Essential Revision For DOHNS PDF

DOHNS
Diploma in Otolaryngology Head and Neck
Surgery Part 2 Revision Guide
Editor
Mr. Benjamin Stew, MBBCh, MRCS, DOHNS
Authors and Contributors
Mr. Tobias Moorhouse, MBBCh, BSc, MRCS, DOHNS
Dr. Rhian Rhys, MBBS, FRCR
Ms. Lucy Satherley, MBBCh, BSc, MRCS
Ms. Ellie De Rosa
Foreword
Mr. Stuart Quine, BMedSc, BM BS, M Phil, FRCS (ORL‐HNS)

Doctors Academy Publications
Exam Revision Guide to DOHNS OSCE. Stew B (Editor). September 2012. 1st Edition. Doctors Academy Publications
i
DOHNS
DOHNS
Diploma in Otolaryngology Head and Neck
Surgery Part 2 Revision Guide
Editor
Mr. Benjamin Stew, MBBCh, MRCS, DOHNS
Specialist Registrar in ENT Surgery
All Wales Higher Surgical Training Programme

Authors and Contributors

Mr. Tobias Moorhouse, MBBCh, BSc, MRCS, DOHNS
Specialist Registrar in ENT Surgery
Dr. Rhian Rhys, MBBS, FRCR
Consultant Radiologist
Royal Glamorgan Hospital, Llantrisant
Ms. Lucy Satherley, MBBCh, BSc, MRCS
Specialist Registrar in General Surgery
Ms. Ellie De Rosa
Doctors Academy Illustrators and Artists
Year 4 Medical Student
University of Cardiff
Foreword
Mr. Stuart Quine, BMedSc, BM BS, M Phil, FRCS (ORL‐HNS)
Program Director for ENT ‐ All Wales Training Programme
Consultant ENT & Head and Neck Surgeon
University Hospital of Wales, Cardiff
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DOHNS
ALL RIGHTS RESERVED
1st Edition, September 2012, Doctors Academy Publications
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ISBN : 978‐93‐80573‐21‐2
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publication without the explicit written permission of Doctors Academy publications. You may
contact us at: [email protected]
iii
DOHNS
Preface
The Diploma of Otolaryngology – Head and Neck surgery (DOHNS) is a qualification sought
by most trainees with an interest in Ear, Nose and Throat surgery. The part 2 OSCE
examination takes place at the Royal College of Surgeons and follows on from the part 1
written examination.
The original revision guide was written to accompany the Doctors Academy DOHNS
course started in 2009. The course was developed with an aim to provide details of the
exam set‐up, improve background knowledge and give candidates the opportunity to hone
the skills required to pass the exam. This guide has been progressively assembled over
the years as the course has gained popularity. The intention was, and is, to provide a
framework around which to base your revision for the part 2 exam. Although we have
attempted to cover most of the syllabus for the DOHNS part 2 exam, due to the wide range
of conditions and disorders covered by this speciality, it needs to be acknowledged that
covering every topic in depth is beyond the scope of this guide. It is hence suggested that
this guide is used as a complementary resource in conjunction with time honoured ENT
textbooks .
It is our hope that this revision guide proves to be an invaluable tool for passing the DOHNS
OSCE examination. Good luck!

With very best wishes,
Mr Benjamin Stew
iv
DOHNS
DOHNS
Foreword
The DOHNS Part B exam not only tests the clinical application of knowledge but also places
emphasis on ‘soft skills’ such as information gathering and information giving. The candidate
sitting the exam can also be expected to be tested on relevant radiology and common
instruments used in managing patients presenting to the speciality. A successful candidate has
to demonstrate a logical and precise approach to the OSCE stations in the examination. The
overall structure of the exam, however, is such that individual components (domains) of the
candidate’s ability to practice the speciality effectively are tested in addition to the global
approach to patient management.
I encourage you to enjoy and benefit from the hard and thoroughly structured frameworks
offered by these authors. They have to be congratulated on producing this excellent aide
memoir for the process of tackling the knowledge levels by providing a succinct description of all
important topics pertinent to the exam. The extremely impressive and vivid illustrations,
coupled with pertinent radiological images and a detailed instrument gallery, complements the
text very nicely. The uninitiated will learn, the widely‐read should pass and the broadly but
selectively experienced reader will derive a perspective from the subject matter.
One of the challenges faced by junior surgeons is the ability to focus and integrate the
information gathered to reach a diagnosis while at the same time developing the thought
process to plan the management. The history taking and communication sections in this book
are laid out nicely. With time and practice, surgeons develop their own internal patterns for
recognising and diagnosing conditions. This expertise can only be acquired by personally
interviewing as many patients as possible whilst being a trainee surgeon and thereafter on
completion of training.
This book is highly relevant for trainees preparing for the DOHNS Part B exam conducted by the
UK Royal Colleges and will provide a framework around which to base the revision. In addition,
this book should prepare the candidate for exams of a similar nature in other parts of the world.
It must be borne in mind, however, that the DOHNS examination is not an end in itself but rather
a beginning. As the trainee progresses through higher surgical training, the importance of clinical
examination does not diminish and this book will act as a vade mecum well beyond the period of
preparation for the exam. It is clear, practical and beautifully produced.

I wish it and its authors well.

Best wishes,

Mr Stuart Quine, BMedSc, BM BS, M Phil, FRCS (ORL‐HNS)
Program Director for ENT ‐ All Wales Training Programme
Consultant ENT & Head and Neck Surgeon
University Hospital of Wales, Cardiff
Honorary Lecturer, Cardiff University

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DOHNS
DOHNS
Contents

1. The DOHNS Syllabus in relation to Part 2 1
SECTION ONE: Common Topics for the DOHNS Part 2
2. The Ear 7
3. The Nose 17
4. The Mouth and Oropharynx 21
5. The Larynx 25
6. Other common DOHNS Head and Neck pathology 31
7. The Thyroid 37
8. Cranial Nerves 41
9. Hearing and Balance 47
10. Imaging 55
SECTION TWO: Communication Skills for the DOHNS Part 2
11. Consent 69
12. Information giving 77
13. Operation note 81
14. Discharge summary 83
15. History taking 85
16. Breaking bad news 87
SECTION THREE: Appendicies
17. Procedures / Examination 91
18. Instrument gallery 93
19. Acknowledgements 109

vii
DOHNS
DOHNS
Abbreviations

AC : Air Conduction

ACP : Air Conduction Pressure
ARS : Acute Rhinosinusitis
BCC : Basal Cell Carcinoma
BC : Bone Conduction
BPPV : Benign Paroxysmal Positional Vertigo
CI : Cochlear Implant
CPD : Continuing Professional Development
CRS : Chronic Rhinosinusitis
CT : Computed Tomography
CSF : Cerebrospinal Fluid
DVLA : Driver and Vehicle Licensing Agency
ENT : Ear, Nose and Throat
FDG : Fluoro Deoxy Glucose
FESS : Functional Endoscopic Sinus Surgery
FNAC : Fine Needle Aspiration Cytology
FOSIT : Feeling Of Something In Throat
GMC : General Medical Council
GORD : Gastro‐Oesophageal Reflux Disease
IAM : Internal Auditory Meatus
ICP : Intracranial Pressure
LMN : Lower Motor Neurone
MEN : Multiple Endocrine Neoplasia
MRI : Magnetic Resonance Imaging
NICE : National Institute of Clinical Excellence
OMU : Osteo‐Meatal Unit
PET : Positive Emission Tomography
PET‐CT : Positive Emission Tomography‐Computerised Tomography
PNS : Post‐Nasal Space
SCM : Sterno‐Cleido‐Mastoid
SPL : Sound Pressure Level
SCC : Squamous Cell Carcinoma
TFT : Thyroid Function Test
TRH : Thyrotropin Releasing Hormone
URTI : Upper Respiratory Tract Infection
USS : Ultrasound Scan
UVB : Ultraviolet B
VZV : Varicella Zoster Virus
viii
The DOHNS Syllabus in relation to Part 2 DOHNS
1. THE DOHNS SYLLABUS IN RELATION TO PART 2:
The original syllabus document can be found at:
http://www.intercollegiatemrcs.org.uk/dohns/pdf/syllabus.pdf
The syllabus is split in to three sections, each with subsections:
PART ONE:
 Good medical practice and care in otolaryngology
 General principles of clinical care
 The patient‐doctor relationship, including communication and consulting skills
 Population, preventive and societal issues
 Professional, ethical and legal obligations
 Appraisal, monitoring the quality of performance, clinical governance and audit
 Risk and resource management
 Information management and technology
 Understanding the importance of probity
 Continuing professional development (CPD), learning and teaching.
PART TWO: Clinical knowledge
 Applied Anatomy and Embryology
 Applied Physiology
 Applied Microbiology
 Imaging
 Pharmaco‐therapeutics
 Acoustics
 Applied Pathology
 Applied Psychology
 Epidemiology and Statistics
 Medicolegal Issues
 Clinical Practice.
Exam Revision Guide to DOHNS OSCE. Stew B (Editor). September 2012. 1st Edition. Doctors Academy Publications 1
DOHNS The DOHNS Syllabus in relation to Part 2
PART THREE: Clinical competencies
Radiology
Audiology and Vestibular testing
Neurology
Otology
Rhinology
Laryngology
Neck
Medical Statistics.
PART ONE:
The take home message from this part of the syllabus is that they are looking for safe,
effective and professional doctors. Themes involving judgement, autonomy, competence and
consistency all appear frequently. The patient‐centered holistic approach is praised and
practitioners are expected to be excellent communicators to both patients and colleagues.
Legal obligations, societal issues and political sensitivities are included in “keeping up‐to‐date”
and are given as equal importance as clinical knowledge and understanding.
Certainly the doctors they are looking for are aware of their own limitations and deal with
criticism and management issues constructively, they aspire self‐improvement and the
improvement of the service they provide.
Nothing that is in this section is not in the GMC, Good Medical Practice publication. Although
structured in general headings it is recommended that delegates spend time reading through
this part of the syllabus, but also that they consult the GMC documentation listed. This adds a
context that will help improve your communication skills during future practice sessions.
Recommended reading referenced in the syllabus:
Good Medical Practice (2001), GMC
Duties of a Doctor (1995), GMC
Seeking Patient Consent: the Ethical Considerations (1998), GMC
Research: The Roles and Responsibilities of Doctors (2002), GMC
Withholding and Withdrawing Life‐Prolonging Treatments: Good Practice in Decision
Making (2002), GMC .
Updated versions of these GMC publications are all available online: www.gmc‐uk.org
The DOHNS Syllabus in relation to Part 2 DOHNS
PART TWO: Clinical knowledge
This section provides a framework that delegates can use to structure their learning. There are
no specifics as to the depth of knowledge that is required, however it is helpful in framing the
breadth of knowledge that is required.
PART THREE: Clinical competencies
This section is considerably more specific. It goes in to detail regarding what competencies are
expected and to what level you are expected to perform each of them. This level of competence
generally ranges from: “(1) knows about”, through “(2) able to apply knowledge, to “(3) able to
perform under supervision” and finally “(4) able to perform independently”. Common questions
and scenarios used to assess this section are the operative note and discharge summary
questions, the clinical examination stations, radiology interpretation stations and the instrument
recognition questions. Topics that have come up in previous DOHNS Part 2 exams are:
Initial assessment and management of airway problems
Initial management of foreign bodies in ENT
Plain films of the neck and chest.
CT scans of the sinuses, petrous bone, neck, chest and brain
Contrast radiology of swallowing
Examination of the ear – auriscope
Myringotomy and grommet insertion (operative note)
Examination of the nose and sinuses– anterior rhinoscopy
Flexible nasendoscopy and examination of the postnasal space
Adenoidectomy and tonsillectomy (operative note)
Examination of the neck.
For further details regarding the level of competency required please consult the syllabus
directly.

