Midline Neck Swellings

Thyroglossal Tract Cyst

This is a mid-line neck swelling forming in the remnant of the thyroglossal tract a . The swelling is commonly between the thyroid and hyoid, but suprahyroid cysts also occur. The convexity of the hyoid bone and thyroid cartilage push the cyst to one side, so it may not be strictly mid-line. The cyst moves on swallowing and on protrusion of the tongue b, c, arrows . It is usually nontender but may present with recurrent episodes of acute swelling and tenderness....

Tonsillectomy

Sores Uvula

Tonsillectomy is one of the most frequently performed operations in the world. Stricter indications for operating, however, are reducing the number of tonsillectomies. Recurrent episodes of acute tonsillitis, interfering with school or work, are the main indications. A quinsy or chronic tonsillitis are other indications, along with marked enlargement interfering with the airway. Fig. 4.62 The tonsillar fossae following tonsillectomy. These are covered with a white yellow membrane for about 10...

Inflammation of the Larynx Laryngitis

Severe Laryngomalacia

Whether acute or chronic, laryngitis presents with hoarseness and generalized hyperemia of the laryngeal mucous membrane. Acute laryngitis commonly follows an upper respiratory tract infection, or is traumatic following vocal abuse. Voice rest is the most effective treatment. Chronic laryngitis may be associated with infection in the upper or lower respiratory tract, but is commonly irritative due to occupation and environment, vocal abuse, or tobacco. The unusual laryngitis of myxoedema must...

Inflammatory Neck Swellings

Cellulitis The Chin

The spread of dental infection must be remembered as a possible cause of inflammatory neck swelling. Fig. 5.18 Cervical cellulitis may develop from a dental abscess in the lower molars and involve the neck laterally. Fig. 5.17 Ludwig's angina. An indurated, tender, mid-line inflammation is characteristic of Ludwig's angina. Bimanual palpation reveals a characteristic woody firmness of the normally soft tissues of the floor of the mouth, which is an early sign. This acute infection may spread...

Salivary Glands

Pictures Empacted Salivary Glands

Fig. 5.2 Grossly enlarged submandibular gland. This develops if an impacted calculus is ignored. A neoplasm of the submandibular gland is the differential diagnosis if the enlargement is persistent and there is no evidence of a calculus on radiograph. The nodular surface and the firm, nontender character on palpation of this gland are also suggestive of a neoplasm, commonly a pleomorphic adenoma or adenoid cystic carcinoma. calculus obstructing the submandibular duct causes painful and...

Infections of the Tonsils Pharynx and Oropharynx Acute Tonsillitis see p196

Acute Tonsillitis

This condition is characterized by sore throat, dysphagia, and pyrexia. The appearance of the tonsils varies. An obviously purulent exudate covering the tonsils is common, and is either diffuse or punctate Fig. 4.52a, b . An apparently less severely infected throat with hyperemia of the tonsils only may, however, be associated with severe symptoms. The tonsillar lymph nodes near the angle of the mandible are large and tender. With acute tonsillitis, the exudate and hyperemia are centered on the...

Oral Candidiasis Thrush

Oral Candida

Monilla, or oral candidiasis thrush , is one of the fungal infections of the pharynx. Extensive white areas cover the entire oropharynx, and are not confined to the tonsil. They are either continuous Fig. 4.56a or punctate Fig. 4.56b . A swab shows Candida albicans and confirms the diagnosis. The condition responds to antifungal mouth washes or lozenges containing nystatin or amphotericin. It is commoner in neonates, and may complicate treatment with broad spectrum antibiotics. Oral candidiasis...

Snoring

Squamous Cell Carcinoma The Uvula

Snoring, although in most cases a relatively trivial problem, may if gross have serious implications. Although snoring is commonly associated with obesity, aging, where the pharyngeal tissues become more lax along with late-night excess food and alcohol intake, there are anatomical factors in the upper respiratory tract that contribute to snoring. Nasal obstruction accentuates snoring but is not commonly the prime cause. Surgery therefore for airway problems to the nose may not be curative. The...

