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Your First ENT Job
A survivor's guide
Marie Lyons
ENT Registrar
North Thames Region
and
Arvind Singh
Specialist Registrar
Royal Marsden Hospital
Foreword by
Ram Dhillon
Consultant in Otolaryngology
Northwick Park Hospital, Harrow
Radcliffe Publishing
Oxford • Seattle
Radcliffe Publishing Ltd
18 Marcham Road
Abingdon
Oxon OX14 1AA
United Kingdom
www.radcliffe-oxford.com
Electronic catalogue and worldwide online ordering facility.
A catalogue record for this book is available from the British Library.
Foreword v
Preface vii
1 Ears 1
Basic anatomy 3
Questions you need to ask about ear problems 10
How to deal with ear problems 12
Preparing patients for ear surgery 31
Ear operations 32
2 Nose 43
Basic anatomy 45
Questions you need to ask about nasal problems 48
How to deal with nasal problems 48
Preparing patients for nasal surgery 54
Nasal operations 55
3 Throat 65
Basic anatomy 67
Questions you need to ask about throat problems 67
How to deal with throat problems 69
Throat/head and neck operations 87
lll
iv Contents
Glossary 107
Index 113
Foreword
v
vi Foreword
vii
viii Preface
one to ask at the time, leave the consent to someone more senior -
it will be less stressful for both you and your patient.
ENT is a great speciality with plenty of variety in the types of
patients and conditions that you treat. We hope you enjoy it.
Marie Lyons
Arvind Singh
September 2005
About the authors
ix
Marie Lyons
I would like to thank my husband Adam for all his help and
support when we were writing this book. He was a wonderful
unofficial editor, correcting my English and making the text
more reader friendly (even for a lay person). I couldn't have
done it without him. I would like to dedicate the book to my
lovely boy Thomas who was born two days after I submitted
the manuscript. He has certainly had early exposure to ENT!
Arvind Singh
I would like to thank my family for their immense support, and
in particular my wife for her patience and understanding
during all the late evenings spent working.
xi
Ears
1
1 Ears
Basic anatomy
The external ear consists of the pinna and the outer ear canal
(see Figure 1.1). The outer third of the ear canal is cartilaginous,
hair-bearing and wax-producing. It is also not particularly
sensitive, which makes it relatively easy to inspect with an
auroscope. The inner third is bony and exquisitely sensitive.
Push too deep into the bony ear canal and the patient will
certainly protest! The outer ear canal ends at the eardrum,
which in a healthy ear is a pale grey structure (see Figure 1.2).
The most obvious features are the handle of the malleus and
antero-inferiorly the cone of light (see below). When you are
shown a picture of the eardrum you can always identify which
side it is on by the direction in which the malleus is pointing. If
the eardrum is on the right side, the malleus will point
upwards and superiorly to the right from the middle of the
eardrum. If it is on the left side, the malleus will point to the left
(amaze your boss at quizzes!).
When looking at the eardrum you will see a cone of light.
This is the part of the drum that is perpendicular to the light
from the auroscope, and its position will change depending on
the health of the eardrum. In a healthy drum it lies antero-
inferiorly.
The eardrum is the lateral border of the middle ear, and some
middle ear structures can occasionally be seen through it. The
3
4 Your first ENT job
Facial nerve
The facial nerve is included in this section as its anatomy is
both complicated and intimately related to the middle and
inner ears. A knowledge of its anatomy will allow you to
determine whether an injury to the facial nerve (e.g. as a
result of a skull fracture) is likely to be temporary and the
various ways in which you can assess the level of injury.
Intracranial part
The facial nerve has mixed sensory, motor and secretomotor
fibres and special sense (taste) fibres. The facial nerve proper
contains motor fibres (supplying the muscles of facial expres-
sion), with the rest being included in the nervus intermedins
which accompanies the facial nerve for part of its course.
8 Your first ENT job
The facial nerve nucleus lies in the caudal part of the pons,
and it loops around the abducens nucleus in the floor of the
fourth ventricle. It emerges at the lower border of the pons with
the nervus intermedins, and both travel to the internal auditory
meatus along with the vestibulocochlear nerve. The facial nerve
enters its bony canal above the vestibule of the labyrinth. At the
first genu lies the geniculate ganglion, and the greater petrosal
nerve leaves the main facial nerve at this point to supply the
nasal and lacrimal glands. Taste fibres from the palate relay
impulses in the opposite direction. The facial nerve proper
turns posteriorly at this point, and the outline of its canal can be
seen between the promontory and the lateral semicircular canal
(see Figure 1.3). Some branches leave the nerve at this point and
join the tympanic plexus. The nerve eventually turns again, this
time inferiorly medial to the aditus ad antrum to reach the
stylomastoid foramen. The corda tympani leaves the facial
Ears 9
Extracranial part
Once it emerges from the stylomastoid foramen, the facial
nerve is embedded in parotid tissue. It usually divides into
upper and lower divisions and it has five terminal branches
(temporal, zygomatic, buccal, mandibular and cervical).