DOHNS
DOHNS
SECTION ONE:
Common Topics for DOHNS Part 2
DOHNS
The Ear DOHNS
2. THE EAR
How to draw a normal tympanic membrane?
Rules to follow:
1. The tympanic membrane is ovoid.
2. The lateral process of the malleus points in the direction of the side (i.e., it points to the
left for the left ear), this denotes anterior.
3. The umbo of the malleus points downward to the opposite side.
4. The long process of the incus is seen on this side.
5. Label left and right.
A. Pars Flaccida
B. Posterior Mallear Ligament
C. Long process of Incus
D. Pars Tensa
E. Annulus
F. Cone of light
G. Umbo of Malleus
H. Handle of Malleus
I. Anterior Mallear Ligament
J. Lateral process of Malleus
Left tympanic membrane
DOHNS The Ear
Normal Ear
Antihelix Fossa triangularis
Helix
Conchal bowl
Tragus
Lobule
PERICHONDRITIS

Definition
Skin and soft tissue infection of the pinna, commonly due to
pseudomonas aeruginosa.
Symptoms
Painful, red ear.
Signs
Thickened, swollen, erythematous pinna.
Management
a) Intravenous antibiotics.
b) Analgesics and Antipyretics. Figure 2.1: Perichondritis of right pinna
OTITIS EXTERNA
Definition
Inflammatory and infective process of the external auditory
canal, commonly with pseudomonas aeruginosa and/or
staphylococcus aureus.
Symptoms
Otalgia, otorrhoea, aural fullness, pruritis, hearing loss.
Signs
Pain on distraction of the pinna, external auditory canal
erythema and oedema, otorrhoea, lymphadenopathy, cellulitis.
Figure 2.2: Note ‐ inflamed EAM commonly
found in otitis externa
The Ear DOHNS
Management
a) Aural toilet.
b) Otic drops – antiseptic, acidifying or antibiotic with or without steroid.
c) ± Aural packing.
d) Analgesics.
HERPES ZOSTER OTICUS / RAMSEY HUNT SYNDROME
Definition
A syndrome of acute peripheral facial nerve palsy associated with otalgia and varicella‐like
cutaneous lesions. Involvement may extend to cranial nerves V, IX and X, and cervical branches
that have anastamotic communications with the facial nerve.
Symptoms
Facial weakness, facial pain, otalgia, hearing loss,
vertigo.
Signs
Vesicular rash involving skin of the external ear, ear
canal ± soft palate (can also include the face).
Management
a) Oral glucocorticoids.
Figure 2.3: Vesicular rash typical of VZV infection
b) Oral antivirals.
c) Analgesics.
d) Eye care.
e) Topical emollients.
OTITIS MEDIA WITH EFFUSION/GLUE EAR
Definition
Persistence of a serous or mucoid middle ear effusion for three months or more due to
overproduction of mucus or impaired clearance.
Symptoms
Asymptomatic, hearing loss, recurrent infections, delayed speech and language development,
behavioural problems, otalgia, tinnitus and balance impairment.
DOHNS The Ear
Signs
Dull, grey/yellow tympanic membrane with reduced
mobility, an air‐fluid level or small bubbles within the
middle ear effusion may be seen.
‐ Tympanometry; flat, type‐B tympanogram.
‐ Pure tone audiometry; of >25dB conductive hearing
loss.
Management
a) Conservative – “Watch and wait”.
Figure 2.4: Middle ear effusion, note air
b) Hearing aid.
bubble superiorly
c) Grommet insertion with/without adenoidectomy.
Reference: NICE guidelines ‘Surgical management of glue ear in children 2008’
ACUTE OTITIS MEDIA
a) Nonsuppurative acute otitis media – inflammation of the middle ear cleft mucosa without the
formation of an effusion or with a sterile effusion.
b) Suppurative acute otitis media – inflammation of the middle ear cleft with suppuration. In
most cases it presents following a viral upper respiratory tract infection, which leads to
disruption of eustachian tube function and a middle ear effusion. Subsequent bacterial
colonisation with Streptococcus pneumoniae (40%), Haemophilus influenzae (25‐30%) and
Moraxella catarrhalis (10‐20%) occurs.
Symptoms
Otalgia, pyrexia, hearing loss, otorrhoea.
Signs
Thickened hyperaemic tympanic membrane with or
without spontaneous rupture.
Management
a) Conservative – “Watch and wait”.
b) Oral antibiotics such as amoxicillin or co‐amoxiclav.
c) Adjuvant therapy such as analgesics and antipyretics.
d) Myringotomy if medical measures fail.
Figure 2.5: Otitis Media
Reference: NICE guidelines ‘Antibiotic prescribing for
respiratory tract infections’
The Ear DOHNS
MASTOIDITIS
Definition
Infection of the mastoid air cells as a complication of an
acute otitis media.
Symptoms
Pain and tenderness over the mastoid process, fever.
Signs
Oedema and erythema of the postauricular soft tissues
with antero‐inferior displacement of the pinna.
Thickened, hyperaemic tympanic membrane and
posterior sagging of the canal wall.
Figure 2.6: Mastoiditis; pinna is
Management
distracted anteroinferiorly
a) Intravenous antibiotics such as co‐amoxiclav or
cefuroxime and metronidazole.
b) CT scan.
c) Cortical mastoidectomy with myringotomy and grommet insertion if evidence of
subperiosteal abscess or if symptoms do not improve with 24‐48hours of intravenous
antibiotics.
d) Adjuvant therapy such as analgesics and antipyretics.
CHRONIC SUPPURATIVE OTITIS MEDIA
Definition
Persistent or intermittent infected discharge through a non‐intact tympanic membrane
(perforation or tympanostomy tube).
Symptoms
Otorrhoea (mucopurulent or blood‐stained), hearing
loss.
Signs
Discharge within external auditory canal, which on
microsuction may reveal oedematous middle ear
mucosa visualised through tympanic membrane
perforation.
Management
Figure 2.7: Large, discharging Pars Tensa
a) Aural toilet. perforation
b) Topical +/‐ oral antibiotics.
DOHNS The Ear
CHOLESTEATOMA
Definition
Destructive and expanding keratinising squamous cell
cyst.
Acquired
a) Primary acquired cholesteatoma – forms as a result
of tympanic membrane retraction.
b) Secondary acquired cholesteatoma – forms as a
result of either disordered squamous epithelium
migration or implantation of squamous epithelium into
the middle ear cavity during surgery.
Figure 2.8: Attic cholesteatoma
Congenital
Results from an abnormal focus of squamous epithelium in the middle ear cavity without
tympanic membrane perforation and without a history of ear infection.
Symptoms
Recurrent or persistent purulent and foul‐smelling otorrhoea, hearing loss, rarely pain, vertigo
or dysequilibrium.
Signs
a) Primary acquired ‐ tympanic membrane retraction containing a matrix of squamous.
epithelium, polyps, granulation tissue, ossicular erosion.
b) Secondary acquired – keratin is usually visible through the perforation or through the
tympanic membrane if of sufficient size.
c) Congenital – occasionally visible behind an intact and normal‐looking tympanic membrane.
Management
a) Imaging – High resolution CT or Diffusion weighted MRI.
b) Audiometry – usually showing a conductive hearing loss.
c) Nonsurgical measures include regular aural toilet, keeping the ear dry and preventing further
contamination through use of ototopical agents.
d) Surgical measures aiming to create a dry and safe ear including mastoidectomy or combined
approach tympanoplasty.
The Ear DOHNS
OSTEOMAS & EXOSTOSES OF THE EXTERNAL AUDITORY CANAL
Definition
Benign osseous neoplasms formed by reactive bone
formation secondary to cold water exposure.
Symptoms
Usually asymptomatic but may cause cerumen
impaction or otitis externa.
Signs
May lead to a conductive hearing loss.
Management
a) Most require no surgical intervention.
Figure 2.9: Exostoses of external auditory
b) Treat any infection. canal
c) ± Meatoplasty.
OTOSCLEROSIS
Definition
Is a primary localised disease of the bony otic capsule. It is characterised by abnormal
removal of mature bone of the otic capsule by osteoclasts, and replacement with woven
bone of greater thickness, cellularity and vascularity. There is often a positive family history.
Symptoms
Slowly progressive unilateral or bilateral hearing impairment, with onset in early adult life.
Hearing classically worsens during pregnancy or oestrogen therapy.
Signs
Normal otoscopic examination or positive Schwartze sign.
‐ Pure tone audiometry; conductive hearing loss.
‐ Tympanometry; type‐As tympanogram.
Management
a) High resolution CT scan.
b) Conservative.
c) Medical treatments – sodium fluoride or bisphosphonates.
d) Surgical – Stapedotomy or Stapedectomy.
DOHNS
ABNORMALITIES OF THE PINNA
Congenital
a) – auricular requiring auricular reconstruc on.

b) Protruding ears/Bat ears – increased distance from the helical rim to the mastoid is thought
to be due to a lack fold or prominent conchal bowl. The deformity commonly requires
otoplasty.
c) External auditory canal atresia – failure of canalisa on of the epithelial plug por n of the
first branchial cle . This deformity results in a hearing loss and may be associated
with concomitant ossicular
Acquired
a) Auricular haematoma – accumula n of blood in the subperichondral space secondary to

blunt trauma. This barrier for diffusion, between the ge and the perichondrium, leads to
necrosis and predisposes to infec Treatment involves evacua on of the haematoma and
to prevent reacculmula .
Figure 2.10a: Large pinna haematoma Figure 2.10b: Post-opera ve image er evacua on
of haematoma and sialas c splin ng
b) Auricular lacer s – expedi repair and preven on of infe n are essen al with or
without debridement.
NEOPLASMS OF THE EXTERNAL EAR
a) Basal cell carcinoma (BCC) – represent 45% of auricular carcinomas. UVB radia n has been
iden fied as a major carcinogen. Lesion appears nodular and ulcerated and typically occurs on
the posterior surface of the pinna and preauricular areas. May be treated with topical 5-
fluorouracil or surgical excision.
Exam Revision Guide to DOHNS OSCE. Stew B (Editor). September 2012. 1st Ed n. Doctors Academy Public ns 14
The Ear DOHNS
b) Squamous cell carcinoma (SCC) – represent 20% of
auricular carcinomas. Lesions appear as plaques or
ulcerations typically over the helix and preauricular
areas. Treatment is with surgical excision but
radiatiotherapy may be indicated for unresectable
lesions.
c) Melanoma – 1% of all melanomas will occur on the
auricle. Present as painless lesions over the helix which
change in size, ulcerate and bleed. Metastatic evaluation
is paramount. Treatment is with surgical excision but
may include adjuvant radiotherapy.
Figure 2.11: SCC of helix of right pinna

TEMPORAL BONE FRACTURES
General considerations
Temporal bone fractures represent roughly 20% of all skull fractures. Blunt trauma to the
lateral surface of the skull often results in longitudinal fractures (80%). A blow to the occipital
skull may result in a transverse fracture pattern (20%). The otic capsule is spared in
longitudinal fractures but damaged in transverse fractures.
Symptoms
Hearing loss, nausea, vomiting, vertigo.
Signs
Battle sign (postauricular ecchymosis), “Racoon” sign (periorbital ecchymosis), external
auditory canal laceration, haemotympanum and bloody otorrhoea. Facial nerve paralysis
occurs in 50% of transverse fractures and 25% of longitudinal fractures.
Management
a) Conductive hearing loss – largely conservative (Haemotympanum resolves) ± myringoplasty
if persistent perforation.
b) Facial nerve paralysis – largely conservative ± facial nerve exploration and decompression.
c) CSF leak – consultation with neurosurgeon.
DOHNS
The Nose DOHNS
3. THE NOSE
Superior concha
Orbit
Ethmoidal air cells Superior meatus
Middle concha
Nasal septum Middle meatus
Inferior concha
Inferior meatus
RHINOSINUSITIS & NASAL POLYPOSIS
Definition/Diagnosis
Inflammation of the nose and the paranasal sinuses
characterised by two or more symptoms;
‐ one of which should be either nasal congestion or nasal
discharge (anterior/posterior nasal drip)
‐ with/without facial pain/pressure
‐ with/without reduction or loss of smell
and/either
‐ Endoscopic signs of polyps or mucopurulent discharge
and/either
‐ CT scan showing mucosal changes within the Figure 3.1: Nasal polyp in left middle meatus
osteomeatal unit and/or sinuses (Lund‐Mackay score)
Acute (ARS) < 12 weeks with complete resolution of symptoms.
Chronic (CRS) > 12 weeks without complete resolution of symptoms.
DOHNS The Nose
Management
a) Consider endoscopy.
b) Consider imaging.
c) Consider cultures.
d) Consider Oral/Intravenous antibiotics (long‐term macrolides for CRS).
e) Topical steroids.
f) Nasal douches.
g) Consider FESS.
Reference: European Position Paper on Rhinosinusitis and Nasal Polyps (2007)
ANTROCHOANAL NASAL POLYPS
Definition/Diagnosis
Benign lesions arising from the mucosa of the maxillary sinus that grow into the nasal cavity and
reach the choana. ACPs are usually unilateral and
appear in younger patients.

Signs and symptoms
Nasal obstruction.
Management
a) Nasal endoscopy.
b) CT and/or MRI.
c) Surgery is the indicated treatment for ACP, with
endoscopic resection the most recommended. Figure 3.2: Antrochoanal nasal polyp

NASAL TRAUMA
Background
Nasal fracture is considered the most common of head and neck fractures. Significant functional
and aesthetic impairment may result if these injuries are not accurately diagnosed and addressed
in a timely fashion.
Complications
Epistaxis: The initial oedema and epistaxis of nasal trauma usually resolve without intervention,
however, persistent epistaxis may require tamponade with nasal packing or rarely identification
and coagulation or ligation of the bleeding vessels.
CSF leak: Usually caused by a significant mechanism of injury and requires consideration with
Neurosurgeon.
The Nose DOHNS
Septal haematoma: Results from bleeding within the subperichondrial plane of the septum.
This collection of blood leaves the cartilage devoid of its blood supply, which is followed by
necrosis and perforation. Treatment involves urgent incision and drainage of the
haematoma and splinting. Antibiotic prophylaxis is required.
Saddle deformity: Loss of structural support following a septal haematoma leads to septal
collapse and a characteristic saddle nose deformity of the nasal dorsum and retraction of the
collumella.
Cosmetic deformity: External physical deformities include the creation of a dorsal hump,
lateral deviation of the dorsum and tip, a widened nasal base and depression and splaying of
the nasal tip. Complex septal deformities may also result including septal spurs, angular
deflections, and complex alterations on nasal symmetry.
NASOPHARYNGEAL CARCINOMA
Background
There two distinct types –
a) Undifferentiated non‐keratinising squamous cell carcinoma, which is more common in
people from Southern China and Hong Kong, and is associated with Epstein‐Barr virus
infection.
b) Differentiated keratinising squamous cell carcinoma, which has similar at risk groups as
other head and neck cancers.
Signs & Symptoms
Epistaxis, nasal obstruction, middle ear effusion, cranial nerve palsies.
Investigations
a) Cytology – biopsy.
b) Imaging – CT and/or MRI.
Management
Radiotherapy or Chemoradiotherapy ± Neck dissection.

