ENT & INTER DEPARTMENT REFERRALS

1. ENT Referrals -To & From Other Branches Dr Harjitpal Singh Assistant Professor Department of ENT

2. HOARSENESS • Hoarseness is a symptom resulting from the underlying disease process • AND IT IS NOT A diagnosis • Hoarseness has a number of causes, ranging from simple inflammatory processes to less common psychiatric disorders to more serious systemic, neurologic, or cancerous conditions.

3. POTENTIAL CAUSES OF VOICE DISORDERS/HOARESENESS a) Misuse/abuse – Yelling, Excessive Talking, Excessive Crying, Chronic Coughing, Throat Clearing, Poor Hydration, Misuse Of Pitch, Chronic Exposure To Irritants, Excessive Muscle Tension b) Structural impairment –Nodules, Cysts, Polyps, Laryngeal Webs, Stenosis, Chronic Upper Airway Impairment, Laryngeal Scarring, Limited Breath Support For Speech, Inflammation Due To Acid Reflux, Laryngeal Papilloma, Growth Involving Larynx C) Neurogenic – Cerebral Palsy, Head Injury, Muscular Dystrophy, Vocal Fold Paralysis, CVA, Parkinson Disease, Myasthenia Gravis D) Psychologic – Mutational Falsetto/ Puberphonia- Unusual high pitch that persists beyond puberty, Conversion Aphonia/Dysphonia e) Hearing loss – May cause patient to speak with high intensity or louder than normal

4. Steroid inhaler laryngitis • Steroid inhaler laryngitis, a clinical entity that is caused by the use of inhaled steroids and manifested by dysphonia, throat clearing, and fullness. • Steroid inhaler laryngitis is a form of chemical laryngopharyngitis induced by topical steroid administration. Symptoms and physical findings mimic laryngopharyngeal reflux, but only respond completely to discontinuation of the inhaled steroid therapy. 

5. Physical Examination • INDIRECT LARYNGOSCOPY Advantages: fast, inexpensive, minimal equiptment • Disadvantages: gag, nonphysiologic, no permanent image capability

6. Physical Examination • Rigid Laryngoscopy (70 or 90-degree telescope) • Advantages: best optic image, magnifies, video documentation • Disadvantages: gag, nonphysiologic, expensive

7. Physical Examination • Flexible fiberoptic nasolaryngoscope • Advantages: well tolerated, physiologic, video documentation • Disadvantages: time consuming, expensive, resolution limited by fiberoptics

8. Physical Examination • Videostroboscopy • Advantages: allows apparent “slow motion” assessment of mucosal vibratory dynamics, video documentation • Disadvantages: time consuming, expensive

9. Physical Examination • Direct laryngoscopy • Available for use with treatment

10. Differential Diangosis • Benign Laryngeal Conditions • Vocal cord nodules are commonly secondary to chronic phonotrauma (vocal abuse) • They are benign lesions that are frequently bilateral, occurring at the junction between the anterior and middle third of the vocal folds. • Management is mainly from the Speech and Language Therapy (SALT) team, however in severe or resistant cases, surgical intervention may be warranted • Muscle tension dysphonia is caused by habitual misuse of the muscles of the larynx or phonatory gap • Commonly present with a hoarse voice worsening towards the end of the day or following prolonged use. • Diagnosis can be confirmed via stroboscopy and the mainstay of management is from the SALT team • Vocal cord polyps are typically benign lesions, however unlike vocal cord nodules, they are normally unilateral and may need surgical excision to exclude malignancy.

11. Differential Diangosis • Laryngeal papillomas are also benign lesions in the larynx, commonly caused by HPV infection • If left untreated, papillomas can grow to cause airway obstruction and hence need surgical excision or debulking. It is not uncommon for patients to need repeat procedures as papillomas can recur. • Reflux laryngitis is a cause of hoarseness caused by acid reflux resulting in inflammation of the larynx. • Clinical examination will often be unremarkable, but IDL will reveal an erythematous larynx. • Reinke’soedemais oedema of the vocal folds. It is strongly linked to smoking. Smoking cessation and voice therapy are the mainstay of treatment.

12. Differential Diangosis • Infective • Laryngitis is inflammation of the vocal cords, commonly following respiratory tract infections • Clinical examination will be normal but IDL will reveal an inflamed larynx. This can be managed conservatively and should result in complete recovery. • Acute epiglottitis is infection of the epiglottis • Neurological • A recurrent laryngeal nerve palsy can be caused by a wide variety of underlying causes, including thyroid cancer, lung cancer, aortic aneurysm, multiple sclerosis , or stroke. • Extensive examinations are key to further delineating the underlying diagnosis such as neck examination and cranial nerve examination. Initial investigation if examination is unremarkable would be CT imaging from skull base to diaphragm to assess for any pathology affecting the recurrent laryngeal nerve.

13. Key Points • Wide range of pathology can result in hoarseness, from inflammatory to neurological • All patients should undergo INDIRECT LARYNGOSCOPY OR flexible nasal endoscopy to allow for the visualization of the larynx and the vocal cords, before further investigations can occur

14. CHRONIC PHARYNGITIS

15. CHRONIC PHARYNGITIS Pharyngitis is defined as inflammation of the pharynx. Chronic Pharyngitis is characterized by hypertrophy of mucosa, seromucinous glands and sub epithelial lymphoid tissues The anatomic region of the pharynx invariably affected in adults is the oropharynx. The predominant symptom is sore throat, which overall is the third most common chief complaint to physicians in an office-based practice.

