Otolaryngology, Head & Neck

The airway first, the neck's compartments, and the nerves that carry the voice.

• ENT covers the ear, nose, throat and neck: the airway's emergencies, the thyroid and the nerves wrapped around it, head and neck cancer, and the high-volume operations whose complications are famous precisely because the operations are so common.
• Its first law is the airway: in any ENT emergency, the question 'is the airway safe, and for how long?' is answered before all others, and the answer can change in minutes.
• Its anatomy is unforgiving by density: the recurrent laryngeal nerve, the facial nerve and the carotid sheath run through the specialty's operative fields, and each has a famous complication named after its injury.
• The neck lump is its oncologic doorway: in an adult, a persistent lateral neck mass is a metastatic node until proven otherwise, and the proof follows a strict order.

CT

What should I notice?

• Stridor

  “A 62-year-old with a muffled voice, drooling, and a high-pitched noise on breathing in: sitting bolt upright and getting tired.”

  • Stridor is turbulent flow through a narrowing upper airway, and its loudness is not its severity: a quietening stridor in a tiring patient is worsening, not improving.
  • The posture, drooling and muffled 'hot potato' voice localise the threat above the larynx: supraglottitis, abscess or tumour, and nobody examines that throat with a tongue depressor casually.
  • The response is a team before a diagnosis: senior anaesthesia and ENT to the bedside, awake fibre-optic assessment, and a plan A, B and C for securing the airway before it closes.

  Live it as a case Surgical tracheostomy

• The neck lump

  “A 58-year-old smoker with a painless, firm lateral neck lump for six weeks, and, on direct questioning, three months of unilateral sore throat.”

  • Age and persistence set the register: a lateral neck mass in an adult persisting beyond weeks is a metastatic node until proven otherwise, and oropharyngeal cancer is the likely primary.
  • The order of investigation protects the answer: examination including the mouth and flexible nasendoscopy, ultrasound with fine-needle aspiration, then cross-sectional imaging. An open biopsy first is the classic error.
  • HPV rewrote this clinic: oropharyngeal cancer now often arrives in never-heavy-smokers with better prognoses, but the pathway is the same.

  Live it as a case

• The goitre going to theatre

  “A large multinodular goitre with nocturnal breathlessness lying flat and a trachea deviated on X-ray: thyroidectomy is booked.”

  • The operation's fame is its complication list, and the list is anatomy: the recurrent laryngeal nerves behind the gland (voice), the parathyroids on its capsule (calcium), and the haematoma that compresses the airway.
  • Compression symptoms, cancer and refractory thyrotoxicosis are the operation's honest indications: cosmesis alone deserves a franker conversation.
  • Pre-operative voice assessment and biochemical control are part of the operation: a euthyroid patient with a documented baseline voice.

  Live it as a case Total thyroidectomy

• The nosebleed that will not stop

  “An 81-year-old on apixaban, bleeding briskly from the right nostril for two hours, swallowing blood, pressure applied to the bones of the nose (which does nothing).”

  • First aid done correctly does most of the work: firm pressure on the soft cartilaginous part of the nose, head forward, ten uninterrupted minutes, ice.
  • Most bleeds are anterior, from Little's area, and reachable: topical vasoconstrictor, then cautery of a seen vessel, then anterior packing in escalation.
  • Posterior bleeds announce themselves by failing all of that: blood down the throat despite anterior control means posterior packing and admission.

  Live it as a case

• Bleeding after tonsillectomy

  “Day 6 after tonsillectomy: a phone call about spitting fresh blood, small volume, now stopped. The family asks if they still need to come in.”

  • Yes: secondary post-tonsillectomy haemorrhage peaks around days five to ten as the slough separates, and a small herald bleed is a rehearsal for a larger one.
  • Every post-tonsillectomy bleed is assessed in hospital: the fossae examined, bloods and group-and-save considered, and admission for observation the default.
  • The active bleed has a scripted response: resuscitate, sit up and lean forward, senior ENT and anaesthesia early, and theatre for control when it does not stop.

  Live it as a case Tonsillectomy