Diagnosis in Otorhinolaryngology Illustrated Guide PDF (2021)

T. Metin Önerci Zeynep Önerci Altunay Diagnosis in Otorhinolaryngology An Illustrated Guide Second Edition 123 T. Metin Önerci Zeynep Önerci Altunay Diagnosis in Otorhinolaryngology  T. Metin Önerci Zeynep Önerci Altunay Diagnosis in Otorhinolaryngology Wit...

T. Metin Önerci Zeynep Önerci Altunay Diagnosis in Otorhinolaryngology An Illustrated Guide Second Edition 123 T. Metin Önerci Zeynep Önerci Altunay Diagnosis in Otorhinolaryngology  T. Metin Önerci Zeynep Önerci Altunay Diagnosis in Otorhinolaryngology With 558 Figures and 74 Tables Second Edition T. Metin Önerci Zeynep Önerci Altunay Department of Otorhinolaryngology Department of Otorhinolaryngology Hacettepe University Faculty of Medicine University of Health Sciences Ankara Haseki Training and Research Hospital Turkey İstanbul Turkey ISBN 978-3-030-64037-8    ISBN 978-3-030-64038-5 (eBook) https://doi.org/10.1007/978-3-030-64038-5 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 This work is subject to copyright. 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This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Contents Chapter 1 Ear 2.5 Sinusitis 101 2.6 Complications of Sinusitis 110 1.1 Ear Anatomy 3 2.7 Nasal Polyposis 119 1.2 Vestibular Anatomy 12 2.8 Nasal Obstruction 125 1.3 ENT Examination 17 2.9 Septum 131 1.4 The Pinna 24 2.10 Epistaxis 136 1.5 External Ear Canal 28 2.11 Traumas 140 1.6 Otitis Media with Effusion 35 2.12 Nasolacrimal Obstructions 149 1.7 Acute Otitis Media 39 2.13 Optic Neuropathy 156 1.8 Chronic Otitis Media 45 2.14 Tumors 160 1.9 Facial Nerve Paralysis 55 1.10 Complications of Otitis Media 61 1.11 Hearing Loss 63 Chapter 3 Throat and Neck 1.12 Otalgia 69 1.13 Temporal Bone Fractures 71 3.1 Acute Tonsillopharyngitis 176 1.14 Tinnitus 73 3.2 Adenoids 180 1.15 Vertigo 75 3.3 Snoring 183 1.16 Eustachian Tube 82 3.4 Temporomandibular Joint 194 3.5 Airway Obstructions 196 3.6 Hoarseness 200 Chapter 2 Nose 3.7 Larynx CA 207 3.8 Cysts 213 2.1 The Common Cold and the Flu 86 3.9 Salivary Gland Tumors 216 2.2 Rhinitis 88 3.10 Oral Cavity 220 2.3 Allergic Rhinitis 93 3.11 Neck Masses 228 2.4 Nasal Vestibulitis, Nasal Furunculosis and 3.12 Neck Malignancies 237 Mucormycosis 97 v  Chapter 1 EAR CO N T E N T S  1.1 Ear Anatomy 3  1.2 Vestibular Anatomy 12  1.3 ENT Examination 17 1.4 The Pinna 24  1.5 External Ear Canal 28  1.6 Otitis Media with Effusion 35  1.7 Acute Otitis Media 39  1.8 Chronic Otitis Media 45  1.9 Facial Nerve Paralysis 55 1.10 Complications of Otitis Media 61  1.11 Hearing Loss 63 1.12 Otalgia 69  1.13 Temporal Bone Fractures 71  1.14 Tinnitus 73  1.15 Vertigo 75  1.16 Eustachian Tube 82 © The Author(s), under exclusive license to Springer Nature 1 Switzerland AG 2021 T. M. Önerci, Z. Önerci Altunay, Diagnosis in Otorhinolaryngology, https://doi.org/10.1007/978-3-030-64038-5_1 2 Chapter 1 Ear  1.1 Ear Anatomy 3 1.1 covered by skin. The shape of the cartilage is very impor- EAR tant since it gives the shape of the auricle. Any necrosis of Ear Anatomy the cartilage may lead to cosmetic deformity. The external auditory canal measures approximately 25 cm. The outer one-third is cartilaginous and the inner two-thirds is bony. The ear is divided into three compartments: external, There is a narrowing at the bone–cartilage junction which NOSE middle, and inner. The pinna is composed of cartilage causes foreign bodies to get stuck in this area. The skin of a c d T H R O AT AND NECK b Fig. 1.1.1 (a) The ear is divided into three compartments: external, part of the ear) into the auditory canal (pink) toward the eardrum. middle, and inner. The pinna is composed of cartilage covered by The eardrum transmits the vibrations to three tiny bones—the mal- skin. The shape of the cartilage is very important since it gives the leus, incus, and stapes—in the middle ear. The stapes passes the shape of the auricle. Any necrosis of the cartilage may lead to cos- vibrations to the inner ear structures (purple), the semicircular canals metic deformity. The external auditory canal measures approxi- and the cochlea (spiral). Auditory sensations are picked up by the mately 2.5 cm. The outer one-third is cartilaginous and the inner cochlear nerve (yellow) and transmitted to the medulla (brainstem), two-thirds is bony. There is a narrowing at the bone–cartilage junc- the thalamus, and ultimately the cerebral cortex (visual photos). tion which causes foreign bodies to get stuck in this area. The skin of (c, d) The external and middle ear develop from the branchial appa- the bony part is very thin lying on the periosteum and does not con- ratus. The middle ear cavity is derived from the endodermal first tain glands, hair follicles, and any adnexal structures. There are two or branchial cleft. The inner ear develops from the otic placode. The first three fissures in the cartilaginous external auditory canal which are arch, or Meckel’s cartilage, contributes to the malleus and the incus. called “Santorini fissures.” These fissures provide a potential route for The tensor tympani muscle derives from the first branchial arch and the spread of infection from the external ear to the parotid area or is innervated by the nerve of the first branchial arch, which is the infratemporal fossa and also of tumors from the parotid area to the mandibular branch of the trigeminal nerve. The second branchial external ear. The Eustachian tube connects the middle ear to the arch, or Reichert’s cartilage, contributes to the suprastructure of the nasopharynx. The posterior one-third of the adult Eustachian tube is stapes. The stapes muscle is innervated by a facial nerve, which is the bony and lies within the petrous portion of the temporal bone. The nerve of the second branchial arch. The chorda tympani nerve, a anterior two-thirds is cartilaginous. In adults, the tube lies at an angle branch of the facial nerve (second arch nerve), joins the first arch of 45° in relation to the horizontal plane, whereas this inclination is nerve to the mandibular lingual nerve. The footplate of the stapes is only 10° in infants. The tube is longer in the adult than in the infant derived from the otic capsule. Thus, a congenital abnormality can and young child. (b) Illustration showing the organs of hearing and occur in one part while the other parts may develop normally the cerebellum. Sound waves are channeled by the pinna (visible 4 Chapter 1 Ear