DOHNS
The Mouth and Oropharynx DOHNS
4. THE MOUTH AND OROPHARYNX
Uvula
Palate
Palatopharyngeus
Palatine tonsil
Palatoglossus
TONSILLITIS
Definition
Infection of the tonsils commonly with β
haemolytic streptococcus, pneumococcus and
haemophilus influenzae.
Symptoms
Sore throat, difficulty swallowing, fever, malaise,
halitosis.
Signs
Erythematous, swollen tonsils with exudates.
Management
a) Analgesia.
b) Antipyretics.
c) Oral/intravenous antibiotics. Figure 4.1: Exudate on tonsil
d) Intravenous fluids.
e) Antiseptic mouthwash.
DOHNS The Mouth and Oropharynx
QUINSY
Definition
Peritonsillar abscess lying in the potential space between
the tonsillar capsule and the surrounding pharyngeal muscle
bed.
Symptoms
Sore throat, difficulty swallowing, ‘hot potato’ voice, fever,
malaise, otalgia.
Signs
Trismus, deviated uvula, peritonsillar collection.
Management
a) Abscess drainage.
b) Intravenous antibiotics.
Figure 4.2 Right sided quinsy
c) Intravenous steroids.
d) Analgesia.
e) Antipyretics.
f) Intravenous fluids.
g) Antiseptic mouthwash.
GLANDULAR FEVER (INFECTIOUS MONONUCLEOSIS)
Definition
Epstein‐Barr virus infection.
Symptoms
Sore throat, fevers, malaise, lethargy.
Signs
Cervical lymphadenopathy, dull/grey tonsils, white slough on tonsils, petechial haemorrhages on
the palate, hepatosplenomegaly.
Management
a) Analgesia.
b) Steroids.
c) Intravenous fluids.
d) ± Oral antibiotics.
E) Advice regarding contact sports.
The Mouth and Oropharynx DOHNS
ORAL CAVITY MALIGNANCY
Background
The most common malignancy found in the mouth is squamous cell carcinoma. Risk factors
include smoking, drinking alcohol and betel nut chewing.
Signs & Symptoms
Persistent, non‐healing ulcer on the lateral
border of the tongue, floor of mouth or gum,
leukoplakia, erythroplakia.
Investigations
b) Imaging – CT ± MRI ± USS.
Management
Figure 4.3: Lesion on Left ventral aspect of
Surgery and/or chemoradiotherapy.
tongue
DOHNS
The Larynx DOHNS
5. THE LARYNX
Pre‐epiglottic space
Tongue
Vallecula
Median
glosso‐epiglottic fold
Supraglottis
Epiglottis Ventricle
Aryepiglottic fold
Pyriform sinus
False cord Subglottis
True cord
Cricoid cartilage
Arytenoid cartilages
Epiglottis
False vocal cord
Aryepiglottic fold
True vocal cord
Glottis (tracheal Cuneiform
wall visible) cartilage
Corniculate
cartilage
DOHNS The Larynx
How to draw the superior view of the larynx as seen on
Flexible Nasendoscopy
Rules to follow:
1. Always label left and right.
2. Start with the vocal folds and work outwards.
3. Keep it as simple as possible.
Left Right
Figure 5.1: Line diagram of normal larynx and surrounding structures
A. Epiglottis
B. Anterior Commisure
C. Ventricle
D. Vestibular fold (false cord)
E. Vocal fold (true cord)
F. Piriform fossa
G. Arytenoid cartilage
H. Rima glottidis
I. Aryepiglottic fold
J. Vallecula
K. Tongue base.
The Larynx DOHNS
INNERVATION OF THE VOCAL CORDS
Arises from Vagus nerve (CNX)
Superior Laryngeal Nerve
Two terminal branches:
Internal Laryngeal Nerve (sensory/autonomic): Supplies mucous membrane of
supraglottis and superior aspect of vocal folds
External Laryngeal (Motor): Supplies Cricothyroid muscle.
Recurrent Laryngeal Nerve
Sensory function: Supplies mucous membrane of inferior aspect of vocal folds and
subglottis
Motor function: All intrinsic muscles of the larynx except for Cricothyroid.

Figure 5.2: Function of muscles supplied by Recurrent Laryngeal nerves
Light Blue: Thyroid cartilage
Dark Blue: Aretynoid cartilage
Yellow: Cricoid cartilage
Orange: Vocal ligament
Red: Muscle
NB: Cricothyroid function: stretches and tenses vocal fold by rocking thyroid cartilage back and forth on cricoid
cartilage
DOHNS The Larynx
VOCAL CORD DISEASE
Background
The larynx plays a pivotal role in airway protection, respiration and phonation. Laryngeal
disease usually presents with dysphonia and a thorough head and neck examination is required
to exclude malignancy. Onset, duration and progression of any voice changes are key parts of
the history.
BENIGN
Vocal cord nodules (Figure 5.3)
Usually affect children or individuals who use their voices
professionally. Bilateral pale lesions are seen at the junction
of the anterior one‐third and posterior two thirds of the vocal
cords.
Vocal cord polyps
Associated with smoking and vocal cord abuse. Commonly
seen as unilateral pedunculated lesions at the junction of the
Figure 5.3
anterior and middle thirds of the vocal cords.
Vocal cord granulomas
Are commonly associated with endotracheal intubation and
gastroesophageal reflux. Lesions are usually unilateral and are
related to perichondritis of the underlying arytenoid cartilage.
Reinkes oedema (Figure 5.4)
Strongly associated with smoking and heavy voice use.
Patients present with diffuse oedematous changes of both
vocal cords. Figure 5.4
Intracordal cyst
May be simple mucus retention cysts or epidermoid cysts containing keratin. Usually seen as
unilateral lesions within the middle third of the cord, associated with an area of hyperkeratosis
on the opposite cord.

The Larynx DOHNS
Saccular cysts
May be congenital or acquired. They occur as a result of obstruction to the mucus secreting glands
within the laryngeal saccule. Examination reveals expansion of the aryepiglottic fold by the cyst
within it, which may extend into the neck through the thyrohyoid membrane.
Laryngocele
Is an abnormal expansion of the laryngeal ventricle, which may be confined by the thyroid cartilage
or extend through the cricothyroid membrane into the neck. They are associated with raised
intralaryngeal pressure such as trumpet playing but may also occur secondary to a malignancy.
Laryngeal papillomatosis
Exophytic warty lesions of the true and false cords. Benign condition but associated with significant
morbidity and mortality. Caused by human papilloma virus, subtypes 6 and 11. The aim of treatment
is remove symptomatic lesions as HPV cannot be eradicated from the larynx.
MALIGNANT
Background
The vast majority of laryngeal malignancy is squamous cell
carcinoma and is associated with smoking and drinking
alcohol. Male to female ratio is 4:1 but the relative
percentage of women is on the rise.
Signs & Symptoms
Hoarseness, dysphagia, haemoptysis, neck lump, pain, Figure 5.5
aspiration and airway compromise.
Investigations
b) Imaging – CT ± MRI ± PET ± USS.
Management
Surgery and/or Radiotherapy with or without
Chemotherapy
Treatment planning is best delivered through a
multidisciplinary tumour team format because of the
complex and multifaceted nature of the disease.
Figure 5.6
DOHNS The Larynx
VOCAL CORD PALSY
Definition
Loss of active movement of the “true” vocal cord, or vocal fold, secondary to disruption of
the motor innervation of the larynx. Disruption can occur along any length of the recurrent
laryngeal nerve and the vagi and may include damage to the motor nuclei of the vagus. This
should be differentiated from fixation of the vocal cord secondary to direct infiltration of the
vocal fold, larynx or laryngeal muscles.
Aetiology
Neoplastic, iatrogenic, idiopathic, traumatic, neurological.
Signs & Symptoms
Dysphonia, cough, haemoptysis, dyspnoea.
Management
a) Conservative.
b) Injection laryngoplasty.
c) Sialastic implants.
d) Tracheostomy.
LARYNGOMALACIA
Definition
It is a common condition of infancy where
the soft immature cartilage of the upper
larynx collapses inward during inhalation,
causing airway obstruction.
Signs and symptoms
‘Squeaking’ stridor on inspiration, feeding
difficulties.
Management
a) Conservative in the majority.
b) Surgery – aryepiglottopexy/
aryepiglottoplasty.
Figure 5.7
Other common DOHNS Head and Neck pathology DOHNS
6. OTHER COMMON DOHNS HEAD AND NECK PATHOLOGY
EPIGLOTTITIS
Definition
Potentially life‐threatening inflammation of the epiglottis and/or supraglottic tissues that
affects adults and children. It is now rare in children as a result of the haemophilus influenza
B vaccination.
Symptoms
Difficulty swallowing, drooling, dysphonia, fever.
Signs
Pooling of saliva, gross supraglottic swelling.
Management
a) Stay calm & call for senior help.
b) Do not attempt to examine the patient.
c) Oxygen/Heliox.
d) Adrenaline nebulisers.
e) Steroids.
f) Antibiotics.
g) May require intubation or tracheostomy.
BRANCHIAL CYST
Definition
Arise from the failure of the pharyngobranchial ducts to obliterate during fetal development.
Another possibility is that they arise from elements of squamous epithelium within lymphoid
tissue (ectopic epithelial cells). They most frequently present in late childhood or early
adulthood, when the cysts become infected – usually after an URTI.
Signs & Symptoms
Usually asymptomatic and found on the anterior border of the sternocleidomastoid muscle
at the junction of the upper third and lower two‐thirds. They may become painful and
tender when infected.
Management
a) Control any infection.
b) Incision and drainage avoided as a general rule.
c) Definitive surgical excision.

DOHNS Other common DOHNS Head and Neck pathology
THYROGLOSSAL CYST
Definition
Midline cyst that occurs as a result of failure of the thyroglossal duct to obliterate during
development.
Signs & Symptoms
Midline or para‐median swelling that rises with tongue protrusion.
Management
a) Control any infection.
b) Ensure normal thyroid function.
c) Sistrunk procedure.
SALIVARY GLAND DISEASE
Background
Most clinically significant diseases of the salivary glands involve the parotid and submandibular
glands. Eighty percent of primary salivary gland tumours occur in the parotid gland and 80% of
these are benign.
BENIGN
Acute viral inflammatory disease
Occurs most commonly in children aged 4‐6 with an incubation period of 14‐21 days where it is
most contagious. Patients’ present with acute bilateral swelling of the parotid glands
accompanied by pain, erythema, tenderness, malaise, fever and occasional trismus.
Acute suppurative sialadenitis
Occurs in the elderly with chronic medical conditions and postoperative patients. Risk factors
include dehydration and immunosuppresion. Patients present with acute swelling of the salivary
glands and fever.
Chronic granulomatous siladenitis
Chronic unilateral or bilateral salivary gland swelling with minimal pain. Differential diagnoses
should include Cat‐scratch disease, Sarcoidosis, Actinomycosis and Wegener’s granulomatosis.
Sialolithiasis
Patients present with acute, painful swelling of the salivary gland, which is aggravated by eating.
A stone may be palpated in the floor of the mouth. Treatment options include a ‘watch and wait’
policy, intra‐oral radiological extraction or salivary gland excision.
Sjogren syndrome
Salivary gland swelling with dryness of the mouth and eyes. More commonly seen in
postmenopausal women and often associated with other connective tissue disease. Diagnosis is
confirmed by detection of autoantibodies SS‐A and SS‐B and salivary gland biopsy. It is a slowly
progressive disease with a high risk for development of malignant lymphoma.
Pleomorphic adenoma
Present as isolated swellings with little associated pain and no known aetiological factors. They
are benign mixed tumours histologically and treatment is complete surgical excision.
Warthin’s tumour
Also known as papillary cystadenoma lymphomatosum and are almost exclusively found in the
parotid gland. Histologically characterised by papillary structures composed of double layers of
granular eosinophilic cells, cystic changes and mature lymphocytic infiltration. Treatment is
complete surgical excision.
MALIGNANT
Malignant salivary gland disease has not been attributed to any specific carcinogenic factors.
Twenty percent of parotid neoplasms, 50% of submandibular neopplasms and 70% of sublingual
neoplasms are malignant. Patients usually present with an incidentally noted mass, however,
pain, facial palsy and cervical adenopathy may be present. Histological types include
mucoepidermoid carcinoma, adenoid cystic carcinoma, acinic cell carcinoma, adenocarcinoma,
squamous cell carcinoma, lymphoma and malignant mixed tumours. Treatment options include
surgical excision with or without neck dissection, radiotherapy and chemotherapy. Optimal
management of these patients is discussed at a multidisciplinary team meeting.
PHARYNGEAL POUCH
Definition
Posteromedial pulsion diverticulum
through Killian’s dehiscence. The
herniation is between
thyropharyngeus and cricopharyngeus
muscles, both part of the inferior
constrictor muscle of the pharynx.
Symptoms
Dysphagia, regurgitation, cough,
weight loss.
Signs
Halitosis, gurgling on palpation of the neck. Figure 6.1
DOHNS Other common DOHNS Head and Neck pathology
Management
a) Conservative.
b) Endoscopic stapling (Dohlmans procedure).
c) Cricopharyngeal myotomy.
d) Diverticulectomy.
BELL’S PALSY
Definition
Idiopathic lower‐motor neurone facial palsy.
Symptoms
Unilateral facial weakness affecting all five divisions of the facial nerve, hypoaesthesia, occasional
fever, malaise and rhinorrhoea and rarely facial or retroauricular pain.
Signs
Facial weakness, inability to close eye in severe cases.
Figure 6.2: Right‐sided facial palsy. Obvious asymmetry at rest and inability to close the affected right eye
Management
a) Ensure other causes of a LMN facial palsy have been excluded.
b) Oral glucocorticoids.
c) Eye care with ointment and artificial tears.
c) Watch and wait with follow up as required.
Grade and
Characteristics
Description
I Normal Symmetrical facial function normal in all areas.
Gross: Slight weakness noticeable. Normal symmetry at rest.
Dynamic:
II Mild
Forehead: moderate to good function.
dysfunction
Eye: complete closure with minimal effort.
Mouth: slight asymmetry.
Gross: Obvious but not disfiguring difference between the two sides.
Noticeable but not severe synkinesis and spasms. Normal symmetry and
tone at rest.
III Moderate
Dynamic:
dysfunction
Forehead: slight to moderate movement.
Eye: complete closure with effort.
Mouth: slightly weak during maximum effort.
Gross: Obvious weakness and severe asymmetry. Normal symmetry and
tone at rest.
IV Moderately
Dynamic:
severe
Forehead – no movement.
dysfunction
Eye – Incomplete closure.
Mouth – asymmetric during maximum effort.
Gross: barely perceptible motion. Asymmetry at rest.
Dynamic:
V Severe
Forehead – no movement.
Paralysis
Eye – incomplete closure.
Mouth ‐ slight movement.
VI Total Paralysis No movement.
Table.6.1: House‐Brackmann scale
*Reference: House JW and Brackmann DE. Facial nerve grading system. Otolaryngol. Head Neck
Surg., 1985: 93, 146–147.
DOHNS
The Thyroid DOHNS
7. THE THYROID
HISTOLOGY