• Is the ear painful? If so, what is the nature and site of the
pain?
• Is the ear itchy?
• Is there discharge? If so, describe the amount, consistency,
colour and smell.
• Is there hearing loss?
• Is there tinnitus (noise in the ears, which can be subjective or
objective)? If so, what is its nature (constant/intermittent/
pulsatile)?
• Is there vertigo (an illusion of movement)?
Table 1.1 The meaning of the results of Rinne's test and Weber's test
the noise of the tuning fork and to report when the noise dies
away. The tuning fork is then placed 2 cm away from an
unobstructed ear canal (see Figure 1.7) and the patient is
asked whether they can still hear it (this tests air conduction).
(A normal positive result occurs when air conduction is better
than bone conduction.)
Weber's test is used to determine whether there is better
hearing in one ear than in the other. A resonating tuning fork is
placed on the midline of the forehead and the patient is asked
first whether they can hear the tone, and secondly whether they
can hear it better on one side. A normal result occurs when the
tone can be heard equally well on both sides.
Trauma
This can be sharp or blunt. Your first priority is always
maintenance of a safe Airway, ensuring that the patient is
Breathing and taking steps to maintain the Circulation. Ascer-
tain the mechanism of injury (remember that head injuries take
priority, as these are much more likely to be fatal).
Ears 13
Inspect the ear and its surroundings. Examine the outer ear
canal, and also examine the facial nerve and document its
function.
Blunt injury
Pre-auricular sinus
• The ear develops from six hillocks of mesenchyme, so it is
not surprising that congenital abnormalities occur. One of
the commonest is a pre-auricular sinus where two of the
hillocks do not fuse properly. It is visible as a small pit in
front of the superior part of the helix.
• Nothing needs to be done about a pre-auricular sinus unless
it becomes infected. If it is merely red with no abscess then it
may settle with antibiotics, but an appointment must be
made to review the patient.
• If there is an abscess, the patient will require incision and
drainage.
16 Your first ENT job
Ports
Railways
While the Chilians have always cultivated a taste for the sea, for
strategical more than commercial reasons railway construction has
of late been strongly favored. In this medium of traffic Chile in
proportion to her area is far ahead of the other West Coast countries.
It is true that the difficulties of topography are less. The oldest
existing line in Latin America was here constructed in 1849 by a
Bostonian, William Wheelright, who later founded the Pacific Steam
Navigation Company, the earliest giving regular steamship service to
Europe from the West Coast. This first railway line was from the port
Caldera to the mining town Copiapó. The line from Valparaiso to
Santiago, also constructed by Americans, was finished in 1863.
Government ownership is popular in Chile, and of the 8000 miles of
road in operation the State owns over 5000, with considerable
extensions planned. Unfortunately six different gauges have been
used, varying from 2 feet 6 inches on the Antofagasta Bolivia Line to
5 feet 6 inches on the Central Railway.
The Central Railway. This is a Government Line connecting
Valparaiso with the capital Santiago, express trains with American
parlor cars making the run of 117 miles in four hours. The road is
now to be electrified. South along the rich Central Valley, the same
Railway runs through sleeping cars to Valdivia and to Puerto Montt,
the latter city 750 miles from Santiago. This section is well worth a
visit, whether from a scenic or a business point of view. A bridge
1400 feet long and 300 above the bed of the Malleco River cost over
$1,000,000.
There are many branches from the main line, some of these
privately owned; most of them to coast ports, a few towards the
Cordillera. Valdivia is the most southern ocean port to which a
branch extends. Farther north, the third city of Chile, Concepción, is
favored, and Talcahuano near by. From Concepción a coast road
leads south to Lota, Coronel, and beyond. From Talca a line goes to
Constitución, of some importance for agriculture, shipyards, and gold
mining. Another branch goes to the port Pichilemu; from Santiago
one extends 72 miles to the port San Antonio, nearer the capital than
is Valparaiso but a secondary port to be improved by the building of
docks. The Central Railway obviously forms a very important part of
the real longitudinal railway, but the section which has the name
Longitudinal begins farther north.
