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Maqbool - S Textbook of ENT 9th Ed
Maqbool - S Textbook of ENT 9th Ed
Mohammad Maqbool
MBBS DLO MS FICS
Ex-Professor and Head
Department of Otorhinolaryngology
Government Medical College
Srinagar, J & K
Suhail Maqbool
MBBS MS
Assistant Consultant
Department of ORL
King Fahad Medical City
KSA
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Textbook of Ear, Nose and Throat Diseases
First Edition : 1982 Second Edition : 1984 Third Edition : 1986 Fourth Edition: 1988
Fifth Edition : 1991 Sixth Edition : 1993 Seventh Edition : 1996 Eighth Edition: 1998
Ninth Edition : 2000 Tenth Edition : 2003
Eleventh Edition: 2007
ISBN 81-8448-081-4
Typeset at JPBMP typesetting unit
Printed at Gopsons Paper Ltd, Noida
This Edition dedicated to
the original Author—
a teacher to many,
a guide to many more and
to me all that and a loving father.
Foreword
Dear Reader,
The eleventh edition of the Textbook of Ear, Nose and Throat Diseases is an
excellent overview for medical students and the general practitioners. It
is a comprehensive review of many of the specific ENT problems which
trouble patients.
ENT problems form a large segment of general practitioner’s patient
evaluation and treatment. These doctors are the primary level of medical
care.
Many physician groups form the secondary level of ENT practice and
they are capable of proper evaluation and general surgical treatment of many disorders.
These secondary level specialists will also sometimes refer to yet more highly trained, tertiary
ENT sub-specialists who have become very skilled in a variety of relatively rare and challenging
issues.
Our hope and belief is that this compact volume, as it has throughout the history of its
publication and evolution, will continue to contribute to the knowledge of the wider medical
community, so that ENT-specific problems can be rapidly and accurately identified and these
patients either treated by their primary care providers, or appropriately referred.
Dr William F House
House Ear Institute
LA California
USA
Preface to the
Eleventh Edition
Through the grace of almighty God and the continuous appreciation of previous editions by
the vast number of medical fraternities from all over the country, the eleventh edition is in
the hands of the readers.
Efforts have been made to make this textbook more informative and update.
A new Chapter on Headache has been added. A few new topics such as Neck masses,
Tumours of Thyroid, Anthrax, etc. have also been incorporated. I am sure that the students
both undergraduate and postgraduate, interns and general practitioners, all will be benefitted.
Any constructive and healthy criticism to make this textbook more informative will be highly
appreciated.
I am highly thankful to my ex-students and colleagues Dr Rafiq Ahmad and Dr Qazi Imtiaz
for their deep interest in the script and additions in the book.
Thanks are due to Shri Jitendar P Vij, Chairman and Managing Director, Mr Tarun Duneja
(General Manager, Publishing) and Mr PS Ghuman (Senior Production Manager) of
M/s Jaypee Brothers Medical Publishers Pvt. Ltd., New Delhi for their kind cooperation.
Thanks are also due to Dr William F House for writing a foreword to this edition.
Mohammad Maqbool
Suhail Maqbool
Preface to the
First Edition
Though there are quite a few books on otorhinolaryngology now available in the country,
omission of some important topics or common conditions is noticed in most of these books. As
such, a student or a clinician feels handicapped and has to waste a lot of time in looking from
book to book for a particular topic or information. A humble effort has been made to prepare
a comprehensive Textbook of Ear, Nose and Throat Diseases which would provide all the necessary
details and conception to the reader. I hope and pray that all the readers of this textbook,
undergraduate and postgraduate students, academicians, and general practitioners will be
benefitted.
I owe personal thanks to my departmental colleagues particularly to Dr Ab. Majid,
Dr Ghulam Jeelani and Dr Rafiq Ahmad for their constant interest and contribution to the text.
I must particularly thank Shri Jitendar P Vij of M/s Jaypee Brothers Medical Publishers
Pvt. Ltd., New Delhi for his help and cooperation. I would feel grateful for any suggestions
and healthy criticism from readers.
Mohammad Maqbool
Contents
24. Development and Anatomy of the Nose and Paranasal Sinuses 147
25. Physiology of the Nose and Paranasal Sinuses 155
26. Common Symptoms of Nasal and Paranasal Sinus Diseases 158
27. Examination of the Nose, Paranasal Sinuses and Nasopharynx 162
28. Congenital Diseases of the Nose 168
29. Diseases of the External Nose 171
30. Bony Injuries of the Face 175
31. Foreign Bodies in the Nose 178
32. Epistaxis 180
33. Diseases of the Nasal Septum 183
34. Acute Rhinitis 190
35. Chronic Rhinitis 192
36. Nasal Allergy, Vasomotor Rhinitis and Nasal Polyposis 201
37. Sinusitis 208
38. Tumours of the Nose and Paranasal Sinuses 226
39. Headache 236
40. Facial Neuralgia (Pain in the Face) 238
Index 427
Introduction
Fig. 1.2: Development of the pinna: A. Primordial elevations on the first and second arches. B and C. Progress
of embryonic fusion of the hillocks. D. Fully developed configuration of the auricle
first and second branchial arches proceed to of importance in infants where the facial nerve
form the ossicles. is likely to be injured during mastoidectomy
The malleus and incus basically develop through the postaural route. In order to avoid
from the Meckel’s cartilage of the first branchial injury to the facial nerve, the usual postaural
arch. From the second branchial arch develop incision is made more horizontally.
the stapes, lenticular process of the incus and the
handle of malleus. Points of Clinical Importance
The foot plate of the stapes is formed by the
1. Hearing impairment due to congenital
fusion of the primitive ring-shaped cartilage
malformation usually affects either only
of the stapes with the wall of the cartilaginous
otic capsule. The ossicles are fully formed at the sound conducting system or only the
birth. sensorineural apparatus because of their
As the ossicles differentiate and ossify, the entirely different embryonic origin, but
mesenchymal connective tissue becomes occasionally both can be affected.
looser and allows the space to form the middle 2. The particular malformation present in
ear cavity. The air cells of the temporal bone each case depends upon the time in emb-
develop as out-pouchings from the tympa- ryonic life, at which the normal develop-
num, antrum and eustachian tube. The extent ment was arrested, as well as upon the
and pattern of pneumatisation vary greatly portion of the branchial apparatus affec-
between individuals. Failure of pneumati- ted.
sation or its arrest is believed to be the result 3. Failure of fusion of the auricle tubercles
of middle ear infection during infancy. The leads to the development of an epithelial-
mastoid process is absent at birth and begins to lined pit called preauricular sinus.
develop during the second year of life by the 4. Failure of canalisation of the solid core of
downward extension of the squamous and epithelial cells of the primitive canal leads
petrous portions of the temporal bone. This is to atresia of the meatus.
Development of the Ear 5
remains as primitive, relatively avascular and organs have not yet budded out in the
poor in its osteogenic response. The first embryo.
ossification centre appears around the cochlea 2. The vestibular apparatus gets developed
in the sixteenth week. By the twenty-third before the cochlea and is less prone to
week, the ossification is complete. disease than the cochlea.
3. The labyrinth is fully formed by the fourth
Points of Clinical Importance month of intrauterine life and maximum
1. The labyrinth is the first special organ anomalies of the labyrinth occur during the
which gets differentiated when the other first trimester of pregnancy.
2 Anatomy of the Ear
Anatomically the ear is divided into three bulocochlear nerves connect the inner ear
parts (Fig. 2.1): with the brain.
i. External ear: The external ear consists of
the pinna, the external auditory canal EXTERNAL EAR
and the tympanic membrane
Pinna
ii. Middle ear: The middle ear cavity with
the eustachian tube, and the mastoid This consists of auricular cartilage covered by
cellular system is termed as the middle skin. The cartilage is irregularly shaped and
ear cleft. is continuous with the cartilage of the external
iii. Inner ear: It comprises the cochlea, auditory meatus, except between the root of
vestibule, and semicircular canals. Vesti- helix and tragus which is filled by fibrous
pyramid and passes behind the round portion of the facial nerve passes deep to the
window niche to the hypotympanum. This posterior canal wall. Lateral to the pyramid is
area is commonly infiltrated with cholestea- the opening for the chorda tympani.
toma associated with retraction of the
posterior segment of the tympanic membrane. Floor
As shown in the Figure 2.7, the facial recess is
It is formed by a thin plate of bone which
superficial to the sinus tympani and is
separates it from the dome of the jugular bulb.
separated from it by the descending portion
This floor may be deficient sometimes and
of the facial nerve and processus pyramidalis.
thus the jugular bulb may project into the
In intact canal wall tympanoplasty, sinus
tympanic cavity.
tympani is not clearly seen so that there is a
danger that the cholesteatoma may be left in Roof
situ with this technique.
It is formed by the tegmen tympani which is
Anterior Wall formed partly of the petrous part of the
temporal bone and partly by the squamous
This wall of the middle ear cavity has three
portion of the temporal bone. This wall sepa-
openings. The eustachian tube opening is seen
rates the middle ear cavity from the middle
in the lower part of the anterior wall. A thin
plate of bone separates the eustachian tube cranial fossa. The petrosquamous suture may
and the middle ear from the internal carotid persist and form a pathway for the spread of
artery. The canal for tensor tympani muscle infection.
is above the opening of the eustachian tube.
Lateral wall
Two more openings are present, the upper one
being the canal of Huguier that transmits the The lateral wall is formed by the tympanic
chorda tympani from the middle ear, and the membrane and partly by bone above and
lower opening is called the glaserian fissure, below and accordingly the cavity of the
which transmits the tympanic artery and the middle ear is divided into three parts:
anterior ligament of the malleus. i. Mesotympanum: It is the portion of the
middle ear cavity which lies medial to
Posterior Wall the tympanic membrane.
The posterior wall in its upper portion shows ii. Epitympanum (attic): It is the portion of
an opening called the aditus ad antrum, which the cavity which lies above the level of
leads from the attic to the mastoid antrum. the horizontal portion of the facial nerve,
Below the aditus is a conical projection called medial to the horizontal part of the
pyramidal process, which transmits the squama (outer attic wall).
stapedial tendon to its insertion into the neck iii. Hypotympanum: It is the part of the cavity
of stapes. At the pyramidal process the vertical which lies below the tympanic sulcus.
Anatomy of the Ear 13
communicates with the mastoid air cells. The triangle is completed by a line which is
medial wall of the antrum is formed by the tangential to the posterior canal wall below
petrous portion of the temporal bone and in and cuts the posterior root of the zygoma
this wall lie the posterior and lateral semi- above.
circular canals (Fig. 2.9). The petrosquamous suture may persist in
The lateral wall of the antrum is formed by adult life (Korner’s septum) and form a false
the squamous portion of the temporal bone. bottom of the antrum which may mislead the
The roof of the antrum is formed by tegmen surgeon and lead to incomplete removal of the
antri which separates it from the middle disease.
cranial fossa and the posterior wall and the floor
are formed by the mastoid portion of the Mastoid Process
temporal bone. The mastoid process is not present at birth and
Surgical anatomy The antrum lies above and starts developing at the end of the first year
behind the projection of a bone called the spine and reaches its adult size at puberty. It
of Henle, on the posterosuperior angle of canal develops posterior to the tympanic portion of
wall. The cribriform area of the bone above the temporal bone. In infancy the mastoid
and behind this spine is the site for the process being absent, the facial nerve emerges
antrum which lies about 13 mm deep from the lateral to the tympanic portion from the
surface in adults and only 3 mm deep in stylomastoid foramen and is likely to get
infants. injured by the usual postaural incision.
The surface anatomy of the antrum is
Mastoid Air Cells
marked by a triangular area called the
Macewen’s triangle which is bounded above by During development of the mastoid process,
the posterior root of zygoma and anteriorly the bone is normally filled with marrow. Only
by the posterosuperior canal wall. Behind, the the mastoid antrum and a few periantral cells
Anatomy of the Ear 15
are present at birth. With development, the b. Deep tip cells: These lie deep to the
mastoid process becomes cellular in a majo- attachment of the posterior belly of
rity of cases (80%)where air cells are large and digastric. The superficial and deep tip
the intervening septae are thin, which is cells are separated by the digastric
regarded as normal. In some cases the mastoid ridge, the facial nerve lies anterior to
remains diploic (acellular) wherein others the this ridge.
cellularity is completely absent (sclerotic). Here 3. Perisinus cells: These are present around the
are various theories to explain the deficient sigmoid sinus.
pneumatization. (1) Wittmaack theory which 4. Perilabyrinthine cells:
states that infantile otitis media interferes with a. Around the labyrinth within the pet-
the resorption of the diploic cells (2) Tumarkins rosa.
theory which states that failure of pneumatiza- b. Supralabyrinthine, above the arch of
tion occurs because of failure of middle ear the superior semicircular canal.
aeration due to eustachian tube dysfunction c. Infralabyrinthine, below the labyrinth.
and(3) Diamant and Dahlberg suggest that d. Retrolabyrinthine, behind the laby-
dense bone is congenital and is a normal rinth.
anatomic variant. 5. Retrofacial cells: These are present behind
the vertical portion of the facial nerve.
Air cell groups of the mastoid From the antrum, 6. Petrosal cells: Air cells may invade the body
the cellular system extends into the adjacent and apex of the petrous bone and may be
bone and is grouped as follows (Fig. 2.10): present under the trigeminal ganglion,
1. Periantral cells around the internal carotid artery or
2. Tip cells: around the eustachian tube (peritubal cells).
a. Superficial: The superficial cells lie 7. Hypotympanic cells tracts.
superficial to the posterior belly of the 8. Zygomatic cells: These extend forwards into
digastric muscle. the zygoma.
Antrum threshold angle It is a triangular area
of bone and is formed above by the horizontal
semicircular canal and fossa incudis, medially
by the descending part of the facial nerve and
laterally by the chorda tympani.
Sinodural angle It is the angle between the
tegmen antri and the sigmoid sinus.
Solid angle This lies medial to the antrum
formed by a solid bone in the angle formed
by the three semicircular canals.
Trautmann’s triangle The triangle lies behind
Fig. 2.10: Different groups of mastoid air cells the antrum, bounded by the sigmoid sinus
16 Textbook of Ear, Nose and Throat Diseases
of the membranous cochlea is attached to the front of the utricle. The ducts from the saccule
osseous spiral lamina (In the attached margin and utricle join to form the endolymphatic
of this spiral lamina is the spiral canal of the duct which occupies the bony aqueduct of the
modiolus) and the outer surface of the membra- vestibule. The saccule is also connected by a
nous cochlea is attached to the inner wall of small duct called ductus reuniens with the duct
the bony cochlea thus dividing the bony of the cochlea.
cochlea into 3 compartments, the upper scala
vestibuli, the lower scala tympani and the Membranous Semicircular Ducts
membranous cochlea or the scala media. These open into the utricle by five openings.
Membranous Labyrinth One end of each duct near the utricle is dila-
ted and is called the ampulla which houses the
The membranous labyrinth is filled with vestibular receptor organ. The vestibular
endolymph and comprises the following (Fig. receptor organ is a specialised neuroepi-
2.12): thelium called crista. The sensory cells have
i. The saccule and utricle cilia, which project into a gelatinous substance
ii. The membranous semicircular ducts probably secreted by the supporting cells. The
within the corresponding bony canals gelatinous substance is dome-shaped in the
iii. The ductus cochlearis in the bony cochlea. ampullae and is called the cupula. In the utricle
Saccule and Utricle and saccule, the specialised epithelium is
called, macula, which lies in a horizontal plane
The utricle lies in the upper part of the
in the utricle and vertical plane in the saccule.
vestibule while the saccule lies below and in
The gelatinous substance lying above the
neuroepithelium is flat in the saccule and
utricle and contains a number of crystals
embedded in it, known as statoconia (otoliths).
Origin Absorption
Perilymph
i. From CSF Through aqueduct of cochlea in
ii. Direct blood filtrate from the subarachnoid space
vessels of spiral ligament.
Endolymph
i. Secreted by stria vascularis or by the Saccus endolymphaticus
adjacent tissues of outer sulcus.
ii. Derived from perilymph across Stria vascularis
Reissner’s membrane.
The pinna which plays a role of sound collec- The tympanic membrane and ossicles not only
tion in some lower animals does not seem to conduct the sound but also increase its
play this function in human beings. The pressure before it is transmitted to the cochlea.
external auditory canal acts as a channel for This increase in sound pressure provided by
the conduction of sounds from the auricle to the tympanic membrane and ossicles is
the tympanic membrane and adds resonance necessary to overcome the impedance (resis-
to it, amplifying it by 10-12 decibels. tance) to the sound transmission, and is called
impedance matching function of the middle ear.
PHYSIOLOGY OF HEARING
Sound is conducted from the external audi- Impedance Matching of Middle Ear
tory canal through the tympanic membrane Transmission of sound from the middle ear
and ossicles to the cochlea which is the sensory containing air to the cochlea containing fluid
organ of hearing. The impulses pass from the (refer to Fig. 2.11) would have been difficult
inner ear through the nerves to central as this means sound transmission from air to
connections and the auditory cortex in the fluid. Because of the difference in the acoustic
brain, where the message is perceived. properties of the two media, most of the sound
The hearing mechanism thus involves two would be reflected back (impeded) and this
components: would mean a loss of about 99.9 per cent of
i. The sound conducting mechanism (trans- acoustic energy. Nature has, thus, provided
mission). with middle ear impedance matching system
ii. The perceptive neural mechanism which overcomes this resistance by increas-
(transduction). ing the sound pressure. The function is
The sound conducting system extends affected by the following.
from the external auditory canal to the i. The large effective surface area of the
cochlear fluids. tympanic membrane (55 mm2) compa-
red to the small surface area of the
Physiology of the Conductive Mechanism footplate of stapes (3.2 mm2) provides a
The functions of the ear include hearing and magnification of about 17 times. This is
maintenance of balance. called hydraulic ratio.
24 Textbook of Ear, Nose and Throat Diseases
ii. The greater length of the handle of Functions of the Middle Ear Muscles
malleus compared to the long process of
The basic function of the intratympanic
incus (1.3:1) called ossicular chain lever
muscles, the stapedius and tensor tympani, is
ratio also provides some gain in the trans-
to protect the inner ear from damage due to
mission.
high intensity sounds. Loud sounds reflexly
The result of the two gains, the hydraulic
stimulate the muscles, which cause stiffness
ratio and the ossicular lever ratio (17 × 1.3 = 22)
of the ossicular chain and thus less of sound
is known as the transformer ratio.
is passed into the inner ear. As these muscles
This is how the middle ear functions as the
have a latent period of contraction of 10 msec,
sound pressure transformation mechanism
these do not provide protection from sudden
and helps in impedance matching of the
explosive sounds. A sound intensity of
sound.
70–90 dB above the hearing threshold is
The tympanic membrane, while prefe-
required to elicit the stapedial reflex.
rentially feeding the oval window with sound
Besides this reflex function the intratym-
waves, also gives a protection to the round
panic muscles help in supporting the ossicular
window. It shields the round window from
chain.
the direct impact of the sound waves and thus
allows it to function as a release point neces-
Functions of Eustachian Tube
sary for fluid displacement of the inner ear.
The reconstruction of the middle ear trans- Eustachian tube helps in aeration of the
former mechanism and round window middle ear. Normally, an aerated middle ear
protection form the principles of tympa- cavity is essential for proper functioning of the
noplasty. tympanic membrane and ossicles and
provides a hypotympanic air bubble for the
Bone Conduction of Sounds
movement of the round window membrane.
Besides air conduction, the sounds are also The eustachian tube helps in equalisation
transmitted through bone, which may be due of pressure in the middle ear. As the atmos-
to vibration of the skull by the subject’s own pheric pressure decreases, as during ascent in
sound waves, the free-field sound energy or an aeroplane, the air in the middle ear
by application of the vibrating body directly cavity gets absorbed and a negative pressure
to the skull. develops inside the middle ear cavity. This can
The stimulation of the sense organs by the be equalised by frequent swallowing move-
bone conducted sounds occurs as a result of ments which open the eustachian tubes.
compressional mechanism of the skull or by Failure to open the tubes results in their
the inertia (lagging behind) of the ossicles and closure (locking) and produces serous otitis
mandible as the skull vibrates. The lagging media.
behind of the mandible produces vibration of A similar situation occurs during the
the cartilaginous meatus which is then decompression phase in pressurised
transmitted to the ear. chambers.
Physiology of the Ear 25
eighth nerve to the central vestibular connec- of the whole, which can still be elicited for
tions which keep the cortex informed about several hours after total oxygen depriva-
the changes in position and posture of head tion or death. The origin of CM is conclu-
and thus help in maintaining the equilibrium. sively shown to be the physical stimulation
of the hair cells.
Electrical Potentials in the Cochlea 3. Summation potential (SP): This also results
Two main types of potentials have been from acoustic stimulation and consists of
identified. a change in EP which may be in the posi-
i. The steady or resting state potentials. tive or the negative sense (SP+ and SP–).
ii. Superimposed AC voltage fluctuations Unlike CM it does not follow the actual
due to acoustic stimulation. instantaneous values of the sound stimu-
The most striking finding is a positive lus, but is proportional to the RMS (root
potential of some 80 mV in the scala media mean square) acoustic pressure.
called the endolymphatic potential or EP. Summation potential becomes the most
Insertion of the electrode into a hair cell conspicuous at higher sound levels, beyond
reveals a negative potential of about 80 mV the point at which distortion begins in CM. It
so that there is an overall potential difference is thought to originate in the hair cell reticular
of 160 mV between the scala media and the lamina area like CM but is probably the
interior of the hair cells, a striking high volt- product of a different mode of differential
age difference to be found across a cell memb- vibration between the organ of Corti and the
rane. A small positive potential of about 5 mV tectorial membrane.
is also noted in the scala vestibuli. Cochlear hydrodynamics means that the
It has been found that the microphonic cochlear fluids vibrate instantaneously from
potentials are a composite of several electri- window to window. These movements are
cal activities. These are as follows. those of a fluid column vibrating back and
1. Auditory nerve action potential (AP): This forth without significant compression and
consists of an aggregate of the action rarefaction of its constituent molecules. This
potentials of the individual nerve fibres. means that a sound wave as such does not
These potentials are similar to those of travel through the cochlear fluids.
other nerves, e.g. a spike discharge prece-
Efferent Cochlear System
ded by a latent period and followed by a
refractory period. Within the auditory nerve there are about 500
2. Cochlear microphonics (CM): This is the main centrifugal fibres coursing from the brainstem
component and confers upon the cochlear to the hair cells. Anatomical studies show that
potentials. It has two elements—CM 1, they originate in the superior olivary nucleus.
which is oxygen dependent and is About one-fifth of them are of homolateral
abolished by oxygen lack or by death of origin and the remainder from the opposite
the individual and CM 2, about 10 per cent side. Ramussen has defined several separate
28 Textbook of Ear, Nose and Throat Diseases
person should be educated and trained in a may also be due to the infections of the exter-
deaf school. nal auditory canal. The discharge may be
serous, mucoid, mucopurulent, purulent,
Tinnitus blood stained, or watery. It may be scanty or
Tinnitus is first important symptom of sali- profuse.
cylate poisoning. Tinnitus associated with Serous discharge is found in allergic otitis
periodic episodes of deafness and vertigo externa. Mucopurulent discharge is com-
constitutes Ménière’s syndrome. Wax in the monly due to benign chronic suppurative
external auditory canal, aero-otitis media, otitis media and the extension of the disease
infections of the ear, acoustic trauma and process to mastoid air cells. A purulent dis-
otosclerosis may be associated with tinnitus. charge usually signifies an underlying bone
Pulsatile tinnitus is seen in glomus jugulare eroding process in the middle ear like
and AV shunts. Fluctuant deafness, fullness cholesteatoma. The discharge in this condition
in ears and tinnitus are found in secretory is usually scanty and foul-smelling. This type
otitis media. of discharge may occur in otitis externa also.
Blood-stained discharge is a feature of
Vertigo malignancy, glomus jugular and granulations.
Watery discharge in the ear may be CSF due
Meticulous history is an important diagnos- to trauma or because of diffuse otitis externa.
tic tool as far as vertigo is concerned. The first
thing to ascertain is whether the vertigo is Earache (Otalgia)
really vertigo (a sense of rotation) or a synco- Pain in the ear may occur due to lesions in the
pal attack in which the patient gets a blackout, ear itself or due to the conditions in the sur-
falls momentarily and quickly regains con- rounding areas (referred otalgia) (Fig. 4.1).
sciousness, or just giddiness. Painful lesions of the ear include the
Vertigo with a discharging ear indicates following:
labyrinthitis. Vertigo of central origin is 1. External ear
associated with other neurological features. a. Furunculosis
Positional vertigo is seen in critical postures b. Impacted wax or foreign body
only. Upper respiratory catarrh followed by c. Perichondritis
vertigo may indicate viral labyrinthitis or d. Diffuse otitis externa
vestibular neuronitis. e. Otomycosis
Patients taking ototoxic drugs may also get f. Myringitis bullosa
vertigo. Unilateral hearing loss with vertigo g. Ramsay-Hunt’s syndrome
is characteristic of acoustic neuroma. h. Traumatic lesions within the external
auditory canal.
Ear Discharge (Otorrhoea)
2. Middle ear
Discharge from the ear is a common manifes- a. Acute suppurative otitis media
tation of ear disease. The discharge is b. Acute mastoiditis
commonly due to middle ear pathology but c. Aero-otitis
History Taking with Symptomatology of Ear Diseases 31
may be seen in the canal due to chronic tensa may be central or marginal. A central
suppurative otitis media, glomus jugulare and perforation may be small or large, but the
malignancy. A deeper look into the canal intact rim of membrane is seen around the
shows the tympanic membrane or its margins of the perforation. A perforation
remnants. is called marginal if no rim or annulus is
The tympanic membrane appears as a seen around or on side of the margin of the
greyish white, translucent membrane set perforation. A marginal perforation is an
obliquely inside the canal. The important land- indication of an unsafe disease. A perfora-
marks on the membrane are as follows: tion in the pars flaccida or attic perforation
1. The short process of the malleus appears indicates an underlying cholesteatoma.
as a small projection in the upper anterior 2. Colour changes in the tympanic membrane:
part of the pars tensa. This landmark is The tympanic membrane normally
least obliterated in disease. appears as a greyish white membrane. A
2. The anterior and posterior malleolar folds congested membrane with prominent
radiate forwards and backwards from this blood vessels is seen in the early stage of
projection separating the pars flaccida acute otitis media while a dull lustreless
above from the pars tensa below. membrane is seen in secretory otitis media.
3. The short process is followed down to note A blue discoloration of the membrane
the handle of the malleus which is directed occurs in haemotympanum and the fla-
downwards and backwards, ending at the mingo pink reflex is seen in otosclerosis
umbo. (Schwartze’s sign).
4. From the umbo a cone of light is seen 3. Position of the membrane: Normally the
radiating anteroinferiorly. position of the membrane is maintained by
5. Sometimes the long process of the incus the pressure of air column on its either side.
may be seen through the posterior part of A bulging congested drum is seen in
the pars tensa, below the posterior exudative stage of acute otitis media. A
malleolar fold. retracted membrane may occur in aero-
The pars tensa of the membrane is arbi- otitis, serous otitis media, and adhesive
trarily divided into four quadrants by two otitis media. The retracted membrane
imaginary lines. A vertical line passes down appears dull, lustreless, with absent or
along the handle of malleus and a horizontal distorted cone of light and has a reduced
line intersects it at the umbo, dividing the pars mobility. The handle of the malleus
tensa into anterosuperior, anteroinferior, appears more horizontal and the short
posteroinferior and posterosuperior quad- process more prominent.
rants. Abnormalities of the membrane are 4. Mobility of the membrane: The mobility of
noted with respect to the quadrant involved. the membrane is tested by the Valsalva’s
1. Integrity: The membrane may be intact or method and by siegalisation. The hyper-
perforated. The site of perforation and its mobile areas of the membrane indicate
shape are noted. A perforation of the pars scarring of the membrane. Restricted
34 Textbook of Ear, Nose and Throat Diseases
1. Alternately compressing and releasing the increasing the pressure in the nasopharynx.
tragus against the external meatus. This This opens up the eustachian tube and allows
alters the pressure in the canal and air to pass into the middle ear cavity. The out-
stimulates the labyrinth. ward movement of the tympanic membrane
2. By moving the polyp or granulations in the is seen through the ear speculum. The test is
ear by a cotton tipped applicator. useful to know the mobility of the membrane
3. By increasing and decreasing the pressure as well as the patency of the eustachian tube.
in the canal with a Siegle’s speculum. This test may normally be negative.
The subjective feeling of giddiness, nausea
or vomiting with or without nystagmus Politzerisation
indicates a positive fistula sign which indicates The tip of the nozzle of the Politzer’s rubber
that there is a fistula in the labyrinth, and that bag is placed in one nostril and the other
the labyrinth is still functioning. nostril closed over it by fingers. The patient is
The fistula sign may be false-negative or given some water to swallow. At the move-
false-positive. ment of swallowing, the air in the bag is
False-negative fistula sign This means that there compressed. The air thus enters the eustachian
is a fistula in the labyrinth but the fistula test tube as it opens up on swallowing. The
is negative. This occurs in a dead labyrinth. outward movement of the tympanic memb-
rane indicates a patent eustachian tube.
False-positive fistula sign This means that there
is no fistula in the labyrinth but the fistula test Eustachian Catheterisation
is positive. This occurs in congenital syphilis
due to the deformed hypermobile footplate An eustachian catheter of a proper size is
and is called Hennebert’s sign. It may also occur passed through the nose into nasopharynx.
after stapedectomy. The tip of the catheter is turned into the eusta-
chian orifice and air is blown down the
Eustachian Tube Patency catheter into the eustachian tube. The move-
ment of the tympanic membrane is observed
The patency of the eustachian tube can be
through the canal or the passage of the air
demonstrated by various tests. However, a
through the tube is heard by an auscultation
patent eustachian tube is not necessarily an
tube, one end of which is placed in the
index of normal function of the tube.
patient’s ear and the other end in the exami-
The nasopharynx is examined by a
ner’s ear. The sound heard by the examiner
posterior rhinoscopy or by a nasopharyn-
indicates the passage of air through the
goscope.
eustachian tube.
Valsalva’s Test Method
The patient is asked to close the mouth and The nasal cavity is anaesthetised by the local
pinch the nostrils and then to blow out, thus use of 4 percent lignocaine spray, the
36 Textbook of Ear, Nose and Throat Diseases
eustachian catheter is passed along the floor voice (using residual air) should be under-
of the nasal cavity without touching it, the tip stood at 12 feet. But most rooms do not allow
of catheter pointing downwards till the more than a 12 feet range, so it is customary
catheter reaches the posterior wall of to consider 12 feet for both speech and whisper
nasopharynx. The catheter is brought as the normal standard.
forwards gently till the tip hooks against the
posterior edge of the soft palate. Now the tip Vocal Index
of catheter is rotated by 90° outwards which It is the relation between hearing loss for
approximates it with the pharyngeal end of speech and whispered voice.
the eustachian tube. The ring on the proximal In conductive deafness the index is small
end of the catheter indicates the direction of and there is little difference between the two.
the tip of the catheter. A Politzer’s bag nozzle In perceptive deafness in which loss is
is attached to the proximal end of catheter and mainly confined to high tones, there may be
is squeezed to allow the air to be blown into considerable discrepancy between the hearing
the eustachian tube through the catheter. If for speech and whisper, so the vocal index is
the tip of the catheter is rotated through 180° high.
towards the other side of the nasopharynx the
patency of the eustachian tube of the other side Threshold for Speech
can be assessed. After the process is over, the
In a person with normal hearing this threshold
catheter is brought back to the position as it
is zero but in a person with moderate degree
was passed into the nasal cavity and
of hearing loss it may be 40-45 dB.
withdrawn gradually from the nasal cavity
without touching its sides and floor.
Speech Audiometer
FUNCTIONAL EXAMINATION OF EAR A trained speaker speaks into a microphone
certain words which are transmitted to the
The tests of hearing are intended to measure the
listener through a pair of head phones. Adjust-
ability to hear sounds (quantitative) and to test
ments are made on the attenuator, which is
and compare the efficiency of the conductive
so adjusted that when the dial is at zero at least
and perceptive parts of the auditory apparatus
50 per cent of the test material is heard.
(qualitative).
Qualitative testing is done by tuning forks
Pure Tone Audiometer
and pure tone audiometer and quantitative by
speech (live or recorded) and pure tone It is used to determine the threshold of hearing
audiometer. for pure tones within a selected band of
All tests should be carried out in a quiet frequencies. The tones are electrically
room. In quiet places, normal distance at produced and can be varied both in frequency
which speech of conversational level can be and intensity. The range of frequencies
heard is about 20 feet, whereas the whispered available may be fixed at octave or half octave
Examination of the Ear 37
intervals between 64 and 8,192 cycles/sec (if trap, cough-drop, etc. Whispered voice is
Helmoltz scale is used) or there may be conti- used at the end of normal expiration and is
nued sweep between 0 and 10,000 cycles/sec. thus easily standardised than conversational
Intensity can be varied, usually in 5 dB voice.
steps from 0 to 100 dB and the intensity dial is
Method Each ear is tested separately. The
so calibrated that at zero for each selected
other ear being masked by the finger on tragus
frequency a person with normal hearing can
or rubbing the non-test ear with a piece of
just hear the test tone.
paper. The distance at which the patient can
As sound at a level of 60 dB or more can be
hear the conversational and whisper voice in
heard in the untested ear, it is advisable to use
a reasonably quiet surrounding are noted. The
a masking apparatus. Masking is essential
distance is reduced for whisper voice in high
when there is considerable difference in the
frequency loss than for conversational voice.
hearing acuity between the two ears, and
In conductive deafness there is little difference
when testing by bone conduction to get correct
in distance at which each can be heard.
results.
The value of the pure tone audiometer test Tuning Fork Tests
depends upon the following:
i. Accuracy of the audiometer. Tuning forks provide a simple, easy and
ii. The way in which the test is carried out. reliable method of testing the hearing. A set
iii. Intelligence of the patient. of 256, 512, 1024, double vibration forks is
Each ear should be tested separately for all commonly used. The following tests are
frequencies (usually 7) with masking of commonly in use:
untested ear when necessary. For bone i. Rinne’s test
conduction, masking of the untested ear is ii. Weber’s test
essential. Only four tones are tested (256-2,048 iii. Absolute bone conduction test.
cycles/sec).
The various hearing tests are described Rinne’s Test
below. The fork is struck gently on the elbow, knee
cap, hypothenar eminence or a rubber pad and
Voice Tests held in such a way so that the prongs vibrate
Speech tests though less accurate are simple against the ear in line with the external canal
and easily understandable to the patient. The at a distance of about 1 inch (Fig. 5.3). The air
conversational and whispered voice tests are conduction of the sound is compared with
conducted in reasonably quiet surroundings. bone conduction. To test the bone conduction,
The material for speech tests may be spondee the foot piece of the fork is placed on the
words or numbers. Spondee words are bisylla- mastoid. The patient is asked to indicate which
bic words having an equal stress on both of the two is louder or where he hears for the
syllables like arm-chair, toothbrush, mouse- longer time.
38 Textbook of Ear, Nose and Throat Diseases
1. AC > BC R+ Normal
+
2. AC > BC (both reduced) R (reduced) Perceptive deafness
3. AC = BC R= Slight conductive deafness
4. AC only no BC R+ infinitely Severe perceptive deafness
5. BC > AC R— Conductive deafness
6. BC only, untested ear masked R—infinitely Very severe conductive deafness
7. BC only, no masking of False-negative Very severe or total
untested ear Rinne (R-false) perceptive deafness
Examination of the Ear 39
Fig. 5.7: Towne’s view Fig. 5.8: X-ray of the skull, Towne’s view showing
sclerotic mastoids with bilateral cavities (choles-
teatoma)
i. Relationship of the sinus plate to the air physics in 1979. The scanner has a diagnostic
cells and thus helps in determination of accuracy of 98 per cent and the great advant-
the posterior extent of the pneumatisa- age is that it is noninvasive and the radiation
tion. involved is only one-third of the dose for a
ii. Superiorly the dural plate, the floor of single lateral skull radiograph.
the middle fossa is visible. The CAT scanner is capable of producing
iii. Aditus, attic and antrum are demon- pictures in a wider range of densities than the
strated. conventional X-ray procedures. It clearly pin-
The external auditory canal and tympanic points pathology like tumours, intracranial
cavity are obscured by the bony labyrinth. bleeding, infarcts, cysts, abscesses, hydro-
Stenver’s projection This is an oblique view of cephalus, aneurysms and various eye and
the skull, taken separately for each side at an ENT lesions. Vascular structures can also be
angle of 12.5o. The view is taken mainly to seen following the injection of an iodised
demonstrate following structures: contrast material in the patient.
i. The upper border of petrous bone
ii. The internal auditory meatus Advantages of CT Scanning
iii. The superior semicircular canal 1. It provides a speedy and accurate diag-
iv. Ossicles like malleus and incus. nosis.
Transorbital view of the petrous apex This view 2. Pin-pointing of the pathological spots
demonstrates both petrosa on the same film facilitates in accurate surgery.
and is commonly taken to visualise the 3. It eliminates the need for painful and risky
internal auditory meati. A difference of 1 mm investigations and exploratory surgery.
or more is significant.
Owen’s projection This is an oblique view CONTRAST RADIOGRAPHY
which demonstrates the attic, aditus, and Radiographic examination after instillation of
antrum. The ossicles are shown clearly within a radio-opaque dye may be done for eusta-
the external auditory canal. chian salpingography and to demonstrate the
X-ray base of the skull The submentovertical lesions of the internal auditory meatus.
view may be required to study the mastoids, The dye may be put either through the
auditory canals, petrous apex, bony eusta- nasopharyngeal orifice of the tube to demon-
chian tube and carotid canal. strate the block in the tube or alternatively, it
may be injected into the middle ear through a
CT Scan tympanic membrane perforation if it is
Computerised axial tomography (CAT) is the present, or a fine needle is used to put the dye
most accurate noninvasive neurodiagnostic into the middle ear.
test available. This test was invented by Dye injected into the middle ear deter-
Hounsfield who received the Nobel prize for mines the patency of the tube as well as helps
42 Textbook of Ear, Nose and Throat Diseases
in assessing eustachian tube function by 4. Patients with any metallic foreign body,
tympanic cavity clearance study. e.g. pacemakers, metallic prosthesis,
In eighth nerve tumours the internal aneurysm clips cannot be imaged and
auditory meatus study is done by injecting the these may have to be removed, as they may
contrast material through a cisternal puncture. sometimes act as sharp, lethal missiles.