Glomus Jugulare

Bifid Uvula

This usually occurs on the margin or from the extension of an ulcer on the floor of the mouth as shown here . Biopsy of this proliferative ulcer showed squamous cell carcinoma. Partial glossectomy in continuity with a neck dissection, or radiotherapy, are the current treatments. Fig. 4.34 Leukoplakia. This is precarcinomatous on the tongue. It may be secondary to dental or dietary irritation. Leukoplakia is also characteristic of tertiary syphilis, and the...

Otitis Externa

Otitis Externa

Eczema of the meatus and pinna see Fig. 2.41 may be associated with eczema elsewhere, particularly in the scalp, or it may be an isolated condition affecting only one ear. Itching is the main symptom, with scanty discharge. The eczematous type of otitis externa usually settles with the use of a topical corticosteroid and antibiotic drop. Cleaning of the meatus may also be necessary, either with cotton wool on a probe, or suction and the Zeiss microscope. Otitis externa tends to recur. The...

The Tongue

Tongue Lesion

This is due to a short frenulum linguae, and apart from the defect of being unable to protrude the tongue, the patient is almost always symptom-free. Speech defects can rarely be attributed to tongue tie necessitating division of the frenu-lum. Fig. 4.21 Tongue tie. This is due to a short frenulum linguae, and apart from the defect of being unable to protrude the tongue, the patient is almost always symptom-free. Speech defects can rarely be attributed to tongue tie...

Aphthous Ulcers see p 172 ff

Traumatic Ulcer Tongue

An area of white superficial ulceration is surrounded by a hyperemic mucous membrane. These commonly occur in crops of two or more, and heal spontaneously in about one week. They are also acutely tender, and affect the nonkeratinizd oral mucous membrane. Although there is no induration on palpation, the histological inflammatory changes are not superficial, and may extend into the underlying muscle. Hydrocortisone pellets to suck, or triamcinolone with Orabase ointments applied to the ulcer,...

Chronic Otitis Media With Effusion

Otitis Media With Effusion Adults

Middle-ear fluid, if persistent, may cause permanent changes in the drum. An otitis media with effusion can cause hearing loss for decades, and the diagnosis is frequently overlooked in a long-standing hearing loss. Impedance audiometry helps in diagnosis. Fig. 2.81 Crossly altered drum. A brown color, with retraction of a flaccid membrane onto the ossicles and promontory, is seen with long-standing middle-earfluid. Bottom arrow indrawn drum onto the promontory top arrow incudostapedial joint....

The Oropharynx Mouth and Lips

Torus Mandibularis

Lip ulceration has numerous causes, eithertraumatic, inflammatory, or neoplastic. The provisional diagnosis can be made from the history and type of ulcer. Biopsy is necessary to confirm the diagnosis. This lesion is a pyogenic granuloma. Although these lesions are frequently small and related to trauma, they may enlarge from secondary infection see Fig. 4.4 and take several weeks to heal. lip. Mucoceles are cystic, nontender swellings presenting on the lips or in the oral...

Malignant Nasal Tumors

Ulcerated Nasal Septum

A nasal polyp that does not appear gray and opalescent should arouse suspicion, as should a polyp that bleeds spontaneously. A solid-looking hyperemic polyp may be an inverted papilloma. Granulation tissue in the nose may be malignant granuloma or carcinoma, and biopsy of any suspicious nasal lesion is necessary. Fig. 3.86 A pigmented polyp may be a Prognosis when radiotherapy is followed by maxillectomy is quite good for an early maxillary carcinoma, but poor when there is extensive invasion....

Epistaxis

Bleeding Telangiectasia Hands

Anteriorly on the septum there is anastomosis of several arteries the sphenopalatine, the greater palatine, the superior labial, and the anterior ethmoidal . This site is called Little's area or Kiesselbach's plexus, and is the commonest site of nose bleeds. Although associated with alarm, most epistaxis is short-lived and trivial. It is better to sit upright since the blood tends to be swallowed, causing nausea on lying down. There are numerous causes of epistaxis. Some,...