Colloid

Follicular cells

Follicle

Follicles
The thyroid gland is made up of follicles which selectively absorb iodide ions from the blood
for the production of thyroid hormones. Twenty five percent of all the body’s iodide ions are
in the thyroid gland. Within the follicles, colloid acts as a reservoir of materials for thyroid
hormone production. Colloid is rich in thyroglobulin.
Follicular cells (thyroid epithelial cells)
Thyroid follicles are surrounded by follicular cells, which secrete T3 and T4.
Parafollicular (C) cells
Dispersed among follicular cells and between the follicles are the parafollicular cells which
secrete calcitonin.

DOHNS The Thyroid
Hyperthyroidism Hypothyroidism
Irritability Mental slowness
Heat intolerance Cold intolerance
Insomnia Hypersomnolence
Sweatiness Dry skin
Weight loss Weight gain
Diarrhoea Constipation
Palpitations / Atrial Fibrillation Bradycardia
Hyper‐reflexia, tremor Slow‐relaxing reflexes
Amenorrhoea Menorrhagia
Table 7.1: Classic symptoms and signs of thyroid dysfunction
T3/T4 TSH
Primary Hyperthyroidism Raised Reduced
Secondary Hyperthyroidism Raised Raised
Subclinical Hypothyroidism Normal Raised
Primary Hypothyroidism Reduced Raised
Secondary Hypothyroidism Reduced Reduced
Tertiary Hypothyroidism Reduced* Reduced*
Table 7.2: Blood results (* check TRH; dysfunction at level of hypothalamus)
HYPERTHYROIDISM
Graves disease
Autoimmune hyperthyroid condition, where antibodies mimic the effect of TSH. Particular
eye signs include lid lag, exophthalmos, ophthalmoplegia, lid retraction, proptosis and
chemosis. Treatment options include hormonal manipulation with carbimazole or surgery.
Toxic thyroid adenoma
Benign tumour of the thyroid gland classified according to its cellular architecture. Thyroid
adenomas may be clinically silent or in this case produce excessive thyroid hormone. Most
patients are managed by watchful waiting but some may undergo surgical excision.
The Thyroid DOHNS
Toxic multinodular goitre
A form of hyperthyroidism characterised by functionally autonomous nodules that emerges
insidiously from non‐toxic multinodular goitre.
HYPOTHYROIDISM
Hypothyroidism tends to be classified according to the indicated organ dysfunction.
Primary
Automimmune disease (Hashimoto’s thyroiditis) and radioiodine therapy for hyperthyroidism
are commonest forms of primary hypothyroidism, where the thyroid gland itself is responsible
for the inadequate production of thyroid hormones.
Secondary
A dysfunctional pituitary gland and subsequent lack of thyroid‐stimulating hormone is usually a
consequence of tumour, radiation or surgery.
Tertiary
Insufficient thyrotropin‐releasing hormone (TRH) from the hypothalamus.
THYROID NEOPLASIA
Background
Thyroid tumours may arise from either the follicular cells or the supporting cells found in the
normal gland.
Papillary adenocarcinoma
Usually affects adults aged 40‐50 years old with multiple tumours within the gland. Ninety
percent of patients will survive 10 years if the disease is limited to the gland. Treatment
involves near‐total thyroidectomy with or without post‐operative radio‐iodine ablation. After
surgery patients require lifelong thyroid replacement.
Follicular adenocarcinoma
Usually affects adults aged 50‐60 years old with a well defined capsule enclosing the tumour.
Hence, tumour spread is via the bloodstream and up to 30% of patients will have distant
metastases at presentation. Treatment is as for papillary adenocarcinoma.
Anaplastic adenocarcinoma
Usually affects adults over 70 years of age and is more common in women. Patients present
with rapid painful enlargement of the thyroid gland, commonly with airway, voice or
swallowing problems. The prognosis is very poor with over 90% of patients dying within one
year even with treatment.
DOHNS The Thyroid
SUPPORTING CELL TUMOURS
Medullary carcinoma
Arises from parafollicular C cells, which secrete calcitonin. Neck metastases are present in
30% patients. Treatment involves near‐total thyroidectomy and radiotherapy. When it
coexists with tumours of the parathyroid gland and medullary component of the adrenal
glands it is called Multiple Endocrine Neoplasia type 2 (MEN2).

Cranial Nerves DOHNS
8. CRANIAL NERVES
CN: Name Sensory/Motor Foramina
I Olfactory Sensory Cribriform plate
II Optic Sensory Optic canal
III Oculomotor Motor Superior orbital fissure
IV Trochlear Motor Superior orbital fissure

V1: Sensory V1: Superior orbital fissure
V Trigeminal V2: Sensory V2: Foramen rotundum
V3: Both V3: Foramen ovale
VI Abducens Motor Superior orbital fissure
VII Facial Both Internal acoustic meatus
VIII Vestibulocochlear Sensory Internal acoustic meatus
IX Glossopharyngeal Both Jugular foramen
X Vagus Both Jugular foramen
XI Accessory Motor Jugular foramen (sp)
XII Hypoglossal Motor Hypoglossal canal
Table 8.1
CNI: OLFACTORY
Olfactory receptor neurons with fibres extending to olfactory bulb through cribriform plate
of ethmoid bone. Stimulation of olfactory receptors allows us to smell. Be sure to test each
nostril with an odorous substance (not ammonia!).
Signs of CNI lesion:
Lesions may be due to blunt head trauma, meningitis or frontal lobe lesions
Lesion to CNI causes reduced sense of smell but does not affect ability to sense pain
from nasal epithelium (since this is carried in CNV).
DOHNS Cranial Nerves
CNII: OPTIC
The optic nerve is part of the central nervous system. It travels via optic canal to the chiasm
where there is partial decussation of fibres from nasal visual fields. Most axons terminate in
the lateral geniculate nucleus and information is relayed to the visual cortex in the occipital
lobe.
Signs of CNII lesion:
The site of nerve injury determines the visual field defect
Injury to the optic nerve causes ipsilateral field loss
Injury at the level of the chiasma causes a bitemporal hemianopia
Injury at the level of the visual cortex causes homonymous hemianopia
Lesions may be due to glaucoma, optic neuritis, trauma, compression by pituitary
tumour or CVA.
CNIII: OCULOMOTOR
The occulomotor nerve arises from the midbrain and runs along the cavernous sinus where
it divides into two branches which enter the orbit through superior orbital fissure. It controls
eye movement, pupil constriction and opening of the eyelid.
Signs of CNIII lesion:
Fixed dilated pupil which does not accommodate
Ptosis
Deviation of eye down and out.
 Causes of injury include trauma, demyelinating disease, increased ICP (causes
herniation and compression), microvascular disease and cavernous sinus disease
CNIV: TROCHLEAR

The trochlear nerve emerges from the dorsal brainstem, passes through the cavernous sinus
and superior orbital fissure and innervates the superior oblique muscle (causes depression
and intorsion of eye). Lesions of nucleus affect the contralateral eye.
Symptoms of injury:
Vertical diplopia due to eye drifting up – difficulty reading/going down stairs, patient
may tilt head down
Torsional diplopia – patient may tilt the head to the opposite side
 Causes of lesions include head injury, increased ICP, infection, demyelination,
neuropathy, congenital defect, infarction and haemorrhage.

CNV: TRIGEMINAL

Supplies sensation of face and mouth as well as the motor supply to the muscles of
mastication.
Three branches: Ophthalmic (sensory), maxillary (sensory) and mandibular (mixed).
Branches of V1 (passes through superior orbital fissure):
Frontal nerve
Nasociliary nerve
Lacrimal nerve
Branches of V2 (passes through foramen rotundum):
Superior alveolar nerves
Facial branches
Nasal branches
Branches of V3 (passes through foramen ovale):
Meningeal branches
Buccal nerve
Auriculotemporal nerve
Lingual nerve
Inferior alveolar nerve
Motor branches of CNV Distributed in V3:
Supplies muscles of mastication, tensor veli palatini, mylohyoid, anterior belly of digastric
and tensor tympani.
Signs of injury:
Reduced sensation over affected area
Weakness of jaw clenching and side‐to‐side movement
Injury to peripheral part of V3 causes deviation of jaw to the paralysed side.
CNVI: ABDUCENS
The abducens nerve controls the lateral rectus muscle, which abducts the eye. The nerve
runs from brainstem through cavernous sinus into orbit through superior orbital fissure and
is vulnerable to injury due to its length.
Signs of injury:
Diplopia, worse in lateral gaze
Inability to abduct the eye
 Causes of injury include compression, infarction, demyelination, infection and
diabetic neuropathy.
CNVII: FACIAL
The facial nerve controls the muscles of facial expression, stapedius, stylohyoid, posterior
belly of digastric and taste to anterior 2/3 of tongue. Parasympathetic fibres supply
submandibular and sublingual glands, lacrimal glands and secretory glands of nasal and
palatine mucosa. The motor portion originates in facial nerve nucleus in pons, whereas the
sensory portion arises from nervus intermedius. The facial nerve enters petrous temporal
bone into IAM, runs through facial canal (gives off the chorda tympani), emerges though
stylomastoid foramen, passes through the parotid gland (but does NOT supply it).
Divides into five major branches:
Temporal
Zygomatic
Buccal
Marginal mandibular
Cervical.
Other branches include:
Branches of CNVII in IAM
Greater petrosal nerve
Parasympathetic supply to lacrimal gland, sinuses and nasal cavity
Sensory fibres to palate
Nerve to stapedius
Chorda tympani
Parasympathetic supply to submandibular gland and sublingual gland
Special sensory taste fibres to anterior 2/3 tongue.
CNVIII: VESTIBULOCOCHLEAR
The vestibulocochlear nerve transmits sound and balance information.
Signs of damage:
Unilateral sensorineural deafness
Tinnitus
Vertigo.