Second degree nystagmus: Also present field of vision in various directions. The
when the patient looks straight in front. jerking of eyes appears at the extreme range
Third degree nystagmus: If still present of vision in normal individuals and should not
when the patient looks in the direction of the be mistaken for labyrinthine nystagmus.
slow component. If the labyrinth is irritated on one side,
Under anaesthesia, the quick component spontaneous nystagmus occurs towards that
is eliminated and only the slow or vestibular side and when the labyrinth is destroyed, the
movement takes place and results in conjugate nystagmus occurs towards the opposite side.
deviation. The function of the vestibular system may
In labyrinthine nystagmus there is a slow be evaluated by stimulating the labyrinth and
component of vestibular origin and a quick noting the change in its response. Induced
component which is of cerebral origin. Each nystagmus may be produced by the following
labyrinth tries to deviate the eyes slowly to tests.
the opposite side due to its tonic activity and i. Caloric test
thus normally the effect is neutralised so that ii. Rotation test
the eyes remain in midline. When one utricle iii. Optokinetic test.
is stimulated due to disease or caloric stimu-
lation, the eyes get deviated slowly to the The Caloric Test
opposite side. When the cerebral cortex In this test the labyrinth is stimulated by the
becomes aware of this deviation, it brings in changes in temperature. This is done by
effect the correcting reflex, thus bringing the irrigating the external auditory canal with hot
eyes quickly back to the original position. The and cold water.
reverse occurs when the labyrinth is Commonly the lateral semicircular canal
hypoactive or dead, i.e. the quick component is tested. The patient lies supine on the table.
to the opposite side and slow component to The head end of the table is inclined 30o
the affected side. forwards. This is done because the anterior
The vestibular nystagmus is fine, always end of the horizontal semicircular canal is
horizontal and does not last for more than six about 30o higher than its posterior end. In this
weeks. position, the horizontal canal thus assumes a
Central nystagmus (due to involvement of vertical plane for easy stimulation.
the central connections) may be horizontal,
Cold caloric test About 5 cc of ice cold water is
vertical or rotatory, is coarse and lasts for a
injected into the external auditory canal. This
longer time.
cools down the surrounding bone and the
How to look for nystagmus The patient is placed temperature variation is transmitted to the
in good light and the examiner faces the labyrinth. Convection currents are set up in
patient. The patient’s head is kept steady and the endolymph and thus the labyrinth is
he is asked to follow the direction of the finger stimulated. Nystagmus occurs and its
tip of the examiner, which is moved across the duration nystagmus is compared on both
44 Textbook of Ear, Nose and Throat Diseases
sides. Normally the nystagmus persists for intensity nystagmus, which may not be visible
about two minutes. This is a simple test but is to the naked eye, becomes obvious.
less informative.
Caloric test with Dundas-Grant apparatus In
Bithermal caloric test (differential caloric test) or patients with perforation of the tympanic
Fitzgerald and Hallpike test This test is done by membrane water cannot be injected into the
irrigating the external auditory canal with external canal. In such patients the Dundas-
water having a temperature 7o above body Grant metallic coil is used. Ethyl chloride is
temperature (44oC) and 7o below body tem- sprayed over the coil and air is passed by
perature (30oC). The canal is irrigated by the pressing the attached rubber bulb. As the air
water at these temperatures for 40 seconds. passes through the coil, it gets cooled and
The onset and duration of the nystagmus enters the ear, thus producing cold caloric
with each stimulation is graphically recorded responses in the ear.
(calorigram—Fig. 5.9). An interval of about
5 minutes should be allowed between the tests. Rotation Test
Cold stimulation produces nystagmus
towards the opposite side and hot stimulation The patient is placed on a revolving Barany’s
produces nystagmus towards the same side. chair which is rotated at the rate of ten revolu-
The duration of nystagmus is measured on tions per second. The chair is then suddenly
both sides. If nystagmus persists for less than stopped and the postrotational nystagmus
the average time, it is called canal paresis noted. Both labyrinths are stimulated at the
(hypoactive). Sometimes caloric responses are same time, hence the test is not of much
enhanced in one particular direction significance.
(directional preponderance). This is due to the
loss of tonus elements and commonly occurs Optokinetic Test
towards the normal ear. A white rotating drum with black vertical lines
Nystagmus may be observed unaided or is used. The drum rotates on a horizontal
with the help of Frenzel’s glasses worn by the plane. The patient is seated at a distance of 3
patient to prevent optic fixation and provide feet from the drum. The drum rotates to one
magnification of the eye movements. Thus low side and then to the other. The patient follows
Romberg and the Unterberger tests for the remains with his eyes closed and walks on the
pathological discrimination of the spinal spot for 80 to 100 steps. The craniocorpograph
vestibular system. The basis of craniocorpo- test considers walking deviation and lateral
graphy is the Unterberger test, established as balance of the patient and provides more
the most sensitive method for accurate clinical explicit information allowing better discrimi-
studies of the spinal vestibular system. nation between central and vestibular peri-
Unterberger gave special consideration to the pheric perturbations or a combination of both.
rotation of the human body in the slow phase Rapidity of the craniocorpograph test
of the nystagmus after a caloric stimulation. makes it useful for group screening, exami-
In the craniocorpograph test, which does nation of children, industrial medical check-
not last more than sixty seconds, the patient ups, legal medicine, driving test, etc.
48 Textbook of Ear, Nose and Throat Diseases
Anotia
This refers to the absence of the pinna.
Fig. 6.1: Microtia
Microtia
This is the term for an abnormally small
and deformed pinna (Fig. 6.1), while macro-
tia indicates an abnormally large pinna. The
cases of absent pinna can be given a prosthesis
or treated by plastic reconstruction using
moulded rib cartilage.
Accessory Auricles
These present as small elevations of skin often
containing the cartilage, just in front of the
tragus or the helix (Fig. 6.2). They need
surgical removal if the patient desires. Fig. 6.2: Accessory auricles
Congenital Diseases of the External and Middle Ear 49
Darwin’s Tubercle
It is small elevation on the posterosuperior
part of the helix. This is an inherited condi-
tion and is homologus to the tip of the ear in
mammals.
Wildermuth’s Ear
The antihelix is more prominent than helix.
The lobule may be absent or adherent to the
Fig. 6.3: Preauricular sinus side of the head.
These are blind tracks lined by squamous This deformity consists of an abnormal
epithelium occurring in the region of the protrusion of the pinna with absence of the
auricle, usually near the tragus and root of the antihelix. Major degrees of the deformity
helix. These arise because of incomplete fusion require surgery, the aim is to create an anti-
of the tubercles during development (Fig. 6.3). helix and thus reduce the prominence of the
auricle.
Collaural Fistulae Lop ear is a more severe variant of bat ear.
These have an upper opening in the floor of
the external auditory meatus and the lower Anomalies of the External Auditory Canal
opening behind the angle of jaw at the ante- The congenital abnormalities of the external
rior border of sternomastoid. auditory canal may present as follows:
These skin tracks usually get infected and, i. Complete atresia
therefore, are treated by dissection of the tract ii. Shallow depression
and excision. The tract may lie deep to facial iii. Changes in the curvature of the canal.
nerve. These conditions are usually associated
with abnormalities of the middle ear. The
Dermoid Cysts
malformed external canal is usually filled with
These may occasionally occur in relation to dense bone, sometimes cartilage and dense
the pinna. fibrous tissue may also be present.
50 Textbook of Ear, Nose and Throat Diseases
7 Diseases of the
External Ear
PERICHONDRITIS
It is the inflammation of the perichondrium
of the auricular cartilage.
Aetiology
It may be due to infection following trauma
Fig. 7.1: Perichondritis (right pinna)
of the pinna itself or to the cartilaginous
meatus due to spread of infection from a inflammatory drugs. Magnesium sulphate
furuncle, or may follow an operative proce- paste may be applied. If the condition does
dure on the ear. Sometimes the infection may not respond to conservative treatment and
follow an insect bite. proceeds to abscess formation, then multiple
Clinical Features incisions are given to drain the pus and pres-
sure bandage is applied.
The patient complains of burning pain in the
ear. HAEMATOMA OF THE AURICLE
The pinna is red hot, swollen and markedly
tender. Since the perichondrium carries the Trauma to the auricle is common in boxers.
blood supply to the auricular cartilage, it may This results in formation of a tense fluctuant
get necrosed and may crumble producing a swelling under the auricular skin. A little
deformed pinna (Fig. 7.1). collection of blood may not require any treat-
ment except pressure bandage but a big
Treatment haematoma requires aspiration or incision
Systemic antibiotics are given in heavy doses drainage with pressure dressing to prevent its
in addition to the analgesics and anti- recurrence. Antibiotics are given to prevent
52 Textbook of Ear, Nose and Throat Diseases
secondary infection. Recurrent injury, parti- Otitis externa may be acute or chronic, and
cularly in boxers and wrestlers produces a localised (furunculosis) or diffuse. It is also
deformity of the pinna called cauliflower ear or classified as infective and reactive otitis
boxer’s ear. externa.
The common symptoms of this disease are Itching and irritation in the ear are common.
itching, pain, discharge and excessive desqua- The patient may complain of discomfort in the
mation. Sometimes impairment of hearing ear which may amount to actual pain. Some-
may also be a complaint. times a scanty discharge is also present.
The canal appears narrowed, and the skin The canal wall is hyperaemic and the
is red, swollen and dry. The epithelial debris fungal debris is seen in the canal with some
may be seen filling the canal. The discharge is discharge.
scanty, thick and foul smelling. Aspergillus niger produces black colonies
The tympanic membrane should be and Candida albicans presents as white
examined by gently passing the speculum into granules resembling wet blotting paper. When
the canal. Scalp and other areas of the skin the debris is removed, the tympanic memb-
are examined for skin lesions. rane looks normal.
54 Textbook of Ear, Nose and Throat Diseases
If the foreign body is in the outer part of Syringing Syringing of the ear may be neces-
the canal, an ear hook may be useful for its sary to remove the wax or a foreign body. It
removal by expert with the patient in the should not be done if there is perforation of
proper position. the tympanic membrane or a history of ear
The foreign bodies lying deep in the discharge.
meatus in children and in patients who are The patient is seated in a proper position
apprehensive are removed under general with the head stabilised and suitably drapped
anaesthesia. Impacted foreign bodies may to prevent water spilling on his clothes. The
need a postaural approach for removal. water for irrigation (usually tap water) is
brought to the body temperature. A proper
IMPACTED WAX IN THE EXTERNAL
sized syringe is filled with this water and the
CANAL
jet of water from the nozzle is directed along
Wax is a mixture of secretions of the ceru- the posterosuperior canal wall. The fluid and
minous and sebaceous glands of the external the debris are collected in the kidney-shaped
auditory canal. It also contains shedded
tray held below the ear. A few syringefuls of
epithelium and dust particles.
fluid may be needed for proper removal of the
Clinical Features wax. If the wax or foreign body is directly hit
by the stream of water it moves deeper and
The wax may get accumulated and impacted
may get impacted. Excessive force used while
in the canal wall producing symptoms of
syringing may damage the canal wall or the
deafness, discomfort, itching and pain. The
tympanic membrane. If the water used is not
pain occurs because of pressure on the nerve
at body temperature, it produces caloric
endings. Tinnitus and vertigo may occur.
stimulation with symptoms of giddiness and
The external canal shows a dark brown
vomiting. The canal should be mopped dry
plug of wax filling the canal and obscuring
the view of the tympanic membrane. after syringing.
8 Diseases of the
Eustachian Tube
9 Acute Suppurative
Otitis Media and
Acute Mastoiditis
Symptoms
Stage of exudation As the inflammatory process
progresses, an exudate collects in the The pain in the ear which had diminished in
tympanic cavity. The patient complains of intensity following the stage of suppuration
marked pain in the ear with deafness. The intensifies with increase in deafness and
tympanic membrane shows bulging and looks profuse discharge continues to drain from the
more congested. Constitutional symptoms like ear. Constitutional symptoms like fever and
fever and malaise occur. bodyache recur. Diagnosis is radiological with
Stage of suppuration The pent up inflammatory X-ray mastoids or CT temporal bone con-
exudate causes pressure necrosis and firming the diagnosis.
perforation of the tympanic membrane. The
Clinical Signs in Acute Mastoiditis
perforation is central. The intensity of pain
diminishes but hearing loss persists. The Ear discharge, usually profuse, purulent or
mucosa of the middle ear if seen through the creamy, for more than 2 weeks duration
perforation is much congested and thickened. following an attack of acute suppurative otitis
The discharge is serosanguinous at the onset media is an important sign of coalescent
and mucopurulent later on. Figures 9.3A to D mastoiditis. The discharge may be pulsatile.
60 Textbook of Ear, Nose and Throat Diseases
Fig. 9.3C: Posterior marginal perforation Fig. 9.3D: Attic perforation (with cholesteatoma)
(with granulations)
Sagging of the posterosuperior canal wall children and infants pus collects over
occurs due to periostitis adjacent to the Macewen’s triangle and can pass along
antrum. vascular channel of lamina cribrosa. It is
The mucosa of the middle ear through a to be differentiated from furunculosis of
central perforation of the tympanic memb- posterior meatal wall as it pushes pinna
rane, if visible, shows marked congestion and forwards to downwards and obliterates
thickening. the retroauricular sulcus (Figs 9.4A and
Mastoid tenderness is another significant B).
sign that occurs as the inflammatory process
ii. Zygomatic abscess It is due to infection of
reaches the cortex.
zygomatic air cells situated at the
Abscesses in Relation to Mastoiditis posterior root of zygoma. Swelling
i. Postaural abscess This is most common appears in front of and above the pinna
form presenting over mastoid. In young (Fig. 9.5). There may be associated
Acute Suppurative Otitis Media and Acute Mastoiditis 61
Treatment
Acute suppurative otitis media In the initial
stages of the disease, nasal decongestants,
antihistaminics, analgesics and antibiotics like
Fig. 9.5: Zygomatic abscess left side
amoxycillin, ampiclox or cephalosporins are
given for about 1 to 2 weeks time to cure the
oedema of upper eyelid. Pus here collects disease. Attention should be given to any nasal
superficial or deep to temporalis muscle. or nasopharyngeal pathology.
62 Textbook of Ear, Nose and Throat Diseases
10 Chronic Suppurative
Otitis Media
Pathology
1. Persistent mucosal disease: Infection reaches
the middle ear either through the
eustachian tube or through a perforated
tympanic membrane. Repeated infection of
middle ear leads to hyperplasia of its
mucosa. These hyperplastic mucosal
proliferations trap the infection which is
responsible for its chronicity. In some cases
especially in sclerotic mastoids, mucosal
proliferation leads to polyp formation (Figs
10.1A and B).
2. Cholesterol granuloma: The middle ear gets
ventilated through the eustachian tube.
When there is mucosal hypertrophy it may
block the posterior portion of the
tympanum, thus creating vacuum which Figs 10.1A and B: Aural polyp
Chronic Suppurative Otitis Media 65
2. Tympanic type: It is usually seen in adults mality of the nose, paranasal sinuses and
who complain of deafness and repeated nasopharynx, and if found, it should be
infection of the ear. On examination, adequately treated.
discharge is seen in the external auditory 2. Aural toilet: Daily aural toilet is an essential
canal. A large central defect is visible in the step for keeping the ear dry. This may be
tympanic membrane. Granulations and done by dry mopping, i.e. cleaning the ear
polypi may be seen in the middle ear. with a sterile cotton tipped probe. Aural
These patients complain of improved toilet is better performed under the
hearing when the external auditory canal microscope and the ear examined in detail
is full of pus, which deteriorates when the for any pathology that may otherwise be
pus is mopped off. This is because pus seals missed by the naked eye.
the defect of the tympanic membrane so 3. Culture sensitivity: Culture sensitivity of the
that the transmission of sound waves is discharge is done to select proper antibio-
better in the presence of pus. tics. Both systemic as well as local anti-
Patch test A cigarette paper or a piece of biotics are used. Local antibiotics are used
gelfoam is placed on the tympanic membrane as ear drops and include neomycin, genta-
perforation and the patient asked if he hears micin, quinolones and chloramphenicol
better. If the hearing improves it means that with or without hydrocortisone.
the patient will be benefited by myringoplasty
alone. Surgical Management (Tubotympanic Type)
The aim of surgery is to provide a safe, dry
Investigations
and a hearing ear.
1. Tuning fork tests and pure tone audio- 1. Adenoidectomy, septoplasty and antrum
metry is done for hearing assessment. washes may be required in some cases,
2. Culture sensitivity test of the discharge where the predisposing factors are in the
helps in selection of proper antibiotics. nose and paranasal air sinuses.
3. X-ray of the mastoids and paranasal 2. Aural polypectomy: Aural polypectomy
sinuses may be needed in some cases. should be done under general anaesthesia
4. Examination of the ear under microscope. using the microscope. The aural polyp
should be removed with utmost care as it
Treatment of Tubotympanic Disease may be attached to the oval or round
The aim of the treatment is to control the window or the facial nerve.
infection, treat the underlying cause, keep the 3. Myringoplasty: When the ear has become
ear dry and finally reconstruct the hearing dry, the tympanic membrane defect should
mechanism. be sealed off so as to prevent further
1. Treatment of underlying cause: Proper infection of the middle ear as well as to
attention should be paid to any abnor- improve the hearing.
Chronic Suppurative Otitis Media 67
Classification
Cholesteatoma is classified as congenital or
acquired.
The acquired variety is further divided into
primary acquired cholesteatoma, and
secondary acquired cholesteatoma.
Fig. 10.3: Postaural fistula Congenital cholesteatoma Cholesteatoma is
thought to be of embryonic origin. It is
adjacent structures with resultant compli- believed that during development, epithelial
cations and hence it is termed dangerous or cell nests get trapped in the parietal bone or
unsafe variety of chronic suppurative otitis elsewhere in the skull, continue to desquamate
media (Fig. 10.3). The main pathological and enlarge causing bony destruction. It is
feature is the formation of “cholesteatoma” most commonly found in the middle ear or
and the inflammatory granulation tissue within the temporal bone particularly the
which cause erosion of the bone. petrous apex. CT is confirmatory.
11 Complications of Chronic
Suppurative Otitis Media
occur are given in Table 11.1 and shown in operations on the stapes or through prefor-
Figure 11.1. med pathways like fracture lines.
In chronic suppurative otitis media,
Labyrinthitis
cholesteatoma may cause erosion of the
Pyogenic inflammation of the labyrinth may semicircular canals, usually of the lateral
result from acute otitis media, following semicircular canal or the stapes footplate and
promontory, thus exposing the labyrinth to
Table 11.1: Complications of CSOM the infective process.
Meningeal Nonmeningeal
Similarly removal of polypi or granula-
tions arising from the promontory may result
1. Extradural abscess 1. Mastoiditis
in labyrinthitis.
(Refer pages 59 and 60)
2. Perisinus abscess 2. Petrositis Labyrinthitis may be circumscribed
3. Venous sinus 3. Facial nerve paraly- (paralabyrinthitis) or diffuse.
thrombosis sis (Refer page 101) In the circumscribed variety the bony capsule
4. Otitic hydrocephalus 4. Brain abscess
5. Meningitis 5. Labyrinthitis
is eroded and membranous labyrinth is
6. Subdural abscess 6. Retropharyngeal exposed (fistula formation). Labyrinthitis is
abscess localised to the area of the fistula only. The
(Refer page 294) patient complains of attacks of dizziness with
72 Textbook of Ear, Nose and Throat Diseases
nausea and vomiting in addition to the ear which means mastoid exploration and
discharge. removing the disease process. Antibiotics
In diffuse labyrinthitis, depending upon the only control the infection and prevent its
severity of the infection the attack may be further spread. Before undertaking surgery,
mild, when the inflammatory exudate is the hearing level and the condition of the
serofibrinous with only a few round cells. other ear must be known for if the affected
This type is called diffuse serous labyrinthitis. If ear is functionally better, then an attempt
the inflammatory process continues the should be made to preserve the labyrinth at
exudate becomes purulent, then the condition operation.
is known as diffuse purulent labyrinthitis. The In more extensive cases, where the whole
patient suffers from severe attacks of vertigo. labyrinth is involved and destroyed with loss
The infective process from the labyrinth may of function, labyrinthectomy should be
cause intracranial complications. performed so that no pockets of the infection
The vestibular symptoms like dizziness, persist.
vomiting and loss of balance are the more
important presenting symptoms. The patient Otogenic Intracranial Infection
lies on the sound ear and looks towards the Infection spreads from the middle ear cleft
diseased ear. The hearing is not markedly to the intracranial structures usually directly.
affected in serous labyrinthitis. In purulent It may travel upwards into the middle cranial
labyrinthitis the vestibular symptoms are fossa or backwards into the posterior fossa.
more severe in nature with intense giddiness, The infection passes through the planes of
frequent vomiting and marked deafness. the dura mater, venous sinuses, subdural
Spontaneous nystagmus is present towards space and pia-arachnoid to the brain tissue.
the healthy side. The patient lies in bed curled Coalescent bony erosion in acute otitis
up on the side of his healthy ear. Vomiting media or the cholesteatoma in chronic otitis
may persist for a few days. media exposes the adjacent structures to the
The recovery usually starts after two infective process. When the infection reaches
weeks and is complete within 4 to 6 weeks of the dura or the sinus wall, these tissues
the attack as by this time the central mecha- respond by the formation of granulations and
nism compensates for the loss of one labyrinth. there may occur extradural and perisinus
Treatment abscess.
If the dura fails in limiting the infection,
Labyrinthitis arising from an attack of acute it gets necrosed and subdural abscess may
otitis media is treated by an intensive course occur from where the meninges get involved.
of antibiotics besides other general measures
like bed rest and prescribing vestibular Invasion of brain tissue Thrombophlebitis of the
sedatives. blood vessels or the venous sinuses occurs
Labyrinthitis which is due to chronic ear as the result of infection and it is thought to
disease is an absolute indication for surgery, be the cause of invasion of the brain tissue.
Complications of Chronic Suppurative Otitis Media 73
The infection may also travel to the brain abscess and evacuating its contents by the
tissue through the perivascular space. Focal removal of the bone till the healthy dura is
necrosis and liquefaction may follow, with exposed.
abscess formation in the brain. The abscess
cavity gets encapsulated, expands and Sinus Thrombophlebitis
presents as a space-occupying lesion.
Lateral sinus thrombosis occurs due to direct
extension of the disease from the mastoid and
Clinical Features of the Intracranial Infection
is often preceded by the perisinus abscess.
In an ear disease, threatening intracranial Thrombosis generally follows a chronic ear
spread, the patient may complain of head- disease and Streptococcus haemolyticus is a
ache, vomiting, and nausea. The site and common causative organism, although other
severity of the headache is variable. Changes gram-negative organisms like E. coli, Pseudo-
occur in the temperature and pulse rate. monas pyocynaeus, etc. have been isolated.
Changes in the level of consciousness may Thrombosis of the sinus is a response to the
occur, drowsiness progressing to coma infection and an attempt to limit the disease
occurs in an uncontrolled disease. Giddiness process. As the infection spreads, thrombosis
may be a feature, indicative of labyrinthine may extend to the adjacent continuing
or cerebellar involvement. In an established sinuses. A cerebellar abscess may develop and
intracranial disease, epileptic fits may occur. septicaemia usually follows.
Neck rigidity results from irritation of the
basal meninges. Nystagmus is common in
Clinical Features
cerebellar abscess. Aphasia is an evidence of
the involvement of the dominant hemisphere. The patient with an ear disease presents with
rigors. The temperature shows sudden rise
Extradural Abscess and fall. There occurs severe shivering and
profuse sweating. The fever is of the
Extradural abscess is the most common
otogenic intracranial complication. It consists remittent type (picket-fence curve). Between
of collection of pus between the bone and the attacks the patient seems well. There may
the dura mater. It may develop in the middle occur thrombosis of the mastoid emissary
or the posterior cranial fossa. vein, with resultant oedema over the mas-
toid process (Greisinger’s sign). In advanced
Clinical Features stages, changes of the intracranial haemo-
dynamic system may occur and the patient
Headache in acute or chronic otitis media may
may present with a cerebellar abscess.
be the only suggestive feature. The patient
has a feeling of being unwell. He complains Lillie-Crowe test or sign This helps to decide
of malaise and may have low grade fever. which lateral sinus is diseased. When one
Most cases are diagnosed at the time of ear lateral sinus is occluded by thrombosis, digital
surgery. Treatment consists of opening the compression of the opposite jugular vein
74 Textbook of Ear, Nose and Throat Diseases
destruction towards the ventricles. Subse- Aphasia Abscess of the dominant temporal
quently cerebral oedema, encephalitis, focal lobe interferes with speech. Nominal aphasia,
necrosis and liquefaction occurs. The micro- i.e. inability to name the common objects is
glial and mesodermal tissues of the blood frequent.
vessels try to limit the spread by the As the abscess spreads involvement of the
formation of a capsule of fibrous tissue motor tracts occurs and manifests as paralysis
around the abscess. The capsule may even of the limbs. Ocular paralysis may be the
undergo hyaline degeneration and calcifi- presenting feature of temporal lobe abscess.
cation.
Finally, an abscess may rupture into the Signs of Cerebellar Abscess
ventricle or subarachnoid space. An expand- 1. Nystagmus which is usually horizonto-
ing abscess and the associated oedema cause rotatory, slow, coarse with the quick
a rise in intracranial pressure with tentorial component towards the diseased side.
herniation and impaction of cerebellar tissue. 2. Muscle incoordination occurs, which is
The commonly found organism in the detected by dysdiadochokinesia and the
brain abscesses are Staphylococcus aureus, finger nose test.
Staphylococcus albus, Streptococcus pyogenes, 3. Asynergia on walking, the patient
gram-negative organisms like E. coli, B. staggers to the side of the lesion.
proteus, Pseudomonas pyocynaeous and anaero- 4. Romberg’s sign is positive, i.e. the patient
bic bacteria. when asked to stand with heels together
and eyes closed, falls towards the side of
Clinical Features the lesion.
The initial invasion of brain tissue is obscu- 5. Muscular atonia and pendular tendon jerks
red by other intracranial complications like are other features of cerebellar abscess.
meningitis or sinus thrombosis. The signs and
Management of Otogenic Brain Abscess
symptoms are those of increased intracranial
tension and focal symptoms depending upon Once the brain abscess is suspected, the
the part of the brain involved. opinion of the neurosurgeon should be
The initial presenting features are obtained and the patient investigated.
headache and vomiting followed by drowsi- 1. Funduscopy gives a clue about papill-
ness and the changes in pulse and tempe- oedema.
rature. As the disease progresses, drowsi- 2. Provided there is no marked rise in intra-
ness proceeds to stupor and coma. cranial pressure, lumbar puncture may be
done.
Focal Signs 3. Plain X-ray of the skull may show a dis-
Visual field In temporal lobe abscess, peri- placed pineal body or gas within the
metry may demonstrate homonymous abscess cavity. The other important
hemianopia. localising investigations include angio-
76 Textbook of Ear, Nose and Throat Diseases
12 Nonsuppurative
Otitis Media and
Otitic Barotrauma
The eustachian tube has two parts, the conscious of an increasing feeling of fullness
medial collapsible part and lateral rigid patent in his ears and an increasing depression of
part, so air can be blown through it easily but auditory acuity, until he feels a cracking at the
it cannot be sucked out. Thus the pressure back of his nose, when the discomfort in his
difference does not occur during ascent in an ear disappears and his hearing returns to
aircraft when the middle ear pressure tends normal.
to be higher than the atmospheric pressure, The two ears may not react synchronously
but it occurs during descent when the middle so that the patient may feel alternating
ear pressure becomes progressively lower discomfort and deafness in the two ears. This
than the atmospheric pressure and, therefore, is not normally painful but in a person who
air tries to suck in through the eustachian tube. has suffered recently from barotrauma the
This is not possible unless the eustachian tube drum becomes very sensitive to stretching and
is actively opened by muscular action. So, pain is very easily induced.
symptoms develop during descent both in a During descent in an aircraft (unlike
aircraft and in deep sea diving. ascent) pressure equalisation in the middle ear
does not take place passively and with the rise
Pathology in atmospheric pressure, an unequal loading
Patients with complete physical obstruction of the two surfaces of tympanic membrane
of the eustachian tube suffer from atmospheric develops which results in impaired hearing.
pressure changes. They first feel severe pain The tympanic membrane becomes indrawn,
on ascent in an aircraft and the pain is relieved and a feeling of discomfort becomes notice-
either by rupture of the drum or by descent. able. The patient then swallows, the eusta-
chian tube opens and symptoms are relieved
Pressure equalization Potentially patent or
by a rush of air into the middle ear. The
completely obstructed eustachian tubes fail to
sequence then begins again.
maintain adequate pressure equalisation
If swallowing does not help, the patient
during rapid changes of atmospheric pressure.
attempts the Valsalva’s manoeuvre and if this
During ascent the relative pressure in the
too is not successful, the continued descent
middle ear rises. The tympanic membrane
increases the symptoms until pain becomes
bulges outwards, increasing the capacity of
intense and deafness severe.
the middle ear cavity, thus limiting slightly
the pressure increase. Finally, the elasticity of Pressure changes Atmospheric pressure does
the eustachian tube is overcome and air is not increase in direct proportion to the dec-
discharged through the tube and pressure is rease in altitude. Pain and physical changes
equalised. This is a passive procedure and in the middle ear are partly due to the
requires no active measures to be taken by the atmospheric pressure displacing the tympanic
subject, though equalisation takes place much membrane inwards but mainly due to the
earlier if the subject swallows. If he does not negative pressure leaving the walls of the
swallow or move his pharynx he will be blood vessels in the mucosa unsupported.
80 Textbook of Ear, Nose and Throat Diseases
Adhesive otitis media is a condition marked Signs The tympanic membrane shows
by adhesions that developed as a result of retraction and chalk patches. Mobility of the
previous inflammation in the middle ear membrane is impaired and scarring may be
cavity. present. Tuning fork tests and audiometry
show conductive deafness.
Aetiology
Treatment
Most otologists believe adhesive otitis media
is a complication of inadequately treated acute Some cases of adhesive otitis media with
otitis media. The condition may follow chronic adequate hearing require no treatment.
suppurative otitis media or secretory otitis Patients with marked deafness may either
media. be prescribed a hearing aid or advised surgery.
However, the results of surgery are not always
Pathology successful because of further adhesion
formation.
Pathological changes occur both in the middle The surgical procedures undertaken are
ear mucosa and the tympanic membrane. the following:
Adhesions develop by way of organisation of 1. Grommet insertion
the inflammatory exudate and connective 2. Exploratory tympanotomy wherein adhe-
tissue proliferation from the inflamed mucosa. sions are broken, ossicles and membrane
The mobility of the ossicles and the membrane freed and silastic sheets are placed in the
is diminished and ankylosis of the ossicles middle ear cavity to avoid further
may occur. adhesions.
plaques of collagen with calcareous deposits when the tympanic membrane is normal and
in the submucosa of the middle ear cavity. only the ossicles are involved. There is no
When confined to the tympanic membrane, it family history but a past history of otitis media
is called a chalk patch or Myringosclerosis. is usually present. Tympanotomy may be
Small plaques may not hamper the func- needed to differentiate the two conditions.
tioning of the middle ear but larger deposits
on the oval window hamper hearing. Treatment
Tympanosclerosis is usually an end result of Small plaques may not need any treatment.
otitis media when healing takes place and Chalk patches can be removed before placing
excessive collagen gets deposited. The exact the graft in myringoplasty. If the ossicles are
aetiological factor remains unknown though involved, removal of the tympanosclerotic
the drying effect of air to which the middle deposits does not help as there occurs scarring
ear is exposed after perforation and severe and adhesions. Silastic sheets may be put in
acute otitis media may be the causative factors. to prevent adhesion formation.
Studies have demonstrated the presence of In fixation of the foot plate of stapes, stape-
tympanosclerosis in 40 per cent of children dectomy may be helpful but in more severe
with ventilation tubes. Tympanosclerosis may cases fenestration is the method of choice for
be difficult to differentiate from otosclerosis restoration of hearing.
82 Textbook of Ear, Nose and Throat Diseases
14 Mastoid and
Middle Ear Surgery
Indications
1. Acute mastoiditis refractory to Medical
treatment
2. Masked mastoiditis
3. Subperiosteal abscess
4. Bezold’s abscess
5. Labyrinthectomy
6. Preliminary to exposure of saccus endo-
lymphaticus for Menier’s disease
Steps of Operation
The hair is shaved for about 5 cm round the
ear. A curved incision is made 1.25 cm behind
the pinna. The upper end of the incision
extends anteriorly above the auricle to the
level just above the external auditory canal
while the lower end extends to the mastoid
Fig. 14.1:Types of mastoidectomy tip. The incision is deepened right to the bone
and after cauterizing the bleeding points a self-
retaining mastoid retractor is applied. The
mastoid cortex is exposed and Mecewen’s
triangle is identified. Removal of the bone is
started in this area either using an electric drill
or a hammer and gouge. The mastoid antrum
is identified by seeing the aditus in its anterior
wall and the lateral semicircular canal in its
medial wall. The mastoid cells are then traced
and removed. The wound is closed with
Fig. 14.2:Instruments used for mastoid surgery interrupted silk sutures after putting a
corrugated drain at the lower end of the
mastoid air cells without disturbing the wound. A pressure dressing is applied. The
middle ear. The osseous superior and external auditory canal is packed with a ribbon
posterior meatal walls are kept intact. The cells gauze.
84 Textbook of Ear, Nose and Throat Diseases
preserve hearing. The procedure is similar to materials like fat, blood clots, temporalis
radical mastoidectomy in that the superior muscle and cortical bone have been used for
and posterior osseous meatal walls are this purpose.
removed, meatal flap constructed and the
cavity is exteriorised. TYMPANOPLASTY
Atticoantrostomy (Bondy’s mastoidectomy) This is an operative procedure of reconstruc-
is a type of modified radical mastoidectomy tion of the sound conducting mechanism of
which is indicated for cases of primary the middle ear. This is based on the following
acquired cholesteatoma with perforation in principles.
the pars flaccida and intact pars tensa with 1. Restoration of sound pressure transformer
the disease limited to the attic and antrum. mechanism of the middle ear.
2. Sound protection of the round window.
Atticotomy (epitympanotomy) This is a proce-
Various types of tympanoplasty techni-
dure used when cholesteatoma is limited to
ques are aimed to achieve these physiological
the epitympanic or attic region. The cavity is
principles.
widely exposed and subsequently cleaned.
Mastoidectomy with tympanoplasty This Prerequisities of Tympanoplasty
operation involves the eradication of disease 1. There should be adequate air-bone gap
in the middle ear and mastoid and to recons- with good cochlear reserve.
truct the hearing mechanism. It is indicated 2. The middle ear and mastoid should be free
in those cases where the disease is widespread of disease to ensure success of the recons-
throughout the mastoid and middle ear. It is tructive procedure.
then necessary to completely eradicate the 3. The eustachian tube should ideally be
disease in the mastoid which can only be done functioning to allow proper aeration of the
by the removal of the posterior canal wall. The middle ear cleft, which is necessary for
principles of radical mastoidectomy apply and optimal functioning of the ossicular chain
the goal is to achieve eradication of disease and tympanic membrane.
and exteriorisation of the mastoid cavity with
reconstruction of the sound conducting Types of Tympanoplasty
mechanism. It may be done as a one-stage Based on the physiological principles, there
procedure or as a two-stage procedure. are five types of tympanoplastic proce-
dures(Wullstein’s tympanoplasty technique)
Mastoid Obliteration Operation (Fig. 14.3).
The aim of the operation is to eradicate the Myringoplasty This means repair of the
disease when present and to obliterate the tympanic membrane perforation only.
mastoid cavity to lessen the problems of Type I Includes myringoplasty but also
permanent cavity in the mastoid. Various involves exploration of the middle
86 Textbook of Ear, Nose and Throat Diseases
Contraindications of Tympanoplasty
1. In presence of residual disease like
cholesteatoma.
2. In ear disease with intracranial compli-
cations.
3. Malignant disease of ear.
4. High-risk patients like diabetics, who are
prone to fulminating infections.
Prosthesis in use for reconstruction of the
Fig. 14.3:Various types of tympanoplasty:A. Type I, ossicles include cartilage struts strengthened
B. Type II ‘a’, C.Type II ‘b’, D.Type II ‘c’, E.Type III,
with stainless steel wires, cortical bone pieces,
F.Type IV, and G. Type V
homograft ossicles and synthetic material like
ear to rule out any other pathology. total ossicular replacement prosthesis (TORP)
Ossicular chain is intact and mobile. and partial ossicular replacement prosthesis
Type II Malleus handle is absent, recons- (PORP).
truction of the tympanic membrane
is done over the malleus remnant Combined Approach Tympanoplasty
and the long process of incus. (CAT)
Type III The malleus and incus are missing.
This operative procedure was developed and
The reconstruction is done by
placing the tympanic membrane promoted, as an alternative to wide access
graft over the head of a mobile stapes techniques in the management of chronic
(Columella type as in birds). suppurative otitis media.
Type IV There is loss of middle ear compo- A combined approach implies a combined
nents. A shallow cavity is construc- access, transmeatal and transmastoid on either
ted by placing the graft over the side of an intact posterosuperior bony canal
round window to create a hypotym- wall.
panic air bubble. The mobile foot Soft tissue approach is by the postaural
plate of stapes is exposed to sound incision. Periosteal tissues are separately
waves. incised and elevated. Bone over the mastoid
Type V There is loss of middle ear compo- cortex and the root of zygoma is exposed.
nents and the footplate of stapes is Meatal skin is elevated from the postero-
fixed. Fenestration of the lateral superior aspect of the meatus and then in
semicircular canal is done for sound continuity with the surface epithelium of any
waves to enter the ear. The round tympanic membrane remnant.
window is shielded by the graft. This Cortical mastoid operation is performed
type of reconstruction is very rarely and the incus and head of malleus are exposed
done these days. in the attic. Posterior tympanotomy is done
Mastoid and Middle Ear Surgery 87
15 Otosclerosis
Tuning fork tests reveal conductive iv. A fluid level may be visible.
deafness. v. Impedance audiometry shows reduced
compliance and negative pressure.
Gelle’s test Place a vibrating tuning fork on
2. Adhesive otitis media
mastoid process, then increase pressure in
i. A history of previous middle ear disease
external auditory canal by Seigle’s speculum
is usually available.
and ask patient if there is any change in
ii. Conductive deafness is usually uni-
intensity of sound after increasing the pressure
lateral.
in E.A.C. In normal subjects there will be
iii. The tympanic membrane shows areas of
decrease in perceived sound whereas in
scarring and chalk patches and is
otosclerosis there will be no change as the
retracted with restricted mobility.
footplate of stapes is already fixed.
3. Ossicular chain disruption
Tympanometry may reveal a A’s’ type of
i. The history is suggestive of head injury
curve. Pure tone audiometry usually shows
or previous ear surgery.
bilaterally symmetrical air bone gap and in
ii. It is usually a unilateral condition.
few cases may show a dip in the bone con-
iii. Impedance audiometry shows increased
duction curve (Carhart’s notch).
compliance.
Carhart’s notch This is a pure tone audiometric iv. Stapedial reflex is absent.
finding and is characteristic of otosclerosis. v. Tympanotomy is diagnostic.
There is a dip in the bone conduction curve 4. Congenital ossicular fixation
which corresponds to 5 db loss at 1000 Hz, i. Deafness is present since birth, is
10 db loss at 1500 Hz and 15 db loss at 2000 nonprogressive, and usually unilateral.