Referred Ear Pain

Siegle Speculum

If examination of the drum and meatus is normal in a patient complaining of earache, the pain is referred. Referred ear pain may be from nearby structures such as the temporo-mandibular joint, neck muscles, or cervical spine. It may also be from the teeth, tongue, tonsils, or larynx. Cranial nerves V, IX, and X which supply these sites have their respective tympanic and auricular branches supplying the ear. Earache also frequently precedes a Bell's palsy. Fig. 1.15 Siegle's speculum has been...

Mucocele Extraction

Caldwell Luc Operation Definition

In the common cold, the nasal mucous membrane is edematous, so the inferior turbinate abuts against the septum to result in obstruction and an excess of mucous which causes the running nose. A similar appearance is seen in nasal allergy, either seasonal hay fever or perennial allergy, but the edematous turbinate mucous membrane appears gray c rather than red b . A persistent purulent nasal discharge usually means that there is a sinusitis. Corticosteroid nasal...

Otitis Eksterna

Chalk Patches Otitis Eksterna

Fig. 2.72 Otitis media with effusion with minimal drum change. The drum may look only slightly different, with a brown color and some hyperemia. A confident diagnosis of middle-ear fluid can only be made if reduced mobility is demonstrated and impedance audiometry Figs. 1.30, 1.31 is needed for confirmation. Fig. 2.73 Otitis media with effusion glue ear . a The color change in this condition is often diagnostic, as well as the reduced mobility. The golden-brown color showing through the...

Inflammation nasal vestibulitis

Septoplasty Splint

Fig. 3.47 Vestibulitis presents as crusting and irritation in the anterior nares with resulting nasal obstruction. Examination shows excoriated vestibular skin and septal mucous membrane. Rubbing or over-diligent cleaning of the nose by the patient usually causes vestibulitis, particularly if, as in this case, the septum is deviated anteriorly and impinges on the lateral wall of the nose. Advice and the use of antibiotic and corticosteroid ointment are effective in controlling vestibulitis....

Middle Ear Effusion

Picture Middle Ear Effusion

Glue ear is common between the ages of three and six years, and uncommonly persists after 11 years. The hearing loss is often slight and varies with colds. The self-limiting nature of the condition calls for conservative treatment, but glue ears are not to be ignored. A marked and persistent hearing loss, interfering with schooling, necessitates surgery. Episodes of transient otalgia are common with glue ears, and frequent attacks of acute otitis media may occur. The drum may also become...

Deviated Nasal Septum

Nose Caudal Dislocation

A congenital or traumatic dislocation of the septal cartilage into one nasal fossa causes unilateral nasal obstruction. If the obstruction is marked, or complicated by recurrent sinusitis, a septal correction is effective surgery. The time-honored operation for this is a submucous resection SMR , but a septoplasty in which cartilage is preserved and repositioned rather than removed is now used. The SMR operation involves removal of much of the septal cartilage and loss of nasal support with...

Acute Otitis Media

Perilymph Fistula

Earache with conductive hearing loss and fever accompanying a head cold characterize acute otitis media. The drum is red and the landmarks are obscured drum distension and pulsation may be seen. Otitis media is common in children, probably due to their short, wide eustachian tube and the presence of adenoids which may be infected near the orifice. Rupture of the tympanic membrane in acute otitis media is not uncommon and muco-purulent otorrhea ensues with a pulsatile discharge. Penicillin is...

Rhinoplasty

Nasal Vestibule Carcinoma

The appearance of a nose with a congenital or traumatic hump of the nasal bones can be improved with rhinoplasty a, b c, d . A deviated nose may be straightened e, f . Fig. 3.29 Rhinoplasty. The appearance of a nose with a congenital or traumatic hump of the nasal bones can be improved with rhinoplasty a, b c, d . A deviated nose may be straightened e, f . Fig. 3.30a-f Nasal tip rhinoplasty. Bulbous or bifid nasal tips can be modified a, b . Incisions for rhinoplasty are...