 Causes of injury include loud noise, Pagets disease, Menieres disease, Herpes zoster,
neurofibroma, acoustic neuroma, brainstem CVA, aminoglycosides.
Acoustic neuroma (Vestibular schwannoma)
Benign primary intracranial tumour of myelin forming cells of CNVIII. It may occur sporadically or
as part of von Recklinhausen neurofibromatosis. Symptoms occur due to compression of
surrounding structures such as CN V, VII, IX and X. Patients present with ipsilateral sensorineural
hearing loss, disturbed balance, vertigo and tinnitus.
Investigations: MRI with contrast, audiology and vestibular tests
Treatment: Conservative, surgical, radiotherapy
CNIX: GLOSSOPHARYNGEAL
The glossopharyngeal nerve supplies motor innervation to stylopharyngeus alone (elevates
pharynx), parasympathetic innervation to otic ganglion and thus parotid and sensory innervation
to upper pharynx, tonsils, posterior 1/3 tongue, external ear and internal part of TM.
 Special sensory supply (for taste) to posterior 1/3 tongue
 Visceral sensory supply to carotid body and sinus
 Major branches
Tympanic
Carotid
Phayngeal
Muscular
Tonsillar
Lingual.
CNX: VAGUS
Most notably the vagus nerve supplies the larynx via the recurrent and superior laryngeal
nerves. It also gives off an auricular branch (Alderman’s nerve) which may cause a cough reflex
when examining the external auditory canal.
CNXI: ACCESSORY
Motor supply to sternocleidomastoid and trapezius. Courses through posterior triangle of
neck – may be damaged in neck surgery.
Signs of injury:
Wasting and weakness of SCM and trapezius.
CNXII: Hypoglossal
Supplies motor fibres to all muscles of the tongue expect palatoglossus.
Tested by asking the patient to protrude their tongue – tongue points towards affected side
Signs of injury:
Signs of LMN disease include as atrophy and fasciculation.
Hearing and balance DOHNS
9. HEARING AND BALANCE
AUDIOMETRY
The audiogram is a graph of a person’s hearing ability and is a standard way of representing a
person’s hearing. The typical range of frequencies tested does not cover the entire range of
human hearing (20‐20,000Hz), instead it includes frequencies considered to be essential in
understanding speech (250‐8,000Hz). The assessment involves pure tones being presented to
the ‘test‐ear’ at a specific frequency (pitch) and intensity (loudness).
Thresholds can be obtained using air conduction (AC) or bone conduction (BC). The comparison
of AC thresholds and BC thresholds provides an initial differentiation between conductive, mixed
and sensorineural involvement. Sensorineural hearing loss is characterised by equivalent air and
bone conduction ie air‐bone gaps of less than 10dB. Conductive hearing loss is characterised by
BC thresholds within normal limits, with a concurrent gap between the poorer AC and better BC
thresholds of at least 10dB. A mixed hearing loss contains air‐bone gaps with the bone
conduction thresholds outside of the normal range.
MASKING
To ensure the auditory function of each ear is measured independently, masking is used.
Rules of masking:
1. Air conduction audiometry – mask if the difference between the right and left air conduction
thresholds is 40dB or more.
2. Bone conduction audiometry – mask where bone conduction threshold is better than air
conduction by 10dB or more.
3. Air conduction audiometry – mask where bone conduction of the better ear is 40dB or more
better than air conduction threshold of the worse ear.
Masking is required for BC testing whenever there is any difference in the AC and BC thresholds,
since there is essentially no interaural attenuation by bone conduction.

DOHNS Hearing and balance
Figure 9.1: Definitions of hearing loss
Example audiograms
Figure 9.2: Sensorineural hearing loss (mild to moderate)
Figure 9.3: Conductive hearing loss

Figure 9.4: Mixed hearing loss
Pure tone average = average over 0.5, 1, 2, 4kHz
SYMBOLS
Right Left
Air conduction O X
‐ with masking ∆ □
Bone conduction < >
‐ with masking [ ]
No response

HEARING AIDS
A hearing aid is
electroacoustic Ear mould
apparatus, which
typically fits in or
behind the ear, and is Connecting tube
designed to
modulate sound for
the wearer. There Microphone
are many types of Battery
hearing aid and Volume control
On/Off
they vary in power,
size and circuitry.
Figure 9.5: Hearing aids
Scala vestibuli
Reissners membrane
Scala Media
Organ of Corti
Scala tympani
Basillar membrane
Figure 9.6: Histology of the cochlea
Figure 9.7: BAHA abutment seen 2 weeks post‐op
COCHLEAR IMPLANTS

A cochlear implant (CI) is a surgically implanted
electronic device that provides a sense of sound to a
person who is profoundly deaf or severely hard of
hearing. An absence or disturbance of cochlear hair
cells causes most cases of deafness. This defect in
normal cochlear function represents a broken link in
the delicate chain that constitutes the human sense
of hearing. CI provide an artificial means to bypass this
disrupted link and thereby allow the transmission of
acoustic information through the central auditory
pathway via direct electrical stimulation of auditory
nerve fibres. Most deaf individuals maintain an
adequate surplus of viable auditory nerve fibres to
permit this intervention. Candidacy for cochlear Figure 9.8: Cochlear implant probe
implantation relies heavily upon the audiologic
evaluation but other considerations and strict criteria exist including lack of medical
contraindication.
TYMPANOMETRY
This examination is used to measure the transmission of energy through the middle ear
(acoustic impedence). It is based on the amount of sound reflected back from the tympanic
membrane when an 85‐B sound pressure level (SPL), low frequency (226Hz) probe tone is
introduced into the sealed ear canal and pressure in the ear canal is varied. When the
pressure in the ear canal corresponds with the pressure in the middle ear cavity, the
tympanic membrane is at its most compliant point and thus absorbs, rather than reflects,
the most sound.
Classification of tympanograms
Type A – normal tympanic membrane mobility and normal middle ear pressure.
Type As – Reduced tympanic membrane mobility and normal middle ear pressure,
consistent with stiff middle ear system eg; otosclerosis.
Type Ad – Hypermobile tympanic membrane with normal middle ear pressure, consistent
with flaccid tympanic membrane or disarticulation of ossicular chain.
Type B – Reduced tympanic membrane mobility, consistent with presence of fluid in middle
ear space.
Type C – Normal tympanic membrane mobility and negative middle ear pressure, consistent
with Eustachian tube dysfunction.
Compliance (ml)
Compliance (ml)
Compliance (ml)
Compliance (ml)
Compliance (ml)
Figure 9.9: The various types of tympanogram
BALANCE
Balance requires the integration of several body systems working together, including the
eyes, ears and limbs. Balance disorders can occur whenever there is a disruption in any of
the vestibular, visual, proprioceptive or cognitive systems. Symptoms may be due to a wide
range of pathologies such as hypotension and brain tumours. There are many terms often
used to describe dizziness including vertigo, dysequilibrium and pre‐syncope.
Otolaryngologists are primarily interested vestibular disorders such as benign paroxysmal
positional vertigo (BPPV), labyrinthitis and Menieres disease.
BPPV
Vertigo usually lasts only for seconds. Brief and intense sensation of spinning that occurs
because of a specific change in the head position. The cause of BPPV is the presence of nor‐
mal but misplaced otoconia within the inner ear. Treatment involves moving these otoconia
through various exercises such as the Epley manoeuvre.
Figure 9.10: The various stages of the Epley manoeuvre
MENIERE’S DISEASE
Vertigo lasts minutes to hours. Inner ear fluid balance disorder that causes lasting episodes
of vertigo, fluctuating hearing loss, tinnitus and the sensation of fullness in the ear. Dietary
changes may be helpful including reducing salt, alcohol and caffeine intake. Stress has been
shown to exacerbate symptoms. Medications such as Betahistine and Furosemide have been
shown to reduce the frequency of symptoms. Surgical treatment options include grommet
insertion, vestibular neuronectomy and labyrinthectomy.
LABYRINTHITIS
Vertigo lasts days. Inner ear infection or inflammation causing vertigo and hearing loss.
Treatment involves vestibular rehabilitation.
VESTIBULAR NEURONITIS
Vertigo usually lasts for days. Viral vestibular nerve infection causing vertigo but no
deafness. Treatment involves vestibular rehabilitation.
Superior
Cochlea
Semicircular canals
Ampulla
Posterior
Ampulla
Lateral
Ampulla Scala tympani
Figure 9.11: Labyrinth
Imaging DOHNS
10. IMAGING
The DOHNS candidate will not be expected to discuss images in detail during the OSCE
examination or comment on the pros and cons of certain imaging modalities. They will,
however, be required to identify common conditions based on a selection of images and to
describe the key diagnostic points.
The role of radiology in ENT has developed greatly over the past few decades. It must be
appreciated that the radiologist has a key role at multidisciplinary team meetings. High
quality imaging allows the extent and stage of disease to be demonstrated to all team
members and this has contributed significantly to confident management advice and
appropriate consenting of the patient.
IMAGING MODALITIES
I. X‐ray
X–rays are indicated in selected circumstances. Please see illustrations below.

Q: Identify and label the parts

Answers:
1 Mandible.
2 Hyoid.
3 Thyroid cartilage.
4 Cricoid cartilage.
5 Epiglottis.
6. Valeculla.
DOHNS Imaging
Larynx
Identify the chicken bone
This 43–year‐old lady presents with a
mass in the left side of her neck.

Q: What is the investigation?
A: Cervical Spine X‐ray AP

Q: What is the abnormality seen?
A: Left Cervical rib
II. Computerised tomography (CT):
CT images are essentially density maps of the human body utilising fairly high diagnostic radiation
doses. CT is good at demonstrating bone detail and this remains its major strength. Modern CT
technology means scanners are incredibly fast requiring just a few seconds of exposure to acquire a
Imaging DOHNS
volume of data from which high spatial resolution images in all planes can be reconstructed.
Examples of where CT is used in ENT
1. Rhinosinusitis.
2. Head and Neck malignancy.
3. Temporal bone.
4. Abscesses.
Q: What is this investigation?
A: CT sinuses demonstrating the
OMU
Q: Name the arrowed air passages
Answers:
1. Ostium.
2. Infundibulum.
3. Middle meatus.
4. Hiatus semilunaris.
Q: What is the name of this unit?
A: Osteomeatal unit
Q: Which sinuses drain into this
unit?
A: Maxillary, Anterior Ethmoids,
Frontal sinuses
A: CT neck at the level of the
thyroid cartilage
Q: What does it demonstrate
(blue arrows)?
A: Large supraglottic tumour,
crossing the midline. Bilateral
cervical lymphadenopathy
(asterisk)
Q: Where do the yellow arrows
point to?
Answers:
1. Sternomastoid.
2. Thyroid cartilage.
3. Internal jugular vein.
4. Cervical vertebra.
DOHNS Imaging
A: CT Sinuses, coronal and axial slices
Q: What is the abnormality shown in asterisks?
A: Antrochonal polyp – seen filling the maxillary sinus and the nostril on the coronal image,
and filling the post nasal space on the axial image
Q: Where do the arrows point to?
1 Cribriform plate.
2 Optic nerve.
3 Unerupted molar tooth.
A: CT neck
Q: What is the abnormality? (blue
arrows and asterisks)
A: Tumour base of tongue crossing
the midline, bilateral necrotic
cervical lymphadenopathy
1. Sternomastoid.
2. Mandible (ramus).
3. Spinal cord.
4. Internal jugular vein.
Imaging DOHNS
A: CT petrous temporal bones
Q: What do the numbers and
circle correspond to?
Answers:
1. Internal acoustic meatus.
2. Cerebellum.
Circle ‐ cochlea.
A: CT petrous temporal bone
Answers:
1. Handle of the malleus.
2. Round window.
3. Mastoid air cells.
Circle ‐ cochlea.
A: CT petrous bones
Answers:
1. Bodies of malleus and incus.
3. Sphenoid sinus.
Circle – lateral semicircular
canal and vestibule.
DOHNS Imaging
A: CT petrous temporal bones
Q: What do the numbers and circle
correspond to?
1. Bodies of malleus and incus.
Circle – lateral semicircular canal and
vestibule.
A: CT brain and orbits, with contrast
Q: What abnormalities are
demonstrated?
Right proptosis,
Right periorbital cellulitis
Right ethmoid sinusitis
Right subperiosteal abscess
Q: Name 2 intracranial complications:
1.Subdural empyema.
2.Venous thrombosis.
3.Osteomyelitis.

CT orbits and brain pre and post contrast report.
Clinical details: Fits, confusion. Right proptosis.
“There is a severe right proptosis with extensive preseptal cellulitis extending up to the forehead and across
the nasal bridge.
In addition there is a large subperiosteal abscess extending along the medial wall of the right orbit to the
orbital apex. There is no radiological evidence of extension through the superior orbital fissure into the
cavernous sinus, the cavernous sinus es are patent bilaterally.
Soft tissue fills the frontal sinuses bilaterally and the right ethmoid and sphenoid sinuses.
The post contrast scans demonstrate increased gyral enhancement with slight effacement of the sulci in
keeping with an evolving cerebritis, there is no convincing evidence of a subdural collection, however a small
shallow isodense subdural collection is difficult to exclude.
Imaging DOHNS
The deep venous sinuses are patent, the petrous bones are normally aerated.
There is a lipoma of the splenium of the corpus callosum.”
Conclusion
 Right orbital cellulitis with large subperiosteal abscess
 Right cerebritis with raised intracranial pressure
 Urgent neurosurgical opinion advised
 Results discussed directly with paediatric team.
A: CT neck sagittal image
Q: Blue asterisk demonstrates a
tumour – where is it located?
A: Base of tongue and valeculla
Q: What do the numbers
correspond to?
Answers:
1.Hyoid.
2.Thyroid cartilage.
3.Cricoid cartilage.
4. Hard palate.
Q; What is this investigation?
A: CT petrous bones
Q: Where is the abnormality (blue
asterisk)
A: Middle ear
Q: Name some differential diagnoses?
Answers:
Glomus tympanicum.
Small cholesteotoma.
Q: What do numbers correspond to?
1. Cochlea (basal turn).
DOHNS Imaging
III. Magnetic Resonance Imaging (MRI)
MR images reflect tissue biochemistry and are particularly influenced by the presence of protons
within the tissues. T1 weighted images carry a great deal of spatial resolution with excellent
depiction of detailed anatomy. T2 weighted images are better at highlighting abnormal tissues.
The STIR sequence retains this positive attribute of a T2 weighted image and suppresses all fat
signal leaving all abnormal tissue and tissue with a high water content as high signal. Scan times
compared to CT are much longer varying from around 2 to 5 minutes per sequence with scans
sometimes taking 40 minutes in total during which the patient must be kept still.
Examples of where MRI is used in ENT:
1. Acoustic neuroma.
2. Head and Neck malignancy.
3. Vertigo.
A: MRI Internal Auditory Meati
arrows)
A very large vestibular schwannoma
bulging into the cerebellum, compressing
the fourth ventricle.
Q: Where do the yellow arrows point to?
Answers:
1. Cerebellum.
2. Pons.
3. Temporal lobe.
A: MRI IAMs T1 with contrast axial.
Q: What is the abnormality? (asterisk)
A: An enhancing intracanicular vestibular
schwannoma.
Q: What do the numbers corresponds
to?
1. Pons.
2. Cerebellum.
3. Fourth ventricle.
Imaging DOHNS
A: MRI IAMs T1 with contrast coronal
asterisk)
A: An enhancing intracanicular
vestibular schwannoma
Q: What do the numbers
corresponds to?
1. Pons.
2. Temporal lobe.
3. Odontoid peg.
4. Lateral ventricle.
What is this investigation?
MRI neck (coronal T1 image)
What is the abnormality? (Blue
asterisk)
Tumour left lateral tongue, not
crossing the midline.
Q: What do the numbers corresponds
to?
1. Mylohyoid muscle.
2. Inferior turbinate.
3. Maxillary sinus.
DOHNS Imaging
IV. Ultrasound (USS)
USS in experienced hands provides useful and rapid imaging assessment of patients with an
undiagnosed neck lump. As well as providing imaging information on neck masses USS can be
used to guide fine needle aspiration (FNA). USS is particularly useful in delineation of thyroid
pathology, cervical lymphadenopathy and evaluating salivary gland tumours.
Examples of where USS is used in ENT
1. Metastatic cervical lymphadenopathy.
2. Paediatric neck lumps.
3. Thyroid pathology.
4. Salivary gland disease