Hz and then back to 5 db loss at 4000 Hz. This ii. Associated congenital abnormalities are
is probably due to the loss of the insertial present.
component of the foot plate of the stapes, iii. Tympanotomy gives the final diagnosis.
which is fixed in otosclerosis. 5. Vander Hoeve’s syndrome
Blue sclerae with osteogenesis imperfecta
Differential Diagnosis of Otosclerosis
constitute this syndrome. There are usually
The following diseases with an intact pathological fractures in long bones. When
tympanic membrane producing conductive the temporal bone is involved, it may
deafness are commonly confused with simulate otosclerosis. The Schwartze sign
otosclerosis. The characteristic features of is absent and acoustic reflex cannot be
these conditions are considered below: elicited.
1. Secretory otitis media 6. Paget’s disease
i. The disease is common in young This is a disease of bones in which osteo-
children. lytic and osteoblastic processes cause
ii. Earache may be the presenting feature. softening of the bones, fractures and
iii. The tympanic membrane is dull, may be deformities. When the temporal bone is
retracted and shows restricted mobility. involved it can lead to deafness like in
Otosclerosis 91
otosclerosis. The stapedial reflex is always 1. Bypassing the stapes: This involves making
present, and the Schwartze sign may also an opening in the lateral semicircular canal
be present. Radiological examination (fenestration operation). This produced an
shows osteolytic lesions of the bones with open mastoid cavity and the patient
mottled appearance. suffered from residual hearing loss, so the
7. Tympanosclerosis procedure did not gain favour.
Chalk patches will be seen on the tympanic 2. Mobilisation of the stapes: The ankylosed
membrane, a conductive hearing loss is stapes was mobilised at the operation.
seen, there is a previous history of middle However, the hearing improvement only
ear disease and tympanometry will show proved partial and reankylosis of the
reduced mobility. stapes occurred frequently.
8. Persistent Stapedial artery 3. Stapedectomy (Shea’s technique): This is the
This is a rare condition in which the large treatment of choice nowadays. The stapes
artery covers the footplate and immobilizes is removed and replaced by a prosthesis
the stapes, resulting in conductive like teflon piston, wire, gelfoam, stainless
deafness. Tympanotomy is diagnostic. steel piston and similar other prosthesis.
Treatment Stapedectomy
Majority of the patients with deafness due to Operative Procedure
stapedial otosclerosis can be assisted either by
It is usually done under local anaesthesia but
medical or surgical methods.
may be done under general anaesthesia.
Medical treatment The prescription of a hearing Permeatal incision is made from the 6 O’clock
aid can help patients overcome the difficulty to 12 O’clock position, 6 mm lateral to the
in hearing. The function of the hearing aid is tympanic annulus at the centre. The tympano-
to amplify the sound waves and this over- meatal flap is elevated, the chorda tympani
comes the resistance to sound transmission. nerve is identified and preserved and any
Hearing aid is advised when surgery is contra- bony overhang of the posterior canal wall
indicated or refused by the patient. In the early removed. The ossicles are palpated with a
stages of the disease sodium fluoride 20 mg probe and stapedial fixation is confirmed. The
thrice a day for 6 months to 1-2 years has been stapedius tendon is cut, incudostapedial joint
used with varying results. Sodium flouride disarticulated, crura broken and a hole made
reduces osteoclastic bone resorption and in the footplate of stapes by a fine straight pick
increases osteoblastic bone formation. which should not go too medially as the utricle
Surgical treatment Rapid advances of surgery lies only 1 mm medial to the footplate of
for otosclerosis have taken place in recent stapes. The stapes should not be moved more
years. The surgery is aimed to allow normal than 0.1 mm. A teflon or stainless steel piston
transmission of sound and has taken three is hooked around the long process of incus
main directions. and fitted in the hole made in the footplate of
92 Textbook of Ear, Nose and Throat Diseases
Osteoma
Osteoma is a smooth, solitary, rounded,
pedunculated tumour from the outer part of
the bony meatus, usually from the region of
tympanosquamous or the tympanomastoid
suture. Treatment is removal by cutting
through the pedicle.
Adenoma
Fig. 16.3: Rodent ulcer on nose and left Benign tumours may arise from both the types
preauricular area of glandular tissues in the external canal. So,
the adenoma could be of following types:
the border of helix, meatal entrance and the
i. Sebaceous adenoma
tragus. Surgical excision is the treatment of
ii. Ceruminoma.
choice. Advanced cases require wide excision
and postoperative radiotherapy. Sebaceous adenoma The tumour arises from
sebaceous glands and is usually seen as
Benign Tumours of the External smooth, skin covered swelling in the outer
Auditory Meatus part of the meatus. Treatment is surgical
The common benign lesions are exostoses, excision.
osteoma and adenoma, sometimes angioma, Ceruminoma (Hidradenoma) This tumour arises
papilloma, fibroma and chondroma may also from the ceruminous glands of the meatal
occur. skin. The lesion presents as a firm skin covered
mass which may be sessile or pedunculated.
Exostoses
Treatment is wide local excision because
Exostoses present as hemispherical smooth chances of its recurrence and turning malig-
bony outgrowths from the canal wall. These nant are marked.
are usually multiple and the condition is
usually bilateral. The exact cause is not known Malignant Tumours of the
but it was thought that repeated swimming External Auditory Meatus
in cold water could be an aetiological factor.
Carcinoma
Exostoses usually do not produce any
symptoms unless these outgrowths obliterate The external auditory meatus is not a common
the lumen of the canal. site for squamous cell carcinoma. The disease
When exostoses are small and symptom- is usually seen in cases having long-standing
less, no treatment is needed but when these suppurative disease. The patient presents with
96 Textbook of Ear, Nose and Throat Diseases
Adenocarcinoma
The tumour may primarily arise from the
glands of the external auditory canal and its
differentiation from squamous cell carcinoma
is difficult on clinical grounds. Fig. 16.4: Sites where chemodectoma can occur
Biopsy is confirmatory and surgery
followed by radiotherapy is the treatment of
choice. Depending upon the extent of involve-
ment, surgery may be limited to radical
mastoidectomy or even subtotal resection of
the temporal bone may be needed to remove
the disease.
Glomus Tumours
Nonchromaffin paraganglionic tissue is
present in the dome of the jugular bulb or Fig. 16.5: Chemodectoma: Carotid body tumour
along the course of Jacobson’s and Arnold’s Histology
nerve or sometimes in the mucosa of the
middle ear. A tumour arising from this tissue The histopathological features include a
is known as glomus tumour, chemodectoma or highly vascular tissue with sheets of eosino-
nonchromaffin paraganglioma (Fig. 16.4). philic epitheloid cells and nerve fibrils.
These tumours are histologically benign but
locally behave like malignant tumours (Fig. Clinical Features
16.5). According to their location they are The tumour commonly occurs in elderly
named as Glomus Jugulare, arising from the females. Depending upon the origin and
jugular bulb, Glomus Vagale, arising from the spread of the tumour, symptoms may be
vagus and Glomus tympanum, arising from aural, neurological, or combination of the two
the promontory. groups.
Tumours of the Ear 97
1. Aural symptoms: The tumour presents in the Type A Tumour confined to the middle ear.
ear with tinnitus, usually pulsatile, deaf- Type B Tumour confined to the middle ear
ness, and blood-stained discharge. and mastoid without destruction of
2. Neurological symptoms: The tumour which infralabyrinthine part of the tempo-
primarily arises from the jugular bulb ral bone.
subsequently involves the adjacent cranial Type C Tumour in middle ear and mastoid
nerves in the jugular foramen and pro- with destruction of infralabyrin-
duces symptoms of their involvement. The thine part of the temporal bone and
seventh and eighth cranial nerve involve- destruction of the petrous apex.
ment produces asymmetry of the face, Type D Intracranial tumour.
dizziness and perceptive deafness.
Pain is not the usual feature unless Staging of Glomus Jugular Tumour
infection is present. Stage I Tumour limited to hypotym-
panum.
Signs Stage II Tumour involves tympanomas-
Otoscopically a reddish blue mass may be toid cavities.
seen behind the tympanic membrane - a rising Stage III Spreads to intracranial structures.
sun appearance. Investigations
Browne’s sign Increasing the pressure in the 1. Hearing tests may show conductive or
external auditory canal by the Siegle’s sensorineural loss.
speculum makes the tumour mass more 2. X-ray examination of the mastoids is of
prominent and red, with increased pulsations. little value though it may show areas of
As the pressure is increased above systolic bone destruction and elargement of jugular
pressure, blanching occurs and pulsations foramen.
disappear to reappear again on release of the 3. CT scan of temporal bone and posterior
pressure. fossa is valuable. Erosion of jugular plate
Once the tumour perforates the drum-head is diagnostic(Phelp’s sign)
it presents as a bleeding vascular polypoidal 4. A retrograde jugular venogram is often
mass in the canal. A bruit may be heard over helpful in diagnosis and determining the
the ear. Evidence of cranial nerve paralysis extent of involvement.
may be present and mostly the seventh, 5. Carotid angiography is helpful is diagnos-
eighth, ninth, tenth and eleventh cranial ing the extent of the tumour as this tumour
nerves are involved. is usually supplied by the ascending
pharyngeal artery.
Classification of Glomus Jugular Tumour
6. Biopsy from the tumour mass is confir-
Oldring and Fisch’s (1979)
matory but should be done very carefully
Classification of the glomus jugular tumour as the tumour is very vascular and bleeds
is as follows: profusely.
98 Textbook of Ear, Nose and Throat Diseases
17 Otological Aspects of
Facial Paralysis
Bony work across the line of the canal partial paralysis of the muscles of facial
damages the nerve. expression of the whole of one side of the face,
5. During radical mastoidectomy, while of sudden onset and there is no evidence of
removing the outer attic wall or the bony any symptom or sign of disease of the ear or
bridge, the nerve may be cut and hence the central nervous system. It is thought to be an
surgeon should be careful at this stage. autoimmune disease. Probably the paralysis
6. Curettage of the middle ear is not advis- is caused by the ischaemia of the arterioles
able as it can damage the nerve. within the fallopian canal.
7. While lowering the facial ridge, the bone
should be cut along the line of the nerve Clinical Features
and one should not go deep to the tym- The paralysis is usually of sudden onset with
panomastoid suture line. a history of exposure to cold, sometimes asso-
8. The nerve may get damaged during stape- ciated with earache. In a vast majority of cases
dectomy during currettage of the bony the paralysis is incomplete and recovery
overhang of the posterior canal wall or at occurs over a period of one to six months. In a
the time of work on the footplate. smaller group of cases the paralysis remains
a permanent feature.
Management of Postoperative Facial Paralysis
In case the facial paralysis is noted imme- Investigations (Fig. 17.3)
diately after the operation, the damage to the Many topographical and electrodiagnostic
nerve is more severe. Immediate exploration tests have been described to know the exact
is done and if a bone piece is found piercing site of lesion and the severity of the damage
the nerve, it is removed or the haematoma that the nerve has suffered. To know the level
drained. If the nerve is cut, its ends are brought of lesion of the facial nerve, the various tests
together and sutured or a graft may be needed used are the following:
to bring the edges together. The graft is taken 1. Schirmer’s test: Blotting paper strips
from the greater auricular or crural nerve of (3 cm × 5 cm) are placed under both the
the leg. lower eyelids, and after sometime wetting
If the paralysis develops later on, it signi- of the blotting paper on the two sides is
fies a lesser damage, probably that the nerve compared. If the facial nerve lesion is
is exposed and paralysis is because of oedema above the geniculate ganglion, lacrimation
or due to pressure of the tight pack. In such on the affected side will be less as the
cases, pack removal and steroids help to greater superficial petrosal nerve is
reduce the oedema and the paralysis recovers. involved.
2. Acoustic reflex: If the lesion is above the
BELL’S PALSY
nerve to stapedius, this reflex is absent and
Bell described this idiopathic infranuclear the patient will complain of discomfort and
lesion of the facial nerve. There is complete or pain on hearing loud sound (phonophobia).
Otological Aspects of Facial Paralysis 105
HEMIFACIAL SPASM
It is a rare condition characterised by violent
hemifacial muscular contractions without
actual paralysis, seen in older patients. In
severe cases the condition becomes intolerable
and resistant to all sorts of treatment except
facial nerve resection to cause complete facial
paralysis.
Fig. 17.3: Topographical and electrodiagnostic
tests of facial nerve IMPORTANT POINTS
In facial nerve palsy one should ask the history
3. Electrogustometry: An electrode is placed on
of:
the tongue and a current of 3-10 mA is
a. Trauma especially head injuries and
given. Normally a metallic taste is
penetrating injuries.
perceived. If the lesion is above the level
b. Previous mastoid and middle ear surgery
of the chorda tympani nerve, the taste
c. Ear discharge and/or ear pain
sensation of the affected side is absent.
d. Slow progressive paralysis (suspect
tumour)
Treatment
e. Recurrent paralysis
Various drugs, like vasodilators (nicotinic f. Bilateral paralysis
acid, nylidrine) vitamins (B1, B12 and B6) have g. Association of hemifacial spasm
been tried without much efficiency. h. Associated deafness.
It has now been seen that prednisolone i. Vestibular symptoms
80 mg/day and tapered off for 9 days is most j. Any eruptions on the pinna or the external
effective. canal.
106 Textbook of Ear, Nose and Throat Diseases
18 Ménière’s Disease
and Other Common
Disorders of the Inner Ear
Variations of the clinical picture may occur ment in speech discrimination ability
owing to the absence of one or more of the are taken as positive data. However a
main features that constitute the disease. negative test does not exclude Méniére’s
disease.The test is contraindicated in
Investigations patients with cardiac and renal diseases as
1. Audiometry: Pure tone audiometry reveals well as in diabetics.
sensorineural deafness. The hearing loss is 5. Electrocochleography: This test is done to
more for the lower frequencies in the early determine the SP/AP ratio which is nor-
stages of the disease. Loudness recruitment mally 20 per cent. More than 30 per cent is
is usually present. The short increment suggestive of Méniére’s disease.
sensitivity index (SISI) test shows a high
score. The tone decay test is near normal. Treatment
Bekesy audiometer traces a type II curve.
There is no definite treatment of this condi-
2. Vestibular function test: Spontaneous
tion. Various methods (medical and surgical)
nystagmus is absent except during an
have been adopted to alleviate the patient’s
attack. Caloric tests show hypoactivity on
symptoms. The general management of the
the affected side. However, a normal
patient is of prime importance. An under-
caloric test does not rule out Ménière’s
standing and sympathetic approach to the
disease as the vestibular system is capable
problem is essential. Strong reassurance and
of recovery in the early stages of the
stressing the nonfatal nature of the disorder
disorder.
is necessary.
3. CT Scan: CT scan of the temporal bone
helps to rule out internal acoustic meatus Treatment of the acute attack The patient is put
pathology. to bed rest. Any of the vestibular suppressants
4. Glycerol test: The glycerol test is regarded is given to control the vestibular symptoms.
as valuable diagnostic tool. Glycerine The following drugs are commonly used—
makes blood hypertonic and reduces the prochlorperazine (Stemetil) 15 to 75 mg daily,
hydrops. orally or by injections; promethazine
Ninety-five percent glycerine, 1.5 cc/ (Avomine, Phenergan); chlorpromazine
kg of body weight with addition of the (Largactil 25 mg thrice daily); or dimen-
same amount of physiological saline is hydrinate (Dramamine).
given orally on a fasting stomach. Pure The dosage is adjusted according to the
tone audiometry and speech audiometry patient’s needs. Sometimes the stellate
are done after intervals of one hour for 2 ganglion block during an acute attack helps
to 3 hours and compared with pretest to relieve the symptoms. The long-term
records. medical treatment has been based on various
Improvement in hearing signifies an theories.
endolymphatic hydrops in about 60 per- 1. Dietetic therapy: It is suggested that low salt
cent of cases. 15 db improvement on pure and limited water intake reduces the
tone audiometry or 12 percent improve- hydrops.
108 Textbook of Ear, Nose and Throat Diseases
2. Vitamin therapy: All the vitamins, coen- with intractable vertigo but with a good
zymes and trace elements have been used. hearing. The middle cranial fossa approach
Favourable effects have resulted from the to the eighth nerve is chosen.
administration of nicotinic acid and 5. Labyrinth destruction: Total destruction of
vitamin A and D. the labyrinth (labyrinthectomy) may be a
3. Diuretic therapy: Diuretics like acetazo- last resort for cases with intractable
lamide have been used on the assumption symptoms and poor hearing levels. The
that these drugs will reduce the hydrops. transmastoid and transmeatal route can be
4. Vasodilators: Such drugs have been used used for labyrinthectomy.
with an idea that they relieve the angio- 6. Selective destruction of vestibular labyrinth by
spastic vascular changes in the endarterial cryosurgery or ultrasound: These physical
distribution of the labyrinthine artery. methods have recently been used for the
Recently betahistadine hydrochloride treatment of Ménière’s disease. This is
(Vertin, Serc) has shown good results. accomplished by selective destruction of
5. Streptomycin therapy: Previously large the vestibular end organs in the labyrinth
doses of streptomycin were used particu- without damaging the cochlea or facial
larly in bilateral cases to inducel laby- nerve.
rinthine damage (Chemical Labyrinthec- 7. Cryosurgical methods: A cryoprobe is placed
tomy). on the semicircular canal or promontory
and subnormal temperature achieved
Surgical treatment of Ménière’s disease Surgery
which causes destruction of the adjacent
is considered for those cases of Ménière’s
labyrinthine tissue.
disease, which do not respond to medical
8. Ultrasound: Ultrasonic vibrations are
therapy and where the disabling symptoms
passed to the semicircular canal by an
continue to occur.
applicator through the mastoid route.
The following procedures have been used:
1. Cervical sympathectomy: The operation is Lermoyez’s syndrome This is a variant of
thought to correct the microcirculatory Ménière’s syndrome in which hearing loss and
fault in the labyrinth and thus relieve the tinnitus occur first, followed by vertigo that
symptoms. appears suddenly and with it hearing and
2. Myringotomy with grommet insertion: The tinnitus improve.
exact mode of action is not clearly known.
Differential Diagnosis of Ménière’s Disease
3. Operations on the endolymphatic sac: The aim
of the operation is to decompress and/or The disease has to be differentiated from other
drain the sac (shunt operation) so that conditions which produce paroxysmal attacks
adequate absorption of endolymph occurs of vertigo, tinnitus or deafness.
with resultant relief of the hydrops. 1. Eighth nerve tumour (acoustic neuroma):
4. Vestibular neurectomy: This involves Differentiation of this condition is difficult
selective section of the vestibular division particularly in the early stages when it only
of the eighth nerve, particularly in cases gives otological symptoms.
Ménière’s Disease and Other Common Disorders of the Inner Ear 109
The main symptom is usually prog- vertigo and tinnitus. However, other
ressive unilateral sensorineural hearing associated focal signs like diplopia, ipsi-
loss associated with tinnitus and dimini- lateral ataxia, facial paralysis and
shed caloric response. However, the homonymous hemianopia indicate that the
vertigo is neither marked nor usually lesion is in the vascular system rather than
paroxysmal. Other neurological deficits in the inner ear.
occur. Audiometry shows a retrocochlear
CAUSES OF VERTIGO
lesion. X-ray studies of internal auditory
meatus and other tests like myelography, V—Vascular i. Vertebrobasilar
and scanning help in the final diagnosis. insufficiency
2. Vestibular neuronitis: This disease is ii. Stroke
characterised by vertigo of sudden onset, iii. Migraine
sometimes occurring in small epidemics, iv. Hypotension
v. Anaemia
often with a recent history of upper respi-
vi. Hypoglycaemia
ratory tract infection. The condition is
vii. Ménière’s disease
usually unilateral but could be bilateral
E—Epilepsy
also.
R—Receiving any treatment
Caloric responses are diminished but
i. Antibiotics
hearing tests are normal.
ii. Cardiac drugs
3. Benign positional vertigo: The patient
iii. Antihypertensive
complains of recurring attacks of vertigo drugs
which are induced by change in position. iv. Sedatives and
Neurological examination is normal, tranquillisers
hearing is unaffected and caloric tests are v. Aspirin
also usually normal. The only consistent vi. Quinine
physical finding is the vertigo and nystag- T—1. Tumour
mus that develop when the head is placed a. Primary i. Acoustic neuromas
in a particular position. The nystagmus ii. Glioma
appears after a few seconds and is iii. Intraventricular
fatiguable. tumour
4. Epileptic vertigo: Cases of epilepsy may b. Metastatic i. Meningeal
present with an attack of vertigo but ii. Carcinomatosis
features-like loss of consciousness, fits, and 2. Trauma i. To labyrinth
normal hearing and caloric tests distin- (temporal
guish it from Ménière’s disease. bone fractures)
5. Vertebrobasilar insufficiency: This condition ii. To brainstem
in which transient episodes of ischaemia (cervical vertebtrae
occur in the distribution of the vertebro- fractures)
basilar arterial system may present with 3. Thyroid i. Hypofunction
110 Textbook of Ear, Nose and Throat Diseases
19 Ototoxicity
20 Tinnitus
17. Autoimmune involvement of the audi- 1. Lidocaine HCl 100 mg infused rapidly
tory end organ. intravenously acts as a local anaesthetic
and blocks multisynaptic junctions. It
Idiopathic tinnitus This is the most common
abolishes tinnitus in 70 per cent of the cases
form of tinnitus. Normally, the reflex pathway
but only for a short period.
from the end organ to the cerebral cortex is
2. Carbamazepine 200 mg three times daily is
through the auditory nerve, cochlear neurons
effective but causes bone marrow
and brainstem and back through the olivo-
depression and hepatotoxicity.
cochlear bundle. This controls the auditory
3. Tocainide HCl (oral salt of lidocaine) 200 mg
apparatus. Some abnormality in this pathway
three times daily is the latest promising
which may be in the form of increased
drug but is not available on a large scale
discharge from the cochlea or demyelination
as yet.
of the nerve fibres, etc. causes the patient to
Besides these antidepressants, and vaso-
hear adventitious sounds. Patients who are
dilators like Nylidrine, etc. are also used.
tense and psychologically unbalanced are
Operations usually undertaken for tinnitus
more prone to have tinnitus.
are the following:
1. Stellate ganglion block
Management
2. Cervical sympathectomy
The patient is to be investigated thoroughly 3. Labyrinthectomy (in very severe cases)
to rule out any organic cause for tinnitus and 4. Cochlear nerve section
if present, treatment should be directed 5. Prefrontal leucotomy
towards the basic cause. The intensity of tinni- 6. Chorda tympani neurectomy
tus is measured by masking sounds. The Other forms of treatment include the
intensity of the sound which masks the following:
tinnitus is the intensity of the tinnitus and as 1. Masking
such a tinnitogram can be plotted. 2. Hearing aid
After excluding all other causes, the 3. Biofeedback
following treatment is given. 4. Noise generators.
21 Deafness
Fig. 21.1:Lesions producing conductive hearing loss (lesions of ear canal and middle ear)
and sensorineural loss (lesions of sensory end organ and eighth cranial nerve)
116 Textbook of Ear, Nose and Throat Diseases
defective. The lesion could be anywhere b. Traumatic causes like traumatic tym-
from the external auditory canal to the panic membrane perforations, ossicular
footplate of stapes. disruption and haemotympanum.
2. Sensorineural deafness: This type of deafness c. Tumours of the middle ear and mas-
is due to abnormality in the cochlea, toid, e.g. glomus jugular and carci-
auditory nerve, neural pathway or their noma.
central connections with the auditory d. Otosclerosis.
cortex. The treatment of conductive deafness
3. Mixed deafness: It denotes that both con- depends upon the cause and such patients can
ductive and sensorineural abnormality is usually be helped by modern microsurgical
present in the deaf person. procedures. Alternatively a hearing aid can be
fitted to overcome the hearing difficulty.
Conductive Deafness
thus remain deaf-mutes. Every effort should The treatment of such patients is difficult.
be made to detect these cases early. Depending upon the degree of deafness,
hearing aids are fitted and auditory training
Detection of Deafness given by the speech pathologist/therapist.
The babies who are at the risk, and the risk
DEAF-MUTE
factors include(1)perinatal infections like
toxoplasmosis, rubella, CMV, herpes and Examination of a Deaf-mute
syphilis (2) Low birth weight(<1.5 Kg.) History
(3) Neonatal bacterial meningiti (4) Kernic-
terus and hyperbilirubinemia (5) Congenital 1. Family history
head and neck malformations (6) Family a. Is there any deafness in the family of
history of congenital deafness (7) Birth either parent?
asphyxia, should be properly screened at 6 b. Are the parents related to each other?
c. How many children are in the family
monthly intervals for hearing loss.
and is any of them deaf?
Similarly if the parents suspect that the
2. Past history of the mother
child is not responding to sounds properly or
a. Is there any history suggestive of
there is failure on the part of child to utter
syphilis?
common words by 18 months to 2 years, a
b. Is there a history of maternal rubella or
hearing handicap should be suspected and
other specific fever during pregnancy?
such patients should be properly investigated.
c. Did the pregnancy go to full-term and
was the confinement normal?
Startle Reflex Test
3. Past history of the child’s general health
The newborn respond, to loud sound by a. Is there any history of neonatal
moving its head, legs and arms. jaundice?
b. What illness has the child suffered to
Cochleopalpebral Reflex date?
Normally a loud sound made near a healthy 4. Speech
infant causes blinking of its eyes. a. At what age, if at all did speech deve-
lop, did the child babble normally? If
so, did he babble for a short time and
Screening Test
then stopped?
A sound is made at 2-3 feet from the head of b. If the child is suspected of being
the baby. A baby with good hearing turns his partially deaf, is the tone defective or is
head towards the sound source at the age of 7 there a difficulty in pronouncing
to 9 months. consonants?
Objective audiological tests like evoked 5. Hearing
response audiometry are the most reliable a. Does the mother communicate with the
method available at present. child by voice or by signs?
Deafness 119
b. Can the child hear when spoken to from 3. Test for 3-6 years children __ seven toys test
another room? and second cube test. Training of deaf
c. What is the greatest distance at which children is carried out in two ways.
the child can hear when spoken to? a. Auditory training or teaching the
d. Does he react to the noise of a motor children to listen and hear to the fullest
car, the wireless, or the door bell? extent to which they are capable.
6. Age of onset b. Speech training: Teaching the child to
a. At what age was deafness first sus- speak properly.
pected? c. Social and general training: Teaching
7. State of development the child to act normally to his
a. What standard of education has the environment.
child reached?
b. At what age were the normal mile- ACOUSTIC TRAUMA
stones, e.g. sitting up, learning to crawl, Acoustic trauma means noise induced hearing
etc. reached? loss. It is directly proportional to civilisation,
c. Is there any evidence of abnormalities i.e. more advanced a country is, more are the
of behaviour such as triancy, lying, chances of noise induced hearing loss. The
stealing or extreme introversion? modern machineries, heavy industries, aero-
d. A school report may give valuable planes, fireworks, notorious old steam and
information about the child’s intelli- diesel engines, pop music and above all
gence. modern warfare and so many other things
which generate noise of high sound pressure
Assessing the Hearing
level (SPL) produce injurious effects to the
After watching and speaking to the child, highly sensitive and delicate auditory end
Sheridan’s test series is followed. organ.
1. Test for babies(Play Audiometry) If the ear is exposed to explosive sounds
a. If 6-14 months__voice and noise-making for a short period only, there occurs a tempo-
instruments rary shift in the hearing threshold, seen on
b. 15-18 months__same audiometry as a steep dip at 4 kHz, called
c. 19-23 months__five toys test. Cup ball, acoustic dip. If the person remains in a noisy
toy motor car, a plastic doll and a toy atmosphere for a long time, the dip involves
bike. The child is given the toys one by other frequencies and finally a flat curve is
one and they are named as they are obtained on audiometry. 40 hours/week of 90
given to him. ‘Here is a cup. He is then dB noise is safe for factory workers.
asked to return them, e.g. give me the This 4 kHz area of basilar membrane is in
cup and so on.’ Instructions are basal turn of cochlea and is first exposed to
repeated at a distance. noise and is first affected.
2. Tests for 2 years old __ six toys test and first Histopathological studies have shown
cube test. degenerative changes in the stria vascularis,
120 Textbook of Ear, Nose and Throat Diseases
hair cells as well as in the supporting cells in Conductive Type of Sudden Deafness
chronic acoustic trauma.
This may be due to sudden impaction of wax
Noise induces vasospasm of the cochlear
in the canal, traumatic perforation of the
vessels and anoxia to the hair cells thus
tympanic membrane, foreign body in the
causing the damage.
external canal, haemotympanum, ossicular
Sociacusis It is the hearing impairment chain disruption or aero-otitis. Examination
because of noise of recreative places like pop of the ear usually reveals the underlying
music, snow mobiles, and car races, etc. disease and treatment is directed towards the
cause.
White noise Like white light, it consists of a
random mixture of all frequencies. The
Sudden Sensorineural Hearing Loss
random movements of electrons in conducer
and vacuum tubes also produce white noise Sensorineural hearing loss of sudden onset
which is audible as characteristic background may be due to the following causes.
“S-h-h-h” from a prolong vaph or radio. The 1. Vascular lesions
sounds of speech form a constantly changing a. Haemorrhage in the labyrinth as occurs
pattern of complex tones, noise and transients. in trauma, hypertension, leukaemia,
purpura, etc.
PRESBYACUSIS (SENILE DEAFNESS) b. Thromboembolism involving the
internal auditory artery.
This is a type of sensorineural hearing loss
c. Vascular spasm may be due to autono-
which results due to the ageing process and
mic imbalance.
is an auditory manifestation of senility.
2. Trauma
Degenerative changes occur in the cells of the
a. Acoustic trauma
organ of Corti and nerve fibres. The patient
b. Fracture of the petrous part of tempo-
of an elderly age group presents with a slow,
ral bone
progressive deafness which may be associated
3. Viral
with tinnitus. The deafness is bilateral and
a. Mumps
symmetrical, commonly affecting the high
b. Measles
tones.
c. Herpes zoster
Treatment d. Encephalitis
4. Miscellaneous
The problem should be explained to the a. Functional
patients, sometimes a hearing aid may help. b. Raised intracranial tension as might
occur during straining, coughing and
SUDDEN DEAFNESS
which may lead to rupture of the round
Sudden occurrence of hearing loss may be due window membrane producing sudden
to various known and unknown causes. Such deafness.
a hearing loss may be conductive or senso- 5. Idiopathic: Majority of the cases of sudden
rineural. deafness fall within this category.
Deafness 121
two identical tuning forks at the same distance noise starts. With true deafness, the voice is
from the two ears will lead to hearing of sound raised markedly, often to a shout, the malin-
in the normal ear. With a suspected malingerer gerer (unless coached) continues in the same
the eyes are blindfolded so that he has no idea tone or only slightly raises his voice.
that the tuning forks are being used. The
tuning forks are struck with moderate Loud Voice Test (Erhard’s Test)
intensity and held at 10 inches away from the The sound ear is occluded by a finger in the
each ear and the following procedure used. meatus. This dampens reception but never
The patient is asked if he hears it, a malingerer completely cuts out loud sounds. The malin-
will maintain one ear as deaf. The fork on the gerer will often deny hearing even the loudest
deaf side is advanced to 3 inches from the ear noises. He denies hearing the test sounds or
and on the other side to 6 inches. The malin- words with the meatus of the sound ear lightly
gerer will now deny hearing the fork with the closed, when these were heard at double the
normal ear though it is at less distance than distance with the meatus open.
before.
Cochleopalpebral Test (Gault Test)
Weber’s Test or Chimani Moose Test
(Lateralisation Test) The sound ear is tightly occluded and a noise
is made near the “deaf” ear. If a slight winking
It is not a reliable test. movement or contraction of the lid of the
A tuning fork of 256 cycles/sec is placed corresponding eye occurs, it indicates that the
on the vertex. If true unilateral conductive sound was heard in the ear. The pupil may
deafness exists, the vibrations are localised in also change in size, it usually contracts
the deaf ear. If true perceptive deafness exists (auditory pupillary reaction). This test is more
then vibrations are localised in the sound ear. valuable in bilateral simulated deafness.
The malingerer will also state that he hears
from the sound ear. The meatus of the sound Stethoscope Test
ear is then tightly occluded. If truly deaf he
will hear either on the sound side or will be One ear piece of the stethoscope is tightly
uncertain. The malingerer will state that he occluded by wax, etc. A funnel replaces the
does not hear the fork at all. chest piece. The malingerer becomes confused
as not knowing whether the words spoken
Lombard’s Test into the tunnel are being conducted to both
ears or to one or other single ear.
It is a fairly reliable test. A barany noise box is
placed in the sound ear and the patient is
Two Speaking Tubes
accustomed to the noise. He is then asked to
count up to 100 or to read aloud from a book The examiner and his assistant react simulta-
in his natural voice and not to stop when the neously short sentences from book of charts,
Deafness 123
each using a separate speaking tube which the Doerfler Stewart Test
patient holds one in each ear with unilateral
The feigned or functional deaf have usually
organic deafness. The sentences spoken into
adopted a subjective reference level for their
the normal ear will be heard clearly and can
hearing. By using a system of superimposed
be repeated. The malingerer will be confused
signals of speech and masking noise in
by the two different voices and only occasional
measured amounts this reference level is
words from one or both speakers can be
disturbed, and on several counts, the test
repeated.
points to deviation from the finding on normal
and on pathological ear. Psychogenic patients
Test During Sleep look more confused (upset) by masking noises
A loud noise wakens a malingerer when he is than patients with organic lesions.
asleep. In this respect it differs from a Hypnosis
hysterical case.
Intravenous injection of a small dose of
pentothal sodium is given. Tests with audio-
Audiometric Tests
meter and with speech are made during
It is impossible to take constant audiograms, hypnosis and results compared with those
no matter how practised the audiometrist is. obtained before hand.
124 Textbook of Ear, Nose and Throat Diseases
Fig. 22.2:Ear hearing aid (postaural) 1. Use of a hearing aid is palliative. It does
not cure deafness, nor does it arrest the
disease producing the deafness. It only
amplifies the sound and, therefore, may
only alleviate the effects of deafness.
2. A hearing aid rarely restores the hearing
acuity to 100 per cent.
3. A hearing aid simplifies to amplify all
frequencies within its range, it does not
select or emphasise certain frequencies
Fig. 22.23:Hearing aid in eye-glass frames over others as the ear does.
Audiological tests like pure tone audio-
metry and speech audiometry give an idea
about the suitability of a hearing aid in the
particular patient. Moreover, the hearing aid
trials should be given to know whether it suits
the patient’s needs or not.
The following disorders can cause severe 2. Electrocochleography: It can give direct
or total hearing loss. indication as to whether a patient will or
1. Congenital deafness will not benefit from an implant.
2. Trauma — Head injury 3. Promontory stimulation: If a patient cannot
— Surgical hear on electrical stimulation, then the
3. Labyrinthitis implant is of no value.
4. Ototoxic drugs The various approaches are as follows:
5. Ménière’s disease 1. Cortical stimulation
6. Meningitis 2. Acoustic nerve stimulation
7. Idiopathic. 3. Single channel intracochlear stimulation
In order to select the patient for cochlear 4. Multiple channel intracochlear stimulation
implant, the following tests are done to 5. Extracochlear stimulation.
evaluate the degree of deafness and to assess Cochlear implants are more useful in post
the quality of the surviving neurons. lingually deaf patients, i.e. who lost their
1. Pure tone audiometry: The patient should hearing after acquisition of language.
show no response on pure tone audio- Criteria for selection of patients for the
metry. implant are:
Hearing Aids and Cochlear Implant 127
i. Bilateral deafness with average hearing The period of time that a patient was deaf
threshold of 95 dB for speech frequencies is also a factor in how much benefit is gained
of 500, 1000 and 2000 Hz. from a cochlear implant. Patients that have
ii. Physically and mentally normal person. been deaf for less than six years usually gain
iii. There should be no improvement to more benefit than those who have been deaf
hearing from a hearing aid. for many years.
iv. Patient should be ready and available for The internal part implanted at operation
postoperative rehabilitation programme. consists of a receiver, an active electrode and
It is an electronic device consisting of two a reference electrode. All material used in the
parts, one part is surgically inserted into the manufacture of the implant are fully tested for
ear, and the other part known as a speech biological compatibility and durability. The
processor is worn on the body. The implant electronic components of the receiver are held
helps the patient in hearing environmental in a sealed housing which is implanted under
sounds and allows speech discrimination the skin behind the ear (Fig. 22.7).
(understanding). The active electrode connected to the recei-
Implant researchers throughout the world ver is inserted into the cochlea through a
have found that people who became deaf late cochleostomy into the basal turn. The contacts
and had fully developed speech before they (platinum-iridium alloy) are enclosed in
became deaf (postlingually deafened) usually silicone and the electrode cable is made in such
gain more benefit from a cochlear implant a way that it can be inserted about 25 mm into
than those who were born deaf or lost their the cochlea. The external components consists
hearing very early (pre-lingually deafened). of the speech processor and transmitter. The
However, many prelingually deafened adults speech processor can be body worn or behind
and children still gain much benefit from a the ear. The speech processor powered by
cochlear implant. batteries converts incoming signals into the
The earlier the prelingual child undergoes required electrical signals.
cochlear implantation the better the results. It
has recently been proved from brain mapping How does the implant work?
that certain areas in the cerebral cortex
develop in response to sound stimuli in a child 1. Sound waves are received by the micro-
as early as 10 months of age. Prelingually deaf phone.
children who have been implanted at the age 2. The signal from the microphone is sent
of 10 months attain normal speech and are along the cable to the speech processor.
integrated into normal schools, hence the 3. The speech processor acts on the signal
younger the child, the greater the potential for according to coding strategies develop to
language development and speech percep- enable optimal hearing with the cochlear
tion. The postlinguals excel after cochlear implant.
implantation as they possess auditory 4. The coded signal is sent through the cable
memory. to the transmitter.
128 Textbook of Ear, Nose and Throat Diseases
Most implant users can tell the difference parents. After six months of use, a majo-
between a man and a woman’s voice and rity of children respond to their names in
they describe speech as sounding natural, quiet environment and spontaneously
mechanical, clangy or muffled (like a radio recognise common sounds in the class-
not tuned accurately to a station). Some room. Children implanted before the age
patients enjoy the sound of music and of 3 years develop vocabulary within 3
some interpret music as noise. In adults months.
with postlinguistic deafness, using the
recent advanced fast stimulating cochlear Selection of Patients for Cochlear
implants 90 per cent of the participants Implant Surgery
have improved communication abilities The suitablity of a person for a cochlear
when using the implant without lip implant is evaluated by several tests. The tests
reading. cover both medical and audiological aspect
c. Telephone Communication: Some postlingual and test results are obtained and evaluated by
patients can hear sounds of speech over the the ENT surgeon and the audiologist. If there
telephone but, in general are not able to are no contraindications, the patient is invited
understand words, and for this reason they to take part in further assessments.
are still denied easy access to the telephone a. Otologic (ear) evaluation: This forms part of
for full communication. They are able to the medical assessment so as to ensure that
determine if there is a dial tone a busy there are no middle or inner ear problems
signal, a ringing tone or whether someone that can interfere with the implantation. A
has answered at the other end. Communi- CT scan of the inner ear is taken to check
cation codes may be devised with family that the cochlea is accessible and electrodes
and friends to help in the use of the can be inserted.
telephone. b. Audiologic (hearing) evaluation: This includes
d. Tinnitus (Noises in the ear): These usually standard hearing tests, hearing aid fitting
diminish or decrease after implantation. and tests of speech understanding with
e. Adult Benefits: Although the cochlear hearing aids. The hearing loss should be
implant cannot fully restore nomal profound and an aided audiogram should
hearing, adult clinical trials indicate 80 per not show any significant hearing. BERA
cent of average sentence recognition after and if necessary electrocochleography are
six months with significant improvement carried out as objective tests to establish
in word and sentence recognition both in the patients threshold and to confirm
quiet and in noisy surroundings compared whether the deafness is sensorineural or
to their ability with hearing aids. central. These tests provide a base line for
f. Child Benefits: Children also show comparison with average cochlear implant
significant gains in sound awareness and performance. In small children it is
speech uderstanding as reported by their particularly important to evaluate if the
130 Textbook of Ear, Nose and Throat Diseases
The programme involves both the patient facial expressions, gestures and hand
and the family. It is directed towards utilisa- movements.
tion of the new auditory clues available, as well ii. Auditory training: Through an auditory
as improvement in communication ability and trainer the deaf person is exposed to
speech production. The success of this therapy various listening situations with different
depends in large measure on the co-operation degrees of difficulty and are taught selec-
of the patient who should also be prepared to tively to concentrate on speech sounds.
work between therapy sessions at home It is very helful for persons using hearing
according to the instructions of the therapist. aids or having cochlear implants.