Deformities

Human Deformities

Abnormal fusion of the nasal processes is uncommon, and may result in varying degrees of deformity. In this case, the nose is bifid with hypertelorism the distance between the eyes being greatly increased . In milder cases, the bifid appearance of the nose is less marked, and may just appear as a rather wide nose. Abnormal fusion of the nasal processes is uncommon, and may result in varying degrees of deformity. In this case, the nose is bifid with hypertelorism the distance between the eyes...

Persistent snoring in a child is the main symptom of enlarged adenoids

Enlarged Adenoids

In day-time there is mouth breathing. Purulent rhinorrhoea if there is secondary sinusitis and epistaxis also occur, with or without nasal symptoms. There is hearing loss due to otitis media with effusion, or earache from recurrent acute otitis media. Adenoids normally regress before puberty and adults with large adenoids are rare. If an adult has nasal obstruction due to postnasal lymphoid tissue, the histology is essential to exclude a lymphoma. Nasal obstruction may occur from birth due to...

Nasel Cyst Hearling Loss

Anterior Nares

Fig. 3.6 Nasoalveolar cysts have a constant anatomical site and spot diagnosis is possible. Externally, there is flattening of the nasolabial fold and flaring of the alae nasi. In the anterior nares the cyst extends into the floor of the nose and displaces the inferior turbinate upwards. Excision via a sublabial incision and enucleation is the treatment. Surgical rupture of the cyst usually means incomplete removal, and predisposes to recurrence. The arrow indicates flaring of ala. Fig. 3.6...

The Tympanic Membrane and Middle

Tympanosclerosis And Grommet Scar

White areas of tympanosclerosis arrows are common findings on examination of the drum. They are of little significance in themselves, and the hearing is often normal. A past history of otorrhea in childhood or grommet insertion is usual. Chalk patches do occur with no apparent past otitis media. Extensive tympanosclerosis with a rigid drum is a sequela of past otitis media, and the ossicles, too, may be fixed or noncontinuous. Fig. 2.53 Scarring of the drum. a A...

Examination of the Pharynx and Larynx

Papillae Circumvallatae

SFig. 1.59 Examination of the pharynx. A tongue h depressor is necessary to I obtain a clear view of the tonsil region in most cases. I Patients vary however in how easily the fauces and posterior aspects of the tongue can be seen. On occasion a very clear view is obtained Fig. Fig. 1.60 Circumvallate papillae. These are often prominent on the base of the tongue. A patient may be alarmed when looking at the tongue to notice these normal structures and mistake them for a serious disease. The...

Examination of the Nose

Instruments are best avoided in children. A good anterior view of the nose can be obtained simply by pressing on the tip of the nose. In this case, a clear view is obtained of a pedunculated papilloma of the nasal vestibule arrow . Fig. 1.44 Examining a child. Instruments are best avoided in children. A good anterior view of the nose can be obtained simply by pressing on the tip of the nose. In this case, a clear view is obtained of a pedunculated papilloma of the...

Hearing Loss

Bone Anchored Hearing Aid

Most hearing loss is easy to diagnose as either a well-defined conductive or sensorineural type. Mixed hearing loss may occur, but this diagnosis is usually non-contributory, and the term is better avoided. Lesions to the left of the red line Fig. 1.16 cause conductive hearing loss, and are frequently curable. Hearing loss to the right of the blue line is due to a sensorineural lesion, and is usually not so amenable to treatment. Fig. 1.16 Conductive and sensorineural hearing loss. Hearing loss...

Examination of the

Furunculosis Due Skin Lymphomas

To see the drum more clearly, therefore, the pinna is retracted backwards and outwards. The index finger may be used to hold the tragus forward. If this step of straightening the meatus accentuates the pain in someone presenting with an earache, one can be virtually certain that the diagnosis is either a furuncle or furunculosis see Fig. 2.43 . Fig. 1.5 Head mirror and speculum. These are used for the initial examination of the meatus and drum. Fig. 1.5 Head mirror and...