a Helix Fossa triangularis Cymba concha Antihelix Scafa Tragus Cavum concha Antitragus b Fig. 1.1.2 The anatomy of the auricle Light cone c Fig. 1.1.4 (a, b) The tympanic membrane is elliptical and slightly Fig. 1.1.3 The external auditory canal is not straight. To see the tym- conical in shape. The apex of this cone, the umbo, marks the inferior panic membrane, the ear canal should be straightened by pulling the part of the manubrium. The diameter of the tympanic membrane auricle posteriorly and superiorly in adults (but inferiorly in infants) measures approximately 9 mm (9–10 vertical; 8–9 horizontal). The surface area is 85–90 mm2. The tympanic membrane is composed of three layers: an outer epidermal layer, an inner mucosal layer, and a middle fibrous layer. The area above the short process of the malleus the bony part is very thin lying on the periosteum and is known as pars flaccida and the area below as pars tensa. The pars does not contain glands, hair follicles, and any adnexal flaccida does not have a middle fibrous layer therefore it is flaccid. structures. There are two or three fissures in the cartilagi- The pars tensa thickens peripherally forming the tympanic annulus. The tympanic annulus does not exist superiorly around the pars flac- nous external auditory canal which are called “Santorini cida. There is a light triangle in the anterior–inferior quadrant of the fissures.” These fissures provide a potential route for the tympanic membrane. The position of this triangle changes superiorly spread of infection from the external ear to the parotid and becomes shorter when the tympanic membrane is retracted. area or infratemporal fossa and also of tumors from the (c) Endoscopic view of left tympanic membrane (A pars flaccida, B posterior malleolar fold, C chorda tympani, D pars tensa, E fibrous parotid area to the external ear. anulus, F light cone, G umbo, H manubri­um mallei, I -short process of malleus, K -anterior malleolar fold)  1.1 Ear Anatomy 5 EAR NOSE T H R O AT AND NECK Fig. 1.1.5 Three smallest bones in the human body responsible for conduction of sound waves in the middle ear. At the top right is the Fig. 1.1.6 Due to the differences in the physical properties of air and malleus (hammer), which strikes the incus (anvil—left of malleus); water, sound vibrations in the air are largely reflected away from the the incus is joined to the stapes (stirrups), which conducts sound surface of the water (99.9% of the energy of air-borne sound is toward the inner ear. Sound waves enter the ear through the external reflected away), with only 0.1% entering the water. Although the sur- auditory meatus and cause the eardrum to vibrate. Vibrations from face area of the tympanic membrane is 85–90 mm2, the effective the eardrum are passed to the malleus and then the stapes via the vibrating area of the tympanic membrane is 55 mm2. The surface area incus. The stapes transmits the vibrations to the fluid-filled cochlea of of the footplate is 3.2 mm2. The ratio of the surface areas of the tym- the inner ear where the vibrations are converted to nerve impulses. panic membrane and the footplate is 55/3.2 = 17.1. This represents Lever effect: the manubrium mallei is 1.3 times longer than the long the hydraulic ratio of the tympanic membrane and stapes footplate, process of the incus. This difference in the lengths of the manubrium producing an increased force at the oval window of 17 times for the mallei and long process of the incus contributes a lever factor of 1.3 human ear since the sound pressure level is equal to the force divided to increase the intensity of the sound (visual photos) (With kind per- by the surface area (P = F/a). The final transformer ratio of the human mission of TESAV) tympanic membrane and ossicular chain is the product of the lever ratio of 1.3 times the hydraulic ratio of 17, which equals 22. This gain compensates the loss due to the air-bone difference Incus Fulcrum Rotation axis Malleus PV Stapes AFP Piston L Stapes suprastructure ATM U PEC TM Piston Rotation axis Fig. 1.1.7 The lever effect of the ossicular chain is of 1.3 to 1 6 Chapter 1 Ear elasticity of the tympanic membrane is also important in creating this phase difference. After the maximum inward movement of the tympanic membrane with a maximum compression of air, the tympanic membrane begins to move outward pulling the stapes footplate with it, whereas the round window is still being pushed inward by the PS compressed air due to the elasticity of the tympanic mem- Ossicular pairing brane providing the phase difference at the two windows necessary for optimum hearing. Due to this phase lag the sound waves reach the round window membrane a little ∆P Acoustic pairing later (x of sound waves length), but in the same phase with the oval window, and strengthen rather than cancel the movements of the cochlear fluid volume. In the perforated ear, the mechanism changes. Since the transformer ratio is normal with a small perforation and intact ossicular chain, the canceling effect will be minimal. If the perforation enlarges and the transformer ratio diminishes the canceling effect of the sound on the Fig. 1.1.8 The round window in the normal ear acts as a relief open- unprotected round window rises and creates 40–45 dB ing at the opposite end of the cochlear perilymphatic duct from the loss. However, if the ossicular chain is interrupted behind stapes footplate an intact tympanic membrane, the loss rises to 60–65 dB since there is no sound pressure transformation for the The sounds produced in the air above the water is oval window and both windows lie behind sound reflected away from the surface of water due to the differ- protection. ent acoustic properties of air and water; 99.9% of the The ideal tympanoplasty operation should restore energy is lost and only 0.1% enters the water. The same is both the sound protection for the round window by con- also valid for the inner ear. The sound waves enter the structing a closed and air containing middle ear and inner ear, a fluid media, from the air. To compensate this, rebuild the sound pressure transformation mechanism an apparatus was necessary to transform air-borne sound for the oval window. That means a tympanic membrane vibrations of large amplitude but small force to a fluid- repair which creates a middle ear cavity lined with mucosa borne sound vibrations of small amplitude but large force. containing air and creating a conduction system between There are two mechanisms to compensate this loss. the tympanic membrane and the oval window. 