The initial benefit received from the implant iii. Speech conservation: It is useful in persons
can be increased by logopedic training or having sudden severe hearing loss who
speech therapy at regular intervals usually a can’t monitor his own speech produc-
couple of hours a week. The time of therapy tion. Here tactile and proprioceptive
that is needed can vary widely from case to feedback is used to monitor the speech
case. The least amount of speech therapy is production.
generally required by people who have been
deaf for only a short time. Many postlingually Other Facilities for Severely
deafened adults with period of deafness of less Deaf Patients can be
than 5 years find speech therapy necessary i. Hard wired system induction loops.
only during the first few weeks following Amplitude modulation or frequency
surgery. modulation or infrared signals.
Intensive initial habilitation and speech ii. Alerting devices to hear a telephone or
therapy is required for deaf born children, door bell or baby cry. These devices
who had no spoken language before receiv- produce extra loud signals.
ing the cochlear implant. The older a congeni- iii. Telecommunication devices, where a
tally deaf child is at the time of implantation, telephone amplifier is attached to a
the more therapy will be necessary in trying telephone to increase the sound or a
to make up for the time that was lost regarding telecommunication device for deaf
speech and language acquisition. (TDD) which converts typed massage
The speech processors can store 3 maps so into sound that can be transmitted over
that the patient can have 3 different prog- the standard telephone lines and at the
rammes to use as the need arises in their other end another TDD converts these
listening environment. For example, one for sound signals back into type written
noise, another for quiet and a third for music. messages.
iv. Closed caption television decoders can
Training of Deaf-mutes
be attached to television sets to provide
i. Speech reading or lipreading: Here patient cues for news, dramas and other
is trained to study the movements of lips programmes.
132 Textbook of Ear, Nose and Throat Diseases
23 Principles of Audiometry
It involves one positive and one negative The formula for decibel (dB) estimation is
excursion. as follows:
3. Pitch: It is the psychological counterpart of t1
frequency. Faster the rate of vibration, dB = 10 log _____
t2
higher the perceived pitch.
4. Intensity: It is the physical measure of Where t1 is the intensity in watts of the
amplitude of mass movement and is the existing sound and t2 the intensity in watts of
measure of loudness of sound. a reference sound.
5. Loudness: It is the physiological counterpart P1
of the intensity. The unit of loudness is Alternatively, dB = 20 log ____
P2
called, decibel which is 1/10 of a bel, the
Where P1 is the sound pressure in dynes/
unit called after Graham Bell, inventor of
cm2 of the existing sound and P2 the sound
the telephone. In the decibel scale the fain-
test audible sound is taken as the unit and pressure of a reference sound. A common
called ‘0’. reference pressure is 0.0002 dynes/cm2.
The scale is as follows: 1 bel is 101, i.e. 10 times The intensity of various noises in decibels
0; 2 bel is 102, i.e. 100 times 0; 3 bel is 103, i.e. is given below.
1000 times 0 and so on. Jet plane with burner 160
When comparing intensities of two diffe- Pain 140
rent sounds, it is often convenient to use in Limit of endurance 130
place of a simple ratio, decibel (dB) which is Discomfort (thunder) 120
equal to ten times the logarithm of a sound Boiler shop 100
under consideration to a reference sound. The Noisy street 80
reference sound usually taken is an intensity Normal conversation 60
which is very close to the normal threshold of Average office 40
hearing of the human ear at 1000 Hz. Quiet street 30
The reason for notation is to reduce a rather Whisper 20
larger ratio to a small usable number. This is Faintest audible sound 0
necessary primarily because of the tremen-
Room Acoustics
dous capability of the ear to hear over a large
dynamic range. It is by reflection on hard walls and by absorp-
In noting the degree of hearing at two tion in loose material that one can control the
different frequencies, it would be a bit awk- acoustic properties of a room. Reflective walls
ward to say that a person hears 1000 units at keep energy from spreading beyond the
one frequency and 40000 units at another. confinements of the room so that even low-
Thus dB notation is used to break a large intensity sounds are heard from one end to
number into small usable numbers. the other. However, such rooms are highly
The sound intensity can be expressed as reverberant, that is, each signal causes
sound pressure in dynes/cm2, or as particle multiple echoes which last for some time
velocity is cm/s or as power in watts. afterwards and tend to obscure subsequent
134 Textbook of Ear, Nose and Throat Diseases
Fig. 23.3: Pure tone audiogram showing (right) normal and (left) sensorineural hearing loss
the tone. The process is repeated several times The hearing threshold level numbers along
and the intensity at which the subject hears the ordinate are read as “hearing loss in
the sound (tone) for 50 per cent of the time, is decibels” at a particular frequency.
taken as the threshold of hearing at that
frequency. Audiogram Interpretation
The audiogram is a graph showing the Normally both air and bone conduction curves
hearing sensitivity for air and bone conduc- superimpose on the graph showing no hearing
ted sounds. The frequency of the tone in cycles loss at 0 to 20 dB.
per second (CPS) or Hertz (Hz) is represen- 1. Conductive deafness: Conductive deafness
ted along the abscissa and hearing threshold occurs due to malfunction of the external
level in decibels (dB) along the ordinate (Figs or middle ear. The cochlea is not affected.
23.3 and 23.4). Therefore, conductive loss shows a loss of
hearing by air conduction tests and normal
Symbols on Audiogram
hearing by bone conduction test (air-bone
Red “0” represents air conduction for the right or AB gap).
ear while blue “X” represents air conduction 2. Sensorineural loss: In this type of hearing
for the left ear. The symbol of > is for bone loss the defect lies in the cochlea and neural
conduction of the right ear and symbol < for pathways. Therefore, thresholds for bone
bone conduction of the left ear. conducted sounds are the same as
136 Textbook of Ear, Nose and Throat Diseases
Fig. 23.4: Pure tone audiogram showing (right) ear conductive loss
thresholds for air conducted sounds of the 1. To evaluate the functional state of the
same frequency, and both show equal auditory system at suprathreshold levels
losses. (Fig. 23.5).
3. Mixed hearing loss: The hearing loss affects 2. To contribute to the localisation of the
both air and bone conduction but the specific lesions of the auditory tracts.
hearing loss for air conduction is more than 3. To predict the outcome of the otologic
the loss by bone conduction. surgery.
Advantages of Pure Tone Audiometry 4. To assess the value of therapeutic mea-
1. It gives an idea about the type of hearing sures such as auditory training or selection
loss (quality). of hearing aid.
2. It gives a measure of the degree of hearing Various parameters tested in speech
loss (quantity). audiometry are as follows:
3. It provides a base line for various recon- 1. Speech reception threshold: The test material
structive and rehabilitative procedures like is recorded live voice. Spondee words are
tympanoplasty and hearing aids.
used. Spondee is a word with two sylla-
4. The method can be used to detect malin-
bles, both pronounced with equal stress
gerers and is useful for medicolegal
and effort like tooth brush, aeroplane,
purposes.
eardrum, sunset, farewell.
Speech Audiometry The intensity, at which the patient
Speech audiometry is aimed at evaluating the identifies 50 per cent of the words and
listener’s responses to speech. Speech audio- repeats them correctly is called speech
metry is helpful in the following: reception threshold (SRT).
Principles of Audiometry 137
The tone is presented at 20 dB above the 2. Mild decay 10-15 (inner ear deafness)
patient’s threshold for that frequency. Every dB/minute
5 seconds 1 dB increment is superimposed. 3. Moderate decay Suggestive of
The tester presents twenty such 1 dB incre- 20-25 dB/minutes retrocochlear
ments for each test. 4. Marked decay deafness like
The SISI test is scored in terms of the 30 dB or above acoustic neuroma
percentage of correctly identified 1 dB incre- in sixty seconds
ments out of a possible 20 increments. The Recruitment
number obtained is multiplied by 5 for getting
It is a phenomenon which occurs in some
the percentage.
pathological diseases of the ear (like cochlear
SISI score over 70 percent usually occurs
lesions) where there occurs rapid growth of
in hearing loss due to inner ear damage, e.g.
loudness in the affected ear disproportionate
in Ménière’s disease. This is called a positive
to the sound stimulus given.
test.
Loudness grows so rapidly that a tone
sounds louder in the impaired ear than in a
Tone Decay Test
normal ear at the same intensity.
(Auditory Adaptation)
The tone is presented to the patient who is Procedure to Demonstrate Recruitment
asked to listen and signal as soon as he hears Alternate binaural loudness balance test (ABLB
a tone at threshold. A stop-watch is started, test, Fowler’s test) For this test, the hearing
which should be stopped when the patient threshold for the poor ear should be at least
signals that the tone is no longer heard. The 25 dB poorer than hearing in the better ear. A
number of seconds for which the tone is heard two-channel audiometer is used for alter-
at threshold is recorded. The stop-watch is nating two tones of identical frequency from
reset and the level of tone raised by 5 dB one ear to the other. The intensity of each tone
without interrupting the tone. This procedure must be individually controllable. The
is continued until. purpose of this test is to compare the growth
i. The patient can hear the tone for a full of loudness in the deaf ear with the growth of
sixty seconds, and loudness in the opposite (normal) ear. In this
ii. Increments up to 30 dB have been way, the degree of recruitment, if present, can
reached and the patient fails to hear the be demonstrated.
tone for at least 60 seconds at that level. The growth of loudness in the impaired ear
The amount of tone decay is expressed as as it is compared with the reference ear, can
be illustrated in a graph (Laddergram).
the number of decibels above the threshold at
which the tone can be heard for a full minute. Decruitment
Interpretation This phenomenon denotes an abnormally
1. Normal 0-5 dB Suggestive of slow growth of loudness and is considered as
in sixty seconds cochlear deafness pathognomonic of retrocochlear lesion.
Principles of Audiometry 139
Pathophysiological Aspects
Fig. 23.9: Brainstem auditory response. Five waves Latency abnormalities
(fast 100 to 2000 Hz) are seen when the responses
1. Peripheral defect: In peripheral hearing
to acoustic clicks are averaged to exclude muscle
potentials. Each probably corresponds to a synapse loss, absolute latency of wave I increases
in the brainstem and has a characteristic time of but the interpeak latencies (IPL) of waves
appearance. Scale shows time after stimulus in I to III, waves III to V and waves I to V
milliseconds
remain normal.
2. Central conduction defects—interpeak
death episode (NMSID). The proximity of the latency abnormality (IPL): Wave I to III IPL
respiratory centres to the auditory brainstem values increase by more than +2 SD, this
pathways is the basis for application of (BERA) suggests a conduction defect between the
in its early detection in suspect apnoeic 8th nerve close to the cochlea and the lower
infants. pontine region, e.g. acoustic nerve or other
pontine tumours.
Wave Generator Site 3. Waves III to V IPL abnormality: If waves
Sohmer and Feinmesser (1967) described elec- III to V IPL values increase by more than
trical recording of the 8th nerve, it was Jewett mean +2 SD, this suggests a conduction
(1971) who successfully demonstrated seven defect between the lower pons and the
upward deflections of submicrovolt ampli- midbrain.
tude during the first 10 msec period following 4. Absence of wave IV and/or V: Brainstem
click stimulation. Such minute electrical lesions such as tumour or degenerative
responses were extracted, with the help of the conditions like anoxaemia, kernicterus, etc.
computer at the scalp from the background can produce such (BERA) abnormality ipsi-
electroencephalogram activity. With the laterally as well as contralaterally.
newer generation of computer now, it is Amplitude abnormality
possible to have variety of far-field scalp 1. Loss of amplitude: The loss of amplitude
averaging system for clinical use. Clinical is assumed to be due to less number of
studies have corroborated the location of the fibres conducting the volley and desyn-
brainstem generation sites, described as chronisation of the volley, secondary to
follows: widely different velocities.
142 Textbook of Ear, Nose and Throat Diseases
ANATOMY
External Nose
External nose has a bony and cartilaginous
structure. The bony framework is formed by
a pair of nasal bones, the frontal processes of
maxillae and the nasal spine of the frontal bone
(Fig. 24.3).
Nasal Cavities
The interior of the nasal cavity is divided into
two halves by a central septum.
The anterior and posterior apertures of the Fig. 24.4:Lateral wall of the nose
nose are called the anterior and posterior
choanae respectively. The nasal cavity has a The medial wall of the nasal cavity is formed
roof, floor, and medial and lateral walls. by the nasal septum.
The floor is formed by the palatine processes The lateral wall of the nose has ridges and
of maxillae and horizontal plates of the two depressions. The ridges are formed by
palatine bones. turbinates. There are three turbinates—supe-
The roof is made of nasal bones, under rior, middle and inferior. While the inferior
surface of the nasal spine of the frontal bone, turbinate is a separate bone, the middle and
cribriform plate of the ethmoid and under- superior turbinates are parts of the ethmoid
surface of the body of sphenoid bone. bone (Figs 24.4 and 24.5).
by periosteum separately (Fig. 24.7). This fibre Blood Supply of the Septum
arrangement is kept in mind while elevating The nasal septum derives its blood supply
the flaps in septal operations to avoid tearing from the following sources.
of the flaps. 1. Long sphenopalatine branch of the internal
maxillary artery (main blood supply to the
septum).
2. Anterior and posterior ethmoid branches
of the ophthalmic artery (supply the
septum in the upper and posterior part).
3. Terminal branches of the greater palatine
artery through the incisive canal.
4. Septal branches of the superior labial artery
(coronary artery of the nose), a branch of
facial artery.
The ramifications of these blood vessels
form an anastomosis (Keissel-Bach’s plexus) at
Fig. 24.7:Mucoperichondrial and mucoperiosteal the anteroinferior portion of the septum called
layers in the septum, septal cartilage (dotted area),
ethmoid and maxillary crest (black): (1) Left anterior Little’s area (see Fig. 32.1). This is a frequent
tunnel,(2) Left inferior tunnel, (3) Right inferior tunnel site of bleeding.
152 Textbook of Ear, Nose and Throat Diseases
Mucosa of Nose
1. The anterior vestibular region has stratified
squamous epithelium. It ends at the
mucocutaneous junction.
2. Respiratory portion of the nasal mucosa is
lined by pseudostratified columnar ciliated
epithelium. The mucosa is firmly adherent
to the perichondrium and periosteum.
3. Olfactory mucosa: This part of the mucosa
occupies the olfactory portion of the nose
which extends over the upper part of Fig. 24.8:Diagrammatic representation of
septum and adjacent lateral wall up to the the paranasal sinuses
superior turbinate. This mucosa has a
yellowish colour and consists of olfactory The posterior wall is formed by the posterior
receptor cells among basal cells and surface of maxilla.
supporting cells. The opening of the maxillary sinus is in the
posterior part of the hiatus semilunaris
PARANASAL SINUSES
between bulla ethmoidalis and the uncinate
A diagrammatic representation of the sinuses process of the ethmoid bone, on the
is given in Figure 24.8. lateral wall of the nose below the middle
turbinate. The capacity of sinus varies between
Maxillary Sinus (Antrum of Highmore) 15 ml to 30 ml.
This is a pyramidal cavity in the maxilla. The The roots of the premolar and molar teeth
sinus cavity may be divided into small spaces may project into the sinus cavity. The marrow
by bony septa. containing bone may be present up to 18
The roof of the sinus is formed by the floor months of age and, therefore, osteomyelitis of
of the orbit. The floor of the sinus lies about the maxilla may occur during this period. The
1 cm below the level of the nasal cavity in posterosuperior dental vessels and nerves
adults and is formed by the alveolar process supply the sinus mucosa.
of maxilla.
Frontal Sinus
The anteriolateral wall is formed by the
anterior part of the body of maxilla. It contains Frontal sinuses are two in number and
the anterior superior dental vessels and develop in the frontal bone. The two sinuses
nerves. are usually unequal in size. The anterior wall
The medial wall is formed by the nasal and floor of the sinus have marrow contain-
surface of maxilla, the perpendicular plate of ing bone, hence, osteomyelitis can develop in
palatine bone, maxillary process of inferior this region at any age. The floor of the sinus
turbinate and the uncinate process of ethmoid. forms parts of the roof of orbit. The posterior
Development and Anatomy of the Nose and Paranasal Sinuses 153
wall forms the anterior boundary of the ante- optic nerve and cavernous sinus. The sinus
rior cranial fossa, hence infection of the sinus opens through the anterior wall in the
can travel to the anterior cranial fossa and sphenoethmoidal recess.
orbit. The frontal sinus is drained by the
frontonasal duct which opens in the anterior BLOOD SUPPLY OF THE NASAL
part of the middle meatus. The average CAVITY
capacity of the sinus is about 7 ml in adults. 1. The main supply is by the sphenopalatine
The sinus is supplied by the supraorbital nerve artery, a branch of the internal maxillary
and vessels. artery which divides into lateral nasal
branches and a long septal branch.
Ethmoid Sinuses
2. Anterior and posterior ethmoidal arteries,
These are multiple air-containing cells situated branches of the ophthalmic artery supply
in the ethmoidal labyrinth. These are arranged the upper part of the lateral wall and upper
in three main groups. Anterior group, middle posterior part of the septum.
group and the posterior group. 3. The greater palatine artery enters through
The anterior group of cells drain into the the incisive canal into the nose and supplies
anterior part of the middle meatus. The the anteroinferior part of the septum and
middle ethmoidal cells drain in the middle adjacent areas of the floor and lateral wall.
meatus on the ethmoid bulla or above it while 4. The superior labial branch of the facial
the posterior ethmoid cells drain into the artery supplies the septum and nasal alae.
superior meatus.
The ethmoid air cells are related laterally Venous Drainage
to the orbit and are separated from it by a thin Veins form a plexus which drains anteriorly
bone lamina papyracea. Posteriorly the eth- into the facial vein, posteriorly into the
moids are related to the optic foramina. pharyngeal plexus of veins and from the
Superiorly the ethmoid air cells may reach to middle part to the pterygoid plexus of veins.
a level above the cribriform plate. These
sinuses are supplied by the anterior and NERVE SUPPLY OF THE NOSE
posterior ethmoid nerves and vessels.
The respiratory portion of the nose is supplied
by the following nerves.
Sphenoid Sinus
1. Anterior ethmoidal branch of the naso-
Sphenoid sinuses develop in the body of the ciliary nerve, supplying the upper part of
sphenoid bone. The two sinuses are unequally the lateral wall and the septum
divided by a septum. 2. Sphenopalatine nerves (long and short),
Superiorly the sinus is related to the frontal branches from the sphenopalatine gang-
lobe and olfactory tracts. Above and poste- lion
riorly lies the pituitary gland in the sella 3. Greater palatine nerve
turcica. Laterally the sinus is related to the 4. Anterior superior dental nerve.
154 Textbook of Ear, Nose and Throat Diseases
From the olfactory portion of the nose, The fibres from this ganglion pass in the
nerve filaments pass through the foramina in greater superficial petrosal nerve.
the cribriform plate of ethmoid and end up in The deep petrosal nerve and greater
the olfactory bulb in which they form superficial petrosal nerves join together to
synapses. form the nerve of pterygoid canal (Vidian nerve)
which joins the sphenopalatine ganglion. The
Sympathetic Supply fibres in the greater superficial petrosal nerve
The preganglionic fibres arise from the first end in the sphenopalatine ganglion. Postgang-
and second thoracic segments of the spinal lionic fibres arise from this ganglion and both
cord and end in the corresponding sympathe- sympathetic and parasympathetic fibres are
tic ganglia. These fibres ascend in the cervical distributed through the sphenopalatine nerves
sympathetic chain to synapse in the superior to the nasal mucosa.
cervical ganglion. The postganglionic fibres
pass from this ganglion around the internal LYMPHATIC DRAINAGE OF NOSE
carotid artery. The fibres pass from the AND PARANASAL SINUSES
internal carotid as the deep petrosal nerve.
Submandibular lymph nodes collect lymph from
Parasympathetic Supply the external and anterior parts of the nasal
The preganglionic fibres arise in the superior cavity.
salivary nucleus in the brainstem and pass in Upper deep cervical nodes drain the rest of
the nervus intermedius to the geniculate the nasal cavity either directly or through the
ganglion. retropharyngeal nodes.
25 Physiology of the Nose and
Paranasal Sinuses
The nose forms the gateway of the respiratory 3. Airconditioning and humidification: The
system and serves the following important highly vascular mucosa of the nose main-
functions. tains constancy of temperature of air and
1. Respiratory passage: Normally, breathing thus, prevents the delicate mucosa of the
takes place through the nose. The inspired respiratory tract from any damage due to
air passes upwards in a narrow stream temperature variations. The humidified air
medial to the middle turbinate and then is necessary for proper functioning and
downwards and backwards in the form of integrity of the ciliated epithelium.
an arc, and thus respiratory air currents are 4. Vocal resonance: The nose and paranasal
restricted to the central part of the nasal sinuses serve as vocal resonators and nasal
chambers. Any anatomical or pathological passages are concerned with production of
obstructive lesion in this region is nasal consonants like M and N. Thus
obstructions of the nasopharynx and nose
important, as this disturbs the air flow.
alter the tone of voice (rhinolalia clausa).
2. Filtration: The nose serves as an effective
5. Nasal reflex functions: The receptive fields
filter for the inspired air.
of various reflexes lie in the nose. These
a. Vibrissae (nasal hair) in the nasal
include sneezing, and nasopulmonary,
vestibule arrest large particulate matter
nasobronchial and olfactory reflexes. These
of the inspired air.
protect the mucosa and regulate the vaso-
b. The fine particulate matter and bacteria
motor tone of the blood vessels. Olfactory
are deposited on the mucus blanket reflexes influence salivary, gastric and
which covers the nasal mucosa. The pancreatic glands.
mucus contains various enzymes like 6. The nasal cavity serves as an outlet for lacrimal
lysozymes having antibacterial proper- and sinus secretions.
ties. 7. Olfaction: This function of the nose is less
c. The mucus with the particulate matter developed in human beings. This sensa-
is carried by the ciliary movements tion plays the most important role in
posteriorly to the oropharynx, to be behaviour and reflex responses of lower
swallowed. animals.
156 Textbook of Ear, Nose and Throat Diseases
The olfactory mucosa is located in roof of of olfacts. Normally the olfactory sense smells
nasal cavity and adjacent area of superior one olfact.
turbinate and upper part of septum. The Olfactometry gives information about the
olfactory cells are distributed in the olfactory following.
mucosa. 1. The extent of the field of smell.
The mechanism of olfactory stimulation is 2. It gives an idea about the patient’s acuity
uncertain. Various theories have been propa- of smell.
gated. The odouriferous substance reaches the 3. Possible parosmia (perverted smell).
olfactory cells by air, probably by diffusion.
The olfactory sensitivity differs in individuals DISTURBANCES OF OLFACTION
and is influenced by many physiological
Hyposmia
factors and pathological changes in the nose.
Diminished sense of smell is termed hypos-
OLFACTOMETRY mia. Its causative factors are the following:
(ODOUR MEASUREMENT) i. Old age (Presbyosmia)
ii. Hypogonadal women, menopause
Various methods have been used to assess the iii. Tobacco smoker, radiation therapy of
olfactory function in man. nose
iv. Surgical removal of the mucosa.
Qualitative Olfactometry
Parosmia
The olfactory sense is assessed by taking a
It is a qualitative change. There occurs an
solution or extract before the patient’s nose.
unpleasant change in sense of smell.
The following primary odours are usually
It may occur in the following conditions:
tested:
i. Skull fractures
1. Etherial—Ether
ii. Injury to uncus of the temporal lobe
2. Camphoraceous—Camphor
iii. May follow administration of strep-
3. Flora(l)—Salicyldehyde
tomycin or tyrothricin.
4. Musky—Phenyl acetic acid
5. Minty—Mint Anosmia
6. Pungent—Formalin
Anosmia is the loss of the sense of smell. Its
7. Putrid—Thiophenol
causes are the following:
i. Obstructive lesions in the nose and
Quantitative Olfactometry
nasopharynx
The measurement of olfactory sense can be ii. Lesions of mucosa
done by an olfactometer. This instrument iii. Trauma__surgical or accidental
gives an idea about the qualitative defects of iv. Neuritis
olfaction. The reading is taken as the number v. Central lesions in the brain.
Physiology of the Nose and Paranasal Sinuses 157
26 Common Symptoms of
Nasal and Paranasal
Sinus Diseases
The nose and paranasal sinuses are closely obstruction may be alternating on the two
related anatomically, so are their presenting sides and may be progressive and persistent.
symptoms. The following symptoms may be The common conditions of the nose and para-
present alone or in combination depending nasal sinuses which result in nasal obstruction
upon the disease process. include deviated nasal septum, ethmoidal and
antrochoanal polypi, hypertrophied turbi-
Nasal Discharge nates, septal haematoma, foreign bodies in
The discharge from the nose may be unilateral nose, nasal and paranasal sinus tumours, and
or bilateral and further it could be watery, granulomatous diseases.
mucoid, mucopurulent, purulent or blood- Besides the lesions in the nose and para-
stained. nasal sinuses, adenoids, tumours and cysts of
Watery discharge is usually found in the the nasopharynx can also cause nasal
early stages of common cold, vasomotor rhini- obstruction.
tis and CSF rhinorrhoea. Mucoid discharge is The symptom of nasal obstruction is often
usually a feature of allergic rhinitis while associated with a history of breathing through
mucopurulent discharge occurs in infective the mouth, and dryness of the throat due to
rhinitis and sinusitis. lack of the humidifying action of the nose.
Purulent discharge is a feature of atrophic
Facial Pain and Headache
rhinitis, foreign bodies in the nose, furuncu-
losis and long-standing sinusitis. Nasal and paranasal sinuses are frequently
Blood-stained nasal discharge usually blamed for headaches and facial pain. Pain
indicates an underlying malignant process, due to involvement of different sinuses has
foreign body or nonhealing granulomas, etc. different characteristics.
is more during early hours of the day and coming into the oropharynx causing various
subsides or diminishes in intensity by after- pharyngeal symptoms.
noon as by that time drainage of the infected Postnasal drip occurs commonly in aller-
discharge occurs. gic and infective diseases of the nose and
paranasal sinuses, due to adenoids or in
Maxillary Sinus Headache Thornwaldt’s disease (bursitis).
Pain due to the involvement of the maxillary
Speech Defect
sinus is more over the maxillary region. It may
be referred to the upper alveolus. Ethmoid Disorders of the nose and nasal sinuses may
sinus pain usually occurs along sides of the result in loss of the resonating function and
nose or in the orbits. this may give a nasal tone to voice like a closed
nose speech as occurs in obstructive lesions.
Sphenoid Sinus Headache
Symptoms due to Extension of the
The pain is referred to the vertex or occiput
Disease to the Adjacent Regions
or may be present behind the eyes.
Facial pain due to other nasal and para- Diseases of the nose or paranasal sinuses may
nasal lesions may occur as in furunculosis, involve adjacent structures like the orbit,
syphilis, due to nerve infiltration as in sinus cranial cavity, cavernous sinus, etc. and
tumours and trigeminal neuralgias. produce symptoms of their involvement.
Epistaxis Sneezing
Bleeding from the nose may be unilateral or Sneezing is the normal nasal reflex to clear
bilateral and may be due to a variety of lesions secretion from the nose and is of great impor-
of the nose, paranasal sinuses and the tance in young children who have yet not
nasopharynx. The aetiology of epistaxis has learnt to blow their nose. It is stimulated by
been discussed in Chapter 32. irritation within the nose, by infection or
allergy, or following inhalation of noxious
Disorders of Olfaction gases or polluted air. The sensory side of the
Various olfactory derangements have already reflex is transmitted through the trigeminal
been discussed. nerve, and stimulation of the skin supplied by
the maxillary division of this nerve by cold,
Postnasal Drip strong light, pain or heat can also stimulate
Normally the secretions from the nose and this reflex.
nasopharynx are carried to the oropharynx by
Snoring
the mucociliary mechanism of the nose, where
from these are swallowed. Many times the Abnormal sound produced through nose
patient complains of excessive nasal discharge during sleep is called snoring. It has many
160 Textbook of Ear, Nose and Throat Diseases
causes like adenoids in children or polypi or pharynx which results in collapse of airway
growth in nose, too much hypertrophied due to suction effect and as respiratory effort
turbinates, oedematous mucosa of nose or soft increases, the resulting apnoea causes prog-
palate. While the treatment of all pathological ressive asphyxia, which results in arousal from
conditions relieves snoring, but some people sleep, with restoration of patency and airflow.
have habitual snoring making others difficult In most of the patients, the patency of airway
to sleep or concentrate on studies if they are is also compromised structurally, which
in same room. For such patients recent laser include obvious anatomic disturbance like
technique has been devised to treat the DNS, adenotonsillar hypertrophy, macro-
snoring. Under local anaesthesia, a small
glossia, retrognathia in a minority of patients,
needle connected to a radio-frequency
and a subtle reduction in airway size in a
generator is inserted into the soft palate
majority of patients. This subtle reduction can
junction of oronasopharyngeal mucosa. The
be usually demonstrated by imaging and
radio-frequency energy is directed through
acoustic reflection techniques.
shaking and disruption. Over few weeks, the
In central sleep apnoea there is transient
body naturally reabsorbs some of the loose
tissue thus relieving snoring. abolition of central drive to ventilatory musc-
les. Purely central apnoea without obstructive
Sleep Apnoea element is very rare. Mixed apnoea is a
combination of failure of central control and
Normal respiration requires air to be displaced
upper airway obstruction.
from external environment to alveolar
membrane to make oxygen available for gas
Clinical Manifestation
exchange. This simple looking involuntary act
is extraordinarily complex. Crucial in this The narrowing of airway during sleep inevit-
process is the ability of upper airway to per- ably results in snoring. In most pateints
mit the unimpeded transport of air to tracheo- snoring antedates the development of obstruc-
bronchial tree. Apnoea results when this tive events by many years.
process is partially or completely interrupted. The nocturnal asphyxia and frequent
The supralaryngeal airway is most susceptible arousal from sleep lead to day-time sleepiness,
to obstruction during the skeletal muscle intellectual impairment, memory loss,
hypotonicity associated with sleep. This personality disturbance and impotence.
resulting in sleep apnoea which is defined as
intermittent cessation of airway during sleep. Other Manifestations
Sleep apnoea is divided into obstructive, central
and mixed types. The obstructive apnoea is Cardiorespiratory in nature. Obstructive sleep
preceded by upper respiratory obstruction apnoea (OSA) is considered to be risk factor
with increasing respiratory effort. for the development of systemic hypertension,
During sleep there is reduced activity and myocardial ischaemia, infarction, stroke and
tone in the muscles of tongue, soft palate and premature death.
Common Symptoms of Nasal and Paranasal Sinus Diseases 161
Management Treatment
Investigations The investigatory part includes: It can be medical or surgical. Medical treat-
1. Detailed history and clinical examinations. ment includes continuous positive airway
2. Observation of patient during sleep. pressure. This has the disadvantage that it
3. Polysomnography, which is detailed cannot be used for long-term management.
examination during sleep with monitoring Surgical treatment includes adenotonsil-
of sleep stages. lectomy, velo-palato pharyngoplasty. In
4. Transcutaneous monitoring of (oxygen) O2 severely affected patients who are unsuitable
saturation during sleep. for surgery, tracheostomy may be done to at
5. Measurement of airflow. least partially reverse the gross cardiopulmo-
6. Continuous ECG monitoring. nary abnormalities.
7. Radiology for identification of adenoid
obstruction of nasopharynx and tonsillar
obstruction of oropharynx.
162 Textbook of Ear, Nose and Throat Diseases
The examination of these regions includes culosis. A dislocated anterior end of the
general examination of the face and nose, septum may be visible.
anterior rhinoscopy, oropharyngeal exami- An assessment of the nasal airway is done
nation, posterior rhinoscopy and various other by keeping a cold glass slide or a metallic
investigative procedures. tongue depressor just in front of the nostrils.
On expiration, the warm air produces an area
INSPECTION AND PALPATION of condensation on the surface. The difference
This is done to detect any deformity, asym- on the two sides is an indication of nasal obs-
metry or swelling of the nose and face. Dep- truction. Alternatively, degree of displace-
ression or deviation of the nasal bridge due to ment, on expiration, of a cotton wick held near
injury or disease may be present. A sinus in the nostrils also gives an idea about the degree
the midline of the nasal dorsum is usually of nasal obstruction.
congenital. Rarely a sebaceous horn may be This initial examination of the nasal vesti-
present. Gentle palpation of the nose may bule without nasal speculum is necessary as
detect crepitus in fractured nasal bones. otherwise blades of the speculum may obscure
Dislocated anterior end of the septum may papillomas, cysts and bleeding points in this
be projecting into the vestibule. The nose must region.
also be observed by standing above and
behind the patient. Examination with a Nasal Speculum
A Thudicum’s speculum or a St. Clair-
ANTERIOR RHINOSCOPY
Thompson’s speculum with a handle are
This procedure is carried out using a head commonly used for examination. These are
mirror and a light source. available in many sizes. The speculum must
Examination of the nasal vestibule is be held in the left hand, keeping the right hand
usually done without a nasal speculum. The free for manipulations.
tip of the nose is raised up and the nostrils The Thudicum’s speculum is held with the
inspected for redness or swelling as in furun- thumb and forefinger of the left hand. The
Examination of the Nose, Paranasal Sinuses and Nasopharynx 163
middle finger rests on one side and ring finger The view of inside of the nose in general is
on the other side to control the spring of the improved by using a vasoconstrictor spray in
speculum. The closed speculum is introduced the nose. Any manipulation of the nose is
into the nasal vestibule and blades of the facilitated by spraying the mucosa with topical
speculum directed in line of opening of the xylocaine 4 per cent.
nostrils. The blades are opened to permit A suction apparatus is a valuable asset for
proper examination of the nose but not so proper examination.
wide as to cause discomfort. Care is taken in The meati are noted for discharge, local
introducing and opening of blades in oedema or redness. The middle meatus is a
inflammatory lesions of the the vestibule. The common site for polypi. The type of discharge
nasal cavities are properly examined. The is noted and a postural test may be done to
floor, lateral wall, septum and posterior note its probable site of origin.
portions of nasal cavities are viewed. The
colour of the nasal mucosa is noted. Normally Postural Test
it is dull red. Variations from normal are If discharge is seen in the middle meatus, it
observed. A congested mucosa is seen in usually means an infection of the anterior
inflammatory lesions while pale or bluish group of sinuses; when discharge in this
mucosa is seen in allergic conditions. Septal region accumulates immediately on its remo-
deviations or spurs are noted. Prominence of val, it indicates that it is coming from the
vessels or crusting is often seen in the Little’s frontal sinus.
area. Perforations of the septum may be If the discharge does not immediately
present. reaccumulate, the patient’s head is turned to
The nasal cavity may be widened as in the side of the normal maxillary sinus and the
atrophic rhinitis. Dryness of the nasal mucosa patient kept in this position for some time. The
and crust formation inside the nasal cavity patient is made to sit upright again and reaccu-
may be seen. mulation of discharge in the middle meatus
The anterior ends of the inferior and indicates involvement of the maxillary sinus.
middle turbinates are visible on anterior rhino-
scopy. These appear as prominent fleshy, firm Examination of the Oral
and red projections on the lateral wall. These Cavity and Oropharynx
do not move on probing. The turbinates may On examination of the oral cavity in relation
appear atrophic and shrivelled up as in to nasal and paranasal sinus disease, it is
atrophic rhinitis. They may be grossly important to note following:
hypertrophied in chronic rhinitis, vasomotor The gingivobuccal sulcus is inspected for
rhinitis and in allergic rhinitis. any fulness or discharge. The anterolateral
The meati are mostly covered by the surface of the maxilla is palpated sublabially.
turbinates and hardly visible on anterior Carious teeth, loose teeth or widening of
rhinoscopy. an alveolus are looked for. Any bulge of the
164 Textbook of Ear, Nose and Throat Diseases
POSTERIOR RHINOSCOPY
This procedure permits the examination of the
posterior aspects of nose and nasopharynx.
The examination is a slightly difficult proce- Fig. 27.1:Method of performing posterior
dure and needs some experience. The rhinoscopy
procedure is explained to the patient.
the posterior choanae (Fig. 27.2). Discharge
The patient is asked to open the mouth. A
may be seen trickling from the meati over the
tongue depressor is used with left hand to
turbinate ends. Discharge from the maxillary
depress the anterior two-thirds of the tongue.
sinus may be seen over the inferior turbinate
The patient is advised to breathe quietly
while discharge from posterior ethmoidal
through the nose, and relax. A warmed
sinuses and the sphenoid sinuses appear
postnasal mirror is held in the right hand and
above the superior turbinate. Antrochoanal
passed into the oropharynx between the
polyp may be seen as a greyish, pale, smooth
posterior pharyngeal wall and soft palate
swelling, coming out of posterior choana into
without touching either.
the nasopharynx.
Topical xylocaine may be needed to pre-
vent gagging and allowing proper exami-
nation. The nasopharynx is examined in a
systematic way using the head mirror and a
light source (Fig. 27.1).