A: Ultrasound of the parotid gland
Q: What is the measured lesion most likely to be?
A: Pleomorphic adenoma
V. Positive Emission Tomography‐Computerised Tomography fusion scan (PET‐CT)
PET images are maps reflecting levels of glucose metabolism within tissues. A short half‐life
isotope 16 fluoro deoxy glucose (FDG) is injected intravenously. The PET scanner detects gamma
rays caused by interaction of positrons emitted by the isotope with electrons within the tissues.
Modern scanners incorporate a CT scanner which co registers the activity with its exact
anatomical location. PET‐CT will detect the clinically occult primary in approximately one third of
cases. It is also valuable in the assessment of suspected recurrence of head and neck cancer.
Imaging DOHNS
VI. Contrast swallow
Routine barium swallows can be useful in demonstrating oesophageal function and pathology including reflux,
pharyngeal pouches, malignant and benign strictures. Water‐soluble contrast swallow are useful when there is a
perceived risk of aspiration.
A: Barium swallow

Q: What does it show?
A: Pharyngeal pouch

Q: What symptoms might the patient have?
A: Regurgitation of food, nocturnal cough

Q: Where does the arrow point to?
A: Oesophagus

DOHNS
DOHNS
SECTION TWO:
Communication skills for DOHNS Part 2
DOHNS
Consent DOHNS
11. CONSENT
TOP TIP
Spend some time asking about the patient’s knowledge of the procedure, as this may well
be the key point of the station. Maybe ask if he knows anyone who has had the
procedure.
This station assesses your ability to obtain an informed consent for an invasive procedure.
It requires you to have a clear and structured approach, and have some understanding of
the procedure.
You are the ST2 trainee with an ENT firm. You have been asked to consent Mr Campbell
for a submandibular gland excision.
Station set up:
Mr. Campbell will be a simulated patient
What you need to cover
Recap clinical history
Establish reason for procedure
Explore patient’s ideas, concerns and expectations
Explain procedure, benefits and complications
Check patient understanding of information
Give an estimate of duration of hospital stay
Allow patient the opportunity to ask questions.

Hidden Agendas
Patients who are due to have an interventional procedure tend to be nervous for a number
of reasons, including misconceptions about the procedure. It is therefore essential that the
doctor obtaining consent from a patient establishes their ideas, concerns and expectations
before the procedure. It is during the consenting process that any problems or issues
should be identified and addressed. Mr. Campbell will probably have a few issues...
DOHNS Consent
How to approach this station:
Introduce yourself, confirm the patient’s identity and obtain consent for the consultation.
Recap the clinical history. Focus on:
Does the patient know why they are in hospital?
What has happened in the lead up to procedure (what symptoms the patient has
experienced, etc.)?
What does the patisent know about the procedure already?

Provide appropriate information regarding the procedure i.e. what will occur (talk Mr.
Campbell through step‐by‐step from arriving on the ward to going home afterwards).
Explain the risks and the benefits of the procedure.
TOP TIP
This station is not about demonstrating your knowledge of the fine details of how to
perform the procedure. Instead the station is focused on determining whether the
patient has any reservations and adverse ideas, which would disrupt the success or the
outcome of the procedure. However, in a station like this it is beneficial to know and
provide some pertinent statistics regarding the procedure.
You must also remember that a patient with capacity has the right to refuse treatment!
Explore his main concerns.
 What does the patient expect?
 Does the patient understand/retain the information about the procedure?
If the patient is happy to proceed:
 Complete the consent form ‐ providing patient has capacity.
If the patient refuses:
 Explore the reasons behind this
 Does the patient have capacity?
 Respect patient’s autonomy.
The facts:
GMC guidelines on obtaining consent are summarised below. You must demonstrate your
knowledge of these guidelines throughout this station, and structure the station around
them.
Consent DOHNS
Key points to tell a patient undergoing key ENT procedures are considered below. (Adapted
from GMC guidelines: Seeking patients’ consent: the ethical considerations).
Obtaining informed consent:
‐ Who can obtain consent?
Ideally the doctor discussing a procedure and obtaining consent from a patient should be
the person who will perform the procedure. This is because they will best know how and
why the procedure is performed and any risks. It may not always be possible for this to take
place, however, so a suitably trained and qualified delegate may be appointed with the task.
This person (often a junior doctor) must understand and relay information about the
proposed procedure or treatment, and risks involved.
‐ When should consent be obtained?
It is good practice to give the patient time to consider their procedure and therefore, except
in emergency situations, obtaining consent should be done well in advance of the operation
date. This allows the patient time to reflect on their options, weigh up the risks and benefits
and ask for further questions if they wish. It is generally considered undesirable to consent
on the day of the procedure, although this is common practice. It is felt this places undue
pressure on the patient to consent.
An ideal scenario for elective procedures would be to discuss the operation in clinic a week
or more prior to admission, providing the patient with written information to take home,
and contact details if they have further questions. On the day of the procedure a formal
written consent should be obtained, if the patient is prepared to proceed.
‐What information to provide?
“Patients have a right to information about their condition and the treatment options
available to them”. GMC guidelines highlight that the amount of information given to each
patient will vary, according to factors including:
The nature of the condition and its severity.
The complexity of the treatment/procedure.
The risks of the treatment.
The patient’s wishes (how much they want to know).
The information the patient ought to know (and which therefore the practitioner obtaining
consent should provide) includes:
Details of diagnosis and prognosis (including what will happen if the condition goes
untreated)
Treatment options (including the option of not treating)
The purpose of the proposed treatment (i.e., the benefits of treating)
Details of the proposed treatment, including:
DOHNS Consent
 Preparation for the procedure
 What the patient may experience during and after treatment
 Subsidiary treatments, such as pain relief, that may be necessary
 How the procedure might affect their lifestyle
 Risks of the procedure, including common and serious side effects
 Who will perform the procedure (and if trainees will be involved).
Other considerations:
It is also necessary to remind patients that they have the right to change their mind and
withdraw consent at any time if they wish.
If the patient has questions about the procedure, you must answer them fully and
honestly. If you don’t know the answer you should find out for them.
You cannot withhold information about the treatment because you feel it may upset the
patient, or cause them to refuse treatment.
You must provide information to the patient in a sensitive manner, and in ways in which
they can understand. If the information is very complex, you should consider breaking the
information into more accessible sections.
Benefits/risks of key ENT procedures:
Below are listed the main benefits/risks of ENT procedures commonly examined in
communication stations. It is a good idea to read about these procedures prior to your
DOHNS examination to gain further information about the indications for the procedure,
the technical aspects, the pre‐operative tests and post‐operative issues that may be
encountered as well as the important things the patient needs to know about the recovery
phase.
Consent DOHNS
Benefits Risks
Tonsillectomy – Relief from rec. tonsillitis – Pain

– Improve snoring – Earache
– Diagnostic – Bleeding
– Injury to teeth
– Jaw pain
– Infections/sore throats
Grommet insertion – Improve hearing – Earache

– Improve earache, tinnitus, – Bleeding
dizziness – Infection
– Scarring of TM
– Residual perforation
– Early extrusion
– Loss of grommet behind the
ear drum
– Hearing loss
Myringoplasty – Closure of perforation – Bleeding
– Relief of discharge – Dizziness
– Infection
– Altered taste
– Numbness of ear
– Painful scar
– Facial nerve injury
– Worsening of hearing
– Risk of failure (20%)
– Protruding ears
Septoplasty ‐ Attempt to improve nasal ob‐ – Pain

struction – Nasal bleeding
– Woody feel of the nose
– Septal perforation
– Septal haematoma
– Nasal adhesions
– Risk of failure
– Altered sensation of upper
teeth

FESS (Functional – Improve nasal or sinus symp‐ – Pain
endoscopic sinus toms – Nasal bleeding
surgery) – Clear sinus disease – Nasal crusting/adhesions
– Damage to the eye
– CSF leak
– Periorbital swelling
– Periorbital bleeding
– Failure of procedure
DOHNS Consent
Excision of neck – Diagnostic – Pain

mass – Removal of mass – Bleeding/haematoma
– Drain insertion
– Infection
– Weak shoulder
– Weak angle of mouth
– Skin/earlobe numbness
– Thickened/painful scar
Nasal polypectomy – Removal of nasal polyps – Pain
– Improve nasal obstruction – Bleeding
– Adhesions/crusting
– Infection
– Recurrence
– Damage to the eye
– CSF leak
Mastoid exploration ‐ Clear ear disease – Bleeding/haematoma

– Dizziness
– Hearing loss / Dead ear
– Infection/discharge
– Altered taste sensation
– Tinnitus
– Protruding ears
– Meningitis/brain abscess
– Recurrence
Submandibular – Diagnostic – Pain

gland excision – Relief of pain/swelling – Bleeding/haematoma
– Infection
– Weakness of angle of mouth
– Altered tongue sensation
– Weakness of tongue
Consent DOHNS
Stapedectomy ‐ Improve hearing – Earache
– Bleeding
– Dizziness
– Tinnitus
– Perforation
– Dead ear
– Deafness
– Altered taste sensation
– Intolerance to loud noise
– Failed procedure
Septorhinoplasty – Improve nasal obstruction – Pain

– Improve external shape of – Nasal bleeding
nose – Woody feel to nose
– Septal perforation
– Septal haematoma
– Nasal adhesions
– Failure
– Recurrence
– Altered sensation upper teeth
Ossiculoplasty ‐ Improve hearing – Bleeding