1. A hydraulic system (with a rather large hydraulic ratio) of large tympanic membrane acting on the small stapes footplate 2. A leverage system (with a rather small lever ratio) of the Inner Ear longer handle of the malleus acting on the slightly shorter long process of the incus The membranous labyrinth is filled with endolymph and The effective vibrating surface of the tympanic membrane has three main parts: three semicircular canals (superior, area compared with the stapes footplate area is of 17 to 1. posterior, horizontal), two otholithic organs (saccule and The lever effect of the ossicular chain is of 1.3 to 1. The 17 utricle), and cochlear duct. The saccule is connected to hydraulic ratio times 1.3 lever ratio yields a total increase of ductus cochlearis by a small narrow duct called ductus pressure at the oval window 22 times. This is termed the reuniens. One duct from utricle and one duct from saccule sound pressure transformer ratio of the normal ear. This 22 join and form the endolymphatic duct which lies in the times increase of pressure equals 26.8 dB which compen- bony aqueduct of the vestibule. The sac has an intraosse- sates the loss. ous portion and a more distal intradural portion. There is The round window in the normal ear acts as a relief a small narrow bony canal in the bony labyrinth of the opening at the opposite end of the cochlear perilymphatic petrous temporal bone called the cochlear aqueduct. It duct from the stapes footplate. The round window mem- contains the perilymphatic duct which arises from the brane movements are largely passive in response to stapes scala tympani of the cochlea draining perilymph into the footplate movements. Moreover, the shielding effect of cerebrospinal fluid in the posterior cranial fossa near the the intact tympanic membrane protects the round win- lateral margin of the jugular foramen. dow from the direct impact of sound and also creates a The cochlea is made up of three canals wrapped phase lag due to both the position of the round window around a bony axis, the modiolus. These canals are the and the elasticity of the intact tympanic membrane. The scala tympani, the scala vestibuli, and the scala media (or  1.1 Ear Anatomy 7 EAR a b NOSE T H R O AT AND NECK c Fig. 1.1.9 (a–c) The temporal bone contains the ear. It has five parts: sure, petrosquamous suture, tympanosquamous suture, tympano- the bony external ear canal, the styloid process, the squamous por- mastoid suture, etc. The mastoid process is not present at birth, tion, the petrous portion, and the mastoid process. There are suture which makes the facial nerve very superficial lines between these various portions such as the petrotympanic fis- Fig. 1.1.11 Left middle ear the relationship of promontorium with Fig. 1.1.10 Left middle ear endoscopic view. I inkus, FS facial nerve, sinüs tympani. P promontorium, YPN round window niche, ST sinüs StT stapes tendon, PE pyramidal eminence, Pt ponticulus, FR facial tympani, S subiculum, Pt ponticulus, YPM round window membrane recess, ST sinüs timpani, S subiculum, YP round window, F funiculus (Courtesy of Ali Özdek) (Courtesy of Ali Özdek) 8 Chapter 1 Ear a a b b c Fig. 1.1.13 Epitympanum, ligaments and folds. (a) superior view, s stapes, cp cochleariform proces, ma malleus, in incus, pil lateral ve medial posterior incudal ligaments, tf tensör fold, mlf lateral malleo- Fig. 1.1.12 (a) Left middle ear, isthmus regions. M malleus, I inkus, PI lar fold, imlf lateral inkudomalleolar fold, is isthmus, pe pyramidal posterior isthmus, AI anterior isthmus, KP kokleariform proses eminence. (b) Lateral view, m malleus, i incus, P Prussak space, 1 ante- (Courtesy of Ali Özdek). (b) Left middle ear mezotympanium rior malleolar ligament, 2 posterior malleolar fold, 3 superior (Ö Eustachian orifice, PF pars flaccida, M malleus, İ inkus, KT chorda incudal fold tympani, ST stapes tendon, P promontorium, AF anulus fibrozis and tympanic sulkus). (c) Left middle ear tympanic segment of the facial nerve (M malleus, İ inkus, FS facial nerve, PE pyramidal eminence, StT stapes tendon)  1.1 Ear Anatomy 9 EAR a b NOSE T H R O AT AND NECK Fig. 1.1.14 Left ear, antrum is opened. (a) The instrument shows the sinodural angle, arrow digastric ridge. MFD middle fossa dura, SS sigmoid sinüs. (b) Left antrum. DKK external ear canal, lssk lateral semicircular canal, I incus, M malleus, OFD middle fossa dura (With kind permission of TESAV) Fig. 1.1.15 Left ear, Körner septum. KS Körner septum, DKK external ear canal, lssk lateral semicircular canal (With kind permission of TESAV) Fig. 1.1.17 Right temporal bone, Trautman triangle between supe- rior petrosal sinüs, posterior semicircular canal, and sigmoid sinus. SS sigmoid sinüs, pssk posterior semicircular canal, OFD middle fossa dura, SPS superior petrosal sinüs, DKK external ear canal, DR digastric ridge (With kind permission of TESAV) Fig. 1.1.16 Left ear antrum is opened, the instrument shows incudo- malleolar joint in the attic area. Posterior tympanotomy performed (arrow), stapes head (star), in the inferior part of posterior tympanot- omy round window niche is seen (With kind permission of TESAV) Fig. 1.1.18 The inner ear comprises the cochlea and the labyrinth. The labyrinth consists of three semicircular canals (superior, posterior, and lateral) and two otolithic organs (utricle and saccule). The utricu- lar duct and the saccular duct join to form the endolymphatic duct 10 Chapter 1 Ear Dura mater Subarachnoid space (CSF) Scala vestibuli Sac Cochlear aqueduct Endolymphatic duct Scala media Scala tympani Endolumph Perilymph Fig. 1.1.20 The cochlea is made up of three canals wrapped around a bony axis, the modiolus. These canals are: the scala tympani, the scala vestibuli, and the scala media (or cochlear duct) Fig. 1.1.19 The connections of the cochlear duct cochlear duct). The cochlear duct has 2½ spiral turns around the modiolus. The cochlear duct (or scala media) is an endolymph filled cavity inside the cochlea, located between the tympanic duct and the vestibular duct. It is separated from scala tympani by the basilar membrane, and from scala vestibuli by Reissner’s membrane (the ves- tibular membrane). The cochlear duct houses the organ of Corti. The organ of Corti rests on the basilar mem- brane. The cochlea interacts with the middle ear via two holes that are closed by membranes: the oval window, which is located at the base of the scala vestibuli and which undergoes pressure from the stapes and the round window, which seals the base of the tympanic membrane and is used to relieve pressure. The triangular scala media, situated between the scala vestibuli and tympani is filled with endolymph, whereas Fig. 1.1.21 The cochlea has three fluid-filled compartments: the scala tympani, the scala vestibuli, and the scala media, which con- the scala tympani and vestibule are filled with perilymph tains the organ of Corti (Courtesy of Paparella, Paparella otopathol- and are linked by a small opening at the apex of the ogy lab director) cochlea called the helicotrema. The neural elements (shown in yellow) are the spiral ganglion neurons and the auditory nerve in the modiolar plane.  