The posterior end of septum is seen as a
vertical edge. On each side of posterior end of
the septum are seen posterior choanae. The
posterior edges of the inferior, middle and
superior turbinates are seen on the lateral side
of the nasal cavity. Hypertrophied posterior
ends of the inferior turbinates appear as
rounded, mulberry swelling on each side in Fig. 27.2:Posterior rhinoscopic view
Examination of the Nose, Paranasal Sinuses and Nasopharynx 165
A lateral tilt of the mirror, brings the lateral Palpation may be needed in doubtful cases
wall of the nasopharynx into view. The naso- of malignancy of the nasopharynx. In children
pharyngeal opening of the eustachian tube and it may be done for adenoids.
a recess above and behind this (fossa of
Rossenmuller) is noted. The fossa of Rossen- NASOPHARYNGOSCOPY
muller is frequently a site of malignancy. Examination of the nasopharynx may be done
The roof and posterior walls of the naso- under topical anaesthesia using a naso-
pharynx are examined next. Adenoid tissue pharyngoscope with a distal light source or
is seen as a pinkish mass at the junction of roof by a fibre-optic nasopharyngoscope. The
and posterior wall of the nasopharynx up to nasopharyngoscope is passed along the
early adult life. The surface shows clefts. inferior turbinate and examination of the
A nasopharyngeal angiofibroma appears nasopharynx done through its window. This
as a red, firm lobulated mass with prominent is useful for evaluating cases of suspec-
vessels unlike the greyish pale, smooth ted cancer and may also be used for guiding
antrochoanal polyp. the tip of the eustachian catheter inside the
Nasopharyngeal cancer may appear as a eustachian orifice.
proliferative or ulcerative lesion. Sometimes
only fulness of nasopharynx is visible. Examination of Nasopharynx with
Retracted Soft Palate
RHINOMANOMETRY
In patients who do not allow proper exami-
Measurement of nasal air flow in studying nation of the nasopharynx, the soft palate may
nasal obstruction and its role in the produc- be retracted. Rubber catheters are passed from
tion of some respiratory and cardiac changes the nose into the oropharynx. The end of the
is still in the research stage. catheter is brought out from the oropharynx
and the two ends tied together. This retracts
DIGITAL PALPATION OF THE the soft palate and thus allows a direct view
NASOPHARYNX of the nasopharynx.
This is an unpleasant procedure for the patient
TRANSILLUMINATION OF
if not done under general anaesthesia. The
THE SINUSES
examiner stands on the right side of the seated
patient and holds the patient’s head against This procedure is done in a darkroom. The
his left hip. The patient is asked to open the light source (the sinus transilluminator) is
mouth and his cheek is pressed between his placed in the oral cavity for testing the
teeth by the left hand fingers of the examiner maxillary sinuses. The light transmitted
to prevent closure of the jaw. through the sinus is seen as glowing of pupils
The examiner passes the fingers of the right and the infraorbital crescent. For the frontal
hand behind the soft palate into the naso- sinus, the light source is placed against the
pharynx. floor of the sinus. The light transmitted is seen
166 Textbook of Ear, Nose and Throat Diseases
as a glow on the anterior wall of the sinus. teeth. The rays pass from above through the
The test is not of much help as thickened roof of the nose to the centre of the film.
mucosa, mucopus, pus or tumour, all show
an opaque sinus. The test is not possible for Views for the Paranasal Sinuses
sphenoids and is not helpful for multiple It is difficult to examine all the paranasal
ethmoid cells. sinuses on one projection, so the examination
of individual sinus requires many views. The
SINOSCOPY few standard views that are taken, which give
It is the direct visualisation of the interior of an adequate idea about the condition of
the maxillary sinus by means of a fibre-optic paranasal sinuses are as follows:
endoscope called maxillary antrumscope. The 1. Occipitomental view (Waters view): The X-ray
endoscope is introduced through a cannula is taken in the nose-chin position with an
which is introduced into the maxillary sinus open mouth. The film demonstrates mainly
after the usual antrum puncture technique, the maxillary sinuses, nasal cavity, septum,
either through the inferior meatus route or frontal sinuses and few cells of the eth-
through the canine fossa. This diagnostic moids. The view taken in the standing
method is specific and accurate as compared position may show fluid level in the
to radiological examination of the maxillary antrum (Fig. 27.3A).
sinus. It markedly reduces indications for the 2. Occipitofrontal view (Caldwell view): The
Caldwell-Luc operation. patient’s forehead and tip of the nose are
kept in contact with the film. This view is
particularly useful for frontal sinuses. A
RADIOLOGICAL EXAMINATION
portion of the maxillary antrum and nasal
OF THE NOSE AND PARANASAL
cavity are also shown (Fig. 27.3B).
SINUSES
3. X-ray the base of the skull (Submentovertical
The following radiological procedures may be view): The neck and head are fully extended
needed for evaluation of diseases of the nose so that vertex faces the film and the rays
and paranasal sinuses. are directed beneath the mandible. The
view is useful for demonstrating sphenoid
Plain X-rays sinuses, ethmoids, nasopharynx, petrous
apex, posterior wall of the maxillary sinus
Plain X-rays of the nasal bones may be and fractures of the zygomatic arch (Fig.
required after injury to determine fractures or 27.3C).
displacement. 4. Lateral view: The patient’s head is placed
The film is taken with the patient’s head in a lateral position against the film and
in the lateral position. This view projects the the ray is directed behind the outer canthus
nose and adjacent areas of the face. A shadow of the eye towards the film.
of the nasal cartilages may also appear. The maxillary, ethmoidal and frontal
In the superoinferior view, the patient sinuses superimpose each other but this film
holds a dental occlusal film in between the is useful for the following purposes.
Examination of the Nose, Paranasal Sinuses and Nasopharynx 167
28 Congenital Diseases
of the Nose
CHOANAL ATRESIA
Congenital atresia of the anterior apertures
(Figs 28.1 and 28.2) of the nasal passage is
seldom seen. This fault occurs when the
original epithelial plugs between the
developing medial and lateral nasal folds fail
to get absorbed during embryonic life.
Posterior choanal atresia is a more
common congenital disease, though its
incidence is also rare. Choanal atresia can be
unilateral or bilateral, bony or membranous,
and complete or incomplete. Various opinions
have been expressed to explain its occurrence.
Fig. 28.2:Nasal atresia
Clinical Features
Bilateral atresia of the posterior nares, though
not always a life threatening airway emer-
gency, produces symptoms of high airway
obstruction and the infant shows considerable
difficulty in breathing immediately after birth.
There is marked difficulty in swallowing
feeds due to the inability to coordinate brea-
thing and swallowing. Tracheostomy may be
Fig. 28.3:Bifid tip with Fig. 28.4:Congenital
needed.
absence of columella cleft nose
Unilateral choanal atresia is usually not
diagnosed early. Such patients present with a the site of obstruction under direct vision.
history of nasal obstruction with a mucoid Figures 28.3 and 28.4 show bifid tip with
discharge and the patient is unable to blow absence of columella and congenital cleft-nose
the nose on affected side. respectively.
ENCEPHALOCELE
This is a rare congenital condition which can
present as a herniation of meninges and brain
Figs 28.5 to 28.8:Dermoid cyst and sinus. Congenital
dermoid cysts of the nose result from persistence of
tissue (Fig. 28.10) through a dehiscence in the
remnants of ectoderm of dural origin in the prenasal frontal bone. The cough impulse is positive,
space i.e. the swelling increases on straining and
coughing. Treatment lies in closing the bony
defect. If the defect is larger, the patient should
be referred to a neurosurgeon.
29 Diseases of the
External Nose
Treatment
Majority of the boils in the nose resolve spon-
taneously. Treatment involves application of
local heat and antibiotic ointment, and analge-
sics to relieve the pain. Antibiotics like penicil-
Fig. 29.1:Furunculosis of lin and cloxacillin may be needed in severe
nose with cellulitis of face
cases.
172 Textbook of Ear, Nose and Throat Diseases
VESTIBULITIS
Diffuse infection of the skin of the anterior
nares may result from frequent trauma as in
nosepicking. This produces traumatic ulcera-
tion and crusting, thus giving a foothold to
the infection. Similarly, persistent nasal
discharge leads to excoriation and infection
of the skin of the nasal vestibule. Sometimes,
the projecting end of a dislocated septal
cartilage stretches the skin of the vestibule,
which gets easily traumatised. Fig. 29.4: Acne rosacea
Diseases of the External Nose 173
Treatment
Small lesions are excised with surrounding
healthy area. A large defect may need skin
grafting. Alternatively radiotherapy is given.
31 Foreign Bodies
in the Nose
Foreign bodies in the nasal passages are not such cases, complaints of nasal obstruction
uncommon especially in children, mentally and unilateral blood-stained, foul smelling dis-
retarded adults. The most common route by charge should make the clinician suspicious
which a foreign body enters the nose is the of a foreign body in the nose.
anterior nares. Sometimes contents from the A foreign body may be visible on anterior
mouth or stomach may enter the nasopharynx rhinoscopy or may be obscured by mucopuru-
and nose during vomiting or coughing. Rarely lent discharge and granulations in long-
a foreign body like gauze pack, injecting standing cases. The foreign body is felt on
needle or a small instrument may be left in probing. Radiological examination of the nasal
the nose during nasal surgery. cavities and nasopharynx is helpful in
demonstrating a radiopaque foreign body
Inanimate Foreign Bodies (Fig. 31.1).
Inanimate foreign bodies found in the nose
include glass beads, buttons, pieces of pencil, Management
paper, peas and beans, metal, plastic pieces The patient is usually held in an upright
and button cells. position and the nasal fossae illuminated. A
Pathology curved hook is passed beyond the foreign
body which is then gently pulled forward. A
A foreign body retained in the nose produces
eustachian catheter usually serves this
an inflammatory reaction and stagnation. This
purpose. When the patient is uncooperative
leads to the formation of granulation tissue
and the foreign body is impacted or deeply
and ulceration. Sometimes a rhinolith may
seated, general anaesthesia may be needed.
form. Sinusitis and soft-tissue infection of the
nose and adjacent face may occur.
Animate Foreign Bodies
Diagnosis Animate foreign bodies include maggots,
The history is suggestive but many a time leeches and other insects. Leech can be
children do not report after the mishap. In removed by putting pinch of salt, or hyper-
Foreign Bodies in the Nose 179
Rhinolith
Concretion formation in the nose results if a
foreign body gets burried in granulations and
remains neglected. This forms a nucleus
around which a coating of calcium and mag-
nesium phosphate and carbonate occurs and
thus a rhinolith forms. Sometimes inspissated
mucopus or a blood clot may be a nidus
around which such a change takes place.
A rhinolith increases in size slowly and is
symptomless at the onset. When large, it
produces nasal obstruction. Examination
shows a brown or greyish irregular mass near
the floor of the nose. It feels stony hard and
Fig. 31.1: Showing a radiopaque
gritty on probing. X-ray shows a radio-opaque
foreign body in the nose of a child
shadow. It is surgically removed under
tonic saline or a few drops of oxalic acid on general anaesthesia. It may be necessary to
their body surface. break it in the nasal fossa and then remove it
Maggots in the nose are asphyxiated with piecemeal. Sometimes a large rhinolith may
a ribbon gauze pack soaked in terpentine oil, necessitate a lateral rhinotomy procedure for
kept in the nasal cavity for some time and then its removal.
180 Textbook of Ear, Nose and Throat Diseases
32 Epistaxis
Little’s Area
The anteroinferior part of the septum is the
most common site of bleeding in majority of
the cases. This is a highly vascular area
marking the anastomosis between the bran- Fig. 32.1:Anastomosis at Little’s area
ches of various blood vessels supplying the
nose. Branches from the anterior ethmoid, Factors like coughing, sneezing, straining
sphenopalatine, greater palatine and superior and blowing play a contributory role by
labial arteries take part in this anastomosis causing rise in the vascular pressure.
(Kiesselbach’s plexus) (Fig. 32.1).
There is a venous plexus near the poste- Aetiology
rior end of the inferior turbinate called The main causes of epistaxis are grouped as
Woodruff’s area, which is another common site under:
of bleeding in the nose. 1. Local
The patient may be a habitual nose picker a. Trauma: External trauma to the nose
and repeated ulceration may be the cause of (accidental), repeated nose picking
the nose bleed. (intentional), surgical trauma (iatro-
Hypertension is a very common disease genic), foreign body in the nose (ani-
and causes epistaxis frequently in elderly mate or inanimate).
patients. The site of bleeding is usually high b. i. Infection
up posteriorly in the nose. Some well-defined • Vestibulitis
cause may be evident on examination. • Acute rhinitis
Epistaxis 181
mucosa, is troublesome for the patient, and nose is packed, as packing disturbs the nasal
delays recovery. physiology and leads to stagnation of the
1. Anterior nasal packing: Anterior nasal secretions with resultant infection. Various
packing is needed when bleeding is haemostatic preparations like adenochrome,
profuse and does not stop on pinching the vitamin C and K, and calcium preparations
nose. A lubricated or medicated gauze is play only an adjuvant role in stopping the
used for this purpose although nowadays bleeding.
merocel packs are preferred. Packing Alternatively, nasal packing may be
should never be done with a dry gauze. replaced by a specially devised (Brighton)
Nasal packing should be tight, starting balloon which has a fixed nasopharyngeal and
from the floor upwards. The pack is sliding anterior nasal balloon. Pressure on the
usually removed after 24 to 48 hours. bleeding vessels is exerted by inflating the
Subsequently after pack removal, the nose balloons.
is again examined and bleeding points
Ligation of blood vessels Rarely a situation may
cauterised.
arise when bleeding does not stop by an
2. Posterior nasal packing: If bleeding is
efficient nasal packing. In such cases ligation
continuous in spite of proper anterior nasal
of the blood vessels supplying the nose may
packing, then posterior nasal pack may be
be the only alternative.
necessary. This can be done under general
The nose is mostly supplied by the external
or local anaesthesia supplemented by
carotid artery through its sphenopalatine
sedation. Rubber catheters are passed from
branches. Thus ligation of the external carotid
the nose to the oropharynx. The threads of
artery in the neck or the internal maxillary
the pack are attached to the ends of the
artery in the sphenopalatine fossa arrests
catheters which are then withdrawn into
bleeding.
the nasopharynx, pulling a gauze pack
Sometimes, bleeding is high up in the nose
along with it. The pack is guided by fingers
from the area supplied by the anterior ethmoid
behind the soft palate. The threads on the
artery. The ligation of ethmoid vessels is done
rubber catheter are tied on a rubber piece
through a periorbital incision in the medial
at the columella. Tight anterior packing is
canthus of the eye.
done. A separate thread attached to the
Besides these measures of controlling
gauze pack is brought out through the
bleeding from the nose, attention should be
mouth.
paid to the underlying cause like hyperten-
Adjuvant therapy Bed rest and sedation are sion, blood dyscrasia, local pathology in the
important. Antibiotics are prescribed if the nose and the treatment accordingly instituted.
33 Diseases of
the Nasal Septum
Clinical Features
Many of us have varying degrees of septal
Fig. 33.1:Nasal septum: Normal and deformed deviations but only a few are symptomatic.
184 Textbook of Ear, Nose and Throat Diseases
The common symptoms produced are the The deflection may be confined to one
following: (C-shaped deflection) or both the sides
1. Nasal obstruction, which may be unilateral (S-shaped deflection).
or bilateral and can be continuous or A cartilaginous or a bony projection (septal
intermittent. spur) may protrude from the septum.
2. Dryness of the mouth and pharynx. Compensatory hypertrophy of the turbinates
3. Recurrent attacks of cold. may be present.
4. Headache and facial pains.
5. Epistaxis. Pathophysiology of Septal Deviations
6. Cosmetic deformity: The dislocated ante- The deviated septum, depending on its loca-
rior end may project out into the nasal tion and degree, is the most common cause of
vestibule or cause deformity of the tip. nasal obstruction. Associated factors like
7. Anosmia may be a complaint of some infection and allergy perpetuate the effects.
patients. Nasal obstruction in turn leads to mouth
8. Pain due to pressure on the anterior breathing with consequent dryness of the
ethmoidal nerve. mouth, pharynx and larynx. These predispose
An external nasal deformity affecting the to recurrent attacks of sore throat, common
cartilaginous part of the nose may be present. cold, tonsillitis and bronchitis. Impairment of
The anterior end of the cartilaginous septum drainage of the sinuses may occur due to
may project into one of the nasal vestibules mechanical obstruction of septal deviations or
(called dislocation of anterior end of the by compensatory hypertrophy of turbinates.
septum) (Fig. 33.2). Anterior rhinoscopy Headache and facial neuralgia might occur
shows deflection of the cartilaginous or bony because of defective aeration and impinge-
septum or combination of both. ment of the septum over the turbinates. Nose
bleeding may also occur. This occurs because
of stretching the mucosal vessels complicated
with dryness of the mucosa and associated
nose picking.
Nasal obstruction is thought to produce
pulmonary and cardiac effects too. Severe
degrees of deflected septum may produce
anosmia.
Submucous Resection of Septum the septum and also to reduce bleeding during
surgery.
Indication
1. Deviated nasal septum producing symp- Steps of Operation
toms like nasal obstruction. 1. A curved incision is made at the muco-
2. When the deviated septum is a predis- cutaneous junction, usually on the
posing factor for sinusitis or recurrent convex side of the deflection.
colds, and if the obstruction is contribut- 2. With an elevator the mucoperichond-
ing to the poor development of the teeth rial flap is elevated and the cartilage
and mouth. exposed.
3. Deviated septum causing epistaxis. 3. Using a knife an incision is made in the
4. Deviated septum preventing access for cartilage anteriorly leaving a strip for
removal of polypi or ethmoidectomy. SMR columellar support. The incision is made
operation may be needed for complete to the subperichondrial space of the other
removal of the polypi. side without cutting the mucoperichon-
5. For taking septal cartilage for graft drium of the other side.
purposes. 4. With an elevator, the cartilage is sepa-
6. To gain, access for other intranasal rated from the mucoperichondrium of
operations, for example trans-sphenoidal the other side without tearing the flap.
hypophysectomy, vidian neurectomy. 5. A long bladed nasal speculum is used to
7. To reduce the roominess in unilateral retract two mucoperichondrial flaps
atrophic rhinitis. from the central cartilage.
The operation can be performed under 6. With scissors, a cut is made in the
local or general anaesthesia. cartilage along the dorsum, keeping a
After xylocaine sensitivity is ruled out, the strut for dorsal support to prevent the
patient’s nose is sprayed with 4 per cent fall of the bridge. Deflected cartilage is
topical xylocaine. A ribbon gauze pack soaked then removed with Ballenger’s knife or
in xylocaine is packed into the nose with an Luc’s forceps. The mucoperiosteum may
idea to anaesthetise the sphenopalatine need elevation from the perpendicular
ganglion and its emerging nerves at the plate of ethmoid, vomer and maxillary
posterior end of the middle turbinate. The crest, if there is an associated bony
pack is carried high up in the nose to block deviation which is then removed.
the ethmoidal nerves. Local anaesthesia is 7. Cartilaginous and bony spurs are
supplemented by an intramuscular injection removed.
of pethidine and diazepam. 8. The flaps are approximated and may be
Surgery starts half an hour later after local stitched.
infiltration of 2 per cent xylocaine and 9. The nose is packed using merocel pack
adrenaline that helps further to anaesthetise to prevent mucosal trauma.
186 Textbook of Ear, Nose and Throat Diseases
10. The patient is given antibiotics and This operation is not advocated for child-
analgesics. The pack is removed after 24 ren up to the age of 18 years. The resection
to 48 hours. Subsequently the nose is operation if performed in young age may
cleaned of the clots and discharge and interfere with the development of the facial
ointment is applied. Liquid paraffin bones.
drops are used to lubricate the nose.
Septoplasty
Complications
This is an advance over the conventional
1. Haemorrhage: The bleeding may be primary, submucous resection operation. The principle
reactionary or secondary. Secondary haemor- of septoplasty is the correction of the deviated
rhage may occur after 5 to 6 days and is due septum with minimal sacrifice of its structure.
to infection. Septal haematoma or abscess Septoplasty is indicated when the deviation
may occur. lies anterior to a vertical line drawn from nasal
2. Perforation: Septal perforation may occur process of the frontal bone to nasal spine of
if tears in the mucoperichondrial flaps the maxilla. In children under 18 years of age,
superimpose on each other. septoplasty is preferrable to SMR. The
3. Flapping septum: Excessive removal of the instruments used are shown in Figure 33.3.
septal structure results in a weak septum The main steps of operation are as follows
which yields to inspiratory negative (Figs 33.4A to C):
pressure in the nose. This causes flapping 1. A unilateral (hemitransfixation) incision is
of the septum and may lead to nasal made in the mucoperichondrial flap at the
obstruction. lower border of the septal cartilage on the
4. Depression of the cartilaginous dorsum left side for right-handed persons.
may occur if an adequate strip of the 2. The mucoperichondrial flap is elevated on
cartilage is not kept superiorly. one side making an anterior tunnel.
5. Drooping of the tip and recession of the Another incision is made in the mucoperio-
columella might occur if the anterior strip steum over the nasal spine on the same
of the cartilage is not preserved. side, elevating the mucoperiosteum from
6. Adhesions may develop between the the nasal spine on both sides thus making
septum and turbinates because of the two more tunnels called inferior tunnels.
trauma at the time of surgery.
34 Acute Rhinitis
35 Chronic Rhinitis
shows granulation tissue in the nose along- antra have been blamed for the atrophic
with whitish debris. Treatment is to find and changes that result in the nose.
treat the underlying causative factors in the
nose and cleaning the nose by removing the Secondary Atrophic Rhinitis
debris. The atrophic changes in the nose occur as
result of underlying nasal disease like chronic
ATROPHIC RHINITIS (OZAENA)
sinusitis, lupus, tuberculosis, syphilis, leprosy
This is a chronic inflammatory condition of or as a result of extensive tissue destruction
the nose characterised by atrophic changes from surgery or accidents.
of the mucosa of the nose and the turbinates.
It is called ozaena when associated with Pathology
foetor. As a result of chronic inflammatory changes,
There are two forms of the disease, the ciliated columnar epithelium of the nasal
primary atrophic rhinitis and secondary cavity and turbinates atrophies and shows
atrophic rhinitis. squamous metaplasia. Glands and goblet cells
become fewer. The endarteritis of blood
Primary Atrophic Rhinitis
vessels causes diminished blood supply to the
The condition is common in young adoles- mucosa. There occurs submucous infiltration
cent females of poor socioeconomic status. by round cells. The bone of the turbinates
Various theories have been put forward to also show atrophic changes.
explain the causation. As a result of the loss of ciliated epithe-
1. Infective theory: Various organisms like lium, thick viscid secretions of the nose get
Coccobacillus foetidus ozaena, Klebsiella ozaena, stagnated and result in secondary infection
and diphtheroids have been isolated from and crust formation. The foetor and loss of
the nose of such patients but it is thought mucosal sensation attracts flies which lay
that these are secondary invaders rather eggs that hatch out into larvae and pupae
than the primary aetiological agents. called maggots.
2. Endocrine theory: The disease is common
in females particularly at puberty. The Clinical Features
higher incidence in females and improve- The main presenting features include dryness
ment with oestrogen therapy has given of nose, nasal obstruction, headache and
rise to speculations that endocrine imba- sometimes epistaxis. Though the nasal cavities
lance has a part to play in its causation. are widened, the patient has a feeling of nasal
3. Deficient diet theory: According to this obstruction because of the crusts. Sometimes
theory deficiency of iron and fat soluble foetor is a very marked feature noted by the
vitamins especially A and D, results in examiner of which the patient is unaware
atrophic changes. because of atrophic changes and anosmia.
4. Developmental factors: Factors like wide Such patients present with a broadened
breadth of the nasal cavities and small nose and widened nostrils. The nasal cavities
194 Textbook of Ear, Nose and Throat Diseases
are filled up with crusts. The mucosa looks narrow the internal dimensions of the nose.
congested and atrophic, turbinates look This has been achieved by submucosal
atrophic and shrivelled up and the nasal implantations in the floor, septum and lateral
cavities are more roomy. Sometimes even the wall of the nose, of various materials like
nasopharynx may be visible on anterior autogenous bone graft pieces, cartilage
rhinoscopy. pieces, dermofat grafts, silicon, paraffin paste,
teflon in glycerine paste, porcelain pellets, etc.
Investigations Partial or complete closure of the nostrils
(Young’s operation) for a period of six months
Various radiological, haematological, and
to few years has been performed with better
serological tests may be needed to rule out
results. The closure is done by raising the
disease like tuberculosis, syphilis, lupus and
skin flaps from inside of the nasal vestibules
leprosy.
and stitching them together. The closure gives
rest to the nose and thus sets up conditions
Management
for epithelial regeneration.
There is no definite treatment of the disease,
Transplantation of the Stenson’s duct into the
however, the symptoms can be relieved to a
maxillary sinus for the moisture of nasal
great extent by various medical and surgical
mucosa, and stellate ganglion block to relieve
methods.
autonomic dysfunction are the other
Conservative treatment Nasal hygiene is procedures performed for this distressing
improved by alkaline douching of the nose. malady.
This removes the stagnant discharge and
Nasal submucosal implantation of pieces of
crusts. Gauze packs soaked in liquid paraffin
placenta has lately been done with varying
may be kept in the nasal cavities to lubricate results.
the nose and loosen crusts.
A solution of 25 % anhydrous glucose in Sequelae and Complications of Atrophic Rhinitis
glycerine used locally in the nose, prevents
1. Consequent to atrophy, septal perfora-
the growth of saprophytic proteolytic
tions occur and deformity of the nose
organisms and helps to retain moisture in the
might occur.
mucosa. Local application of oestrogen to the
2. Due to unhygienic conditions in the nose,
nasal mucosa may prove helpful. Weekly
maggot formation might occur causing
injection of placental extract (Placentrex) in
extensive destruction of tissues.
the turbinates has shown beneficial results.
Placental extracts act as local biogenic Rhinitis Sicca
stimulants and helps in regeneration of the
This is a mild form of atrophic rhinitis in
epithelium and glandular tissue. Iron and
which dryness of nasal mucosa and crusting
vitamins are also helpful.
occurs, particularly in the anterior portion.
Surgical methods The aim of various surgical This condition is usually seen in people
procedures (endonasal microplasty) is to working in dusty surroundings.
Chronic Rhinitis 195
ANTHRAX
It is an acute infectious disease caused by
Bacillus anthracis and affects usually cattle, the
sheep, goats and horses. Human beings
contract it by contact with animal hair, hides
or waste. The disease may affect lungs (wool
sorter diseases) or loose connective tissue
giving rise to malignant oedema, necrosis of
mediastinal lymph nodes and pleural
effusion, followed by respiratory distress,
cyanosis, shock, coma and death.
More commonly anthrax occurs in form
of a pustule called anthrax boil or malignant Fig. 35.2: Xeroderma pigmentosa
pustule (Fig. 35.1). This cutaneous form
exhibits redness, induration, vesiculation mask, gown, hand washing and incineration
with central ulceration and a black eschar. of contaminated material.
Rarely anthrax may occur in intestinal tract.
XERODERMA PIGMENTOSA
Treatment
It is a rare disease of skin starting in childhood
Preventive measures are a must for inhalation. and marked by disseminated pigment
Anthrax, high doses of antibiotics, respiratory discolourations, cutaneous ulcers, muscular
support and attention to vital signs is essential. atrophy and death. There is roughness and
For cutaneous anthrax, lesion is kept clean dryness of skin with ichthyosis (Fig. 35.2).
and covered with sterile dressings, frequent
oral hygiene and skin care, plenty of fluid GRANULOMATOUS
intake, and small nutritious meals. Isolation LESIONS OF NOSE
precautions are to be observed like use of
LUPUS VULGARIS OF NOSE
Lupus vulgaris is a chronic form of tuber-
culosis which affects the skin and mucosa.
This condition is common in females parti-
cularly in early adult life. In the nose, it starts
at the mucocutaneous junction of the septum.
The typical early lesion is a reddish nodule
which gradually ulcerates and the lesions
spread over to the floor of the nose, turbi-
nates, skin of upper lip and the adjacent face.
Fig. 35.1: Anthrax pustule The ulceration may be followed by fibrosis
196 Textbook of Ear, Nose and Throat Diseases
Treatment
The disease is treated by antitubercular
therapy.
phages and fibroblasts. Lepra bacilli may be rhinoscleromatis (Frisch bacillus). The disease
seen in macrophages. has a worldwide distribution and in India is
usually seen in Madhya Pradesh, Mumbai,
Treatment
Delhi, Uttar Pradesh and Punjab. Central and
Diamino diphenyl sulphone (Dapsone) is the eastern Europe and central and south
standard drug for leprosy. America are other endemic areas of this
disease. The disease starts in the nose and
RHINOSPORIDIOSIS
may spread to the nasopharynx, larynx, and
The disease is caused by the fungus Rhino- bronchi. Histology of the lesion shows a
sporidium seeberi or R. kinealyi. The disease in picture of granuloma characterised by plasma
India is usually limited to coastal states like cells, lymphocytes and eosinophils among
Kerala, Tamil Nadu, Karnataka, Maharashtra which are scattered large foam cells (Mikulicz
and Orissa. The disease is endemic in some
cells) with vacuolated cytoplasm, and
parts of Africa and Sri Lanka as well. The
mononuclear cells with nucleus (Russell bodies)
mode of infection is thought to be dust from
having an eosinophilic cytoplasm and enve-
the dung of infected cattle. It principally affects
loping large quantities of Frisch organisms.
the mucosa of the nose but the lesion can occur
in other areas like the nasopharynx, pharynx, Clinical Features
bronchi, skin, etc. The disease is clinically
Four stages of disease may be clinically seen.
characterised by formation of bleeding
1. Prodromal stage (or catarrhal stage): This
papillomatous and polypoidal lesions arising
stage passes with symptoms and signs of
from the septum or the nasal vestibule which
nasal catarrh.
have a strawberry appearance.
2. Atrophic stage: Changes occur in the mucosa
Histology shows vascular fibromyxo-
of the nose which resemble atrophic
matous structure, in which are found large
rhinitis. Anosmia is not a usual feature in
cells containing sporangia.
such cases.
Treatment 3. Nodular stage: Bluish red nodules appear
These growths are removed by wide excision at the mucocutaneous junction of the
and cauterisation of the base. Systemic septum. These have initially a rubbery
therapy with amphotericin-B may be useful consistency but later on become pale and
for patients with widespread lesions. hard. A cartilaginous feel of the nose is
Other fungal infections like rhinophyco- typical.
mycosis, aspergillosis, blastomycosis, cryp- 4. Stenotic or cicatrising stage: As the disease
tococcosis, actinomycosis and candidiasis may progresses, adhesions develop and the
be rarely encountered in the nose. nostrils get stenosed. Stenosis of the
nasopharynx may also occur.
RHINOSCLEROMA Diagnosis of the disease is by its typical
This is a progressive granulomatous disease lesions in the nose and its cartilaginous feel.
of the respiratory tract caused by Klebsiella Biopsy is confirmatory.
Chronic Rhinitis 199
Treatment
Streptomycin is the drug of choice at present.
It should be prescribed for a period of two
to three months depending upon the res-
ponse. Rifampicin, cotrimoxazole, tetracycline
and ampicillin may prove helpful.
Surgery may be required to re-establish
the airway.
Stewart’s Granuloma
(Malignant Nasal Lymphoma) autoimmune disease. The mechanism is
probably based on delayed hypersensitivity.
A disease characterised by apparent chronic It is characterised by necrotising granulo-
inflammatory granulation tissue in the nose matous lesions of the upper respiratory tract.
with rather rapid destruction of the nose and The lesions are smaller and have less
midfacial region with little systemic distur- tendency to involve the cartilage and bone
bance and no evidence of pulmonary or nasal in contrast to Stewart’s type. Besides lesions
involvement is now considered to be malig- in the upper respiratory tract, the Wegener’s
nant lymphoma (Fig. 35.6). Microscopy of the type is characterised by generalised vasculi-
lesion shows necrosis with atypical cellular tis and focal glomerulitis.
exudate (NACE) and is considered to be The clinical picture is of insidious onset
consistent with histiocytic lymphoma. of non-specific upper respiratory infection.
The disease is treated by full dose radio- The patient complains of fever, malaise and
therapy to the midfacial region and regional blood-stained nasal discharge. Granulo-
lymph nodes. Surgical debridement and matous lesions may be seen in the nose.
reconstruction can be undertaken to minimise Urine analysis shows red cells, casts and
the deformity. Steroids and cytotoxic drugs proteinuria. ESR is raised and serum proteins
have no role in the treatment. show increase in gamma globulins. Biopsy
from the nose or even renal biopsy may be
Wegener’s Granuloma
needed for confirming the diagnosis. Histo-
The disease is of unknown aetiology, logical picture reveals giant cell granuloma
however, it is currently thought to be an and features of vasculitis.
200 Textbook of Ear, Nose and Throat Diseases
36 Nasal Allergy,
Vasomotor Rhinitis
and Nasal Polyposis
NASAL ALLERGY appear red and the patient may present with
an attack of bronchospasm.
Nasal allergy occurs as a result of altered
reactivity of the nasal mucosa to an antigen Perennial nasal allergy This type of allergy can
(allergen). It is a Ige mediated type I hyper- occur any time during the year and the
sensitivity response. It can occur due to a symptomatology is similar but not so marked
variety of substances and changes affect the as in the seasonal type of allergic rhinitis.
mucosa of the nose, paranasal sinuses and Perennial allergic rhinitis may be due to
sometimes the mucosa of the lower respi- inhalant substances like house dust, smoke,
ratory tract also. There are two types of nasal spores, etc. or ingestants like milk, egg, fish
allergy, seasonal and perennial. and cheese. This type can also be due to certain
drugs, bacteria and contactants like clothes
Seasonal nasal allergy (hay fever, pollinosis)
and perfumes.
Seasonal nasal allergy is due to inhalant
allergens like pollens of flowers, trees, fungi
Pathology
grasses and weeds. Depending upon the
climate and environment, the peak months of When the allergen comes in contact with the
seasonal allergy vary from place to place. sensitised mucosa, there occurs release of
Besides the nose, conjunctiva and bronchial histamine and other kinins producing vaso-
mucosa may also be involved. The patient dilatation, increased capillary permeability
during an attack presents with intense and copious secretions from the mucosal
irritation in the nose and eyes associated with glands. This results in congestion, oedema and
sneezing, nasal obstruction, profuse discharge swelling of the mucosa. Cellular infiltration
and excessive watering of eyes. of the mucosa by eosinophils, plasma cells and
On examination, the nasal mucosa appears lymphocytes takes place. Because of oedema
swollen and pale or may have a bluish tinge. and blockage secondary bacterial infection
There is watery nasal discharge and dimini- may occur. Polyp formation in the nose and
shed nasal airway. The conjunctiva may sinuses and frank sinusitis may occur as the
202 Textbook of Ear, Nose and Throat Diseases
disease progresses. Complications like serous nose is pulled downward. This fact
otitis media, suppurative otitis media and differentiates it from the familial
bronchial asthma may occur. transverse nasal groove.
iii. The allergic salute The often dripping nose
Investigations is being wiped off by the children with
A detailed history is helpful in pinpointing the hand. The thenar eminence is rubbed
against the tip of the nose with rest of
causative substance. Blood picture and nasal
the hand stretched out as in salute.
smears reveal increase in eosinophils. Skin
iv. Long, thin, silky eye lashes are usually seen
tests with various allergens are carried out to
in young girls suffering from chronic
identify the underlying causative agent.
allergic rhinitis.
Sometimes provocative tests by the allergens
are done to note the response. Treatment
There are certain diagnostic clues to allergy
Treatment is based on avoidance of the
found in the children or young adults suffer-
allergen if possible, pharmacotherapy and
ing from chronic allergic rhinitis which can
immunotherapy. Pharmacotherapy includes
often be recognised as such by keen clinicians:
the use of antihistaminic drugs alongwith
i. The allergic shiners found as dark areas
nasal decongestants to improve the nasal
under the eyes as a result of discolou-
airway.
ration in the lower orbitopalperbral
Local application of drugs like silver nitrate
grooves caused by venous stasis.
15 per cent solution on anterior part of inferior
An additional factor is spasm of
turbinate on opposite area of septal mucosa
Muller’s muscle, a smooth muscle that for several days after application of local
is the only involuntary eyelid muscle. anaesthesia (xylocaine 4%), and through
This muscle impedes venous return in steroid nasal sprays and injections of steroid
the skin and subcutaneous alveolar preparation into the turbinates may reduce
tissues of the lower eyelids so that in inflammation though the last mentioned
addition to discolouration, oedema treatment method has been reported to cause
occurs, resulting in ‘bags’ under the eyes. sudden blindness. Local spray of sodium
ii. The transverse nasal crease is another cromoglycate preparations which prevent the
visual sign. This appears in children as a release of histamine from the mast cells is
horizontal hypopigmented or useful in some patients.
hyperpigmented groove across the lower If the allergen is identified, the subject
third of the nose, where the bulbous, soft should avoid contact with it. Ingestant aller-
portion meets the more rigid nasal gens can be eliminated from the diet. Immuno-
bridge. It results from constant rubbing therapy involves desensitisation by increas-
of the itching obstructed nose and takes ing the doses of the allergen injected intra-
at least two years of develop. The allergic dermally. This restores IgE serum levels and
crease disappears when the tip of the increases IgG antibody levels.
Nasal Allergy, Vasomotor Rhinitis and Nasal Polyposis 203
3. Vasomotor Imbalance: Polyposis may occur this water-logged mucosa leads to polyp
due to an imbalance between the sympa- formation.
thetic and the parasympathetic tone. 6. Mixed aetiology: Allergy predisposes the
4. Role of allergy: Allergic reactions of the nasal tissues to infection and the allergy itself
mucosa produce vasodilatation and may be to bacterial proteins, hence it is
increased permeability of the vessels as a contended that both allergy and infection
result of which fluid moves out of the are in aetiological factors.
intravascular compartment and causes
water logging of the tissues. This oede- Pathology
matous mucosa subsequently presents as Macroscopically, the polypi appear as pale,
a polypoidal mass. soft smooth masses. Sometimes these are
5. Infection: It is also believed that long-stand- opaque and fleshy. Histologically the polypoi-
ing infection gives rise to perilymphangitis dal tissue shows fibrillar stroma with wide
and periphlebitis resulting in poor absorp- spaces filled with intercellular fluid in the
tion of tissue fluid in the mucosa and thus submucosa. The blood vessels and nerve fibres
Nasal Allergy, Vasomotor Rhinitis and Nasal Polyposis 205
are scanty. Epithelium may be of the ciliated antihistamines, decongestants and/or anti-
columnar type or may have undergone biotics.
squamous metaplasia. IgA, IgG, eosinophilic B. Surgical Treatment:
and round cell infiltration of tissues is seen. 1. Functional endoscopic sinus surgery
There is an association between nasal (FESS) is the surgical treatment of
polyposis, bronchial asthma and aspirin choice. In this procedure all polypi are
allergy and this is known as Samter’s triad. removed under endoscopic control
Clinical Features especially from the key area of the
osteomeatal complex. This procedure
The main symptoms are nasal obstruction,
helps to preserve the normal function
hyposmia and postnasal drip. Associated with
of the sinuses. FESS can be done under
these are symptoms of rhinorrhea, sneezing
local analgesia although general
and sometimes headache. Ethmoidal polypi
anaesthesia is preferred.
are seen on anterior rhinoscopy as pale,
2. Nasal Polypectomy: Ethmoidal polypi
smooth, soft masses. These are usually bilateral
are removed under general or local
and multiple and are seen in all ages but are
anaesthesia with the help of a nasal
more commonly in adults. In children these
are invariably associated with cystic fibrosis. snare or a Luc’s forceps. More than one
The differences between the ethmoidal and sitting may be necessary for complete
antrochoanal polypi are summarized in a table removal of the polypi.
form at the end of the chapter. Antrochoanal Postoperatively, antihistaminics are given
polyp arising from the antrum goes towards for a prolonged period and lavage of the
the posterior choana and is seen on posterior antrum if needed may be done to clear the
rhinoscopy as a pale, polypoidal mass in the infection as recurrence is common. Recurrent
nasopharynx. The soft palate is sometimes ethmoidal polypi are dealt with by perform-
displaced downwards and the polyp may ing ethmoidectomy either via an endoscopic or an
present in the oropharynx. Anterior external approach.
rhinoscopy may not reveal any abnormality The exenteration of the ethmoid air cells
in the nose. This condition is mostly unilateral and diseased mucosa (ethmoidectomy) can be
and the polyp is usually single. Antrochoanal done either by the intranasal route, external
polyps occur in the young, commonly during approach or through the transantral approach.
the second decade of life. Ethmoidectomy should be done carefully to
X-ray examination of the paranasal sinuses avoid damage to the orbital contents, optic
helps in diagnosis. nerve and cribriform plate.