– Dizziness
– Tinnitus
– Altered taste
– Residual perforation
– Deafness
– Failure
– Painful scar
– Protruding ears
– Numbness of ear
DOHNS Consent
Previous DOHNS Part 2 scenarios:
‐ Consent for Superficial Parotidectomy in young female model / actress with a pleomorphic
adenoma (she doesn’t elude to her career straight away).
‐ Consent for Myringoplasty for chronically discharging ear in a ten‐year‐old with concerned
parent.
Extra scenarios for practice:
‐ Consent for Septoplasty in 35 year‐old gentleman for which the indication is nasal obstruc‐
tion, but he believes it will cure his snoring.
‐ Consent for nasal polypectomy in a 45 year‐old, the patient is a professional wine‐taster and
has lost work but is hoping to get back to work soon following the operation.
Oral – Information giving DOHNS
12. Oral – Information giving
This station assesses your ability to give information to patients, or parents, in a way that
they understand and that allays their fears. These stations are not about taking a clinical
history.
TOP TIP
There is always a “hidden agenda” of some sort. Actors are not as good as patients at
hiding these, it can be easily brought to the surface by asking: “Is there anything else you
are particularly worried about?” or “Have we missed anything you would like to talk
about?”
Always begin by introducing yourself, stating your position.
Most scenarios involve explaining a relatively complicated concept to a patient or parent and
will require you to break the information up in to manageable “chunks”. A good way of
ensuring that you are not either patronising the patient or pitching the information at too high
a level is to check what they know first.
A good tool to use is the “Check – Chunk” method of relaying information that is commonly
taught on Communication Skills courses.
Check – Chunk:
Begin by establishing what the patient means when they say certain words or refer to certain
symptoms or diagnoses (“Check”) and then give a small bit of information relative to that
(“Chunk”) then repeat the process. A common pitfall is to assume you know exactly what the
patient is talking about and give them a lot of information that is entirely irrelevant to what
the scenario is geared towards.
Patient: “My GP says that I suffer with BPPV, this means nothing to me all I know is that I get
dizzy when I look left. Can you tell me what is wrong with me?”
Doctor: “What do you understand about BPPV?” [CHECK]
Patient: “To be honest, it could mean anything”
Doctor: “It stands for Benign Paroxysmal Positional Vertigo; it’s a long name which is why we
shorten it. The most important thing you can take from that is it is a benign condition and
does not represent anything life threatening [CHUNK].
DOHNS Oral – Information giving
Patient: “It doesn’t stop me from feeling dizzy! The GP said something about crystals in my
ear, I think he’s making it up!”
Doctor: “I know it sounds a bit far‐fetched, but what do you understand about these
crystals?” [CHECK]
Patient: “The GP gave me a big explanation about the inside ear but he rushed through it so
fast it sounded like a lot of complex words to me.”
Doctor: “Your dizziness is certainly caused by crystals in the inner ear these are generally a
loose fragment of a larger organ in the ear that spins around inside the ear and causing you
to feel dizzy.” [CHUNK]
Etc. etc.
It is very tempting to dive in with the answer without checking, the process does feel
unnatural to most people; particularly surgeons who want to give answers straight away. It
is a long process, but you can be sure you are addressing all of the concerns that the patient
has.
If at any stage you are feeling lost a quick recap will not only help you get back on track but
it will score you marks as this is something that helps your patient appreciate that you were
listening to them and is accommodated for on the mark sheet.
Draw the conversation to a close with a quick summary and always ask: “Is there anything
else you are particularly worried about?” or “Have we missed anything you would like to talk
about?”. It is good practice to ask if the patient has any questions or whether they want
anything explaining again in more detail. This will almost always flag up the “Hidden
Agenda” in an actor, if there is one.
An important factor to accommodate is that the information is generally emotionally loaded
for the individual, so be very careful how you word your explanation. A good way of ensuring
you don’t put your foot in it is to make sure that you don’t end up doing all the talking. This
is when you can veer off on a tangent and either lose the patient or not address the
concerns that the examiner has marks for.
TOP TIP
If you are the only one doing the talking, you are doing it wrong!
Oral – Information giving DOHNS
Summary:
‐ Environmental considerations
‐ Introduce yourself
‐ Establish rapport
‐ Check – Chunk
‐ Recapitulate when required
‐ Address hidden agenda
‐ Draw consultation to a close
‐ Summarise the information
‐ Allow time for further clarification and questions
‐ Gentleman had diagnosis of BPPV given by GP. Has come to ENT for treatment, has
questions about condition and treatment. (Hidden Agenda: Is a van driver by occupation,
need to give information re: DVLA)
‐ Mother has a 3 year‐old child who is deaf in one ear, she has not noticed this but the
school has referred to audiology. Play audiometry shows a dead ear on the right hand side
(Hidden Agenda: Mother has questions about cochlear implantation)
Extra Scenarios for practice:
‐ Reassure a patient with globus that their Barium swallow is normal and that they do not
require an examination under anaesthetic. The most likely cause for their symptoms is
reflux (Hidden Agenda: The patient believes that they have cancer).
DOHNS
Written – Operation note DOHNS
13. Written – Operation note
This station assesses your ability to provide written information in an operation note. It
requires you to have a clear and structured approach, and provide concise information
about what was done during the procedure as well as provide post‐operative instructions
You are the ST2 trainee with an ENT firm. You have been asked to write the operation note
for a microlaryngoscopy and biopsy.
Station set up:
‐ Blank operation note provided
What you need to cover:
‐ Name of operation
‐ Indication for procedure
‐ Incision
‐ Findings
‐ Procedure
‐ Post‐operative plan.
‐ Document clearly and concisely the steps of the operation
‐ If the operation was particularly difficult document this
‐ Record any intra‐operative complications and what was done to deal with these
‐ Document that haemostasis was checked prior to closure
‐ Document any biopsies or tissue sent for histology or swabs for microscopy
‐ Post operative instructions should include any relevant information regarding frequency
of observations, diet and fluids, antibiotic use, whether the patient needs to stay in
overnight, anticipated time for review/discharge and follow up plan.
Example: Microlaryngoscopy and biopsy
Indication: Hoarse voice
Incision: N/A
Findings: Reinkes oedema
Procedure: Laryngoscopy performed using Lindholm laryngoscope
Microscope used to assess vocal cords
Microinstruments used to take multiple biopsies
1:1000 adrenaline patty used for haemostasis
Teeth/TMJ/PNS clear
DOHNS Written – Operation note
Post‐op: Close airway observations
Can eat and drink as able
To stay in overnight, home tomorrow if well
Follow up in OPD in 2 weeks with results of histology
Previous DOHNS Part 2 questions:
‐ Operation note for grommet insertion and adenoidectomy, for enlarged adenoids in
recurrent glue ear. The anaesthetist is happy for the patient to go home later today.
Additional questions for practice:
‐ Operation note for oesophagoscopy and removal of impacted meat bolus (no bone) at level
of cricopharyngeus.
‐ Operation note for excision of lymph node for confirmation of lymphoma in level one
lymph node, submental region.
Written – Discharge summary DOHNS
14. Written – Discharge summary
This station assesses your ability to provide written information in a discharge summary. It
requires you to have a clear and structured approach and to provide concise information
about investigations/interventions performed during the patients admission as well as
provide post‐discharge instructions/ follow up information to the patients GP.
Station set up:
You are the ST2 trainee with an ENT firm. You have been asked to write the discharge
summary for a patient who was admitted for total thyroidectomy.
Blank discharge summary provided
‐ Patient details
‐ Consultant responsible for care
‐ Methods of admission (elective/emergency)
‐ Dates of admission
‐ Diagnosis
‐ Operation/procedure
‐ Clinical narrative (reason for admission, presenting complaint, relevant clinical findings,
investigations and results, progress during admission, any complications)
‐ Outstanding investigations/results
‐ Medications at discharge and any changes/additions made
‐ Discharge destination
‐Follow up plan.

Example: Elective admission for total thyroidectomy

July 1st 2012

Dear Doctor Jones,

Re: Mrs Brown, 123 Any Street, Anytown
DOB: 24/5/1975
Admitted: June 10‐11th 2010 (Elective admission)
Consultant: Mr. Smith (Consultant ENT Surgeon)
Diagnosis: Multinodular goitre
Procedure: Total thyroidectomy on June 10th 2011
DOHNS Written – Discharge summary
This lady was admitted on June 10th for an elective total thyroidectomy of a multinodular
goitre, which was causing compressive symptoms. Clinically she was euthyroid and
ultrasound, performed prior to admission, confirmed a multinodular goitre with the FNA
inconclusive. Based on her ongoing unpleasant symptoms, Mrs Brown was keen to proceed
with a total thyroidectomy. Bloods, including her thyroid function tests (TFTs) were normal on
admission and pre‐operative flexible nasendoscopy performed at the bedside revealed
normally functioning vocal cords. There were no intra‐operative complications.
Post‐operatively she complained of tingling in her fingers but calcium was within the normal
range and her symptoms resolved spontaneously. She was commenced on thyroxine 100mcg
daily on day one post‐operatively and has been advised that she will require life‐long
thyroxine replacement. She was discharged home on 11th June. We would be most grateful if
you could arrange for her to attend the surgery for her TFTs and calcium level to be checked
next week and we have arranged to see her in clinic in 2 weeks time with the results of the
histology. Her sutures are absorbable and therefore do not require removal. We have advised
her to contact you immediately if she gets any further symptoms of hypocalcaemia.

Yours sincerely,
Mr Green
ST2 to Mr Smith

Additional cases for practice:
‐ Emergency admission for quinsy (second episode), aspirated once successfully. Discharged
following 48 hours of IV antibiotics with 10 day course to complete on discharge (no drug
allergies). Bacterial swab not available on discharge.
‐ Elective admission for septorhinoplasty for post‐traumatic nasal obstruction and cosmetic
deformity, uneventful recovery.
‐ Elective admission for diagnositic laryngoscopy and biopsy. Lesion highly suspicious for
laryngeal cancer. Appropriate investigations have been organised and the patient will be
reviewed in outpatients as a matter of urgency.

Oral – Taking a history DOHNS
15. Oral – Taking a history
This station assesses your ability to take a focused history. It requires you to have a clear
and structured approach, and to use both open and closed questioning to gain the
information required to reach a diagnosis and determine appropriate investigations.
You are working in an ENT outpatients clinic. You have been asked to take a history
from Mr Davies who has been referred to the clinic by his GP with a hoarse voice.
Station set up:
Mr Davies is a simulated patient. The examiner may ask you questions about your working
diagnosis and what investigations you may arrange.
‐ Duration of presenting complaint
‐ Progression of symptoms
‐ Any associated symptoms
‐ Past medical history and fitness for investigation/surgery
‐ Medication use including anticoagulants
‐ Social history especially smoking and alcohol intake
‐ Family/occupational history
‐ Patients ideas and concerns and expectations (hidden agendas)
‐ Summarise history to patient to check understanding
‐ Prepare the environment appropriately i.e. at 45 degree to the patient, no barriers
between you
‐ Introduce yourself
‐ Check the patients name
‐ Ascertain the presenting complaint through open questioning
‐ Use closed questions to clarify the symptoms and determine if there are any other
associated symptoms or red flags
‐ Determine any relevant past medical history and ask about relevant social history
without being judgemental about smoking/alcohol intake
‐ Summarise the pertinent points from the history
‐ Discuss the patient’s ideas about what the problem might be and their concerns
‐ Determine a management plan and inform the patient
Example: History taking of hoarse voice
“How long have you had a hoarse voice?”
“Is the hoarseness constant or intermittent?”
“Have you had any other symptoms?”
DOHNS Oral – Taking a history
‐ Pyrexia
‐ Sore throat
‐ URTI symptoms
‐ Dysphagia and/or weight loss
‐ Pain
‐ Otalgia
‐ Neck lump and/or FOSIT
‐ GORD symptoms
“Is it getting worse?”
“Do you use your voice at lot (i.e., voice abuse)
“Are you a smoker?”
“Do you drink alcohol?”
‐ Take a history off this 40‐year‐old non‐smoker with anosmia (Hidden agenda: the patient is
a chef)
‐ Take a history off this 21‐year‐old patient with facial pain (Hidden agenda: the patient
thinks they have a brain tumour)
‐ Take a history off this 50‐year‐old patient with BPPV (Hidden agenda: he operates a crane
in a steel works and gets dizzy when looking down and to the left)
Oral ‐ Breaking bad news DOHNS
16. Oral ‐ Breaking bad news
This station assesses your ability to deal with difficult situations and break bad news to
patients with empathy.
You are an ST2 trainee working in ENT. Two weeks ago you saw a 55‐year‐old lady with
a hoarse voice. On flexible nasendoscopy she had a lesion on her vocal cord so you
arranged a laryngoscopy which she had last week. At operation she was found to have a
T3 laryngeal cancer.
Station set up:
Mrs. Jones will be a simulated patient. The examiner may ask you questions at the end of
the station.
What you must cover:
‐ Prepare the environment appropriately for breaking bad news
‐ Make sure patient is expecting test results.
‐ Briefly recap history and investigations so far
‐ Break the bad news using lay person terms
‐ Give the patient a plan of what will happen next
‐ Ascertain if she has any questions and deal with these appropriately
‐ Offer to speak to her family
‐ Arrange follow up
Hidden Agendas
This station is not about knowing all about laryngeal cancer. The focus of the
consultation is likely to be about breaking bad news and dealing with the patient’s
reaction. Patients may deal with bad news in a number of different ways – they may
become very upset, angry or may be in denial. They may already have fears about cancer
due to family history or personal experience or may have been doing their own internet
research.
‐ Prepare the environment appropriately i.e., no barriers between yourself and the
patient, tissues on hand, give your bleep to someone else
‐ Take a nurse with you and ask the patient if they would like their partner or a family
member to be present
‐ Introduce yourself and the nurse
‐ Check the patients name
DOHNS Oral ‐ Breaking bad news
‐ Briefly recap the history‐ what symptoms she’s had, when they started etc and recap the
investigations performed so far
‐ Discuss the patient’s ideas about what the problem might be and her concerns (she may
volunteer that she is worried about cancer)
‐ Give a warning shot that you have bad news
‐ Empathically break the news of her cancer using lay person terms
‐ Give her time for the diagnosis to sink in and to react
‐ Give the patient time to ask questions
Advise her on:
‐ Treatment options
‐ Support available for her and her family
‐ Establish if the patient wishes to inform her family or if she would like you to do so
‐ It may be helpful to offer written information or contact with a specialist support service
e.g., Head and Neck Specialist nurse
‐ Ensure the patient goes away with a clear plan of what will happen next
‐ Ensure the patient has a follow up appointment and knows whom to contact if they have
any questions/concerns.
 FNAC of this elderly gentleman’s thyroid nodule has come back as Anaplastic
carcinoma. Explain the diagnosis and address any concerns he may have
 Following pharyngoscopy and oesophagoscopy for odynophagia and aspiration,
explain to the patient that the biopsy from their hypertrophied right piriform fossa has
come back as poorly differentiated squamous cell carcinoma.
 Explain to this patient with a neck lump that FNAC contains poorly differentiated
carcinoma. Explain the diagnosis and further management, address any concerns they
may have.
OSCE Examinations DOHNS
SECTION Three:
Appendices
DOHNS
OSCE Examinations DOHNS
17. OSCE Examinations
Listed below are recommended structures for the commonly occurring examination stations.
It is recommended that candidates practice summarising their findings, though it has not been
a required step in recent DOHNS OSCEs.
Ear
1. Introduction
2. Consent
3. Test otoscope (ensure speculum is clean)
4. Inspection: external ear, canal and tympanic membrane
5. Tuning fork testing (512Hz)
6. Free field testing
7. Fistula sign
8. Facial nerve assessment (check if required)
9. Special tests for vertigo (check if required)
Neck
1. Introduction
2. Consent and exposure to level of clavicles
3. Inspection (swallowing and tongue protrusion for obvious midline lesions)
4. Palpation (systematic, recommended starting‐point: tail of parotid, commonly forgotten)
Flexible Nasendoscopy
1. Introduction
2. Consent
3. Local anaesthetic
4. Systematic endoscopic examination, whilst talking to actor
(i) Nasal cavity
(ii) Post‐nasal space (including fossae of Rosenmüller)
(iii) Oropharynx (tongue base and vallecula)
‐“Stick your tongue out”
(iv) Epiglottis and supraglottis
(v) Vocal cords, appearance and mobility
‐“Say Eeeee” (two pitches) or “Count to 5”
(vi) Piriform fossae
‐ Puff cheeks with nose held (warn patient first)
Observe for lesions and obvious asymmetry. Comment on any abnormality seen, stating its
anatomical location. Also note quality of mucosa and secretions.
DOHNS
Instrument gallery DOHNS
18. Instrument gallery
Head and Neck
Oesophagoscope and handle assembly showing fibre light inserted along internal groove and connection to
fibre optic lead from light source
Assorted Adult Oesophagoscopes (top to bottom: 50cm, 30cm, 20cm)
DOHNS Instrument gallery
Bronchoscope assembly and description of ports
(a) ventilation connection
(b) fibre‐optic connection (light source)
(c) suction connection (using fine plastic tubing via perforated rubber tip)
(d) viewing window and instrumentation port (sliding interchangeable port mounted). Note rubber
adaptor for Hopkin’s rod, instrumentation is via open aperture
Hopkin’s rod attachment to optical bronchoscopy forceps
(a) suction connection
(b) fibre optic connection (light source)
(c) sleeve in downward position locking Hopkin’s rod in place
Assorted Adult Bronchoscopes (top to bottom): Size 6.5, 7.5, 8.5); side vents distinguish
these from oesophagoscopes
Laryngoscopes; LEFT, Lindholm laryngoscope; RIGHT, anterior commissure laryngoscope
(C)
Other laryngoscopy items: (b) wet gauze or blue gum‐shield (gum/teeth
protection)
a) suspension and laryngoscope attachment
(c) laryngeal suction
Close‐up of tip Close‐up of tip Close‐up of tip
Laryngeal instruments