1.1 Ear Anatomy 11 EAR NOSE T H R O AT AND NECK Fig. 1.1.22 Sensory hair cells in the ear. Color SEM of hair cells in the This triggers a response in the hair cells, which release neurotrans- cochlea, the inner ear’s auditory sense organ. The crescent-shaped mitter chemicals that generate nerve impulses. The nerve impulses areas across the center are numerous stereocilia and are located on travel to the brain along the auditory nerve. This process can transmit top of supporting hair cells. Sound waves entering the inner ear dis- information about the loudness and pitch of a sound. Magnification: place the fluid that surrounds the stereocilia, causing them to bend. ×2000 when printed 10 cm wide (visual photos) Helicotrema Scala media Scala vestibuli Oval window Tectorial membrane Scala tympani Round window Fig. 1.1.23 The cochlea interacts with the middle ear via two holes the stapes and the round window, which seals the base of the scala that are closed by membranes: the oval window, which is located at tympani and is used to relieve pressure (With kind permission the base of the scala vestibuli and which undergoes pressure from of TESAV) 12 Chapter 1 Ear 1.2 posterior canals and make a bulge on the medial wall of aditus ad antrum. The semicircular canals are oriented at Vestibular Anatomy approximately right angles to each other. The superior semicircular canals are parallel to the posterior semicircu- lar canals of the other side. The three semicircular canals of the bony labyrinth are Each semicircular canal has an ampullated and non- named according to their position: superior, posterior, ampullated end. All semicircular canals ampullated and and horizontal. Horizontal semicircular canal makes a nonampullated ends open separately into the vestibule, 30° angle with the horizontal plane. Indeed they are con- except the nonampullated ends of the superior and the siderably more than a semicircle in circumference. The posterior semicircular canals which unite to form a com- superior and posterior canals are in diagonal vertical mon canal before opening into the vestibule. Therefore, planes that intersect at right angles. The superior canal three canals open by five openings into the vestibule. lies transverse to the long axis of the petrous bone and Receptors are located in the semicircular canals of the ear forms the arcuate eminence on the superior surface of the which provide input on rotatory movements (angular petrous bone. The posterior canal lies parallel to the pos- acceleration), and in the utricle and saccule, which gener- terior surface of the petrous bone. The lateral semicircu- ate information on linear acceleration and the gravita- lar canal lies at an angle between the superior and tional pull. Fig. 1.2.2 Semicircular canal planes are at right angles (orthogonal) to each other (With kind permission of TESAV) Fig. 1.2.1 The horizontal semicircular canal makes a 30° angle with the horizontal plane (With kind permission of TESAV)  1.2 Vestibular Anatomy 13 EAR posterior horizontal superior a b NOSE T H R O AT AND NECK Fig. 1.2.3 (a, b) Semicircular canals lie at right angles to each other and the superior semicircular canals are parallel to the posterior semicir- cular canals of the other side (With kind permission of TESAV) Fig. 1.2.4 Each semicircular canal has an ampullated and nonampullated end. All semicircular canals ampulla- ted and nonampullated ends open separately into the vestibule, except the nonampullated ends of the superior and posterior semicircular canals which unite to form a common canal before opening into the vestibule (With kind permis- sion of TESAV) Fig. 1.2.5 Vestibular nerve action potentials. (a) Even when the head is immobile, stimulations go to the vestibular nuclei from semicircu- a b c lar canals. (b) Any movement toward the Kinocilia (the longest one) increases the stimulation rate. (c) The reverse movement of cilia away from the kinocilia decreases the stimulation rate (With kind permis- sion of TESAV) 14 Chapter 1 Ear Fig. 1.2.6 Endolymph flow in head rotation head rotation the posterior canal. (a) Ampullopetal inhibition, (b) a b Ampullofugal stimulation (With kind permission of TESAV) ampullopetal ampullofugal movement movement ampulla nerve cells cupulla CNVIII CNVIII 100ms 100ms sal Dor Maculla sacculi An ter ior Maculla utriculi al ter La Fig. 1.2.8 The inner ear comprises the cochlea and the labyrinth. The labyrinth consists of three semicircular canals (superior, posterior, and lateral) and two otolithic organs (utricle and saccule). The utricu- lar duct and the saccular duct join to form the endolymphatic duct. Fig. 1.2.7 The positions of the maculas of the utriculus and sacculus The saccule is connected by a small duct, ductus reuniens with the and topographic arrangement of the hair cells according to striola. cochlear duct Receptors in the utricle and saccule generate information on linear acceleration and the gravitational pull. (With kind permission of TESAV)  1.2 Vestibular Anatomy 15 EAR NOSE T H R O AT AND NECK Fig. 1.2.9 Balancing stone from the inner ear. Color SEM of crystals the movement of the stones causes nerve impulses that form the of calcium carbonate on the surface of an otolith. An otolith or otoco- basis of the sense of balance. In humans, otoconia can range in size nium is a calcified stone that is found in the otolith organs of the from 3 to 30 μm (millionths of a meter) across (visual photos) inner ear. They are attached to sensory hairs, and, when the head tilts, 16 Chapter 1 Ear Auditory cortex Talamus Mesencephalic level Inferior colliculus