CT scan clinches the diagnosis and shows
the exact extent of the polyp. Treatment of Antrochoanal Polyp Polypectomy
is done either using a long-bladed nasal
Treatment of Nasal Polyp speculum and visualising the pedicle under
A. Medical Treatment: This involves the use endoscopic vision, which is then grasped and
of local and systemic corticosteroids, avulsed, or alternatively the soft palate is
206 Textbook of Ear, Nose and Throat Diseases
retracted and the polyp is grasped, avulsed the region of the middle meatus may
and delivered orally. present as a polypoidal mass. This is
In the postoperative period, antrum lavage usually single and has an opaque and
may be necessary to clear the antrum of fleshy look.
infected material. Recurrent antrochoanal 5. Meningocele: A prolongation of meninges
polypi were treated by the Caldwell-Luc may occur in the nasal cavity and appear
approach previously and that the diseased as soft, cystic polyp-like swelling parti-
mucosa of the antrum was removed along cularly in young children. Hence, it is
with the polyp but this procedure is now always advisable to aspirate a polypoidal
largely out of favor. swelling in a younger patient for cerebro-
spinal fluid.
Differential Diagnosis of Nasal Polyp 6. Malignancy of nose: A malignant lesion in
A variety of lesions may present as polypoidal the nose (carcinomatous, sarcomatous or
masses in the nose. Ethmoidal and antro- melanotic) may present as a polypoidal
choanal polyps have already been described. mass. However, it is usually friable and
1. Hypertrophied turbinate: A hypertrophied bleeds easily on touch. Sometimes poly-
turbinate may sometimes be mistaken for poidal changes are associated features of
a polyp. The turbinate is pink in colour, malignancy. Therefore, all polyps removed
sensitive to touch as compared to an from the nose should be examined
ethmoidal polyp and is firm to feel unlike histologically.
the softness of a simple polyp. A probe 7. Nasopharyngeal angiofibroma: Nasopharyn-
cannot be passed around the turbinate as geal angiofibroma (Figs 36.3 and 36.4),
it is attached laterally and has no pedicle particularly a less vascular variety, may be
like an ethmoidal polyp. confused with an antrochoanal polyp. A
2. Rhinosporiodiosis: This fungal infection of history of epistaxis in an adolescent male
the nose produces a bleeding polypoidal with a lobulated mass in the nasopharynx
mass in the nose usually arising from indicates a nasopharyngeal lesion rather
the septum and is strawberry like in than antrochoanal polyp. Sometimes
appearance. It is common in people living prominent vessels are visible on the
in coastal areas of India. Histology is tumour surface.
confirmatory. 8. Hamartoma: Hamartoma means “fault” or
3. Angiofibroma of septum: It presents as a “misfire” (Greek). It is a developmental
bleeding polypoidal mass in the nose. A malformation consisting of a tumour-like
careful examination reveals its site of growth of tissue. It is a benign lesion but
origin. may become large enough to cause trouble
4. Transitional cell or squamous papilloma: according to size and location and but it
Papilloma arising from the lateral wall in rarely becomes malignant.
Nasal Allergy, Vasomotor Rhinitis and Nasal Polyposis 207
Aetiology:
Unknown Bernoulli phenomenon,
Accessory Ostium polysaccharide changes,
Vasomotor imbalance,
allergy, infection, mixed
Age:
Children and adolescents Adults
Origin:
Maxillary Antrum Ethmoids
Appearance:
Unilateral, Single Usually bilateral and
multiple
Site:
Posteriorly (choana) Anteriorly
208 Textbook of Ear, Nose and Throat Diseases
37 Sinusitis
tion of more than one sinus is marked by pain Tenderness on applying pressure over the
over all the sinuses. Besides the pain, other sinus indicates underlying inflammation.
symptoms of acute sinusitis include nasal Anterior rhinoscopy reveals generalised
blockage, and excessive mucopurulent nasal congestion of the nasal mucosa, and localised
discharge. oedematous mucosa in the neighbourhood of
the ostium of the sinus. Presence of mucopus
Signs in the nose is suggestive of sinus infection and
its position determines the sinus involved.
Usually no external signs are present except
Posterior rhinoscopy also reveals the
in fulminating cases where, there may be
presence of mucopus and congestion.
redness and oedema of the soft tissues of the
face over the sinus involved (Figs 37.1A Investigations
and B).
The X-ray examination of paranasal sinuses,
occipitomental view (Water’s view), is helpful
in revealing the condition of the sinuses (Figs
37.2A and B). The sinuses appear as hazy and
may show a fluid level.
CT sinuses is diagnostic.
Treatment
Bedrest is important in the acute stages.
Antibiotics are given in full doses. Usually
penicillin or broad-spectrum antibiotics like
amoxycillin, cefuroximes and amoxycillin-
clavulinic acid combinations are prescribed.
Fig. 37.1A:Acute frontal sinusitis causing Nasal decongestants, help in relieving the
cellulitis of the left eyelids nasal obstruction as well as reducing oedema
of the sinus opening and thus help in drainage
of the sinus. Medicated steam inhalations
through the nose are soothing. Analgesic and
antipyretic drugs are prescribed to combat the
pain and pyrexia. Surgery is avoided in acute
sinusitis. However, if the symptoms do not
subside, particularly in frontal sinusitis with
increasing cellulitis, then drainage of the
frontal sinus is done through the floor of
frontal sinus above the inner canthus. This
Fig. 37.1B:Acute ethmoid sinusitis with procedure is known as trephining of the frontal
orbital cellulitis sinus.
210 Textbook of Ear, Nose and Throat Diseases
Pathology
The mucosa of the sinus shows chronic
inflammatory changes. The cilia get damaged
by the infection with resultant inadequate
drainage of the sinus cavity, particularly the
maxillary sinus where the ostium is situated
Fig. 37.2A: X-ray PNS (Water’s view) showing high up in the medial wall. The retained secre-
haziness of the left maxillary sinus (maxillary sinusitis) tions thereby lead to reinfection. Periphlebitis
and perilymphangitis may occur, leading to
oedema and polyp formation, the so-called
hypertrophic or polypoidal sinusitis. Sometimes,
there occurs metaplasia of the ciliated colum-
nar epithelium to the stratified squamous type
with intersperced papillary hyperplastic
epithelial and inflammatory cells producing
a picture of papillary hypertrophic sinusitis.
Occasionally the chronic inflammatory
process may induce atrophic changes in the
sinus mucosa with increase in submucosal
fibrous tissue (atrophic sinusitis).
Technique
FESS can be done under local anaesthesia in
adults and co-operative patients, but in
children and in apprehensive patients general
anaesthesia should be given. After sedation
Fig. 37.10: Instruments for Caldwell-Luc operation local mucosal spray with 4 per cent xylocaine
216 Textbook of Ear, Nose and Throat Diseases
with adrenaline and packing of nose with partition called the ground lamella, which is
xylocaine lotion, a thorough endoscopic exa- the posterior bony attachment of middle
mination of the nasal cavity should be done turbinate and separates the middle ethmoidal
by using 0° and 30° endoscope. cells from posterior group of cells. The anterior
Firstly endoscope is passed between the ethmoidal cells being situated around the
nasal septum and inferior turbinate examin- frontal recess and anterior to anterior
ing thoroughly the whole area upto the ethmoidal artery, are removed by using 30°
choana, visualising both eustachian tube endoscope and upward biting forceps. Some-
openings and the nasopharynx. Secondly times it is necessary to open the agar nasi cells
endoscope is passed along the middle meatus to have proper view of the area. After remov-
to examine for any pathology and then ing anterior cells the opening of frontonasal
between the middle turbinate and the septum duct is seen which is cleared by removing the
upto anterior wall of sphenoid sinus and its diseased mucosa surrounding it.
ostium. The posterior ethmoidal cells and the
The lateral wall of nose is infiltrated with sphenoid sinus should be opened only if the
2 per cent xylocaine with adrenaline at various CT scan has indicated presence of any disease
points on uncinate process upto posterior end. in this area. The posterior ethmoidal cells are
In case of canine fossa puncture a sublabial reached by gently perforating the basal
injection of 2 per cent xylocaine is also done. lamella with tip of Blakesley’s forceps and the
Using 0° telescope, an incision is made with a cells are carefully removed upto the anterior
sickle knife on uncinate process from the level wall of sphenoid. In this area posterior
of middle turbinate downwards along the ethmoidal cells form a very close relationship.
curve of the uncinate process till just above The sphenoid sinus anterior wall is perfo-
the inferior turbinate. The uncinate process is rated and the ostium widened. Any pathology
grasped firmly with Blakesley’s forceps and in sphenoid sinus should always be removed
removed with a twisting movement, exposing under direct vision especially towards lateral
the infundibulum. This procedure is known wall which is having close relation to optic
as infundibulotomy. Next the bulla ethmoidalis nerve and internal carotid artery.
and middle ethmoidal cells are removed with Indications of FESS
Blakesley’s forceps. Here the dissection must
Common indications:
stop on reaching the ethmoidal roof supe-
i. Chronic sinusitis not responding to
riorly, as there is anterior ethmoidal artery and
medical treatment.
any injury to roof may expose the dura and
ii. Sinonasal polyposis
medially a thin bone separates it from
iii. Extramucosal fungal sinusitis
cribriform plate. Laterally, the lamina
iv. Mucoceles
papyracia is the limit of dissection. Here only
side of the forceps and not the tip, should be Uncommon indications:
used to prevent accidental perforation, i. Recurrent acute sinusitis
posteriorly the limit of dissection is a bony ii. Headache and facial pain
Sinusitis 217
Complications of Sinusitis
Osteomyelitis Infection from the sinus can lead
to osteitis in compact bone and osteomyelitis
in cancellous or diploic bone (Figs 37.13A and
B). Acute infection of the frontal sinus or
ethmoid labyrinth may lead to osteomyelitis
with resultant orbital cellulitis and proptosis. Fig. 37.13B:Frontal mucopyocele with fistula
It may also be complicated by cavernous sinus
thrombosis and cerebral abscess in the frontal eventually perforation takes place through
lobe. either the outer or the inner bony tables of the
skull. If infection is not controlled, spread to
Pathology
the meninges may take place with consequent
Infection spreads either directly from mucous meningitis and brain abscess, or to sagittal and
membrane to the diploe or through throm- cavernous sinuses with resulting septicaemia
bophlebitis of veins of the sinus to the veins and cases end fatally. Osteomyelitis of maxilla
of dura (dura being internal periosteum of is rarely a complication of maxillary sinusitis.
culvarium and responsible for the nutrition of It usually occurs in infants (almost unknown
skull through it nearly all the vessels are in adults) from infection in one of tooth buds.
conveyed to the cranial vault). Retrograde Begins with febrile illness. Swelling and
thrombosis takes place from the dural veins redness develop over the cheeks. Soft parts
to the veins of diploe. There the pus forms and are indurated. Later there is discharge of pus
the thin boneplates are destroyed and from the alveolus or into the nose or abscess
Sinusitis 219
may point about the lower orbital margin. 4. Temperature persistently elevated with
Many cases of osteomyelitis skull result from slow pulse.
exacerbation of a chronic infection of frontal 5. Kernig’s sign positive.
sinus which has followed swimming. 6. Abdominal reflexes disappear early.
7. Moderate leucocytosis.
Symptoms 8. CSF examination shows increased pressure
1. Febrile illness with headache may be clear turbid or frankly purulent.
2. Oedema and tenderness over the infected Pneumococci type II and IV and strepto-
bone—soft, ‘doughy’ swelling. cocci may be found. Cell count is increased.
In 1-2 days another patch of oedema Chlorides are decreased, sugar decreased or
developes at a distance from the first and an absent and protein is increased.
area of healthy skin in between (Spreading
Treatment
osteomyelitis).
1. High doses of broad spectrum antibiotics.
Treatment Intensive course of antibiotics and
2. Inj. Cefatraxone 1 gm. I/V b.i.d till
localised abscesses are drained and sequestra
symptoms subside.
removed.
Cerebral Abscess
Intracranial Complications
It may result from infection of any of para-
Meningitis: Most common complication of
nasal sinus but most common after chronic
acute ethmoidal and sphenoidal sinusitis.
frontal sinus infection. Anterior pole of
Symptoms homolateral frontal lobe is most common site
1. Severe headache of abscess, usually secondary to osteitis of
2. Photophobia posterior wall of sinus.
3. High temperature
Symptoms
4. Constipation
5. Convulsion 1. Persistent frontal pain or headache after
6. Paralysis of some cranial nerves drainage of infected frontal sinus.
7. Unconsciouness 2. Nausea and vomiting.
8. Febrile delirium. 3. Anorexia and loss of weight.
Signs Signs
1. Persistent and gradually increasing Tongue coated, breath foul. Bowels—consti-
headache. pated. Other signs of meningitis. Frontal lobe
2. Drowsiness. lesion symptoms, e.g. marked change in
3. Neck rigidity less severe than in cases character, defects in memory and unilateral
when meningitis follows lesions adjacent anosmia. Some motor disturbance of contra-
to posterior cranial fossa. lateral face and extremities due to pressure on
220 Textbook of Ear, Nose and Throat Diseases
Treatment
If during operation, a defect is seen in
posterior wall. Wall should be removed and
dura exposed. Dura may be unduly tense and
pulsations of brain absent then exploration of
brain may be necessary. Fig. 37.14A:Frontal mucocele (right)
Carotid angiography or ventriculography
may help by showing displacement of blood
vessels or deformity of ventricle. If abscess is
found, it should be drained or excised if its
capsule is firm sufficiently.
Pathology
i. Degenerative changes in the vessel wall
ii. Sluggishness of blood flow, and
iii. Pathological changes in blood. Fig. 37.14B:Frontoethmoidal mucocele (left)
Pathological Types
1. Cysts associated with fusion of embryo-
logical elements forming the maxilla (Fig.
37.17) may be separated into the follow-
Figs 37.16A and B: Cysts: A.Dentigerous. B.Dental
ing:
a. Medial group in which there are three
recurring attacks of bronchitis or bron- forms.
chiectasis, etc. i. Median alveolar cyst which sepa-
Sinusitis may produce focal sepsis else- rates the upper central incisor teeth.
where. Arthritis, fibrositis, dermatological ii. Median palatal cyst which lies bet-
disorders may also be associated. ween the palatine processes of the
Kartagener’s Syndrome developing maxillae.
iii. Nasopalatine cyst arising from tissue
The association of sinusitis, bronchiectasis and in the incisive canal or nests in the
dextrocardia is known as Kartagener’s papillapalatine and present either on
syndrome. the palate or on the nasal floor.
Sinusitis and bronchiectasis may be b. Lateral group in which there are two
associated with keratosis in the external ear. forms:
Cystic Swelling of the Nose and
Paranasal Sinus
Dentigerous Cyst
The cyst arises from the follicle around an
unerupted tooth (Fig. 37.16A). The tooth is
seen in the cyst cavity on X-ray. Treatment is
to remove the cyst along with the unerupted
tooth.
Fig. 37.17:Cysts associated with fusion of embryo-
Dental Cyst logical elements forming the maxilla: (A) Lateral
alveolar cyst. (B) Nasopalatine (incisive canal) cyst.
The cyst arises around an infected tooth (Fig. (C) Median alveolar cyst. (D) Nasoalveolar cyst, and
37.16B). The infection produces a granulo- (E) Median palatal cyst
Sinusitis 223
Fibroma
Pure fibromas are rare. When it occurs, it
arises from posterior end of middle or inferior
Fig. 38.2:Inverted papilloma turbinate and hangs back into nasopharynx.
It is of darker appearance, denser than
Hence the tumour is also called transitional cell
polypus, and of firmer texture on probing or
papilloma.
palpation. May arise from septum or floor of
It is commonly found in males, is mostly
nose. They differ from nasopharyngeal
unilateral and spreads to adjacent sinuses (Fig.
fibromas—by occurring later in life, much less
38.2). It arises from the lateral wall of the nose
vascular and in their site of origin (Fig. 38.4).
and presents as a firm red or grey mass.
Treatment is wide surgical excision through
Osteoma
lateral rhinotomy approach. Sometimes it may
undergo malignant change. Origin is near epiphyseal centre line (as in long
bones) and ceases to grow when the affected
Haemangiomas bone ceases to grow (as in long bones).
Vascular tumours may arise in the nose (Fig. Histopathology Fetissof (1929) discusses
38.3). The commonly found lesion is capillary theories:
haemangioma of the septum. It presents as a a. Arnold’s osteoma develops in remnants of
cartilage remaining unossified in ethmoid.
b. That they arise in the periosteum, in areas Cysts: Due to blockage of mouth of a gland
either torn of by trauma or by the initiation and gradual expansion of gland by retained
of chronic inflammation. He came to secretion. Usually occur in floor of nose just
conclusion: behind the vestibule of nose. Often small.
i. that the growth is from within out-
Treatment
wards by metaplasia of fibrous into
bony tissue. Not necessary if no symptoms. Excision can
ii. that the ossification at the periphery be done.
performs secondary role.
Chondroma
iii. the fibrous tissue filling the inter-
stitious space—of the spongiose bone Pure chondroma is very rare and may occur
is a direct continuation of periosteum in ethmoid.
covering the osteoma. Squamous Cell Carcinoma
iv. that the theory of origin from the of the Nose
periosteum split off during the period
It is the most common type of malignancy
of development is the most probable.
involving the nose. It may present as a bleed-
Symptoms Pressure with increasing obstruc- ing polypoidal or sessile mass in the nose, in
tion, pressure-atrophy and destruction of older age group, with symptoms of nasal obs-
neighbouring bone and neuralgia. truction and epistaxis.
Causse (1934) describes: (a) a period of sub- Squamous cell carcinoma may arise from
jective phenomena (b) early objective pheno- the vestibule, lateral wall, and nasal septum
mena (c) advanced objective phenomena with and extend to the adjacent columella, upper
compression of neighbouring parts. lip and face (Figs 38.5 to 38.12). Metastasis may
occur to the facial or parotid nodes.
Treatment
Radiotherapy is the treatment of choice.
If no symptoms, leave alone or removal, by Advanced tumours need radiotherapy with
removing bone around the base and whole
tumour detached.
Section shows—typical osteitis fibrosa with
increased vascularity and a few giant cells.
Diagnosis—smooth, solid, hard and ill-
defined inflammation or other physical signs
makes the diagnosis obvious.
Adenoma
Histologically they contain cavities lined with
cuboid or cylindrical epithelium and filled
with mucoid material. Fig. 38.5:Malignancy of the nose, involving palate
Tumours of the Nose and Paranasal Sinuses 229
Olfactory Neuroblastoma
This is a neuroectodermal tumour and may
arise from the cribriform plate of the olfactory
area. It consists of varying proportions of
Fig. 38.8:Patient of malignancy of neuroblasts. Surgery is the treatment of choice.
left maxillary sinus (2) Prognosis is poor.
230 Textbook of Ear, Nose and Throat Diseases
Fibrous Dysplasia
It is a condition in which normal bone is
replaced by collagen, fibroblasts and varying
amounts of osteoid tissue. The condition may
affect the facial bones and present as facial
Fig. 38.12:Growth left maxillary sinus with orbital swelling or alveolar deformity. It presents as
involvement
a bony hard, diffuse and painless swelling
usually at puberty. The swelling may cause
Malignant Melanoma
proptosis.
These are rare tumours arising from the The growth ceases at 20 to 25 years of age.
melanocytes present in the nasal mucosa. Two clinical types are generally recognised,
Most patients are over the age of 50 years. The viz. monostotic and polyostotic. Radiology
most common symptoms are nasal obstruc- shows ground glass appearance of the bone
tion and epistaxis with a blackish mass inside depending upon the relative amount of
the nose. Bone erosion and regional and connective tissue to bone. Biopsy shows
systemic metastasis are uncommon. Treat- fibrous and osseous tissue. Treatment is
Tumours of the Nose and Paranasal Sinuses 231
Diagnosis Investigation
The disease occurs mostly after 40 years of age. Detailed examination of the nose and naso-
Visible facial swelling, a bleeding friable mass pharynx should be supplemented by radio-
in the nose, fulness of the gingivobuccal logy and proof puncture.
region, palatal and alveolar swelling, prop- 1. Radiological examinations: Plain views of the
tosis and facial neuralgia should raise suspi- paranasal sinuses like occipitomental view,
cion of malignancy in the nose and paranasal occipitofrontal view, oblique view of the
sinuses. An unresolving acute or chronic ethmoid and base of the skull are of limited
sinusitis may occur as a result of an under- value in diagnosis showing any bony
lying malignant process. destruction and the rough extent of
tumour (Fig. 38.14). CT sinuses gives better
Spread of Malignant Lesions of
assessment of the base of the skull and
the Paranasal Sinuses
posterior extension of the tumour along-
Local spread After filling the cavity, the growth with a clear idea of the bony destruction.
causes bone destruction and may involve MRI can help in distinguishing tumours
facial surface of the maxilla and skin over the from sinus inflammations. It is also useful
face. Medially, the growth initially pushing to depict swellings arising from deeper soft
out the lateral wall of nose, may present in tissues of the face, intracranial compart-
the nose, wherefrom it may involve the ment and the orbit.
ethmoids and nasopharynx. 2. Biopsy: Tissue is taken for histopathological
The growth may spread to the cranial examination if growth is seen in the nose
cavity from the nose and nasopharynx. or oral cavity. Exploration of the antrum
234 Textbook of Ear, Nose and Throat Diseases
39 Headache
remembered that it is the most common cause its low oral bioavailability, high incidence of
of facial pain and is unlikely to have this clas- headache recurrence and contraindication in
sical presentation. Swelling and redness of the patients with coronary artery disease. Hence,
eyes and cheek, nasal obstruction and the new 5th receptor agonists such as
rhinorrhoea are common accompaniments of zelmitriptan, rizatriptan and nartriptan have
pure migraine, and should not lure the become increasingly popular due to their
otolaryngologist into thinking that nasal or better safety profiles.
sinus disease must be present.
Management of migraine is divided into Prophylaxis
abortive or symptomatic treatment for
If the attacks occur more than twice each
immediate relief of symptoms and prephy-
month, prophylactic agents such as calcium
lactic therapy for prevention of attacks.
channel blocker (flunarizine), beta blockers
Symptomatic Treatment (propranolol) or cyproheptadine should be
given.
Analgesics (paracetamol, naproxen or aspirin)
should be taken immediately when the attack Cluster Headache
begins and then repeated every 4 to 6 hours
as necessary. Absorption is improved by Treatment is with ergotamine, or sumatriptan
ingestion of antiemetics such as domperidone, given in anticipation of attacks or with
10 to 20 mg. In recent years serotonin (5th) methysergide or verapamil for the duration
receptor agonists have been introduced for the of cluster. In case of severe clusters, patients
management of acute migraine. They act by may require hospitalisation. Oxygen, given at
reversing the dilation of cranial vessels seen a rate of 6 to 8 litres/minute, often affords
during migraine. Sumatriptan is the prototype relief within 10 minutes. Lithium may be of
5th receptor agonist. However, it is limited by value in chronic cluster headache.
238 Textbook of Ear, Nose and Throat Diseases
40 Facial Neuralgia
(Pain in the Face)
The tissues of the face which contain pain- liquids, or by ingestion of sweet or spicy foods,
sensitive nerve endings are skin, mucosa, suggests an origin in the teeth. Where dental
teeth, periosteum, blood vessels and the disease is not obvious, but this story is present,
articular fat pads within the temporomandi- percussion of the teeth is a useful clinical
bular joints. exercise.
Pain in the face is a common presenting Temporomandibular joint strain is
feature, and in history taking it is important common, and is due to the patient developing
to find out about the type of pain, its distri- an abnormal biting pattern, frequently secon-
bution, the duration of attacks, what stimu- dary to orthodontic problems, or due to
lates them, and about any features which ill-fitting or absent dentures. The pain is
make the pain worse. centralised in the temporal region, but may
Pain caused by skin or mucosal lesions spread to the ear, and along the skin over the
should be fairly easily excluded by exami- mandible. The temporomandibular joints are
nation of these tissues. Skin pain is caused by tender when the mouth is opened and closed,
boils, cuts, bruises and burns which should and some sideways deviation of the jaw on
be obvious. The well-known pain within the full opening is apparent. If the patient is seen
nose associated with acute viral infections is during an acute episode, slight spasm of the
diagnosed by rhinoscopy, when an acutely masticatory muscles will be apparent.
infected mucosa will be apparent. Radiography demonstrates that this is a
Pain due to periosteal disease in the face is functional abnormality, as signs of joint
caused by acute inflammation, cysts and degeneration are absent, but there can be limi-
tumours. Much of the periosteal area can be tation of opening of the joint on one side.
palpated, for example, the anterior walls of Treatment is orthodontic.
the sinuses, and the palate, and there will be Vascular pain is characterised by the des-
evidence of swelling or tenderness on cription of the pain as throbbing in character,
pressure. and it is made worse by stooping or straining
Dental pain is associated with dental caries. or by increase in the temperature of the face.
The characteristic story that it is stimulated Infective pains have a vascular component, for
by change of temperature, as in drinking hot example, the pain of acute sinusitis and a tooth
Facial Neuralgia (Pain in the Face) 239
pulp infection are throbbing in character. In sharp pin prick. Neuralgic pain arising in the
the absence of signs of infection, one should absence of evidence of neurological disease
think of migraine, migrainous neuralgia and occurs in postherpetic neuralgia, when there
temporal arteritis. will be a history of previous shingles, and in
Migrainous neuralgia is sufficiently diffe- trigeminal neuralgia.
rent from migraine to be identified as a sepa- Trigeminal neuralgia rarely occurs before
rate clinical entity. The patient is commonly the age of 40. The trigeminal sensory derma-
male, aged between 25 and 40, and the attacks tome always encloses the painful parts, and
of pain, which last for a short period varying the ophthalmic area is least often affected. The
from a few minutes to an hour or two, are pain is frequently stimulated by touching a
excruciating in degree, unilateral in distribu- specific part of the face—the trigger area—and
tion, centered around or deep to the eye, and initially consists of a series of short sharp
accompanied by ipsilateral nasal obstruction spasms of pain, each one lasting a few
with rhinorrhoea. Attacks can occur once or minutes, but it can progress to a period of pain
more in 24 hours, and typically waken the lasting several hours. The pain is severe, and
patient about 3 am. A group of very similar if the patient is seen during an acute attack,
attacks can occur over several weeks or spasm of the muscles of the ipsilateral side of
months, and disappear, only to return in a the face will be noted. Treatment is with
similar fashion, perhaps years later. The pain carbamazepine (Tegretol) starting with a dose
is frequently precipitated by alcohol ingestion. of 100 mg twice a day, and increasing the dose
Treatment is with clonidine hydrochloride until relief is obtained. The natural history of
(Dixarit). this condition is very variable, and the
Temporal arteritis always occurs after the symptoms can disappear for a long period of
age of 55 and gives rise to acute throbbing time, only to recur. Surgical treatment with
vascular-type pain in the temporal region. It radio-frequency rhizotomy may be required
is part of a giant-cell arteritis affecting many in patients uncontrolled by medical therapy.
of the vessels of the head and neck, and is Atypical facial neuralgia is a rather unsatis-
accompanied by lassitude and slight fever. factory label applied to patients who have
The temporal arteries are tender to touch and long-standing, often deep-seated, pain in the
feel thickened, and the overlying skin can be face in the absence of any clinical signs or of
red. Temporal arteritis is an important disease any characteristic history. These patients have
to diagnose because although it is uncommon, often consulted many specialists and have had
its complications are serious, and it is innumerable unsuccessful trials of medical or
amenable to treatment with systemic steroids. surgical treatment. They are often depressed,
Neuralgic pain is sharp and burning in but this can be as much a function of their
character, and is interspersed with periods unremitting ailment as of psychological
which are either free from pain or with a imbalance. Treatment is unsatisfactory, a
background ache. It occurs in disease affect- combination of psychotropic drugs and
ing the nerves, when there will be evidence of psychotherapy giving the greatest chance of
altered sensation either to light touch or to a success.
Oral Cavity and Pharynx
Common Symptoms of Oropharyngeal Diseases and the Method of Examination
Common Diseases of the Buccal Cavity
Cysts and Fistulae of the Neck
Salivary Glands
Pharyngitis
Tonsillitis
Adenoids
Pharyngeal Abscess
Tumours of the Pharynx
Miscellaneous Conditions of the Throat
Larynx and Tracheobronchial Tree
Physiology of the Larynx
Common Symptoms of Laryngeal Diseases
Examination of the Larynx
Stridor
Acute Laryngitis
Chronic Laryngitis
Laryngeal Trauma
Laryngocele
Oedema of the Larynx
Foreign Body in the Larynx and Tracheobronchial Tree
Laryngeal Paralysis
Tracheostomy
Disorders of Voice
Tumours of the Larynx
Block Dissection of the Neck
Thyroid
Bronchoscopy
Oesophagus
Common Oesophageal Diseases in ENT Practice
Oesophagoscopy
Laser Surgery in ENT
Principles of Radiotherapy
Syndromes in Otorhinolaryngology
Common ENT Instruments
41 Oral Cavity and Pharynx
probably play a defensive role. The strategic phagus. Once the cricopharynx opens, the
location of the faucial tonsils and nasopharyn- food passes into the oesophagus. It is carried
geal lymphoid tissues suggests that these down by peristaltic waves. The cardiac
structures are concerned with sampling of air sphincter opens in response to the peristaltic
and food and thus constantly monitor the waves and food thus enters the stomach.
bacterial flora. Antibodies are formed against In addition, deglutition also serves the
these microorganisms and thus help in the following functions.
body’s defence mechanism. Since these i. Disposal of dust and bacteria-laden
lymphoid structures atrophy with the growth mucus conveyed by ciliary action to the
it appears that this defence mechanism is pharynx from nasal passages, sinuses,
mainly active during childhood. tympanic cavities, larynx and tracheo-
bronchial tree.
DEGLUTITION ii. Opening of the pharyngeal ostia of
Deglutition is a process by which food passes pharyngotympanic tubes, to establish
from the oral cavity into the stomach through equalisation of pressure on the outer and
the oesophagus. This process involves three inner surfaces of the tympanic
stages: membranes.
The resting intrapharyngeal pressure is
First stage (voluntary) After the food is masti-
equal to the atmospheric pressure. During
cated and made into a bolus, the posterior part
swallowing there is a transitory rise of about
of the tongue propels the food into the
40 mm Hg pressure at the pharyngo-oeso-
oropharynx. The soft palate rises and closes
phageal junction. There occurs a region of
the nasopharynx.
raised pressure about 3 cm in length. During
Second stage (pharyngeal stage) In this stage swallowing this pressure falls abruptly just
food passes from the oropharynx into the before the pharyngeal peristaltic wave reaches
oesophagus. During this stage, the larynx is this zone. This indicates a relaxation of the
raised and laryngeal inlet gets closed to sphincter. Immediately after the bolus has
prevent food from going into the trachea. passed, the sphincter contracts strongly with
Retroversion of the epiglottis helps to close the a rise of pressure to 50-100 mm Hg. This
approach to the laryngeal inlet. Breathing abrupt closure coincides with the arrival of the
momentarily stops and the nasopharyngeal pharyngeal peristaltic wave and has the
isthmus remains closed. The pharynx is function of preventing reflux while peristalsis
elevated and the pharyngo-oesophageal is occurring in the upper oesophagus. When
junction opens to receive the bolus which is the bolus has passed further down the oeso-
pushed down by contraction of the circular phagus, the pressure in the pharyngo-
muscles of the pharynx. oesophageal zone returns to normal, i.e. the
Third stage (esophageal stage): This stage sphincter returns to the normal state of tonic
consists of passage of food down the oeso- contraction.
248 Textbook of Ear, Nose and Throat Diseases
COMMON SYMPTOMS OF
OROPHARYNGEAL DISEASES
Pain
Pain is a common symptom in the oropharyn-
geal area usually resulting from acute
infections like tonsillitis, tonsillar abscess,
trauma and sometimes due to carcinomas.
Pain from the oropharyngeal diseases may be
referred to the ear (referred otalgia).
Difficulty in Deglutition
Difficulty in deglutition may result from acute Fig. 42.1:Causes of dysphagia
infections of the oral cavity.
Dysphagia means difficulty in swallowing. This
can result from a variety of lesions in the oral Difficulty in Respiration
cavity, pharynx and oesophagus (Fig. 42.1). Trauma, tumours and infections can lead to
The lesions could be inflammatory, paralytic airway obstruction. Ludwig’s angina,
or neoplastic. diphtheria and peritonsillar abscess may
Odynophagia is painful deglutition caused by involve the larynx and result in dyspnoea.
inflammatory lesions in the oropharynx or
supraglottis. Regurgitation occurs in paralytic Difficulty in Speech
lesions of the soft palate when the ingested Palatal paralysis or sometimes adenoidectomy
material regurgitates into the nose. Paralysis lead to improper closure of the nasopha-
of the pharynx may lead to dysphagia as well ryngeal isthmus with resulting hypernasality
as to aspiration into the trachea. of voice called rhinolalia aperta.
250 Textbook of Ear, Nose and Throat Diseases
Many lesions of the oral cavity are dealt by a characteristic fishy odour. Acute stoma-
the dentists. Some of the common diseases of titis can be caused by staphylococcal,
otolaryngologist interest are described here. streptococcal or gonococcal infections.
3. Fungal stomatitis (moniliasis, thrush):
STOMATITIS Stomatitis caused by Candida albicans is
known as thrush or moniliasis.
Stomatitis is a general term for diffuse inflam- The infection is common in debilitated
mation of the mouth. Inflammation of the oral patients, marasmic children and patients
mucosa can be caused by local and systemic receiving broad-spectrum antibiotics. The
diseases. lesions appear as white raised patches on the
buccal mucosa, tongue and gingivae. These
Local Causes
patches may coalesce to form a membrane
Traumatic stomatitis The trauma may be due which can be removed. Diagnosis can be
to ill-fitting dentures, hot foods, corrosives, confirmed by microscopical examination that
simple cut of the mouth, too vigorous use of a show the fungal hyphae.
hard toothbrush, medicaments, fumes, smoke The disease is treated by local application
and radiotherapy. of 1 per cent gentian violet or a suspension of
nystatin glycerine. The underlying debility
Infective stomatitis Inflammation of the oral
needs attention.
cavity may result from viruses, bacteria or
fungi. Lichen planus The mucous membrane lesions
1. Viral infections like herpes simplex or of this disease of unknown aetiology appear
herpes zoster start as small painful vesicles as dull white or milky dots in a lace-like
which later ulcerate, involving the lip, arrangement. The associated skin lesions help
buccal mucosa and palate. in diagnosis.
2. Bacteria may produce inflammation like in Other local causes are the following:
acute ulcerative stomatitis (Vincent’s i. Aphthous ulcers
angina), also known as trench mouth, with ii. Behcet’s syndrome
Common Diseases of the Buccal Cavity 253
Deficiency of vitamins like the B-complex Bullous lesions without erythema around
group and vitamin C also cause mucosal them occur on the oral mucosa and the skin.
ulceration, particularly of the lips, angle of The bullae rupture leaving a raw area. The
mouth and gingivae as in pernicious anaemia, cause is unknown. Treatment is by steroids.
tropical sprue and malabsorption syndromes.
Idiopathic Oral Fibrosis
Mucosal ulceration of the oral cavity and
(Submucous Fibrosis)
pharynx may be the presenting feature of
agranulocytosis, leukaemias, polycythemia This consists of progressive fibrosis involving
and infectious mononucleosis. the oral mucosa and is accompanied by
trismus.
Recurrent Ulcerative Stomatitis
Aetiology
(Aphthous Ulcers)
The exact aetiology is not known but various
Recurrent painful ulcerations of the oral predisposing factors are betel-nut, pan and
mucosa is a common condition of unknown tobacco chewing. Females are more affected
aetiology. Various factors like viruses, endo- than males and the disease is most common
crine disturbances, psychosomatic factors, in the age group of 30-50 years.
habitual constipation and autoimmune
reaction have been put forward as probable Clinical Features
causative factors. The lesions, single or Various stages of the disease are the following:
multiple, present as small superficial ulcers 1. Prodromal stage: In this stage, the patient
surrounded by erythema. These usually occur complains of soreness and intolerance to
in the gingivobuccal groove, tongue or buccal spices and salts. The ulcers and blisters are
mucosa and are very painful. There is no not seen.
definite treatment but cauterisation of the 2. Stage II: In this stage, the patient has sense
ulcers and local steroids in the form of hydro- of stiffness inside the mouth and some
cortisone lozenges may help. Attention should difficulty in opening the mouth. There is
be given to orodental hygiene and underlying pallor over the soft palate and fauces.
nutritional deficiencies or constipation. 3. Advanced stage: The patient has marked
trismus and difficulty in protrusion of the
Behcet’s Syndrome
tongue. The incisor bite is reduced from
This is a disease of unknown origin, charac- the normal 4.5 cm to 2.5 cm. The mucosa
terised by ulcerations of the oral cavity, of the oral cavity and oropharynx looks
254 Textbook of Ear, Nose and Throat Diseases
pale and rigid. The vestibule of mouth is fibrous tissue and infiltration by lymphocytes
obliterated and the patient cannot puff out and plasma cells.
the cheek. The anterior faucial pillars are
markedly fibrosed with marked limitation Treatment
of movement of the soft palate. The uvula There is no satisfactory treatment. Various
looks like a rudimentary bud. It is not clear methods adopted are steroids (locally),
whether this should be regarded as sectioning of fibrotic bands and vitamin A
precancerous condition or not. administration. The anaemia and hypochlor-
hydria are corrected.
Diagnosis
Tongue Ulcers
A history of betel chewing with the charac-
Various ulcers of the tongue are described in
teristic symptoms and signs suggest the
Table 43.1.
diagnosis. The blood picture is of anaemia and
the ESR is raised. Acquired Immunodeficiency
Biopsy shows atrophy of the epithelial layers Syndrome (AIDS)
with increased mitotic activity of the basal AIDS was first recognised in 1981. The cause
layers. Subepithelial tissue shows increased of the disease is the HIV virus. These patients
thickening and hyalinised collagen and have a specific impairment in the cell-
Simple
1. Dyspeptic Multiple, small, painful and on a red base.
2. Dental Caused by irritation of a sharp tooth, has features of chronic simple ulcer.
It has sloping edges, slight induration and heals on removal of the offending tooth.
Chronic nonspecific Has the features of a chronic simple
(e.g. following fissures) ulcer with slight induration.
Tuberculous Usually associated with pulmonary tuberculosis, situated on the tip of the tongue,
painful, undermined edges and thin pale granulation tissue on the floor.