19. SYMPTOMS • Discomfort or pain in throat • Foreign body sensation in throat • Dry Cough • Tiredness of voice • Retching or gagging

20. SIGNS • Congested post wall • Odema of the wall • Nodules on the wall • Lateral pharyngeal bands

22. EPISTAXIS

23. EPISTAXIS • Epistaxis is a greek word meaning nose bleed, has been a part of the human experience from earliest times.

24. CLASSIFICATION OF EPISTAXIS • Primary –no obvious cause • Mild – no hemodynamic alteration • Anterior : Kiesselbach’s plexus/Littles area • Seasonal : cold dry months • Unilateral : one nostril bleed • Secondary-cause present • Moderate to severe- hemodynamically unstable • Posterior : Woodruff's plexus • Perennial: throughout year • Bilateral : bleeds into throat or from both nostrils

25. SYSTEMIC CAUSES • Diffuse oozing, multiple bleeding sites, or recurrent bleeding may indicate a systemic cause. • Then we need to look into specific causes

26. SYSTEMIC CAUSES(Cont.) • Haemophilia • Hypertension • Raised venous pressure in cardiac or pulmonary diseases e. g miteralstenosis • Leukemia • Liver disease (e.g., cirrhosis,Factordefeciency) • Medications e.g., aspirin, anticoagulants, nonsteroidal anti-inflammatory drugs • Platelet dysfunction & Thrombocytopenia

27. SYSTEMIC CAUSES(Cont.) • Liver disease • Hepatic cirrhosis(deficiency of factor II,VII,, IX, and X) • Kidney disease(Chronic nephritis) • Drugs • Sallicylates and other analgesic • Anticoagulant therapy • Mediastinal compression(tumor causing raised venous pressure) • Acute general infection(influenza, measules, whooping cough) • Vicarious menstruation -during the period.

28. ETIOLOGY AND AGE Children - foreign body, nose picking Adults - trauma, idiopathic Middle age - tumors Old age - hypertension

29. AetiologyLocal Causes Trauma • Nose picking, • Fractures (nasal bone, sinuses and/or skull base) • Nasal intubation • Surgery Infections ●Fungal infection ● Suppurative sinusitis ●Influenza, Measles,Diphtheria,Tuberculosis ● Atrophic rhinitis

30. Local Causes • Septum disorder (deviated nasal septum )- spur,perforation. • Foreign body. .

31. Angiofibroma Local Causes • Neoplasms of thenose, nasopharynx and sinuses Hemangioma Carcinom of the Nasopharynx

32. Environmental reason • High altitudes (drier and lower atm. pressure) • Air-conditioning • Extreme changes in temperature

33. Idiopathic • Vast majority of cases come under this category • “Spontaneous” is a better description. • Usually initiated by minor ‘digital’ trauma. • Often associated with atmospheric drying.

34. OTALGIA

35. OTALGIA Otogenic or Primary otalgia: is the pain that originates by a disease within the ear. Referred or secondary otalgia: is the pain that originates by a disease outside the ear.

36. WHEN TO LABEL AS REFERRED OTALGIA CLINICALLY NORMAL • Pinna • External auditory meatus • Tympanic membrane • Mastoid process Referred earache may be a presenting symptom of head and neck cancer

37. COMMON NON ENT CAUSES OF OTALGIA • Dental causes (caries, abscess, impacted teeth, malocclusion) • TMJ dysfunction • Cervical spine arthritis • Psychogenic

38. ETIOLOGY OF REFERRED OTALGIA A. Via trigeminal nerve • Teeth: infection, impacted 3rd molar, malocclusion • Oral cavity: infection, ulcer, malignancy, Ludwig’s angina, sialadenitis, salivary calculus • Temporo-mandibular joint: arthritis, dysfunction • Nose & PNS: impacted DNS, sinusitis, neoplasm • Nasopharynx: infection, post- adenoidectomy, adenoiditis, tumor • Trigeminal neuralgia

39. ETIOLOGY OF REFERRED OTALGIA (cont.) B. Via glossopharyngeal nerve • Tonsil: tonsillitis, peritonsillar abscess, posttonsillectomy, neoplasm • Oropharynx: infection, ulcer, retropharyngeal +parapharyngeal abscess, trauma, neoplasm • Eagle’s syndrome (stylalgia) • Glossopharyngeal neuralgia C. Via facial nerve: Herpes zoster oticus, vestibular schwannoma

40. ETIOLOGY OF REFERRED OTALGIA (cont.) D. Via vagus nerve: Larynx + hypopharynx: neoplasm, infection, tuberculosis, trauma, foreign body E. Via second & third cervical nerves: Herpes zoster, cervical spondylosis & arthritis

42. Cervical Spine Artheritis • Cause crepitus or neck and ear pain with neck movements • Decreased neck range of motion • Tender spinous processes or Para-spinal muscles • Pain referred to ear from C2,C3 cervical nerve root

43. Psychogenic Otalgia When no cause to the pain in ears can be found, it suggest a functional origin. The patient in such cases should be kept under observation with periodic re-evaluation.