Reticular formation Brainstem level Cochlear nucleus Superior olivar complex Vestibulocochlear nerve CN VIII Reticular formation Fig. 1.2.10 Central hearing pathway  1.3 ENT Examination 17 1.3 EAR ENT Examination Tuning Fork Tests NOSE Weber Test Tuning fork tests are generally performed with a 512-Hz fork. The vibrating fork is placed on the patient’s fore- head. Sound lateralized to the poor hearing ear indicates a conductive hearing loss. Sound lateralized to the better T H R O AT AND NECK hearing ear suggests a sensorineural hearing loss in the opposite ear. Rinne Test Fig. 1.3.2 Pathologies in the inner ear and the hearing nerve cause sensorineural hearing loss The vibrating fork is placed first on the mastoid bone. When the patient no longer hears, the tuning fork is False Rinne brought 1 cm away from the external meatus. The result is expressed as “Rinne positive” when sound is heard longer When the fork is placed on the bone, the vibrations are by air and “Rinne negative” when sound is heard longer conducted by bones of the skull to both cochleas. A by bone. Normally the sound of the fork is perceived patient with a total loss of hearing in one ear can hear the louder when placed in front of the ear canal (Rinne sound in the better ear by bone cross-conduction if the positive). fork is placed on the mastoid bone of the diseased ear. The patient does not hear when the fork is brought in front of the external meatus after sound is no longer heard by mastoid bone conduction. The result is reported as a negative Rinne indicating the presence of conductive hearing loss, when in fact a false-negative Rinne has occurred. Tympanometry Tympanometry is an indirect measure of the mobility (compliance) of the tympanic membrane and ossicular chain under different pressures. The mobility of the tym- panic membrane is greatest when the pressure on both sides of the tympanic membrane is equal. Compliance is reduced as air pressure is increased or decreased from normal. High acoustic energy is applied in the ear canal, some of this energy is absorbed and the remainder is reflected back and received by the probe. When the mobil- Fig. 1.3.1 Pathologies in the external and middle ear cause conduc- ity is decreased, the energy is reflected more than the tive hearing loss 18 Chapter 1 Ear Fig. 1.3.3 Tuning fork tests. (a) Normal hearing: Weber a b test, the sound heard by both ears is equal, no lateralization; Rinne test bilateral +. (b) Conductive hearing loss in the right ear: Weber test, the sound is lateralized to the right ear; Rinne test is negative on the right ear, positive in the left ear. (c) Sensorineural hearing loss in the right ear: Weber test, the sound is lateralized to the left ear. Rinne test is positive in both ears; however, the duration is shorter in the right ear. (d) Total hearing loss in the right ear: Weber test, the sound is lateralized to the left. Rinne is positive in the left ear c d and negative in the right ear Table 1.3.1 Tuning fork tests and type of hearing loss Rinne Weber Type of hearing loss (diseased ear) Positive Not lateralized Normal hearing Positive Lateralized to the Sensorineural hearing better ear loss Negative Lateralized to the Conductive hearing diseased ear loss Negative Lateralized to the Total sensorineural better ear hearing loss Fig. 1.3.4 Soundproof hearing test rooms  1.3 ENT Examination 19 normal. In ears filled with fluid, tympanic membrane EAR thickening, or ossicular chain stiffening, the reflected energy is greater than in normal ears (Tables 1.3.2 1.3.3, 1.3.4 and 1.3.5). Vestibular tests should not be performed if the patient is taking vestibular suppressants or alcohol. NOSE Electronystagmography (ENG) analyzes the eye move- ments. Eye movements that are tested include saccade, pur- suit, and gaze. Saccade is a rapid eye movement made to bring the target onto the fovea. Pursuit is following a mov- ing object. Gaze is fixation of the eyes on a target 20–30° bilaterally for at least 30 s. ENG recordings are also made with positional tests, optokinetic tests, and caloric tests. T H R O AT AND NECK All abnormalities in the oculomotor tests, such as in saccades, tracking, and gaze, indicate CNS disease. Fig. 1.3.5 Audiometer to test hearing Failure of fixation suppression during caloric tests shows CNS disease (Table 1.3.6). a Frekanslar (HZ) b Frekanslar (HZ) 125 250 500 1000 2000 4000 8000 125 250 500 1000 2000 4000 8000 -10 -10 0 0 10 10 Isitme Seviyesi dB (ISO - 1964) Isitme Seviyesi dB (ISO - 1964) 20 20 30 30 40 40 50 50 60 60 70 70 80 80 90 90 100 100 110 110 120 750 1500 3000 6000 c Frekanslar (HZ) 125 250 500 1000 2000 4000 8000 -10 0 10 Isitme Seviyesi dB (ISO - 1964) 20 30 40 50 60 70 80 90 100 110 120 750 1500 3000 6000 Fig. 1.3.6 Audiograms. (a) Normal hearing curve, (b) hearing loss due to acoustic trauma, and (c) conductive-type hearing loss due to otosclerosis 20 Chapter 1 Ear Table 1.3.2 Causes of conductive hearing loss Table 1.3.3 Causes of sensorineural hearing loss Cerumen Presbyacusis Congenital ear atresia Noise-induced hearing loss Foreign body in the external ear canal Ototoxicity Hemotympanum Endolymphatic hydrops Chronic otitis media Acoustic neuroma Tympanic membrane perforation Labyrinthitis Ossicular chain disruption Transverse temporal bone fracture Temporal bone fractures, longitudinal Enlarged vestibular aqueduct syndrome Benign tumors of the middle ear Congenital inner ear abnormalities Malignant tumors of the middle ear Other Other a b c 10 10 10 8 8 8 6 6 6 4 4 4 2 2 2 0 0 0 -400 -200 0 +200 -400 -200 0 +200 -400 -200 0 +200 Fig. 1.3.7 Classification of tympanograms. (a) Type A: The curve tive quality of the tympano-ossicular system as air pressures change peaks at 0 mm H2O, indicating no pressure difference exists between in the external canal. This type of tympanogram is generally associ- the middle ear and the external environment. (If the peak of the ated with middle ear fluid. (c) Type C: The peak of the curve occurs curve is lower than the normal type A curve, stiffening of the ossicu- with higher negative pressures (maximum compliance is reached at lar chain is often associated. If the peak of the curve is very high, it negative pressures, meaning the pressure in the middle ear is nega- suggests ossicular discontinuity). (b) Type B: The tympanogram is tive). This curve indicates eustachian tube dysfunction relatively flat or dome-shaped. This shows little change in