Syphilitic
1. Primary Occurs on the lip, characteristic induration, enlargement of regional glands,
scrapings of ulcer will show spirochaete on dark ground illumination.
2. Secondary Snail track ulcers and mucous patches.
3. Tertiary Single gummatous ulcer on dorsum of tongue near midline with punched out
appearance and wash lather base. No fixity of tongue. Rarely multiple gumma.
Herpetic Multiple painful ulcers starting as vesi-cles.
Malignant Usually at margin of anterior two-thirds (squamous epithelioma) not painful,
local lesion may be an ulcer: (i) with raised everted edges with induration of base
and surrounding area, (ii) a warty proliferation, (iii) a nodule in the tongue, or (iv)
a fissure with restriction of free mobility. Regional lymph glands enlarged and
hard.
Common Diseases of the Buccal Cavity 255
mediated immunity. The disease is prevalent Acute bronchitis and sinusitis are prevalent
in homosexuals, intravenous drug users and during all stages of HIV infection—severe
those receiving repeated blood transfusion. cases occurring in patients with lower CD4
The common ENT manifestations of this and T cell count. All sinuses can be involved
disease include recurrent upper respiratory although the maxillary sinus is the one most
infection, oropharyngeal ulceration, muco- commonly infected. High incidence of
cutaneous herpes simplex and Kaposi’s sinusitis results from an increased frequency
sarcomas. Kaposis’s sarcoma (KS) lesions are of infection with an encapsulated organism
typically palpable but not exophytic, purple like Haemophilus influenzae and Streptococcus
in colour, discrete, initially painless and may pneumonia. In patients with low CD4 T cell
involve any part of body. counts, one may see mucormycotic infections
Oral lesions including thrush, hairy leuko- of the sinuses. Mucormycosis of sinuses in
plakia and aphthous ulcers are particularly patients with HIV infections may progress
common in patients with untreated HIV more slowly.
infection.
Thrush due to Candida infection and oral hairy Management
leukoplakia secondary to EBV infection are AIDS is a fatal disease. No definite treatment
usually indicative of fairly advanced disease, is available till date. Various antiviral drugs,
i.e CD4 + T cell counts < 300/uz. Thrush
Amphotericin chemotherapy and modulation
appears as white cheesy exudates often on an
of the patient’s immune system by various
erythematous mucosa in the posterior
mechanism are under study.
oropharynx. Most commonly seen in the soft
palate, early lesions are seen along the gingival CYSTS OF MOUTH
border. Diagnosis is by direct examination of
Cysts of the oral cavity may be of develop-
the scrapings for pseudohyphal elements.
mental origin or may occur because of other
Oral hairy leukoplakia presents as white frond lesions.
like lesions generally along lateral borders of
the tongue or on adjacent buccal mucosa. Developmental Cysts and
Treatment consists of topical podophyllin Lingual Thyroid
or systemic therapy with acyclovir. Cysts may develop at the sites of embryonic
Aphthous ulcers of posterior oropharynx are fusion in the line of fusion of the two maxillae
also seen with regularity in patients with HIV and from the tissues of the incisive canal (like
infection. nasopalatine cysts) or at the sites of fusion of
Topical anaesthetics provide symptomatic the premaxilla with maxilla between the
relief of short duration. incisor and canine teeth.
Esophagitis secondary to Candida, CMV or HSV
Mucous Cysts
infections may present as odynophagia and
retrosternal pain. Oesophagus may also be the The orifice of a mucous gland may get blocked
site of Kaposi’s sarcoma and lymphoma. as a result of trauma or infection which leads
256 Textbook of Ear, Nose and Throat Diseases
Retention cysts of the minor salivary glands The tissue when operated upon can be
or cystic degeneration of the sublingual transplanted in the form of slices at various
salivary glands may lead to the development sites in neck and in the submandibular
of a cystic swelling in the floor of mouth under salivary gland area.
the tongue called the ranula (Fig. 43.1). It
presents as a greyish white, cystic swelling CARCINOMA OF THE TONGUE
commonly seen in children. This swelling may Squamous cell carcinoma is the most common
sometimes burrow deep in the tissues of the cancer of the tongue. The aetiology is uncer-
floor of the mouth between muscles into the tain but factors like chewing tobacco or betel
neck, when it is called a plunging ranula. nut, smoking, syphilis and poor orodental
Treatment is either complete excision or hygiene are thought to play a part. The disease
marsupialisation of the cystic cavity. affects males more frequently than females.
The lesions present as a slough covered
Lingual Thyroid
ulcerated mass with raised margins which
It is an ectopic thyroid situated at the fora- bleed easily on touch. The surrounding
men caecum, at the junction of anterior two- areas are indurated and may involve the
thirds and posterior one-third of dorsum of adjacent floor of the mouth. Lymph node
the tongue. It may be only functioning metastasis is common, particularly from the
thyroid tissue and may give rise to dysphagia, posterior one-third, where the lesion is usually
dyspnoea, impairment of speech or haemor- poorly differentiated and metastasis is
rhage (Fig. 43.2). bilateral.
Common Diseases of the Buccal Cavity 257
Treatment
Heavy doses of antibiotics, clindamycin with
metronidazole are given. If the infection does
not subside, it may require incision and
drainage. Respiratory obstruction may need
a tracheostomy.
AMELOBLASTOMA
(ADAMANTINOMA) (FIG. 43.7)
This tumour arises frequently from the
mandible. It is thought to arise from the
remnants of epithelial cells of Malassez in the
periodontal membrane. The tumour extends
Fig. 43.5:Pleomorphic adenoma of the palate into the surrounding marrow spaces and
Common Diseases of the Buccal Cavity 259
Treatment
Surgical excision of cyst along with the tract
(Sistrunk’s operation) is the treatment of
choice. Figs 44.1A and B: A. Thyroglossal fistula,
and B. Thyroglossal cyst
BRANCHIAL APPARATUS AND ITS
ABNORMALITIES
branchial clefts and intervening bars are the
At about 35 days of intrauterine life, 6 grooves branchial arches. Each arch contains a central
appear on the side of the neck. These are the cartilage.
Cysts and Fistulae of the Neck 261
Treatment
Treatment involves excision of the cyst.
Branchial Fistula
A branchial fistula may be unilateral or
bilateral and may represent a persistent
second cleft. The external orifice of the fistula
is nearly always found in the lower-third of
the neck near the anterior border of
Fig. 44.2A:Branchial cyst (F) sternomastoid.
Branchial fistulae which are clothed with
muscle and are lined with columnar ciliated
epithelium, discharge mucous and are often
the seat of recurrent attacks of inflammation.
When complete, the internal orifice of the
fistula is commonly found in the anterior
aspect of the posterior pillar of fauces, just
behind the tonsil. As a rule, the track is blind
and ends in the region of the lateral pharyn-
geal wall. It is frequently a congenital condi-
tion but can be acquired. The extent of fistula
can be determined by radiography following
Fig. 44.2B:Branchial cyst (M)
the injection of a radiopaque medium.
Branchial Cyst Treatment
A cyst arising from the second branchial cleft When causing troublesome symptoms, it
is the most common, and usually occurs should be removed by dissection. In a fistula
around 20-25 years (even up to 50) of age (Figs without an internal opening, a purse-string
44.2A and B). suture is inserted subcutaneously round the
The second arch branchial cyst is most external orifice 3 days before the operation.
commonly found at the junction of the upper After a radiopaque medium has been injected,
two-third and the lower one-third of sterno- the suture is tied and a radiograph taken. Pent-
mastoid muscle, along its anterior border. The up secretions distend the tract and can be
cyst is always lined by squamous epithelium. followed more easily in depths of the wound.
262 Textbook of Ear, Nose and Throat Diseases
Operation A transverse incision is given and lymphatic system to link up with other
extended upwards as far as the limits of the lymphatic vessels or with the venous system
wound permit. A second transverse incision accounts for the appearance of these swellings.
is made at a higher level and the mobilised Cystic hygroma, like sternomastoid tumour,
part of fistula is brought out of it till its is earliest to appear, usually during early
termination, it usually passes through the fork infancy or may be present at birth.
of the common carotid and extends to the
lateral pharyngeal wall. Site
Branchial cartilage and cervical auricle can It occupies the lower-third of the neck and
be present at the site of external orifice of the passes upwards towards the ear as it enlarges.
branchial fistula. Due to its many compartments and their
intercommunications, the swelling is softly
Cystic Hygroma
cystic and partially compressible but it is
Aetiology brilliantly translucent. It often extends
downwards behind the clavicle to lie upon the
At about the sixth week of intrauterine life, dome of pleura, sometimes into the axilla or
primitive lymph sacs develop in the may occur in the groin or mediastinum.
mesoblasts. The principal pair is situated in
the neck between the jugular and subclavian Pathology
veins, and corresponds to the lymph hearts
of the lower animals (Fig. 44.3). Sequestration It consists of an aggregation of cysts, like a
of lymphatic tissue consequent upon failure mass of soap bubbles, the larger cysts are near
of an important tributary of the primitive the surface while smaller ones lie deeply and
tend to infiltrate the muscle planes. Each cyst
is lined by a single layer of endothelium,
having the appearance of mosaic and is filled
with clear lymph.
Clinical Course
During infancy its behaviour is uncertain, it
may grow rapidly and obstruct respiration
and aspiration of the contents may be
required. It may become the seat of inflam-
mation from nasopharyngeal infection.
Treatment
Complete dissection of the cyst at an early age
is the treatment of election. Later the cyst
Fig. 44.3:Cystic hygroma becomes more adherent and, therefore, its
Cysts and Fistulae of the Neck 263
Treatment
Treatment is excision.
MANAGEMENT OF METASTATIC
CERVICAL NODES
Squamous cell carcinoma metastatic from
stratified squamous epithelium of the upper
Fig. 44.5:Neck abscess (CT scan) aerodigestive tract is certainly the most
Cysts and Fistulae of the Neck 265
common cell type and source of metasta- examinations and tests that are ordered
tic cervical nodes. Other sources of the same should make sense and be based on the profile
epidermoid cell cancer include the skin, of the patient. The work-up should begin with
oesophagus, bronchi, and occasionally the the thorough history and then progress to the
uterine cervix. The most common site for physical examination. After palpation and
squamous carcinoma is the larynx, but such measurement of the mass, the extent of nodal
cancers do not metastasize until they move off disease in all patients should be staged
the true vocal cord into the lymphatic-rich according to the system proposed in the 1976
mucosal beds. Lesions of the nasopharynx, revision of the report of the American Joint
lateral pharynx (tonsil), and hypopharynx Committee on Cancer Staging and End Results
(pyriform sinus and posterior third of the Reporting (Table 44.1).
tongue) metastasize earlier and more
frequently than either oral or vocal cord Table 44.1: Staging of nodal disease
lesions. When they are small, detection and
N1 Single clinically positive homolateral node
performance of biopsies are more difficult.
<3 cm in diameter.
Sinus cancers are locally destructive but slow N2a Single clinically positive homolateral node
to metastasize to nodes. 3 to 6 cm in diameter.
Adenocarcinoma metastasis to cervical N2b Multiple clinically positive homolateral
nodes not more than 6 cm in diameter.
lymph nodes may originate in salivary glands, N3a Clinically positive homolateral node(s)
thyroid, or the gastrointestinal and genito- >6 cm in diameter.
urinary tracts. The source of enlargement of N3b Bilateral clinically positive nodes.
the supraclavicular nodes, especially those in
the left medial supraclavicular position near
The physical examination must include
the thoracic duct, is more likely to come from
more than the head and neck area to form a
below the diaphragm. This is the classic
rational conclusion. Within this area, however
Virchow’s node.
examination should include inspection and
Melanoma or lymphoma can metastasize
palpation wherever possible of the salivary
to any node in the head and neck region.
glands, thyroid, soft tissues of the neck, the
Melanoma, of course, usually arises in the skin
lips, the mucous membranes of the cheek, the
but occasionally originates from mucous
floor of the mouth, tongue, palate, alveolar
membrane. It is capable of skipping primary
ridge, soft palate, tonsils, nasopharynx,
nodal drainage systems and appearing in a
oropharynx, and hypopharynx including the
node some distance from the primary site
base of the tongue and the pyriform sinus. In
(Lymphoma is more common and is usually
manifest as a unilateral, large, soft node). addition, indirect mirror laryngoscopy and
nasopharyngoscopy should be done. If after
DIAGNOSTIC WORK-UP inspection and palpation of these structures
There are endless tests that can be performed no suspicious mass is found, further studies
on a patient with a lump in the neck. The are indicated. These studies are expensive and
266 Textbook of Ear, Nose and Throat Diseases
time-consuming and should be ordered only If no gross tumour is seen, blind punch
when the possible yield is realistic. biopsies are advised.
There are a variety of blood tests that, 2. Laryngoscopy: Careful fibreoptic exami-
although not diagnostic, may provide a clue nation of larynx and hypopharynx should
to the cause of the lymphadenopathy, espe- be done. Hypopharynx and larynx
cially when considered with other diagnostic constitute the common primary sites of
criteria. These include complete blood count, squamous cell which metastatize to neck.
mono tests, ASO titres, standard test for 3. Oesophagoscopy/Bronchoscopy:
syphilis, T3 and T4 tests, carcinoembryonic Tumours from upper end of oesophagus
antigen test, rheumatoid factor, and serum and bronchi also metastasize to the neck,
protein and serum calcium determinations. so careful oesophagoscopy and broncho-
The chest radiograph is absolutely critical. scopy should be done.
It should be of high quality with multiple 4. CT scan/MRI of neck and chest.
views to discern a pulmonary primary. A 5. Ultrasonograph/CT (Abdomen), if needed.
barium swallow or cinefluoroscopic film of 6. Bone scan, if needed.
swallowing may be helpful in evaluating the 7. Exploratory surgery.
oesophagus prior to endoscopy. The radio-
graph cannot completely replace oesophago- TUMOURS OF THE
scopic examination. However, sinus X-rays PARAPHARYNGEAL SPACE
are very important since there is no reasonable The tumours most commonly encountered in
way of evaluating the sinuses by any other the parapharyngeal space include salivary
means except the Caldwell-Luc surgical gland neoplasms, neurogenic tumours, and
approach for the maxillary sinuses. metastatic deposits from primary carcinoma
Thyroid scans are helpful when the thyroid elsewhere in the body. The neurogenic
gland is bulky or the neck is obese. The scan tumours most commonly encountered include
is usually unable to detect a mass of less than neurofibroma and paraganglioma. A vast
1 cm in diameter and most nodules over 1 cm array of other benign and malignant
in diameter can be palpated as easily as they neoplasms may be rarely encountered. These
can be scanned. Certainly there is no harm in lesions represent neoplastic degeneration of
ordering a thyroid scan in a non-pregnant the tissues that exist in this potential space.
individual, but it is of limited assistance. There are reports of occasional patients with
lipoma, rhabdomyoma, rhabdomyosarcoma,
Other Battery of Tests
lymphoma, meningioma, and chondrosar-
1. Nasopharyngoscopy: Nasopharynx is one coma in the parapharyngeal space.
of the common sites of occult primary Metastatic involvement of the parapha-
particularly from the area of fossa of ryngeal lymphatics may be suspected in the
Rosenmuller. Careful fibreoptic naso- patient with a known primary focus of
pharyngoscopic inspection is mandatory. carcinoma. The parapharyngeal space may be
Cysts and Fistulae of the Neck 267
the first site of metastasis for patients with nervous system. These microscopic compo-
carcinoma of the nasopharynx, nasal cavity, sites are composed of granular cells that
palate, or maxillary sinus. In circumstances in contain catecholamines. These cells are neuro-
which a primary neoplasm is unsuspected, the ectodermal in origin. The carotid paragang-
diagnosis may not be made until a tissue lioma of carotid body is sensitive to changes
sample has been obtained. Paralysis of the in pH, PO2, and PCO2.
cranial nerves in the jugular foramen as they Paragangliomas are well encapsulated
enter the parapharyngeal space results in the brownish tumours with a firm consistency.
jugular foramen syndrome or Vernet’s Microscopic examination shows clusters of
syndrome.
epithelial cells (Zellballen) in a highly vascular
SALIVARY GLAND TUMOURS fibrous stroma. These lesions are histologically
similar to the pheochromocytoma that may
Less than 5 per cent of parotid tumours start
develop in adrenal medulla. In contrast to
in the deep portion of the parotid gland and
pheochromocytoma, however, cervical para-
extend into the parapharyngeal space.
Nevertheless 50 per cent of all parapharyngeal gangliomas rarely secrete catecholamines.
space tumours, excluding metastatsis, are of There have been isolated reports of secreting
salivary gland origin. Neoplastic degeneration jugular, laryngeal, and carotid paragang-
of minor salivary glands situated within the liomas; however, routine preoperative
soft palate, lateral pharyngeal wall, and screening for vasopressors in patients with
tonsilar pillars may result in a parapharyn- solitary paragangliomas of the head and neck
geal space mass as well. is not indicated unless the patient’s clinical
A presumptive diagnosis is often possible findings suggests the secretion of vasoactive
based upon physical examination and the substances. Fluctuating systemic hyper-
characteristic radiographic findings. Pain is tension, palpitations, and blushing would be
unusual. Bimanual palpation allows identi- an indication for further evaluation. Approxi-
fication of a firm, relatively mobile mass. The mately 10 percent of patients with para-
preferred treatment for these tumours is gangliomas have a family history of the
surgical excision. Excisional biopsy is pre- disease. Patients with familial paraganglioma
ferred. Incisional biopsy should be employed may demonstrate multiple lesions. These
only for tumours considered inoperable. In patients are at a higher risk of having an
circumstances in which histologic evaluation associated pheochromocytoma and should
is considered necessary prior to excisional
undergo preoperative screening for vasoactive
biopsy, fine needle aspiration is a useful too.
substances. Patients with familial paragang-
NEUROGENIC TUMOURS lioma should undergo angiography to rule out
multiple clinically unrecognized lesions.
Paragangliomas
The paragangliomas are named according
Paragangliomas are neoplasms that arise from to their site of origin. Paragangliomas of
the paraganglionic bodies of the autonomic jugular bulb are the glomus jugular para-
268 Textbook of Ear, Nose and Throat Diseases
These features do not imply malignancy. Neurofibroma may arise on the cranial nerves
Schwannomas arising in cranial nerves in in the parapharyngeal space.
close proximity to a bony foramen may extend
through the foramen, forming a dumbbell- Malignant Neurofibroma
shaped tumour. The schwannoma is Invasion of adjacent tissue or metastasis is an
uncommonly found in the lateral portion of indication of malignancy. Malignant neuro-
the neck. fibroma may occur sporadically however, it
is more frequently found in patients with von
Neurofibroma
Recklinghausen’s disease. The clinical findings
The neurofibroma also arises from the include sudden growth or recurrence after
schwann cell. Neurofibromas are often apparent complete removal of a benign
subcutaneous and may be multiple. The neurofibroma. Malignant neurofibroma may
neurofibroma is not encapsulated. Nerve be histologically indistinguishable from
fibres are incorporated within the tumour and fibrosarcoma, except for its relationship to a
pass through it. This contrasts with the nerve trunk. Electron microscopy demons-
schwannoma. Cystic and degenerative trates a basement membrane in malignant
changes are uncommon. neurofibroma that is lacking in fibrosarcoma.
von Recklinghausen’s disease is associated Nevertheless, many pathologists will not
with a multiple neurofibroma. Sarcomatous make a diagnosis of malignant neurofibroma
transformation is reported in 6 to 16 per cent unless the patient has von Recklinghausen’s
of patients with von Recklinghausen’s disease. disease.
the soft tissue extent of the lesion. Angio- the second most common type seen and they
graphically, haemangiomas are well- are associated with a 9 per cent recurrence
circumscribed lobular masses that have a rate. Mixed types are uncommonly found and
persistent dense tissue stain and are supplied are associated with a 25 per cent recurrence
by multiple slightly enlarged arteries. A rate. Therapy for these intramuscular haeman-
proximal artery surrounds the lesion, and giomas requires ligation of the feeding vessels
multiple smaller arteries enter the haeman- and excision of the mass. As with lymph-
gioma at right angles. Arteriovenous shunting angiomas, the surgeon must remember that
is usually not present. The angiographic these are benign lesions and care must be
appearance reflects the type of vessels that taken to avoid injury to vital structures.
compose the haemangioma. Capillary venous Because most congenital lesions involute
malformations have dilatated, ectatic spaces spontaneously, conservative therapy is the
that fill during the venous phase and rule for many haemangiomas. One must
demonstrate prolonged contrast pooling and constantly reassure both the child and the
more numerous vessels. parent that involution is expected. If the
Haemangiomas that are located in the deep tumour shows unusually rapid growth,
subcutaneous tissues, fascia, and muscles of haemorrhage, or recurrent infection, biopsy
the neck tend to be infiltrating and difficult to is indicated, and definitive therapy must be
treat. Although the lesions do not undergo initiated. This obviously must be indivi-
malignant degeneration or metastasize, local
dualised based on several factors, including
control is difficult and is frequently not
patient age, site of lesion, size of lesion, depth
achieved. The intramuscular haemangioma is
of extension, and the general characteristics
an example of such an invasive lesion. It
of the mass. Steroids are often a helpful
usually presents as a localised mass with
adjunct to surgical excision, but radiotherapy
a rubbery consistency and distinct margins. It
and sclerosing agents, though often recom-
is mobile and is not associated with a bruit,
mended in the past, are generally avoided. The
thrill, or pulsation. Cutaneous involvement
steroids are felt to interrupt proliferation for
may be present and there may be functional
several possible reasons, including blockage
abnormality of the involved muscle. Patients
of estradiol receptors or interference with the
often complain of pain secondary to
release of heparin or angiogenic factors from
compression.
mast cells.
The most common type of intramuscular
haemangioma is capillary haemangioma. In
TERATOMA
the neck, the scalene, trapezius, and sterno-
cleidomastoid muscles are frequently Teratomas are developmental lesions that
involved. This lesion is associated with a contain tissue elements derived from all three
30 per cent recurrence rate following appro- germinal layers. The cells found in the lesion
priate therapy because of its infiltrative nature. may be in any stage of differentiation, and
Cavernous intramuscular haemangiomas are when cells are quite immature, malignancy is
Cysts and Fistulae of the Neck 273
unusual, however, and the histologic changes contains speckled calcification in approxi-
most likely represent immaturity of the tissue. mately 50 per cent of cases; the trachea and
Cervical teratomas generally present as a mass the oesophagus are displaced posteriorly, and
in the neck that is discovered at birth. It may there may be associated pulmonary atelectasis
be seen in stillborn children and rarely or collapse. On ultrasound, a teratoma is
presents after the age of 1 year. An in utero generally of mixed echogenecity and usually
diagnosis can be made on ultrasound when a can be differentiated from a cystic hygroma,
cervical mass is demonstrated that is of mixed which appears as a multilocular cyst with
echogenicity and displaces the trachea possible mediastinal extension, or from a
posteriorly. Calcification may be present. congenital goitre, which has a solid
There may be some confusion with cystic appearance.
hygroma, but this mass typically presents as Patients do not seem to have an increased
a multiloculated, non calcified, cystic mass. incidence of other congenital anomalies, but
maternal hydramnios has been incriminated
These lesions are encapsulated and are usually
as a predisposing factor. The differential
partially cystic, having a variegated appear-
diagnosis is broad and includes cystic
ance on cut section. Microscopically, the
hygromas, branchial cysts, cavernous
lesions are composed of a mixture of mature
haemangiomas, thyroglossal duct cysts,
elements derived from ectoderm, mesoderm,
laryngoceles, goitres, desmoid tumours, and
and endoderm and of immature or embryonic
lipomas. Cystic hygromas are generally
tissue, including embryonic neuroectoderm.
differentiated by their more cystic appearance
Consequently, most are classified as emb- and ill-defined margins. Branchial cysts, in
ryonal teratomas. contrast, are distinguished on the basis of their
Cervical teratomas are sometimes referred size, location, and fluctuance.
to as teratomas of the thyroid gland. They Once the diagnosis of a cervical teratoma
cause symptoms secondary to pressure, and is made, surgical excision is mandatory to
this frequently results in upper airway prevent upper airway obstruction or pulmo-
compression and obstruction, patients may nary compromise. Without intervention, most
present with stridor, cyanosis and possible patients die. Even in those patients who do
apnoea. In addition, there may be dysphagia survive long enough to undergo surgery, there
secondary to oesophageal compression. Plain is a mortality rate associated with the
neck radiographs reveal a soft tissue mass that condition.
45 Salivary Glands
Complications
Orchitis, pancreatitis and encephalitis are the
usual complications.
Treatment
Isolation, care of oral hygiene and sympto-
matic treatment is instituted. Difficulty in
opening the mouth may need feeding through
a straw. Steroids are given in cases where
orchitis develops. Fig. 45.1A:Acute parotid abscess
Salivary Glands 275
Treatment
Nearly all parotid tumours are radioresistant.
Surgery is the treatment of choice and various
surgical procedures are the following:
1. Extracapsular excision is done for very
small superficial tumours.
2. Superficial parotidectomy with preser-
vation of the facial nerve is done for most
of tumours when
i. Tumour has broken its confines, or
Fig. 45.1B:Pleomorphic adenoma ii. Tumour has recurred after local
excision.
As recurrence is very common following
local excision only, superficial parotidec-
tomy is now recommended as the treat-
ment of choice even if the tumour is small
in size.
3. Total parotidectomy with or without block
dissection of neck for malignant lesions of
the parotid.
Frey’s Syndrome
(Auriculotemporal Nerve Syndrome)
Mikulicz Disease
It comprises the following:
i. Symmetrical enlargement of the salivary
glands.
ii. Narrowing of the palpebral fissures due
to enlargement of the lacrimal gland.
Fig. 45.2:Submandibular sialadenitis
iii. Parchment like dryness of the mouth.
Calculus
The most common site for salivary calculus is
within the submandibular gland or its duct
(Wharton’s duct). It is fifty times more
frequent here than in the parotid gland and
its duct. This is because salivary secretions
from the submandibular gland are more
Fig. 45.3:Calculus in the left submandibular
mucoid and are rich in calcium. These salivary gland duct (X-ray floor of mouth)
calculi consist of phosphates of calcium and
magnesium.
Salivary colic sometimes occur at the
Clinical Features commencement of a meal.
Painful swelling of the gland (Fig. 45.2) before A calculus in the Wharton’s duct or in the
or during meals is characteristic of this gland is seen in the lateral or occlusive view
condition. The patient should be given fruit of the submandibular region (Fig. 45.3).
juice to sip at the time of clinical examination.
Treatment
Little or no saliva pours out from the orifice
of Wharton’s duct on the affected side. A stone 1. Stones in the duct should be removed
in the Wharton’s duct can be detected by under local or general anaesthesia. The
bidigital palpation. tissues immediately behind the stone are
278 Textbook of Ear, Nose and Throat Diseases
ACUTE PHARYNGITIS
Acute inflammation of the pharyngeal mucosa
may be an accompanying feature of many local
and systemic diseases. It may follow an attack
of common cold and may be a feature of other
infections like measles, chickenpox or
influenza. Acute inflammatory lesions of the
pharynx may develop after trauma by a
foreign body or after instrumentation. Fig. 46.1:Faucial diphtheria
The patient’s chief symptom is sore throat,
associated with fever and other constitutional Faucial Diphtheria
symptoms. Examination reveals diffuse
congestion of the pharyngeal wall, uvula and The condition caused by Corynebacterium
adjacent faucial tissues. Depending upon the diphtheriae is associated with membrane
severity of infection, there may be oedema of formation on the faucial tonsils. The memb-
the lining mucosa and uvula and enlargement rane is greyish white and extends to the uvula
of the glands of the neck. and soft palate. It cannot be easily removed
Treatment consists of bed rest, analgesics and on removal leaves a raw bleeding surface
and antibiotics preferably penicillin or (Fig. 46.1).
erythromycin. There occurs marked toxaemia associated
with a fast pulse rate, disproportionate to the
MEMBRANOUS PHARYNGITIS rise in temperature. Palatal and peripheral
Various diseases, local or systemic, are asso- nerve paralysis and myocarditis are the
ciated with membrane formation in the complications that can occur up to the second
pharynx. or third week of infection.
280 Textbook of Ear, Nose and Throat Diseases
Aetiology
Fig. 46.2:Palatal perforation:
Postgranulomatous infection Stenosis occurs due to scar tissue formation
which may occur due to the following causes:
SPECIFIC INFECTIONS OF THE
1. Infections
PHARYNX (FIG. 46.2)
a. Acute, e.g. scarlet fever or gangrenous
Tuberculosis tonsillitis.
b. Chronic, e.g. scleroma, syphilis, lupus.
Tuberculosis of the pharynx usually results as
2. Operative measures
a secondary manifestation to advanced
a. For removal of neoplastic disease
chronic pulmonary tuberculosis. Mucosal
b. Removal of tonsils and adenoids
ulceration with undermined edges occurs in
c. Electric cauterisation.
the oropharyngeal region. The chief complaint
3. Trauma
of the patient is pain with dysphagia.
a. Accidental wounds
Treatment is by antitubercular drugs.
b. Corrosive poisonings.
Lupus Vulgaris
Clinical Features
Lupus of the nose may extend posteriorly to
involve the pharynx, soft palate and fauces. Difficulty in nasal breathing, altered voice
Tubercles appear on the pharyngeal mucosa (rhinolalia clausa or muffled speech) and
which break down with subsequent cicatri- dysphagia are the main symptoms.
sation and scarring of the fauces and soft
palate. Treatment
Syphilis Treatment is dilatation with bougies or
The pharynx is usually involved in the surgical division of the adhesions and
secondary stage of syphilis. It shows diffuse Thiersch’ graft may be undertaken.
47 Tonsillitis
The palatine tonsils are subepithelial lym- hyperaemia and oedema with conversion of
phoid collections situated in-between the lymphoid follicles into small abscesses which
faucial pillars. These help in protecting the discharge into crypts. When tonsils are
respiratory and alimentary tracts from inflamed as a result of generalised infection
bacterial invasion and are thus prone to of the oropharyngeal mucosa, the condition
frequent attacks of infection. is termed catarrhal tonsillitis.
When the inflammatory exudate collects in
ACUTE TONSILLITIS the tonsillar crypts, these present as multiple
Acute tonsillitis is mainly a disease of child- white spots on an inflammed tonsillar surface,
hood but is also frequently seen in adults. giving rise to a clinical picture of follicular
tonsillitis (Fig. 47.1). Sometimes exudation
Aetiology
It may occur as a primary infection of the
tonsil itself or may secondarily occur as a
result of infection of the upper respiratory
tract usually following viral infections.
Common causative bacteria include hae-
molytic Streptococcus, Staphylococcus,
Haemophilus influenzae and Pneumococcus.
Poor orodental hygiene, poor nutrition and
congested surroundings are important
predisposing factors for the disease.
Pathology
The process of inflammation originat-
ing within the tonsil is accompanied by Fig. 47.1:Oropharynx showing follicular tonsillitis
284 Textbook of Ear, Nose and Throat Diseases
from crypts may coalesce to form a membrane the parapharyngeal space with abscess
over the surface of the tonsil, giving a clinical formation.
picture of membranous tonsillitis. When the 4. Acute otitis media: Infection from the tonsil
whole tonsil is uniformly congested and may extend to the eustachian tube and
swollen, it is called acute parenchymatous result in acute infection of the middle ear.
tonsillitis. 5. Acute nephritis and rheumatic fever are the
other complications of streptococcal
Clinical Features tonsillitis.
The patient presents with discomfort in the
throat, difficulty in swallowing and generali- CHRONIC TONSILLITIS
sed body symptoms like malaise, anorexia, Chronic inflammatory changes in the tonsil
fever and bodyache. On examination the are usually the result of recurrent acute
patient is febrile and has tachycardia. The infections treated inadequately. Recurrent
tonsils appear swollen, congested with exu- infections lead to development of minute
date in the crypts. There may occur oedema abscesses within the lymphoid follicles. These
of the uvula and soft palate. become walled off by fibrous tissue and
The jugulodigastric (tonsillar) lymph surrounded by inflammatory cells.
nodes are enlarged and tender. The most common and the most important
cause of recurrent infection of the tonsils is
Treatment
persistent or recurrent infection of the nose
General management of the patient includes and paranasal sinuses. This leads to postnasal
bed rest, and giving plenty of fluids. Anal- discharge which then infects the tonsils as
gesics are given to relieve pain and fever. well.
Antibiotics are prescribed according to the cul-
ture sensitivity report. However, penicillin is Clinical Features
the drug of choice. Erythromycin and ampi- Symptoms include discomfort in the throat,
cillin may be needed for resistant cases. recurrent attacks of sore throat, unpleasant
taste (cacagus) and bad smell in the mouth
Complications of Acute Tonsillitis
(halitosis). Sometimes there occurs difficulty in
1. Chronic tonsillitis: Repeated attacks of acute swallowing and change in the voice. On
tonsillitis result in chronic inflammatory examination, the tonsils may appear hyper-
changes in the tonsils. trophic and protruding out of the pillars.
2. Peritonsillar abscess: Spread of infection These are diffusely congested, mouths of
from the tonsil to the paratonsillar tissues crypts appear open from which epithelial
results in development of abscess between debris may be squeezed on pressure. The
the tonsillar capsule and the tonsil bed. anterior pillars are hyperaemic. Sometimes the
3. Parapharyngeal abscess: Infection from the symptoms of sore throat and dysphagia are
tonsil or peritonsillar tissue may involve associated with small fibrotic tonsils (chronic
Tonsillitis 285
Postoperative Complications
Haemorrhage Besides the complications that
may arise because of anaesthesia, the main
surgical problem is haemorrhage. It could be
primary (during operation), reactionary (within
the first 24 hours), or secondary (between fifth
to tenth postoperative day) haemorrhage.
Excessive bleeding at the time of operation
usually arises because of trauma to an aberrant
vessel or paratonsillar vein.
Reactionary haemorrhage usually arises as a
result of slipping of a ligature or because of
the postoperative rise in blood pressure. If a
clot has formed in the fossa, it is removed. This
allows the muscular contraction and retrac- Fig. 47.3:Acute peritonsillar abscess
tion of the blood vessel.
A gauze pack may also be held in the fossa peritonsillar abscess (Fig. 47.3) is described in
for a few minutes to control the bleeding. textbooks as being a direct communication
However, if the bleeding does not stop, the and progression of acute exudative tonsillitis.
patient is reanaesthetised and the bleeding Little study has been done on the true
vessel is ligated. Sometimes, the tonsillar aetiology and pathogenesis of peritonsillar
pillars may need to be stitched over a pack to abscess. A group of salivary glands (Weber’s
control the bleeding. glands) proven to be located in the supra-
Secondary haemorrhage is the result of tonsillar space have been shown to be
infection. Bleeding is usually mild. Antibiotics, implicated in its pathogenesis (Fig. 47.4). A
antiseptic mouth washes are given in addition review of peritonsillar abscess has been under-
to bed rest. taken, and evidence has been presented to
Surgical trauma During tonsillectomy, trauma support the premise that the true cause for
may occur to the pillars, soft palate, teeth or peritonsillar abscess is not necessarily an
uvula. extension of an acute exudative tonsillitis, but
Pulmonary complications Pulmonary complica- an abscess formation of Weber’s salivary
tions may result because of inhalation of blood glands in the supratonsillar fossa.
or tonsillar tissue, with the result collapse, There occurs accumulation of pus between
pneumonia or lung abscess may occur. the tonsil capsule and tonsil bed. In most of
the cases, pus collection occurs anterosuperior
PERITONSILLAR ABSCESS (QUINSY, to tonsil but may sometimes occur laterally or
PARATONSILLAR ABSCESS) posteriorly. A mixed bacterial flora of
Peritonsillar abscess is a complication of acute streptococci, staphylococci and pneumococci
or chronic tonsillitis. The pathogenesis of grows on culture of the pus.
Tonsillitis 289
Treatment
When pus is suspected, it should be drained.
The following are the sites of drainage:
1. The most prominent part of the swelling
should be selected and drainage done.
2. Alternatively, the intersection of an ima-
ginary line drawn from the base of the
uvula and another imaginary line drawn
along the anterior faucial pillar is the site
of drainage.
3. Sometimes the drainage is done through
the supratonsillar crypt.
Fig. 47.4:Weber’sglandinthe supratonsillarspace, The peritonsillar abscess draining forceps
resting on the superior pole of the tonsil (From
is introduced and opened up to drain the
Parkinson,RH:TonsilandAlliedProblems.Macmillan,
NewYork, 1951) abscess. The tip of a guarded sharp scalpel can
be used to make an incision and the abscess
drained by sinus forceps. Anaesthesia is not
Clinical Features
needed as the pain is already intense and a
The condition usually affects adolescents and sharp stab for the drainage does not add to it.
is mostly unilateral. The patient complains of Besides drainage, heavy doses of antibiotics,
unilateral throat pain after a few days of sore usually coamoxiclox or clindamycin are
throat. The pain gradually becomes severe and prescribed in addition to antiseptic mouth
may radiate to the ear. Swallowing is washes and analgesics.
markedly painful so the patient even allows
Interval tonsillectomy In view of the painful
the saliva to dribble out. The patient feels
nature of this condition and the possible
extremely ill.
serious complications that may arise,
Examination shows a toxic patient, with
tonsillectomy is advocated after 6 to 8 weeks,
the head inclined towards the side of the
when the inflammation has subsided. Now it
abscess. There is trismus because of spasm of
is not thought to be necessary in all cases.
the pterygoid muscles. There is a unilateral
swelling of the palate and pillars on the side Abscess tonsillectomy (Quinsy tonsillectomy) This
of the abscess. The tonsil is displaced down- procedure of draining the peritonsillar abscess
wards and medially. The oedematous uvula by removing the tonsil has been advocated by
is pushed towards the opposite side with its some surgeons. It is done on the assumption
tip usually pointing to the side of the that since the tonsil forms the medial wall of
290 Textbook of Ear, Nose and Throat Diseases
the abscess, therefore, tonsillectomy would because of extension of this abscess to the
give drainage to the abscess as well as save parapharyngeal space.
the patient from interval tonsillectomy. Extension of the inflammatory process
However, this procedure is not favoured as from the peritonsillar space can lead to
the abscess may rupture during anaesthesia laryngeal oedema with resultant asphyxia.
with consequent problems of aspiration. Systemic infection with the development of
Besides as the tissues are acutely inflamed, septicaemia and multiple abscesses may
there occurs severe bleeding and chances of occur.
systemic dissemination of infection are more.
Peritonsillitis
Complications of Peritonsillar Abscess
It is a stage in the development of peritonsillar
The abscess may rupture spontaneously and abscess before the pus formation. The clinical
cause aspiration and asphyxia. Spread of features are those of severe tonsillitis with
infection to the parapharyngeal space can trismus. The peritonsillar tissues are severely
cause parapharyngeal abscess. inflamed but there is no displacement of
Thrombosis of the internal jugular vein or the tonsil. Heavy doses of antibiotics cure the
even a carotid artery rupture can occur condition and prevent abscess formation.