The South Longitudinal. From Calera on the Valparaiso-Santiago
Railway a branch leads 45 miles to Cabildo, where begins the
Longitudinal proper. This because of construction difficulties is of
narrow gauge, one metre. On account of poor equipment and
service, and the competition of steamship lines along the coast, its
traffic is at present small; but with better facilities and increase of
population it will be of much value. At last accounts there was weekly
service to Antofagasta with two changes of cars, not counting the
one from Valparaiso or Santiago in order to reach Cabildo. Here,
three hours from Santiago, the South Longitudinal is taken to the city
of Copiapó; for the Longitudinal has two sections. The ride is through
a fairly pleasant country with varied scenery, the region being partly
agricultural and partly mineral. In this section are heavy grades,
rising to 6 per cent, requiring 28 miles of the rack system. Branches
or other connecting lines here and there reach the sea. The road
passes through the important port Coquimbo, and the adjoining
Serena, at which point, 200 miles from Valparaiso, the desert land
begins; though in river valleys there is still some verdure. From
Vallenar on the main line a branch runs 31 miles to the port Huasco.
A private line from the port Carrizal, 92 miles north of Huasco and 73
south of Caldera, crosses the Longitudinal. At Copiapó we come to
the old line from Caldera, a fairly good port, shipping copper and
doing considerable other business, though not a port of the first
class. A branch in the other direction extends to San Antonio.
The North Longitudinal. At Copiapó we change to the North
Longitudinal from which there is a branch to Chañaral, about 50
miles north of Caldera, on a large but exposed bay in one of the
richest mineral districts of Atacama, with large smelting works, and
exporting gold, silver, and copper. A private (British) railway system
of 184 miles, crossing the Longitudinal, serves a nitrate district and
the port of Taltal, 100 miles south of Antofagasta; a primary port on a
well protected bay, with piers fitted with steam cranes, a centre of the
nitrate and copper industries. Taltal is a modern town with important
business houses. Besides gold, silver, and copper, the Province has
some undeveloped nitrate land.
Farther on at Aguas Blancas, a railway belonging to the Bolivia-
Antofagasta Company runs to Caleta Coloso, a port six miles south
of Antofagasta and connected by rail with that city as well as with
various nitrate properties. Farther still the Longitudinal crosses the
Antofagasta-Bolivia Railway at Baquedano, where some traffic is
exchanged. It is the intention of the Government to construct its own
line to Antofagasta and to the port of Mejillones some miles north.
Beyond this crossing, from Toco on the Longitudinal, the Anglo-
Chilian Nitrate and Railway Company’s Line branches to the port of
Tocopilla. At last Pintados, the one time terminus is reached, where
connection is made with the Nitrate Railways, which go on to Iquique
and Pisagua. But in spite of this the Government Line is now being
prolonged to the former city. It is intended ultimately to extend the
main line to Arica, 175 miles farther, a section likely to be
unprofitable commercially but desired for other reasons. From Arica
there is a railway to Tacna, near the Peruvian border, hence on
completion of this section there would be through rail service from
near the northern border to Puerto Montt in the far south, a primary
port on the Gulf of Reloncavi. The length of the road from Puerto
Montt to Jazpampa the present terminus, east of Pisagua, is 1902
miles; to Taratá, the most northern town in the mountains, the
distance is 207 miles more.
The Antofagasta-Bolivia Railway. The Bolivian section of the
important Antofagasta Railway has already been referred to. That in
Chile deserves further consideration. British owned, like most of the
Chilian railways not belonging to the State, it is the longest and most
important of these. Although uncommonly narrow with a 2 foot 6 inch
gauge, the sleeping cars are more comfortable than some with
double the width. The road operates 835 miles of main track to La
Paz, 518 of these in Chile. There is semi-weekly service to La Paz in
practically two days, besides local trains. One thousand, two
hundred and fifty miles of track are controlled by the Company. The
climb begins at once, the road in 18 miles getting 1800 feet above
the sea. At km. 36 a branch 70 miles long goes to the Boquete
Nitrate Fields, altitude 5622 feet. At Prat, km. 59, a branch goes
down to Mejillones, a new port, opened by the Company in 1906,
called the finest harbor on the coast, capable of holding the fleets of
the world (it was said when these were smaller) and so protected
that shipping suffers no inconvenience from bad weather. Tocopilla,
37 miles north of Antofagasta, has direct rail connection with that city
by a line 43 miles long. The main Antofagasta line, crossing the
Longitudinal at km. 96, at km. 116 enters the principal nitrate district
of this region and leaves it 35 miles beyond. In this section are 24
oficinas, as the nitrate plants are called, some of them models of
their kind.