the reflec-  1.3 ENT Examination 21 EAR a NOSE T H R O AT AND NECK b c Fig. 1.3.8 Auditory brain stem response test. (a) Illustration showing the semicircular canals and the cochlea (spiral). Auditory sensations the organs of hearing and the cerebellum. Sound waves are chan- are picked up by the cochlear nerve (yellow) and transmitted to the neled by the pinna (visible part of the ear) into the auditory canal medulla (brain stem), the thalamus, and ultimately the cerebral cor- (pink) toward the eardrum. The eardrum transmits the vibrations to tex (visual photos). (b) The source of potentials. (c) Normal auditory three tiny bones, the malleus, incus, and stapes, in the middle ear. brain stem response with six waves from five different anatomic sites The stapes passes the vibrations to the inner ear structures (purple), Table 1.3.4 The source of the potentials Caloric test: Each ear is irrigated with water at 30 and 44°. Air may also be used for this purpose. The caloric Anatomic localization Wave stimulus causes nystagmus. Nystagmus is classified Cochlea, eighth nerve I and II according to the direction of the fast phase. Cold stimu- Cochlear nucleus III lus causes nystagmus to the opposite side and warm stim- ulus causes nystagmus to the same side. The caloric test Olivary complex IV only tests the horizontal semicircular canals. More than Lateral lemniscus V 20% difference between the two ears is interpreted as Inferior colliculus VI weakness or canal paresis on that side (Table 1.3.7). 22 Chapter 1 Ear Fig. 1.3.9 Dix Hallpike maneuver for benign positional vertigo. Bringing the head to the head-hanging position may cause vertigo and nystagmus Table 1.3.5 Differential diagnosis in positional vertigo Peripheral Central Latent period + − Adaptation a + − Fatiguea + − a Vertigo adapts by holding the patient’s head in the same position; vertigo fatigues on repeated positioning a Fig. 1.3.11 Axial temporal MR image of the cochlea. Semicircular b canals and cochlear and vestibular nerves can be identified Fig. 1.3.10 (a, b) Temporal bone CT scans. External auditory meatus, middle ear cavity, attic, mastoid air cells, cochlea, semicircular canals, and internal acoustic canal (and falciform crest in the internal acous- tic canal) can be seen  1.3 ENT Examination 23 Table 1.3.6 Electronystagmography abnormalities EAR Test with abnormality Location of lesion Saccade test CNS Gaze test NOSE  Spontaneous nystagmus suppressed by Peripheral visual fixation  Spontaneous nystagmus not suppressed by CNS visual fixation  Unilateral or bilateral gaze nystagmus CNS  Periodic alternating nystagmus CNS T H R O AT AND NECK  Rebound nystagmus CNS  Upbeating or downbeating nystagmus CNS Fig. 1.3.12 Axial temporal MR shows acoustic neuroma in the left cerebellopontine angle Tracking test CNS Optokinetic test CNS a Table 1.3.7 Caloric test abnormalities Unilateral or bilateral weakness Peripheral Directional preponderance Peripheral or CNS Failure of fixation suppression CNS Caloric inversion or perversion CNS b Fig. 1.3.13 (a, b) Electrovideonystagmography to record the eye movements and to analyze the nystagmus 24 Chapter 1 Ear 1.4 The Pinna a Fig. 1.4.3 Macrotia is a large pinna b a Fig. 1.4.1 (a) Preauricular skin tags are generally unilateral. They can be removed before school age if they cause cosmetic deformities. (b) b Cartilage remnants in front of the tragus Fig. 1.4.4 Prominent ear. (a) Posterior view before the operation and (b) 3 months after the operation. In prominent ears, the fold of the antihelix is either absent or poorly formed and the angle between the posterior surface of the conchal cartilage and the cranium is over 300°. There is an autosomal dominant inheritance. It is also referred to as bat ears or lop ears. Prominent ears should be corrected before school age, between 4 and 6 years Fig. 1.4.2 Preauricular fistulas are due to fusion abnormalities dur- ing embryogenic development of the auricle. Seventy-five percent of cases are unilateral. If the orifice of the fistula is narrow, the debris may occlude the orifice and cause a secondary infection. The whole sinus tract should be removed surgically  1.4 The Pinna 25 EAR a b NOSE T H R O AT AND NECK c d e f Fig. 1.4.5 Abnormalities of the auricle range from minor abnormali- mal deformity. (c, d) In type II there is a severe deformity, although ties that require no treatment to total absence of the pinna. Since the the remnant of the pinna is present. (e, f) In type III deformity there is embryological development of the pinna is completely different no pinna. Generally, the external ear canal is completely atresic. In from the middle and inner ear, it is not generally associated with some patients, the lobule may be present. The optimum age for sur- middle and inner ear abnormalities. However, atresia of the external gery is around 5 years until the other auricle reaches its adult size and ear canal may accompany microtia. (a, b) In type I microtia deformity, the costal cartilage development is sufficient to be used in recon- the deformity is only limited to the helix and antihelix and it is a mini- struction. It is also important to operate on children before school age 26 Chapter 1 Ear Fig. 1.4.6 In the complete absence of the auricle, an auricular Fig. 1.4.9 Malignant tumor in the auricle implant may give a natural appearance Fig. 1.4.7 Sebaceous cyst in the postauricular sulcus. Complete Fig. 1.4.10 A burn in the preauricular skin and pinna due to cleaning removal is necessary to prevent recurrences with pure antiseptic agent (Courtesy of TESAV) Fig. 1.4.8 A benign mass located in the anteroinferior part of Fig. 1.4.11 Auricular hematoma the helix  1.4 The Pinna 27 EAR NOSE T H R O AT AND NECK Fig. 1.4.12 Hemangioma at the auricle. These tumors may regress spontaneously. Steroid treatment for young patients under 1 year of age may be useful (Courtesy of TESAV) a b c Fig. 1.4.13 (a) Neurofibromas of the pinna. (b) Axial CT image shows problems. Since these tumors have malignant potential, any change massive involvement of deep tissue planes. (c) Cafe-au-lait spots, in the behavior of the tumor such as sudden increase in size, pain, which are characteristic of NF1, are also frequently seen in patients etc., should warn the surgeon about the possibility of malignancy. with NF2. Neurofibromas may be solitary or may occur as part of neu- Extensive surgery is required for massive tumors. Conservative