(a) laryngeal grasping forceps; angled to the left

(b) laryngeal scissors; angled upwards

(c) laryngeal cupped biopsy forceps; straight
Commonly used retractors

(a) Volkmann retractor (large)
(b) Volkmann retractor (small)
(c) Kilner retractor
(d) Langenback retractor (small)
(e) Langenback retractor (large)
MaGills forceps
Tracheal dilator Cuffless, non‐fenestrated tracheostomy tube
with introducer and inner tube
Otology
Auroscope
Assorted aural specula
Seigle’s pneumatic speculum 512Hz Tuning fork; longer decay than
higher frequencies, less vibratory
stimulus than lower frequencies
Barani box; effective for masking up to 100dBHL Myringotome, ends can be straight or angled
Graft press forceps Screw‐type vein press. Both used to prepare graft tissue in
otological procedures
Jobson Horne probe
Wax hook
Aural suction catheters Crocodile forceps, small and large
Rhinology
(C)
(a) (b)
(a) Thudicum’s speculum (b) Alar retractor (c) Killians speculum
Selection nasal speculae
Selection of FESS instruments:

(a) Large straight Blakesley forceps
(b) 90 degree Blakesley forceps
(c) 45 degree Blakesley forceps
(d) Backward punch
(e) Small straight Blakesley forceps
(f) Downward biter
(g) Round‐ended suction
(h) Antral probe
Rapid Rhino
nasal pack

Merocel nasal
pack
Items required for posterior packing in epistaxis
(a) Urinary catheter (female)
(b) 20ml syringe (inflate balloon of catheter with air)
(c) Vaseline gauze
(d) Tilley’s nasal packing forceps
(e) Gauze pads (protect alar cartilage)
(f) Umbilical clamp

Walshingham’s forceps; for manipulating
nasal bone fractures. Different forceps
for left and right side (note “L” and “R”
Tilley’s nasal packing forceps markings), plastic covered end applied to
skin surface of respective nasal bone
Tonsillectomy
Draffin rods
Boyle‐Davis gag with Daughty tongue depressor
Burkitts straight forceps
Mollisons pillar retractor
Curved negus forceps
Luc’ holding forceps Mollisons pillar retractor
Negus ligature pusher
Gwyn‐Evans dissector
Eve tonsil snare
Miscellaneous
Commonly used preparations:

(a) Otological creams and drops
(b) Proflavine cream: topical bacteriostatic disinfectant commonly used for packing post‐drainage of
pinna haematoma
(c) Ichthammol glycerin: used in aural packing in severe otitis externa. Ichthammol exhibits anti‐
inflammatory and mild antimicrobial effects, the hyperosmolar glycerin draws out oedema
(d) Naseptin cream: Peanut oil is a base, check allergy to peanuts and soya before use. Also contains
chlorhexidine (bactericidal) and neomycin (bacteriocidal)
(e) Bismuth Iodoform Paraffin Paste (BIPP) pack; Bismuth (bacteriostactic and bacteriocidal) Iodine
(Bacteriocidal). Commonly used as a pack after otological procedures and can be used as a nasal pack for
epistaxis.
Co‐phenylcaine: 5% Lidocaine Hydrochloride & 0.5%
Phenyephidrine Hydrochloride. Used topically to
prepare nasal mucosa
Silver nitrate cautery sticks. Nitric acid is
produced on contact with water, creating a
chemical burn
Dental syringe, commonly used with “Lignospan”
cartridges (2% Lignocaine and 1:80,000 Adrenaline)

DOHNS
19. Acknowledgements
 Clinical Images from:
Otolaryngology Houston: www.ghorayeb.com
 Current diagnosis and treatment in Otolaryngology‐Head and Neck Surgery. Lalwani A; et al
 Hand drawn vector images based on:
Grays Anatomy. 40th Edition, 2008. Churchill Livingstone, Elsevier Publications.
DOHNS
Index
THE DOHNS SYLLABUS IN RELATION TO PART 2 1‐3
Part one: 1
‐ Medical Practice publication 1
Part two: Clinical knowledge 1
Part three: Clinical competencies 2
SECTION ONE: Common Topics for DOHNS Part 2 5‐66
THE EAR 7‐16
Abnormalities of the pinna 14
‐Microtia 14
‐Protruding ears/Bat ears 14
‐External auditory canal atresia 14
‐Auricular haematoma 14
‐Auricular lacerations 14
Acute otitis media 10
‐ Non‐suppurative acute otitis media 10
‐ Suppurative acute otitis media 10
Acoustic neuroma 45
Cholesteatoma 12
‐Acquired 12
Primary acquired cholesteatoma 12
‐Secondary acquired cholesteatoma 12
‐ Congenital 12, 29, 42
Chronic suppurative otitis media 11
Herpes zoster oticus / Ramsey Hunt syndrome 9
‐ Oral glucocorticoids 9
Mastoiditis 11
Neoplasms of the external ear 14
‐Basal cell carcinoma (BCC) 14
‐Squamous cell carcinoma (SCC) 15
‐Melanoma 16
Otitis externa 8, 13,106
Otitis media with effusion/glue ear 9
Osteomas & exostoses of the externa auditory canal 13
Otosclerosis 13, 51
Perichondritis 8, 28
‐ Pseudomonas aeruginosa 8
Temporal bone fractures 15
‐Conductive hearing loss 15
‐Facial nerve paralysis 15
‐CSF leak 1, 73
Tympanic membrane 7, 10, 11, 30, 91
THE NOSE 17‐20
Antrochoanal nasal polyps 18
Nasopharyngeal carcinoma 19
‐Undifferentiated non‐keratinising squamous cell carcinoma 19
‐Differentiated keratinising squamous cell carcinoma 19
DOHNS
Nasal trauma 18
‐ Epistaxis 18, 4, 103, 106
‐ CSF leak 18
‐ Septal haematoma 19
‐ Saddle deformity 19
‐ Cosmetic deformity 19
THE MOUTH AND OROPHARYNX 21‐24
Glandular fever (infectious mononucleosis) 22
Oral cavity malignancy 22
Quinsy 22, 84
Tonsillitis 21, 73
THE LARYNX 25‐30
Benign 28, 32,45, 53
‐ Vocal cord nodules 28
‐ Vocal cord polyps 28
‐ Vocal cord granulomas 28
‐ Reinkes oedema 28
‐ Intracordal cyst 28
‐ Saccular cysts 29
‐ Laryngocele 29
‐ Laryngeal papillomatosis 29
Flexible Nasendoscopy 26
Innervation of the vocal cords 27
‐ Superior Laryngeal Nerve 27
‐ Recurrent Laryngeal Nerve 27
Laryngomalacia 30
Malignant 29
Vocal cord disease 28
Vocal cord palsy 30
OTHER COMMON DOHNS HEAD AND NECK PATHOLOGIES 31‐35
Bell’s palsy 34
‐ House‐Brackmann scale 34
Benign 32
‐ Acute viral inflammatory disease 32
‐ Acute suppurative sialadenitis 32
‐ Chronic granulomatous siladenitis 32
‐ Sialolithiasis 32
‐ Sjogren syndrome 33
‐ Pleomorphic adenoma 33
‐ Warthin’s tumour 33
Branchial cyst 31
Epiglottitis 31
Malignant 33
Pharyngeal pouch 33
Salivary gland disease 32
Thyroglossal cyst 32
THE THYROID 36‐40
Histology 37
‐ Classic symptoms and signs of thyroid dysfunction 38
‐ Blood results 38
Hyperthyroidism 38
st
Exam Revision Guide to DOHNS OSCE. Stew B (Editor). September 2012. 1 Edition. Doctors Academy Publications 112
DOHNS
‐Graves disease 38
‐Toxic thyroid adenoma 38
‐Toxic multinodular goitre 38
Hypothyroidism 39
‐Primary 39
‐Secondary 39
‐Tertiary 39
Supporting cell tumours 40
‐Medullary carcinoma 40
Thyroid neoplasia 39
‐Papillary adenocarcinoma 39
‐Follicular adenocarcinoma 39
‐Anaplastic adenocarcinoma 39
CRANIAL NERVES 41‐46
CNI: Olfactory 41
CNII: Optic 42
CNIII: Oculomotor 42
CNIV: Trochlear 42
CNV: Trigeminal 43
CNVI: Abducens 43
CNVII: Facial 44
CNVIII: Vestibulocochlear 44
CNIX: Glossopharyngeal 45
CNX: Vagus 45
CNXI: Accessory 45
CNXII: Hypoglossal 46
HEARING AND BALANCE 47‐54
Audiometry 47
Balance 53
‐ Disease 53
‐Labyrinthitis 54
‐Vestibular Neuronitis 54
‐Labyrinth 45, 54
Cochlear Implants 51
Hearing Aids 49
‐Histology of the cochlea 50
‐BAHA abutment seen 2 weeks post‐op 50
Masking 47
Air conduction audiometry 47
Bone conduction audiometry 47
‐ Air conduction audiometry 47
‐ Example audiograms 48
Symbols 49
Tympanometry 51
IMAGING 55‐65
Computerised tomography (CT) 55
Examples of where CT is used in ENT 57
Imaging Modalities 55
Larynx 26‐31, 45, 56
DOHNS
SECTION TWO: Communication skills for DOHNS Part 2 67‐88
Consent 69‐76
Oral ‐ Breaking bad news 87‐89
Oral – Information giving 77‐79
Oral – Taking a history 85‐86
Written – Operation note 81‐82
Written – Discharge summary 83‐84
SECTION Three: Appendices 89‐109
OSCE Examinations 91
Flexible Nasendoscopy 3, 26, 84, 91
Instrument gallery 93‐107
Head and Neck 93‐105
Miscellaneous 106‐107
Otology 2, 99
Rhinology 2, 101

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DOHNS

ISBN : 978‐93‐80573‐21‐2

Cover page Design : Sreekanth S.S

Type Setting : Lakshmi Sreekanth

AC : Air Conduction

ABNORMALITIES OF THE PINNA

a) – auricular requiring auricular reconstruc on.

a) Auricular haematoma – accumula n of blood in the subperichondral space secondary to

NEOPLASMS OF THE EXTERNAL EAR

CN: Name Sensory/Motor Foramina

I Olfactory Sensory Cribriform plate

II Optic Sensory Optic canal

III Oculomotor Motor Superior orbital fissure

IV Trochlear Motor Superior orbital fissure

V Trigeminal V2: Sensory V2: Foramen rotundum

VII Facial Both Internal acoustic meatus

VIII Vestibulocochlear Sensory Internal acoustic meatus

IX Glossopharyngeal Both Jugular foramen

X Vagus Both Jugular foramen

XI Accessory Motor Jugular foramen (sp)

XII Hypoglossal Motor Hypoglossal canal

Tonsillectomy – Relief from rec. tonsillitis – Pain

Grommet insertion – Improve hearing – Earache

Septoplasty ‐ Attempt to improve nasal ob‐ – Pain

Excision of neck – Diagnostic – Pain

Mastoid exploration ‐ Clear ear disease – Bleeding/haematoma

Submandibular – Diagnostic – Pain

Septorhinoplasty – Improve nasal obstruction – Pain

Ossiculoplasty ‐ Improve hearing – Bleeding

Close‐up of tip Close‐up of tip Close‐up of tip

(a) Thudicum’s speculum (b) Alar retractor (c) Killians speculum

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