Going in either direction this part is traversed at night; otherwise
one might be refreshed by the sight of a little green at Calama, 149
miles from Antofagasta, at six a.m. This was a copper mining centre
in Inca days and a smelter is here now. At this altitude some persons
stop a day, a good plan if one is not sure of his heart; though oxygen
is now carried for use in emergency. At km. 254 is a short branch, 6
miles, to Chuquicamata, to be referred to later. Just beyond the
Conchi station is a graceful viaduct with six lattice girder spans of 80
feet each, supported on steel trestle towers. This, called the highest
viaduct in the world, is 336 feet above the water of the Rio Loa, at an
altitude of nearly 10,000 feet. Here a branch line runs to the copper
mines of Conchi Viejo. At San Pedro station, 195 miles, at 10,600
feet altitude, are reservoirs blasted from the solid rock, on which the
Company spent $6,000,000 to supply Antofagasta, the nitrate fields,
and the railway with water. The water comes from three different
places, one of them 37 miles northeast and 14,500 feet above the
sea: this source capable of supplying 6000 tons of water daily
through 11-inch pipes.
The road now passes two snow capped volcanoes, from one of
which smoke may be rising, and crosses a stream of lava one-third
of a mile wide and several miles long, to the summit of the main line,
13,000 feet. Soon after, a borax lake belonging to a British company
may be seen; 24 miles long, it is the largest single deposit in the
world and the chief source of the world’s supply. At Ollague, where
snow storms occasionally impede traffic, is a branch to the rich
copper mines at Collahuasi. The Bolivian frontier is soon afterward
crossed, and at Uyuni a change is made to the broader gauge line to
La Paz.
The Trans-Andine Railway. Of all the railroads of Chile, the
Trans-Andine is naturally the most famous, as a part of the only
trans-continental railway south of Panama; but financially, as yet it is
hardly a success. With post-war increase of traffic, there will
doubtless be an improvement. The Trans-Andine section of metre
gauge begins at Los Andes, altitude 2723 feet, 88 miles from
Valparaiso. A change is here made from the State Line, 5.5-foot
gauge. It is a distance of 43 miles to the tunnel, a steep climb up the
Aconcagua River Valley, with a maximum grade of 8 per cent; 20
miles of rack railway are employed. There are 25 tunnels, and on the
Aconcagua River or its branches, 118 bridges. The scenery is wild
and the journey delightful. Sheds have been erected against snow
and land slides. Up to 1916 the road was closed for several months
each winter; but with an increase of sheds and with a force of men
continually digging, the road was kept open through the years 1916,
’17 and ’18; it was seriously blocked in July, 1919. While previously
passenger traffic was the more remunerative, in 1916 unusual efforts
were made for the benefit of important freight which it was
impossible to ship by sea.
The tunnel is at a height of 10,486 feet, its length is 10,385 feet,
each practically two miles. The boundary line is near the middle,
each country building to that point; but the whole is operated as one
line from Los Andes to Mendoza. The line was opened in the
Centennial year, April 16, 1910, in time for the Exposition at Buenos
Aires. The cost of the Chilian section was about $15,000,000.
Operation is at a loss, interest being paid by the Government. The
capitalization is $317,000 a mile. Fifteen Trans-Andine projects have
been put forward, most of them for the south, one from near Puerto
Montt. One in construction is from Talcahuano to Bahia Blanca by
way of Temuco. A road from Punta Arenas to the Loreto coal fields is
the most southern railway in the world, as that is the most southern
city. The early construction is expected of an important road at the
north from Salta in Argentina by Huaytiquina on the border to
Antofagasta. Of wagon roads there are said to be 20,000 miles.
The Arica-La Paz Railway is described on page 222.
CHAPTER XXXII
CHILE: RESOURCES AND INDUSTRIES
Mining
Agriculture
Forestry
Stock Raising
Manufacturing
Investments
Activities in Chile in the immediate future for which about
$15,000,000 have been appropriated by the Government include
work or equipment on railways, roads, bridges, barracks,
waterworks, sewer systems, building construction, and port works.
These furnish opportunities to which many others may be added.
The possibilities in agriculture, fruit raising and canning are obvious;
those in fisheries, saw mills and lumber, development of water
power, in factories of various kinds may be noted, as well as for large
capitalists in mining. A $10,000,000 contract for the electrification
and equipment of four zones of the Government railways has been
concluded with a combination of several American interests.
THE EAST COAST