man- rofibromatosis in patients with Recklinghausen’s disease. Solitary agement is the best option neurofibromas should be excised if they cause functional or cosmetic Fig. 1.4.14 Treacher Collins syndrome is a hereditary condition caus- ing auricular deformities, abnormalities of the external ear, and hearing loss 28 Chapter 1 Ear 1.5 External Ear Canal See Table 1.5.1. Table 1.5.1 Differential diagnosis between acute mastoiditis and furunculosis Acute Furunculosis mastoiditis History of acute otitis + − media Hearing loss + − (only if external ear canal is occluded) Fig. 1.5.1 If cerumen completely fills the external ear canal, it may Tympanic membrane Hyperemic or Normal (if can be cause conductive type hearing loss. Cerumen is the product of both bulging seen) sebaceous and apocrine glands which are located in the cartilagi- nous portion of the external ear canal. There are two basic types, Pain on the mastoid + − “wet” and “dry.” Caucasians have a greater than 80% probability of area having wet, sticky, honey-colored ear wax. In the Mongoloid races Pain with manipulation − + the dry, scaly, rice-brand type is more common of pinna or tragus Postauricular sulcus May be Present obliterated X-ray Mastoids Mastoids normal opaque Fig. 1.5.2 Cerumen deep in the external ear canal, the tympanic membrane can not be seen  1.5 External Ear Canal 29 EAR a NOSE Fig. 1.5.4 In some people there is excessive cerumen production. T H R O AT AND NECK The cerumen generally occludes the narrowest part of the external ear canal at its midportion. These patients need periodic cleaning. The use of cotton swabs can push the cerumen deeper in the ear canal, which occludes the ear canal completely and makes removal more difficult b a b Fig. 1.5.3 (a, b) Cerumen may cover the tympanic membrane like a layer and may give the impression of a pathologic eardrum. After cleaning the cerumen, the normal tympanic membrane is seen Fig. 1.5.5 Removal of cerumen is done either by an ear curette or syringing. Adequate visualization and exposure is necessary to avoid trauma. (a) If the cerumen is not hard enough, it may be removed with suction after being softened by ear drops. (b) Water irrigation is another method. After the ear canal has been straightened by pulling the pinna backward and upward, water at body temperature is administered in the posterosuperior direction. The water passes between the ear canal and the cerumen and pushes the cerumen outward. If the tympanic membrane is perforated, ear irrigation should not be done 30 Chapter 1 Ear Fig. 1.5.6 Anterior wall of the external ear canal is prominent pre- venting the anterior part of the eardrum from being seen a b Fig. 1.5.7 (a–d) Exostoses may narrow the external ear canal and small and symptom-free. They do not require any treatment unless may cause debris and cerumen to collect behind them. They are gen- they cause problems (e) Axial CT scan showing exostoses in the erally seen in swimmers. They are bony, hard, and usually remain external ear canal  1.5 External Ear Canal 31 EAR c d NOSE T H R O AT AND NECK e Fig. 1.5.7 (continued) Fig. 1.5.8 External auditory canal stenosis in a diabetic patient due to recurrent ear canal infections and trauma 32 Chapter 1 Ear a b Fig. 1.5.9 Acute otitis externa. The ear canal is hyperemic and nar- rowed due to swelling. Manipulation of the auricle or tragus is painful c Fig. 1.5.10 Acute otitis externa. The ear canal is slightly narrowed due to swelling and is full of cerumen and purulent material Fig. 1.5.11 (a, b, c) Otomycosis. Several fungi may cause infections in the external ear canal. The most common type is Aspergillus (A. niger or A. flavus). Candida may occasionally be the agent. Fungal hyphae may be seen in the external ear canal  1.5 External Ear Canal 33 EAR NOSE T H R O AT AND NECK Fig. 1.5.12 Metal piston used in a stapedectomy was extruded into the external ear canal a b c d Fig. 1.5.13 Foreign bodies in the external ear canal. (a) Foam, (b) red bead, (c) pencil sticks used for scratching the external ear canal, (d) cotton in the depth of the ear cavity 34 Chapter 1 Ear Fig. 1.5.14 Polyp extruding from the external auditory canal. It Fig. 1.5.16 Keratosis obturans. Desquamated epithelium accumu- should be examined histologically lates and may form a large impacted mass in the meatus, causing erosion of the bony canal Fig. 1.5.15 A mass in the anteroinferior part of the external ear canal  1.6 Otitis Media with Effusion 35 1.6 EAR Otitis Media with Effusion NOSE a T H R O AT AND NECK Fig. 1.6.2 Right ear. The tympanic membrane is vascularized and the transparency of the tympanic membrane is slightly diminished b Fig. 1.6.3 Right ear: otitis media with effusion. In long-standing effu- sions, the tympanic membrane has a dull or opaque appearance with vascularization on it Fig. 1.6.1 (a) Right ear. Otitis media with effusion. Air–fluid level can be seen behind the transparent tympanic membrane. (b) Left ear. Air bubbles within the tympanic cavity 36 Chapter 1 Ear Fig. 1.6.4 Right ear. Otitis media with effusion. The tympanic mem- Fig. 1.6.6 Right ear. In long-standing effusions, the retraction pock- brane is opaque, has lost its transparency, is vascularized, and ets most frequently develop in the posterosuperior part of the tym- retracted. Please note that the light reflex is shorter and moved panic membrane. The retraction pocket just behind the malleus upward due to retraction of the tympanic membrane handle is seen and its apex can be identified. The pocket is clean con- taining no debris. The membrane lies on the incus and stapes. Behind the translucent thinned tympanic membrane, the incudostapedial joint and stapes tendon are clearly seen Fig. 1.6.5 Left ear. Otitis media with effusion. Retractions occur mostly in the weak parts of the tympanic membrane, such as the Fig. 1.6.7 Right ear. Retraction pocket with debris in it pseudomembranous parts or pars flaccida, due to middle ear nega- tive pressures  1.6 Otitis Media with Effusion 37 EAR NOSE T H R O AT AND NECK Fig. 1.6.10 Mucoid material in the external ear canal after myrin- Fig. 1.6.8 Left ear. Adhesive otitis media. The tympanic membrane is gotomy in otitis media with effusion thinned and lies on the promontorium. The short process of the mal- leus and malleus handle is more prominent due to retraction of the membrane. Fibrous annulus is clearly identified Fig. 1.6.11 Thick and sticky mucoid material obtained from