Complaint of problem - symptoms

ID/ evaluate problem - signs, Ix

Resolve the problem - Tx

• Infection of EE (otitis externa) or ME (chronic suppurative otitis media - hearing loss)
• Acute or chronic infection
• Otitis externa: pus, no perforation of eardrum
• Common bacteria are staphylococcus aureus, pseudomonas aerugenosa, proteus mirabilis
• Chronic otitis: fungal superinfection with Candida albicans and Aspirgenlus niger (eg. ABX eardrops have killed bacteria but allow fungus to grow)
• Don't need culture - empirical Tx
• Chronic OM: recurrent ear discharge, eardrum perforation, pus, ossicular damage -> various degree of hearing loss
• Cholesteatoma: retraction pocket, epithelial debris, ear discharge, hearing loss -> complications (pocket erodes surrounding structures): facial nerve palsy, brain abscess. Occurs in superior part (never in central part). Needs Tx to prevent complications

• Hearing pathway (EE to temporal lobe cortex)

1. Conductive: EE, eardrum, ossicles

2. Sensorineural: cochlea, auditory nerve, brain

3. Mixed

• EE or ME
• Ear wax impaction, chronic otitis media, secretary otitis media, tympanosclerosis and otosclerosis
• Usu. more chronic problems
• If acute: traumatic injury of the eardrum and ossicles, acute otitis media, and acute otitis externa
• DIAG: perforated eardrum
• Acute: fresh blood, 95% heal themselves (if not contaminated by infection), keep dry (no ABX)
• Chronic: will not heal, repeated infection (cannot keep ear dry)
• DIAG: otitis media with effusion/ glue ear/ secretory otitis media
• Fluid collection behind intact eardrum - retracted eardrum, fluid level, handle of maleus move horizontal
• Blue drum

• IE pathology: cochlear hair cell damage
• Eg. Degenerative (elderly), ototoxic drugs (eg. Aminoglicosides), acute labyrinthitis, Meniere's disease (uncommon in HK), chronic exposure to loud noise
• May have tinnitus + vertigo
• If see unilateral sensory hearing loss - suspect acoustic neuroma (perform MRI)

• IE canal (cochlear nerve) or CNS (central asc pathway + temporal lobe hearing cortex)
• Eg. Acoustic neuroma and stroke.

• Clear, purulent and blood stained
• Nature: colour, smell important
• Clear: non-infective rhinitis (eg. allergic/ vasomotor rhinitis); assoc.: nasal obstruction, itchiness, sneezing, hyposmia.
• Purulent: infection; eg. sinusitis, foreign bodies (esp. children)
• Blood-stained: malignancy in the nose and sinuses (need endoscopy + radiology)

• Hypertrophic nasal turbinates (chronic rhinitis), deviated nasal septum, nasal polyps, nasal tumour (uncommon; exclude in differential Dx)

• Common in childhood (hypervascular Little's area at the nasal septum)
• Severe epistaxis in adult: HT (aggravates the severity of bleeding)

• Acute: common cold, URTI, acute tonsillitis, apthous ulcer
• Chronic: chronic pharyngitis, chronic tonsillitis.

• Sinister symptom of pharyngeal malignancy (commonest = NPC)

• Obstructive upper aw: soft palate, pharynx, tongue base, larynx
• Possible symptom of OSA

• Speech (1) Vibration of the vocal cord mucosa (2) Resonance of the upper aw (3) Articulation
• Hoarse = abn vocal cord mucosa
• Eg. Vocal cord nodule (fibrosis, symmetrical), polyp (asymmetrical), oedema, laryngitis, vocal cord paralysis, papilloma (esp. young children, STD from mother), carcinoma (irregular, fixes vocal cord in advanced stages)
• Need stroboscope to see vibration of vocal cord mucosa (cannot be seen with normal light)

• Aw obstruction in larynx or trachea
• Sound loudest dur inspiration
• Eg. Mass (eg. Adult laryngeal ca, childhood laryngomalacia (common in newborn, benign, collapse of laryngeal structures), uncommon bilateral vocal cord paralysis)
• Remember: acute epiglottitis (fever, stridor, dysnpnoea): manipulation may cause complete aw obstruction, take lateral X-ray, Tx: ABX, intubation/ tracheostomy

• Many varieties
• Common: cervical lymphadenopathy, thyroid mass, salivary gland mass
• Cervical lymphadenopathy (1) Infection (2) Malignancy in H&N
• Thyroid mass is in midline - eg. Thyroid nodule, thyroid tumour, thyrotoxicosis, thyroglossal cyst (higher)
• Parotid gland mass: usu. tumour; 90% salivary gland tumours of parotid + submandibular glands = pleomorphic adenoma or adenolymphoma
• Common malignant salivary gland tumours = adenolymphoma or mucoepidermoid carcinoma