Foreign body occluding the airway
b. Retropharyngeal abscess
c. Tetanus
d. Severe myasthenia gravis
e. Laryngeal CA with Obstruction
THYROID CARCINOMA
PAPILLARY CANCER
• Most common, affect younger patients.
• Psammoma bodies are usually present in histologic sections.
• Distant metastases to lungs, bone, skin, and other organs occur late.
• Papillary = Popular = Psammoma = Palpable lymph nodes = Positve 131
I uptake = Positive prognosis = Post-op 131
I scan to
diagnose/treat metastases
Staging
Primary tumor (T)
TX: Primary tumor cannot be assessed.
T0: No evidence of primary tumor is found.
T1: Tumor size is 2 cm or less in greatest dimension and is limited to the thyroid.
T2: Tumor size is greater than 2 cm but less than 4 cm, and tumor is limited to the thyroid.
T3: Tumor size is greater than 4 cm, and tumor is limited to the thyroid or any tumor with minimal extrathyroidal extension
(extension to sternothyroid muscle of perithyroid soft tissues).
T4a: Tumor extends beyond the thyroid capsule and invades any of the following: subcutaneous soft tissues, larynx, trachea,
esophagus, or recurrent laryngeal nerve.
T4b: Tumor invades prevertebral fascia, mediastinal vessels, or encases the carotid artery.
Regional lymph nodes (N)
NX: Regional nodes cannot be assessed.
N0: No regional node metastasis is found.
N1a: Metastasis is found in level VI (pretracheal and paratracheal, including prelaryngeal and Delphian) lymph nodes.
N1b: Metastasis is found in unilateral, bilateral, or contralateral cervical or upper/superior mediastinal lymph nodes.
Distant metastasis (M)
MX: Distant metastasis cannot be assessed.
M0: No distant metastasis is found.
M1: Distant metastasis is present.
Stages
Stage Younger Than 45 Years Age 45 Years and Older

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I Any T, Any N, M0 T1, N0, M0
II Any T, Any N, M1 T2, N0, M0
III T3, N0, M0, T1, T2, T3, N1a, M0
IVa T1, T2, T3, N1b, M0, T4a, N0, N1, M0
IVb T4b, any N, M0
IVc Any T, any N, M1
FOLLICULAR CANCER
• Peak incidence at 40 years of age.
• They tend to invade blood vessels and to metastasize hematogenously to visceral sites, particularly bone. Lymph node
metastases are relatively rare, especially compared with papillary cancers.
• Hürthle cell cancer is a variant of follicular carcinoma and has a relatively aggressive metastatic course.
• Follicular = Far-away metastasis = Female (3:1) = FNAB NOT (diagnosed by tissue structure) = Favorableprognosis
Staging
Stage Younger Than 45 Years Age 45 Years and Older
I
Any T, any N, M0 (Cancer is in the thyroid
only)
T1, N0, M0 (Cancer is in the thyroid only and may be found in one or both
lobes)
II
Any T, any N, M1 (Cancer has spread to
distant organs)
T2, N0, M0 and T3, N0, M0 (Cancer is in the thyroid only and is larger than
1.5 cm)
III
T4, N0, M0 and any T, N1, M0 (Cancer has spread outside the thyroid but
not outside of the neck)
IV Any T, any N, M1 (Cancer has spread to other parts of the body)
MEDULLARY THYROID CANCER
• Secrete calcitonin. ACTH, histaminase, and an unidentified substance that produces diarrhea may also be secreted by these
tumors. Large amounts of amyloid are evident by histologic examination.
• Metastases are mostly found in the neck and mediastinal lymph nodes and may calcify. Widespread visceral metastases occur
late.
• Medullary = MEN II = aMyloid = Median lymph node dissection = Modified neck dissection if lateral nodes arepositive
Staging
I Cancer is less than 1 centimeter (about 1/2 inch) in size.
II Cancer is between 1 and 4 centimeters (about 1/2 to 1 1/2 inches) in size.
III Cancer has spread to the lymph nodes.
IV Cancer has spread to other parts of the body.
ANAPLASTIC GIANT AND SPINDLE CELL CANCER
• Occur most often in patients older than 60 years of age. Anaplastic thyroid cancers are aggressive cancers, which rapidly invade
surrounding local tissues and metastasize to distant organs.
• There is no number staging system used for anaplastic cancer.
Other tumors found in the thyroid include Hodgkin lymphomas, a variety of soft tissue sarcomas, and metastatic cancers of lung,
colon, and other primary sites. Small cell cancers of the thyroid are rare, are histologically similar to lymphoma, and spread to both
lymph nodes and distant sites.