the mid- dle ear in a patient with otitis media with effusion Fig. 1.6.9 Right ear. Otitis media with effusion due to nasopharyn- geal carcinoma. Amber color and retraction of the tympanic mem- brane. A unilateral otitis media with effusion in adults always necessitates a detailed search for nasopharyngeal carcinoma 38 Chapter 1 Ear Fig. 1.6.12 Right ear. Sheppard grommet ventilation tube, which Fig. 1.6.14 Sheppard grommet ventilation tube extrusion. A tube in was inserted due to otitis media with effusion 6 months earlier. The the external ear canal with wax around it, 8 months after insertion. tympanic membrane looks normal. The ventilation tubes ventilate After extrusion, tympanosclerosis or membrane scarring may occur. the middle ear. The appearance of the drum returns to normal after a A small tube causes less trauma but is extruded more rapidly while. The tubes should stay in place for at least 6 months or more to have a normal middle ear physiology Fig. 1.6.13 Left ear. A 1.25 mm Paparella drain tube in the posterior inferior quadrant of the tympanic membrane. The tympanic mem- brane appears normal after 3 months of insertion of the ventilation tubes. Behind the transparent tympanic membrane the inner flanges of the tube can be seen. A myringotomy incision is generally made in the posterior inferior quadrant of the tympanic membrane. Some surgeons prefer to insert it in the anterosuperior quadrant to reduce the risk of early extrusion. Insertion of the ventilation tubes in the posterosuperior quadrant of the tympanic membrane should be avoided since it may damage the incudostapedial joint or long pro- cess of the incus  1.7 Acute Otitis Media 39 1.7 EAR Acute Otitis Media See Tables 1.7.1, 1.7.2, and 1.7.3. NOSE a b T H R O AT AND NECK Fig. 1.7.1 (a) Normal tympanic membrane. The short process of the promontorium to be seen. Note the light reflex in the anteroinferior malleus and malleus handle is seen. The tympanic membrane is quadrant of the membrane. (b) Eustachian tube dysfunction. Note transparent, sometimes allowing the long process of the incus and the vascularization along the manubrium mallei Fig. 1.7.2 Otitic barotrauma (hemotympanum). The tympanic mem- brane appears blue due to hemorrhagic fluid collected in the middle ear. It is due to an inability to ventilate the middle ear following an abnormal function of the eustachian tube. Otitic barotrauma is usu- ally seen during descent in flight or during scuba diving. No treat- ment is needed. If there is associated upper respiratory tract infection or allergy, topical and systemic oral decongestants with antihista- mines may help recovery. To prevent further episodes the patients are advised not to go scuba diving when their nose is obstructed because of the difficulty of inflating the eustachian tube. Frequent flyers and regular sufferers are advised to use prophylactic measures to prevent eustachian tube problems, such as topical nasal decon- gestants and chewing gum etc 40 Chapter 1 Ear a a b b c Fig. 1.7.3 Bullous myringitis in (a) the right ear and (b) the left ear. The malleus handle is hardly visible. Bullous myringitis is due to a viral or Mycoplasma pneumoniae infection of the tympanic mem- brane. There is severe ear pain, but no hearing loss. Draining the blebs may provide immediate relief from pain. Only the outer epithe- lial layer should be punctured. Complete puncturing of the tympanic membrane may result in perforation Fig. 1.7.4 Acute otitis media, hyperemia stage. (a) Hyperemia in the attic region of the left ear; the patient complains of ear pain only for the last 1 h. (b) Hyperemia in the attic region and the posterosuperior part of the tympanic membrane of the left ear; the patient complains of ear pain only for the last 3 h. (c) Hyperemia in the attic region and the posterosuperior part of the tympanic membrane of the right ear; slight bulging of the tympanic membrane has started  1.7 Acute Otitis Media 41 EAR a b NOSE T H R O AT AND NECK c d e Fig. 1.7.5 Acute otitis media. Different phases of the exudative ear). (d) More severe bulging (right ear). (e) More severe bulging and stage. (a) Bulging in the posterior half of the tympanic membrane opaque tympanic membrane (left ear). There is conductive-type (right ear). (b) Slight bulging of the tympanic membrane (left ear). (c) hearing loss Due to bulging the malleus handle cannot be differentiated (right 42 Chapter 1 Ear a b Fig. 1.7.6 Acute hemorrhagic otitis media in the right ear. Bulging of the tympanic membrane due to hemorrhagic purulent material in the middle ear Fig. 1.7.8 Suppurative stage in acute otitis media (right ear). (a) Purulent material filling the external ear canal and preventing the drum from being seen. (b) The small perforations in the tympanic membrane are seen after cleaning the purulent material in the external ear Fig. 1.7.7 Acute hemorrhagic otitis media in the right ear. There is severe bulging associated with severe ear pain. Due to extensive bulging, white-colored epithelium is seen on the tympanic mem- brane. The malleus cannot be identified  1.7 Acute Otitis Media 43 EAR a b NOSE T H R O AT AND NECK Fig. 1.7.9 Suppurative stage in acute otitis media (left ear). (a) nal ear. Note the perforation is located at the anterior superior quad- Purulent material filling the external ear canal and preventing the rant. If drainage is not adequate, myringotomy at the lower quadrants drum from being seen. (b) The small perforations in the tympanic may be necessary membrane are seen after cleaning the purulent material in the exter- a c b d Fig. 1.7.10 Resolution stage. During healing small perforations are ear; (b) right ear; (c) left ear, stapes muscle tendon is seen through seen in different parts of the tympanic membrane. All these perfora- the perforation; (d) left ear tions close by themselves without any additional treatment. (a) Left 44 Chapter 1 Ear Fig. 1.7.13 The perforation closed by pseudomembrane formation Fig. 1.7.11 The perforations of the tympanic membrane close by the Table 1.7.1 Contributing factors for recurrent acute otitis media epithelium coming from the edges of the perforation. Sometimes minor interventions may be needed if the perforation is big Day care center Smoking at home Bottle feeding No mother milk nutrition Immune insufficiency Cleft palate Table 1.7.2 Pathogenesis of acute otitis media Upper respiratory tract infection Edema of the eustachian tube Nasal obstruction