48 Adenoids
Clinical Features
Hypertrophied nasopharyngeal tonsils may
produce symptoms because of their size. The
symptoms may be nasal or aural. Fig. 48.1:Posterior rhinoscopic view of the
nasopharynx showing adenoids
The common nasal symptoms include
frequent attacks of cold, persistent nasal
discharge, nasal obstruction and snoring. adenoids on the posterosuperior wall of the
The common aural symptoms include nasopharynx (Fig. 48.1).
recurrent attacks of earache, deafness and ear In a long-standing case, the child presents
discharge. The other important symptoms with a typical appearance called “adenoid
include headache possibly due to infected facies” (Fig. 48.2). There is a dull look, pin-
material in the nasopharynx and nocturnal ched nostrils, open mouth, narrow maxillary
cough because of postnasal discharge. Lack arch, retracted upper lip and protruding teeth.
of appetite and mental dullness have also been A lateral view X-ray of the nasopharynx
attributed to adenoids. may sometimes be done to show an adenoid
Examination reveals mucoid or muco- mass.
purulent discharge in the nose.
Complications of Adenoids
Throat examination reveals postnasal
discharge and in a cooperative child, poste- These include recurrent attacks of otitis media,
rior rhinoscopy shows enlarged mass of secretory otitis media, maxillary sinusitis and
292 Textbook of Ear, Nose and Throat Diseases
pneumonia, collapse or abscess may arise atlantoaxial joint, though a rare complication
because of aspiration of blood or adenoid may result because of trauma, infection,
tissue tags. decalcification of the vertebra or laxity of the
Damage may occur to the eustachian tube anterior vertebral ligament.
openings and soft palate. Subluxation of the
49 Pharyngeal Abscess
Besides the peritonsillar abscess, infection lary space and inferiorly with the media-
from a tonsil can travel to the retropharyn- stinum. It is divided into prestyloid and
geal or parapharyngeal spaces and lead to poststyloid portions by the styloid process.
development of an abscess.
ACUTE RETROPHARYNGEAL
Retropharyngeal Space
ABSCESS
The retropharyngeal space is bounded ante-
riorly by the buccopharyngeal fascia and Aetiology
visceral fascia over the oesophagus and poste- It is an uncommon condition, usually affect-
riorly by the anterior layer of the deep fas-
ing children. It results from suppuration of
cia over the cervical vertebrae. Inferiorly this
the retropharyngeal lymph nodes secondary
space communicates with mediastinum. The
to infection in adenoids, sinuses or tonsils.
space contains lymph nodes of Ranvier’s
The abscess may occur in adults after trauma
which drain the nasopharynx, part of
by a foreign body or on endoscopy.
oropharynx and the paranasal sinuses.
A retropharyngeal abscess develops Clinical Features
because of infection in this space.
The patient complains of fever, malaise and
Parapharyngeal Space difficulty in swallowing. The abscess in the
It is a lateral pharyngeal space which extends late stages may present with respiratory
from the base of skull above to the level of difficulty.
the hyoid bone below. The patient is ill, febrile and looks toxic.
It is bounded medially by the fascia over The posterior pharyngeal wall may appear
the pharynx and laterally by the fascia over bulging. X-ray of the soft tissues of the neck,
the medial pterygoid muscle and the parotid shows a widened retropharyngeal space
glands. Posteriorly lies the carotid sheath with (Fig. 49.1). There is increased distance bet-
its contents. The space communicates with ween the laryngotracheal air column and
the retropharyngeal space and the submaxil- anterior border of the cervical vertebra.
Pharyngeal Abscess 295
PARAPHARYNGEAL ABSCESS
The infection may travel to the parapharyn-
geal space from the tonsils, teeth or the other
oropharyngeal or parotid lesions, as well as
from the submandibular glands.
Clinical Features
The patient looks ill, toxic and febrile and
Fig. 49.1:Lateral X-ray of the neck showing widening complains of difficulty in swallowing and
of the prevertebral space in retropharyngeal abscess may present with trismus.
The oropharyngeal examination may
reveal a primary focus of infection. Exami-
Treatment nation of the neck shows a diffuse tender
swelling below the angle of the mandible on
Systemic antibiotics are given. The abscess the affected side.
needs drainage. The patient is held supine
on the table with the head end lowered to Treatment
prevent aspiration of pus into the larynx. An Antibiotics are given to control the infection.
incision is given in the posterior pharyngeal The abscess is drained through a lateral neck
wall and the pus sucked out. incision given anterior to the sternomastoid
from the angle of the mandible to the hyoid
CHRONIC RETROPHARYNGEAL
bone.
ABSCESS
Early drainage is done to prevent serious
This occurs due to tuberculosis of the cervical complications like thrombosis of major vessels
spine. Radiography of the cervical spine and spread of infection to other spaces.
50 Tumours of the Pharynx
This is a benign but locally invasive lesion of The tumour from its origin in the naso-
the nasopharynx. It occurs almost exclusively pharynx, fills the nasopharyngeal space and
in males between 10 and 25 years of age. The may spread anteriorly to the nasal cavities. It
tumour tends to regress or stop growing after may extend to the pterygopalatine fossa and
25 years of age. present in the orbit or cheek. The tumour can
The aetiology of the condition is unknown. spread to the intracranial cavity by eroding
Various factors which are thought to be its base or through its foramina.
causative agents include hormonal, traumatic
Clinical Features
and allergic factors. It is thought that the lesion
arises from the ventral periosteum of the skull Gradually increasing nasal obstruction and
as a result of hormonal imbalance or recurrent attacks of epistaxis are the common
persistence of embryonic tissue. presenting symptoms.
Examination reveals a reddish vascular
Pathology mass in the nasopharynx which may extend
The tumour consists of two main components, into the nasal cavities. There may be seen
viz. vascular and fibrous. prominent blood vessel traversing over the
Tumours of the Pharynx 297
tumour surface which bleeds easily and extending into the nose and antrum. To avoid
profusely on probing, therefore, probing or profuse bleeding, it is important to go around
palpation of the nasopharynx should not be the tumour mass and remove it en masse.
done. Cryosurgery and diathermy have been help-
ful in reducing the bleeding during operation.
Investigations Hormonal therapy for the tumour is of
doubtful value. Radiotherapy is used for the
X-rays of the nasopharynx base of the skull
recurrent tumours and in patients unfit for
and paranasal sinuses determine the extent of
surgery.
the tumour. External carotid angiography
Prior external carotid artery ligation may
helps in its diagnosis (Tumour blush), to deter-
be done with the hope of reducing haemor-
mine the extent of tumours and to know the
rhage. Recently external carotid artery
main blood supply.
embolisation by gel foam has been tried as a
The typical clinical features of this condi-
temporary measure to reduce the bleeding
tion make preoperative biopsy unnecessary.
during surgical removal.
Biopsy should be avoided due to risk of severe
haemorrhage. Malignant Tumours of Nasopharynx
Clinical Features
Varied symptoms are characteristic of naso-
pharyngeal malignancy. The symptoms can
be grouped as under:
1. Nasal symptoms: Nasal obstruction and
epistaxis can occur.
2. Aural symptoms: Because of effects on the
functioning of eustachian tube, the patient
may present with conductive deafness
because of serous otitis media or acute
otitis media.
3. Neurological symptoms: Malignant tumours
of the nasopharynx are known to produce
various neurological lesions particularly
cranial nerve paralysis. Because of the Fig. 50.1:Bilateral metastatic neck nodes in a
intracranial and extracranial spread of case of nasopharyngeal carcinoma
Tumours of the Pharynx 299
Symptoms usually occur late in the disease. are more common than papilloma or
Patients usually present with soreness or adenoma.
discomfort in throat and difficulty in Malignant tumours of the laryngopharynx
swallowing. Excessive salivation and an are common in India. The aetiology is
earache may be presenting features. unknown. Plummer-Vinson syndrome is
Examination reveals a proliferative or an thought to be a precancerous condition. Betel-
ulcerative type of lesion in oropharynx. There nut chewing and smoking may play a part in
is a high incidence of lymph node involve- its causation.
ment, particularly the upper deep cervical Cancer of the laryngopharynx commonly
groups of nodes are involved. affects the males of the elderly age group
Diagnosis is confirmed by biopsy. except cancer of the postcricoid region which
is more common in females.
Staging
Histology
T1 — Tumour less than 2 cm in diameter.
T2 — Tumour 2-4 cm in diameter. Squamous cell carcinoma (moderately differ-
T3 — Tumour more than 4 cm. entiated) is the most common type of cancer
T4 — Massive tumours invading adjacent of this region. Adenocarcinoma, adenoid
stuctures. cystic carcinoma, and malignant lymphomas
may also rarely occur.
Treatment
Site
Radiotherapy is usually the treatment of
choice for management of tumours of pala- Pyriform fossa is the most common site, follo-
tine arch, soft palate and posterior pharyngeal wed by postcricoid and posterolateral pharyn-
wall. Wide surgical excision with recon- geal wall cancer.
struction of the oropharynx is the alternative
modality of treatment. Spread
Proliferative or ulceroinfiltrative type of
TUMOURS OF THE HYPOPHARYNX
lesions may occur. The growth may involve
This part of the pharynx lies posterior to the the aryepiglottic folds and spread to the larynx
larynx and extends from the lower limit of the causing its fixation. Spread may occur to the
oropharynx up to the upper end of the thyroid cartilage and the growth may extend
oesophagus. It includes two pyriform fossae, through the thyrohyoid membrane to the soft
the postcricoid region and the lateral and tissues of the neck.
posterior pharyngeal wall. Downward spread involves the cervical
Benign tumours of this region are uncom- oesophagus. Lymphatic spread is common
mon and present as smooth, slow-growing and lymph node involvement occurs early.
masses. The tumours of mesodermal origin Deep cervical nodes and paratracheal nodes
Tumours of the Pharynx 301
Clinical Features
The patient usually presents in the late stages
when the growth is well advanced. The early
symptoms are vague and the patient may
complain of discomfort in the throat or pain
on swallowing.
Dysphagia is the main presenting
symptom. It is usually complained of in the
Fig. 50.2:Parapharyngeal tumour
late stages and is progressive. The patient may
present with a lymph node mass in the neck CT scan shows the details of extension
without any pharyngeal symptoms. Some (Fig. 50.2).
patients present with pain in the ear (referred
otalgia) or a muffled voice. Treatment
GLOBUS HYSTERICUS
(GLOBUS PHARYNGES)
It is a functional disorder in which the patient
complains of a lump in the throat. There is no
dysphagia. Examination reveals nothing
significant in the throat. The patient often has
a cancer phobia.
The patient needs to be reassured. Tran-
quillisers may be prescribed. If the symptoms
persist, a barium study of the larynx or
endoscopy may be done to rule out any
hidden organic lesion. Fig. 51.1:Left sided soft palate palsy,
uvula shifted to the right
Causes
1. Muscle spasm as found in the following:
a. Tetanus
b. Arthritis of temporomandibular joint
c. Acute parotitis
d. Mumps
e. Alveolar abscess
f. Impacted wisdom tooth
g. Hysteria.
2. Unreduced dislocation of the TM joint.
3. Contractures due to the following: Fig. 51.3:Cleft palate and lip
a. Burns
b. Lupus vulgaris to external scarring, Esmaich’s operation
c. Cancrum oris (removal of a wedge-shaped piece of bone
d. Operated scars with the narrow end towards the alveolus in
e. Application of radium the region of the angle of mandible forming a
f. Submucous fibrosis with adhesion false joint at the site) is done.
bands.
4. Carcinoma of the cheek, tonsil (Fig. 51.2), CLEFT PALATE
maxilla, and parotid gland. Cleft palate (Fig. 51.3) can be of the following
5. True ankylosis following arthritis of types.
temporomandibular joint. 1. Incomplete
a. Bifid uvula
Treatment
b. Cleft of soft palate only
Treatment is directed towards the cause. If due c. Cleft of soft palate and part of hard
to true ankylosis, excision of condyle is the palate.
line of treatment. If due to false ankylosis due 2. Complete, involving both the soft and hard
palate. It may be of the following types:
a. Unipartite, when there is a cleft on one
side of the premaxilla while the other
side is fused with the alveolus.
b. Bipartite, when there are cleft on either
side of the premaxilla and cleft palate
communicates with both the clefts.
Treatment
Optimum peak for correction of the deformity
is before the child begins to speak, i.e. about
Fig. 51.2:Carcinoma of the left tonsillar fossa 18 months.
306 Textbook of Ear, Nose and Throat Diseases
Clinical Features
Two types of symptoms may be present.
Classically, the patient complains of a dull
or intermittent pain in the throat and ear on
that side, especially after deglutition.
Difficulty in swallowing and a foreign body
sensation in the throat persist. On the other
hand, the patient may present with the styloid
process-carotid artery syndrome. An elonga-
ted styloid process may impinge against
carotid arteries and cause disturbances in
Fig. 51.4:Operations for cleft palate repair circulation as well as irritation of the nerve
plexus around the vessels. The patient comp-
Various operative procedures followed are lains of parietal headache and pain along the
shown in Figure 51.4. distribution of the artery involved.
The diagnosis of an enlongated styloid
Four-flap method A release cut is made on either
process can be made by palpating for process
side at the periphery of the palate and an
through the tonsillar bed and by radiography,
oblique cut from the point of junction of the
which shows an abnormally long process.
soft and hard palate parts in the cleft reaching
the releasing cut. The four flaps of mucoperio- Treatment
steum thus shaped are raised from the bone.
A “push back” of the flaps brings the edges Treatment of a symptomatic elongated styloid
together. The edges are paired, mucoperiosteal process is its surgical removal.
flaps are raised from the nasal septum and In transpharyngeal excision, tonsillectomy is
suture of these flaps closes the gap. done and the styloid process felt through the
tonsillar fossa, where it is exposed by a
dissecting forceps. The periosteum is elevated
ELONGATED STYLOID PROCESS
around the process and a portion of it is
(STYLALGIA)
removed.
The styloid process of the temporal bone is The enlarged styloid process can also be
about 2.5 cm long in an adult. In 4 per cent of excised by an external approach. An incision
the population the styloid process is grossly is given along the anterior border of the
enlarged and may give rise to symptoms. The sternomastoid from the tip of mastoid to the
elongated styloid process can be felt through hyoid bone. The anterior border of the sterno-
the pharynx in the tonsillar bed or posterior mastoid muscle is retracted, the process
pillar and the process is in close relationship exposed by a deep dissection and a portion of
with the glossopharyngeal nerve. it is removed.
52 Larynx and
Tracheobronchial Tree
Epiglottis
This is a flattened leaf-like cartilage, attached
to the angle between the thyroid laminae by
the thyroepiglottic ligament. It projects
upwards behind the hyoid bone and its
superior margin is free.
Arytenoid Cartilages
These are pyramid-shaped cartilages situated
Fig. 52.2: Interior of the larynx on the cricoid lamina (Fig. 52.3). The base of
Larynx and Tracheobronchial Tree 309
and end in upper deep cervical lymph nodes. Glottis It consists of the vocal cords, anterior
The part of the larynx below the vocal cords commissure, and posterior commissure.
is drained by lymphatics which end in the Anterior commissure is the area where the
pretracheal, paratracheal and lower deep two vocal cords are attached to the angle of
cervical nodes. The lymphatics may also end the thyroid laminae.
in lymphatics of the superior mediastinum. Posterior commissure is the area at the
The vocal cords themselves are practically posterior end of the vocal cords, between the
devoid of lymphatics. two arytenoids.
Subglottis It is the area of the larynx which
Nerve Supply of the Larynx
extends from 5 mm below the level of the vocal
The superior laryngeal nerve is sensory to the cords up to the lower border of the cricoid
laryngeal mucosa above the vocal cords. cartilage. The undersurface of the cords is
Besides it is motor to the cricothyroid muscle excluded.
through its external laryngeal branch. Mucosa
Supraglottis It is the region of the larynx above
of the larynx below the vocal cords and all
the level of the vocal cords and includes the
other intrinsic laryngeal muscles are supplied
ventricles, vestibular bands and vestibule.
by the recurrent laryngeal nerves.
Comparison of Infantile with the
Average Measurements of
Adult Larynx
Adult Larynx
1. Size: The difference in size is not only real,
Up to puberty the size of the larynx both in
but also relative, for the lumen of infantile
males and females is almost the same but
larynx and trachea is smaller in proportion
thereafter in males it increases nearly twice in
to the body as a whole. The greatest
its anteroposterior diameter. The measure-
“choke” is present in the subglottic region
ments are given in Table 52.1.
which predisposes to stridor. The normal
subglottic diameter in infants is 6 mm,
Table 52.1: Measurements of the larynx
5 mm is taken as reduced and 4 mm
Males Females represents stenosis.
2. Consistency of the tissues of the larynx: In
Length 44 mm 36 mm
Transverse diameter 43 mm 41 mm
young children all the laryngeal tissues
Anterior diameter 36 mm 26 mm including the cartilaginous framework,
musculature, and mucous and submucous
tissues are softer than in adults.
Surgical Subdivisions of the Larynx
The cartilage is softer and more pliable
For clinicosurgical purposes, the larynx has and the mucosa loose and less fibrous.
been divided into three main regions: 3. Position: In the infant the larynx is placed
i. Glottis high and it descends continually during
ii. Subglottis development. In a foetus of 5-6 weeks the
iii. Supraglottis. larynx is situated opposite the basiocciput
312 Textbook of Ear, Nose and Throat Diseases
but by the fourth month the lower border It has the following ramifications:
of the cricoid lies opposite the upper 1. Right superior lobe bronchus: It arises from
border of the fourth cervical vertebra. At the right principal bronchus and is
seven months it lies about the middle of divided into three segmental bronchi—
the sixth vertebra and it is still found in apical, posterior, and anterior.
this position at full term. After birth further 2. Middle lobe bronchus: It arises from the
descent occurs until in adult life it lies anterior aspect of the main bronchus,
opposite the lower border of the sixth is directed forwards and downwards to
cervical vertebra, while the top of the be divided into two segmental bronchi,
epiglottis lies opposite the lower border of the lateral and medial.
the third cervical vertebra. 3. Right inferior lobe bronchus: The inferior
As a result of the higher position of the lobe bronchus gives the following seg-
larynx in infants, the entry of the air current mental bronchi—apical, medial basal,
is straighter than in adults and the anterior basal, lateral basal, and poste-
epiglottis less overhanging. In adult life the rior basal.
axes of the pharynx, larynx, and trachea
meet at a more acute angle. Left Main Bronchus
4. Shape: The upper end of the larynx and
trachea is funnel-shaped in infants, the The left main bronchus is longer, narrower
cricoid plate being tilted backwards while and more horizontal. It divides into the
the tracheal lumen becomes smaller as it following subdivisions.
descends. This funnel shape disappears in 1. Left superior lobe bronchus.
older children and adult females while it 2. Left inferior lobe bronchus.
reappears in a modified form in the adult The left superior lobe bronchus gives the
male, the backward tilt of the cricoid following ramifications.
cartilage being replaced by the forward tilt
Lingular bronchus: It arises as its branch.
of the thyroid cartilage but the tracheal
The superior lobe bronchus itself divides
lumen no longer diminishes as in an infant.
into the following.
1. Apicoposterior, which divides into: (i) api-
TRACHEOBRONCHIAL TREE
cal, and (ii) posterior segmental bronchi.
Anatomy 2. Anterior segmental bronchus.
The trachea divides at the level of the upper The lingular bronchus which is a branch
border of the fifth thoracic vertebra into two of the left superior lobe bronchus divides into:
main bronchi separated by a projection of the (i) superior lingular, and (ii) inferior lingular
lowest ring of trachea called carina. bronchi.
The left inferior lobe bronchus divides into
Right Main Bronchus the following segmental bronchi: (i) apical
The right main bronchus is wider, shorter and bronchus, (ii) anterior basal, (iii) lateral basal,
more vertical than the left main bronchus. and (iv) posterior basal.
Larynx and Tracheobronchial Tree 313
There is no medial basal bronchus on the During inspiration the bronchial diameters
left side. increase. Absence of these movements on
The successive divisions of the bronchial bronchoscopy denotes fixation of the bron-
tree are termed principal bronchi, lobar chial wall by a neoplastic process. The
bronchi, segmental bronchi, bronchioles and advantage of this widening on inspiration is
terminal bronchioles. taken in removing a foreign body by forceps.
53 Physiology of
the Larynx
4. Function of larynx during deglutition: The the food into the pyriform fossae. The
larynx moves up towards the base of the sphincteric mechanism of the larynx
tongue and thus brings the pharyngo- comes into action and prevents the
oesophageal junction nearer to the bolus. passage of food into the laryngotracheo-
The epiglottis curls backwards and directs bronchial tree.
54 Common Symptoms of
Laryngeal Diseases
Symptoms due to involvement of the larynx patient can cough and vocal cords are seen
include alteration or loss of its functions. to approximate on coughing.
Hence the symptoms are referrable to chan-
ges in voice, difficulty in breathing and incom- STRIDOR AND DYSPNOEA
petence of the laryngeal sphincters producing Structural changes in the larynx may produce
difficulty in swallowing. stridor and dyspnoea. Stridor is noisy
CHANGES OF VOICE breathing produced by obstruction to air flow.
It may occur during inspiration or on expi-
Various changes in voice can be of the ration depending upon the site of obstruction.
following types: An obstructive lesion in the larynx and trachea
1. Hoarseness of voice: This phrase implies a may produce dyspnoea and cyanosis.
rough, husky voice. Any disease which Increased respiratory rate, indrawing of the
interferes with vibration of the vocal cords, larynx and trachea into the mediastinum, and
approximation of the vocal cords or their recession of the intercostal spaces and
movements produces a change in voice. A supraclavicular fossae indicate a laryngeal or
breathy voice occurs due to air leak as is tracheal obstructive pathology.
seen in vocal cord paralysis.
Loss of vocal range may occur in singers WEAK CRY
due to structural changes in cords like
nodules, polyps and thickening. Diseases of the larynx in infancy produce
2. Puberphonia: Crackling of voice or break in distress and make the baby cry. Any lesion
voice occurs at puberty in males as the which prevents the approximation of the cords
larynx grows. results in a weak cry.
3. Vocal asthenia: Fatigue or weakness of the
voice may occur particularly in weak COUGH
elderly persons due to muscular weakness. Dry cough may be due to laryngeal involve-
4. Functional aphonia: Complete loss of voice ment. Small neglected foreign bodies in the
may occur in hysterical females. The larynx and trachea, aspiration of fluids due to
Common Symptoms of Laryngeal Diseases 317
Clinical examination of the larynx includes is done, particularly the nodes deep to the
external palpation and indirect laryngoscopy. sternomastoids.
The complete examination may necessitate
direct laryngoscopy, radiography and INDIRECT LARYNGOSCOPY
stroboscopy.
This simple procedure provides the view of
EXTERNAL PALPATION the interior of the larynx and is great clinical
value. The following items are required.
Examination of the neck is very important in 1. A headmirror and a light source.
laryngeal diseases. Laryngeal cartilages 2. Laryngeal mirror (different sizes are availa-
(thyroid and cricoid) are felt for thickening, ble).
tenderness and broadening. 3. Tongue cloth (a piece of gauze for holding
The larynx remains stationary during quiet the tongue).
breathing but moves on deglutition and on 4. A spirit lamp or a hot water bowl for
deep breathing as during exercise and warming the mirror.
respiratory obstruction. It descends on deep
inspiration and ascends on expiration. Procedure
When the larynx is moved laterally on the
The patient and the examiner face each other.
vertebral column, it produces a grating
The procedure is explained to the patient to
sensation which is normally elicited. In
gain his cooperation and relaxation. The
conditions like postcricoid malignancy or
patient sits with his head upright and tilted
other retropharyngeal lesions this sign is
slightly forward from the shoulders (Fig. 55.1).
absent as the larynx is pushed forwards and
The light is focussed on the patient’s lip.
its movements over the vertebral column does
The mirror of proper size is warmed to prevent
not occur.
fogging of its surface. Its temperature is tested
Examination of neck nodes A detailed on the examiner’s hand. The patient is asked
examination of the lymph nodes of the neck to put out his tongue which is held by a gauze
Examination of the Larynx 319
Procedure
The patient lies supine on the operation table,
his neck is flexed but the head is extended at
the atlanto-occipital joint. This position brings
the larynx in direct axis with the oral cavity
Fig. 55.4A:Instruments used for direct
laryngoscopy and thus facilitates the introduction of the
laryngoscope.
The laryngoscope is held in the right hand
and passed from the right angle of the mouth.
The teeth and lips are protected. The endo-
scope is passed into the oral cavity till the
posterior part of the tongue is visualised. It is
passed to the midline and the base of the
tongue is elevated. This brings the epiglottis
into view. The tip of the laryngoscope is
guided behind the epiglottis and advanced,
lifting the handle of the laryngoscope
Fig. 55.4B:Fibreoptic laryngoscopy upwards. This brings the posterior part of the
322 Textbook of Ear, Nose and Throat Diseases
The larynx may be divided into three compart- because a negative pressure develops below
ments: supraglottic, glottic, and subglottic. the site of obstruction and thus, laryngeal
Obstruction at each level produces charac- structures tend to collapse inwards narrowing
teristic physical findings that may be helpful the airway and causing a noisy breathing,
in diagnosis. The supraglottis includes the while on expiration these structures are forced
epiglottis and false cords (vestibular folds). apart.
The glottis is bounded by the true cords. The When the obstruction lies below the vocal
subglottis extends below the true cords to the cords, stridor is either heard both during
inferior edge of the cricoid cartilage. inspiration and expiration or mainly during
Stridor is the hallmark of laryngeal expiration depending upon the severity of obs-
obstruction. truction. The timing of stridor with respira-
Level of Physical findings
tory phase gives an idea about the site of
obstruction obstruction. Similarly, if voice is hoarse, the
lesion is likely at the level of cords. Stridor with
Supraglottic Stridor is inspiratory and charac-
terised by a lowpitched flutter. a clear voice indicates that the obstruction is
Voice may be normal. not at glottic level.
Glottic Stridor is inspiratory and expi- Stridor is produced by a number of condi-
ratory and exhibits a phonatory
quality. Dysphonia is present.
tions which cause narrowing of the larynx or
Subglottic Stridor is mainly expiratory. trachea. It is mainly a problem of children,
Voice may be normal. Brassy, because the larynx is relatively small and
barking cough is characteristic. laryngeal tissues are sensitive, lax, flabby and
susceptible to oedema and spasm.
Stridor is noisy breathing heard when
Common Causes of Stridor
there is obstruction to the free flow of air
through the larynx or trachea. Stridor may be 1. Laryngomalacia
inspiratory or expiratory. When obstruction 2. Acute laryngotracheobronchitis and acute
lies mainly in the larynx, stridor is inspiratory laryngitis
Stridor 325
1. Cause Web Incurved Softness of Deficiency of FB adenoids Acute simple Papilloma, cysts
larynx tissue, e.g. calcium whooping laryngitis,
myasthenia cough laryngotracheo-
gravis bronchitis,
measles
and diphtheria
2. Age of At or soon Soon after Soon after At birth to Variable Variable Usually before
onset after bith birth birth 2nd year 2 years
3. Onset of Not sudden Not sudden Not sudden Sudden Sudden Sometimes Gradual
attacks sudden
4. General Not affected Not affected Usually weak Weak Adenoidal or Acute fever Effects of
health temporary illness obstruction
5. Stridor Inspiratory Inspiratory Inspiratory During attacks During attacks Inspiratory or Inspiratory or
by day mainly inspiratory to and fro to and fro
inspiratory or to and fro
6. Stridor Present Diminished Diminished Attacks awake Only during Present, often Present in
during sleep the patient attacks worse severe cases
7. Dyspnoea Variable Variable Variable Severe during Severe during Often severe Sometimes
attacks attacks severe
8. Cyanosis Rare Rare Rare Severe during Severe during Often severe Sometimes
attacks attacks severe
Textbook of Ear, Nose and Throat Diseases
Acute nonspecific laryngitis usually follows viral laryngoscopy reveals a diffuse congestion of
infections of the upper respiratory tract. the laryngeal mucosa. The vocal cords look
Bacteria are the secondary invaders. dull red and slightly oedematous. Arytenoids,
aryepiglottic folds and vestibular bands may
Predisposing Factors show varying degrees of oedema. Thick secre-
Excessive vocal use, smoking, sinusitis and tions appear on the surface of the laryngeal
tonsillitis predispose to laryngitis. Similarly mucosa. The larynx in a normal person and in
irritant fumes, intubation and instrumental acute laryngitis is shown in Figures 57.1 and
trauma are the other contributory factors. 57.2, respectively.
Pathology
The mucosa of the larynx becomes congested
and may become oedematous. A fibrinous
exudate may occur on the surface. Sometimes
infection involves the perichondrium of the
laryngeal cartilages producing perichondritis.
Chronic inflammation of the larynx may present often associated with smoking and vocal
as a diffuse lesion or produce localised effects abuse.
in the larynx. A variety of factors are 5. Irritant fumes: Chronic irritation of the
responsible. larynx may result from fumes inhaled in
1. Chronic infection: Chronic laryngitis may be factories and is likely to produce chronic
produced by a chronic inflammatory focus laryngitis.
in the tonsils, pharynx, teeth, gums or
paranasal sinuses. The larynx is exposed Pathology
to infected material from these sites and
The histopathological examination shows
gradually develops features of chronic
mucosal thickening and infiltration with
inflammation.
plasma cells and leucocytes. Capillaries
2. Vocal abuse: It is an important cause of
appear engorged and the connective tissue
chronic laryngitis. Teachers, salesmen,
elements are increased.
public speakers, etc. whose occupation
demands a constant use of voice with
Clinical Features
strain and tension suffer more from this
problem. The main presenting symptom of the patient
3. Smoking: Tobacco has harmful effects on is hoarseness of voice, i.e. change in the quality
the laryngeal mucosa. Inhalation of smoke of voice. Tiredness of voice is also a frequent
produces oedema and chronic inflam- symptom. The patient may complain of some
matory changes in the mucosa which foreign body sensation in the throat and may
eventually lead to hyperkeratosis and frequently cough to clear his throat.
leukoplakia. Examination reveals a red, hyperaemic,
4. Alcohol: Alcohol produces chronic inflam- and irregular laryngeal mucosa. It appears
matory changes in the pharyngeal mucosa swollen and thickened. The mucosa is
and the nearby laryngeal mucosa gets diffusely involved. The cords may appear
involved. Moreover, alcohol drinking is granular and thickened.
Chronic Laryngitis 333
Treatment
Treatment is microsurgical excision. The
polyp should be properly grasped, pulled
medially and carefully trimmed off by the
scissors without causing damage to the cords.
CONTACT ULCER
It is a form of localised lesion characterised
by epithelial thickening on the vocal proces-
Fig. 58.2: Vocal cord granuloma ses of the arytenoid cartilage. There is no true
ulceration so the better term for this condition
is obscure but there is usually a history of vocal is contact pachydermia. The condition results
abuse. from the misuse of voice. It results from the
Theories of aetiology include inflamma- faulty production of voice rather than from
tory irritation and localised vascular disease its excessive use (Fig. 58.3).
but these have not been substantiated. The lesions appear on the vocal processes.
The thickened hyperplastic epithelium gets
Pathology heaped up around a crater, at the floor of
which lies the vocal process. On indirect
Localised vascular engorgement and micro-
laryngoscopy, the heaped edge of one side
haemorrhages occur, followed by oedema
may appear fitting in a crater on the opposite
(Fig. 58.2). The stroma is scanty, relatively
cord giving an appearance of an ulcer. The
acellular and distended with mucoid exudate.
condition responds to voice rest and proper
The epithelium is normal. Histology may
speech therapy. Surgery is required if con-
differentiate the polyp into three types:
servative treatment fails. Microsurgical
gelatinous, transitional and telangiectatic.
excision of the hyperplastic epithelium is
Clinical Features
The main symptom is hoarseness of long
duration. A large polyp may result in choking
spells. Laryngoscopy reveals translucent
sessile or pedunculated lesion arising from the
vocal cord usually near the anterior commis-
sure and sometimes it arises from both the
cords.
The polyp may hang down into the sub-
glottic region and become visible only on
coughing or phonation. Fig. 58.3:Contact ulcer
Chronic Laryngitis 335
granulation tissue produces swelling of the suggestive of tuberculosis and make biopsy
aryepiglottic folds and epiglottis leading to unnecessary, which, however, should be done
turban-shaped epiglottis. Ulcers with mouse- in doubtful cases.
nibbled appearance may appear on the false
and true cords. Treatment
Treatment is voice rest and proper antituber-
Clinical Features
cular chemotherapy.
The history is suggestive of pulmonary
tuberculosis. Weakness of the voice is a typical LARYNGEAL LUPUS
feature. The patient complains of odyno- Lupus vulgaris is an indolent form of
phagia (painful deglutition), which is more for tuberculosis. It is a rare disease which affects
solids than for semisolids, as the semisolids females more than males. It involves a slow
form a coating over the ulcers having exposed destructive process. Laryngeal lupus is
nerve endings. The pain may radiate to the always secondary to lupus vulgaris of the
ears. nose. The nasal lesions itself may be active or
Examination of the chest reveals features may have healed. The epiglottis, aryepiglottic
of pulmonary tuberculosis. Laryngoscopy folds and arytenoids are the most treatment
shows interarytenoid thickening or heaping common sites involved. The disease may
of the mucosa. Arytenoids may appear cause destruction of the epiglottis. Superficial
oedematous and the epiglottis may appear ulceration, areas of cicatrisation and charac-
turban-shaped. Superficial ulcerations may be teristic pallor of the surrounding mucosa are
visible on the ventricular bands or vocal cords. typical features.
Mucosa of the laryngeal ventricle may show The disease runs a painless course and it
a prolapse. is often the active or healed nasal lesions which
Adduction weakness of the vocal cords is attract the attention during examination.
considered an early sign of tuberculosis. A Antitubercular treatment should be given if
positive sputum and X-ray of the chest are the lesions are active.
59 Laryngeal Trauma
Trauma to the larynx and trachea may be the laryngeal tissues may be present on
caused by external injury like vehicular external examination. Laryngoscopy may
accidents, blows, suicidal cut throat attempts, show mucosal ecchymosis, laceration, oedema
endoscopic procedures, intubation or and distortion of the endolaryngeal contours.
tracheostomy. X-rays of the soft tissues of the neck and
cervical spine are helpful. Tomograms provide
Pathology a detailed view of the injured tissue.
The degree of damage depends upon the
nature and severity of the injury. Displace- Treatment
ment or fracture of the laryngotracheal Tracheostomy may be needed for restoration
cartilages may occur with or without muco- of the airway. Exploration of the larynx may
sal tear of the larynx and pharynx. be required for restoration of the normal
Lateral blows may fracture the thyroid anatomy. The displaced and fractured cartil-
cartilage in the midline with tearing of the ages are repositioned and wired together to
vocal cords. Supraglottic fracture of the avoid subsequent stenosis. Mucosal lace-
thyroid cartilage with displacement of the rations are stitched and antibiotics given to
epiglottis may occur and occasionally there prevent infection.
may occur total separation of the larynx from
the trachea.
LARYNGEAL STENOSIS
Clinical Features Laryngeal stenosis may occur because of con-
Hoarseness of voice, difficulty in breathing, genital webs, atresia, inadequately treated
stridor and pain on swallowing may be the laryngotracheal injuries, high tracheostomy or
presenting symptoms. as a sequelae to injury by intubation.
Swelling of the soft tissues of the neck, The presenting features include hoarseness
subcutaneous emphysema and tenderness of of voice and difficulty in breathing.
338 Textbook of Ear, Nose and Throat Diseases
A laryngocele is an air filled sac produced in Sometimes a combination of the internal and
the larynx due to dilatation of the laryngeal external varieties occurs.
saccule which is vestigial in human beings.
The dilatation may occur congenitally or due Symptoms
to raised intrathoracic pressure as occurs in
persons engaged in playing wind pipe Majority of the cases are asymptomatic. The
instruments or weight lifting. internal laryngocele produces hoarseness of
voice and may produce dyspnoea due to
Types
pressure changes. The external laryngocele
Internal laryngocele The dilatation remains presents as a cystic swelling in the neck.
confined to the larynx. This produces a cystic Diagnosis is done by clinical examination.
swelling under the vestibular bands and The swelling increases in size on performing
aryepiglottic folds. the Valsalva’s manoeuvre.
External laryngocele The dilated air sac may X-ray of the neck, anteroposterior view,
project through the thyrohyoid membrane shows an air filled sac which becomes
into the neck, producing a compressible cystic prominent on the Valsalva’s manoeuvre. If
swelling in the region of the thyroid cartilage. symptoms are troublesome, the sac is excised.
61 Oedema of the Larynx
Oedema of the larynx is not a disease as such b. Chronic inflammatory lesions like
but is a manifestation of various conditions tuberculosis, syphilis and leprosy.
affecting the larynx or the body as a whole 2. Traumatic
(Fig. 61.1). a. Foreign bodies in larynx
b. Trauma to the larynx by external
Aetiology injuries, endoscopy, and intubation
c. Inhalation of irritant fumes
1. Inflammatory
d. Swallowing of corrosives
a. Acute laryngitis, laryngotracheobron-
e. Postoperative as after the operations on
chitis, epiglottitis, diphtheria, acute
the larynx itself, pharynx, tongue and
perichondritis or abscess of the larynx.
floor of the mouth.
Inflammatory lesions like peritonsil-
3. Neoplastic: Neoplastic diseases of the larynx
lar abscess, retropharyngeal abscess
when associated with ulceration and
and Ludwig’s angina may spread to
infection are associated with oedema.
larynx leading to laryngeal oedema.
4. Angioneurotic oedema: Oedema may
develop in larynx due to allergy.
5. Systemic diseases: Laryngeal oedema may
be the manifestation of prolonged heart
failure, renal failure and myxoedema.
ANGIONEUROTIC OEDEMA
(QUINCKE’S OEDEMA)
Allergic oedema due to antigen-antibody
reaction may involve the larynx. This may be
due to sensitivity to some foods, drugs
including antibiotics, insect bite, parenteral
Fig. 61.1: Indirect laryngoscopic view showing sera or because of worm infestation. Some
laryngeal oedema cases remain idiopathic.
Oedema of the Larynx 341
Pathology
tion. Therefore, if untreated, nasal obstruction
The oedema may occur as a result of irritation, in the newborn period could and often does
allergy or inflammation. There occurs prove fatal, whereas in adulthood, nasal
distension of the submucosal tissues with obstruction may be regarded as a mere
tissue fluid, lymph and inflammatory exudate. annoyance.
Swelling of the laryngeal tissues seen in Differentiation of upper from lower airway
tuberculosis and myxoedema is called pseudo- obstruction is crucial. Stridor, supraclavicular,
oedema. In tuberculosis the swelling is caused sternal, and intercostal retraction with
by inflammatory infiltration with accumula- cyanosis are consistent with upper-airway
tion of cells. In myxoedema, the swelling of obstruction. On the other hand, lower-respi-
the tissues is caused by myxomatous changes. ratory obstruction often produces asymmetry
of chest expansion with wheezing on
AIRWAY OBSTRUCTION IN
auscultation. Dullness to percussion, dec-
CHILDREN AND ADULTS
reased breath sounds, or presence of rales
The human newborn is an obligate nasal support obstructive atelectasis. Hyperreso-
breather by virtue of the intranarial position nance suggests obstructive emphysema.
of its larynx (Fig. 61.2). Approximation of the Rarely is lower-airway obstruction by itself an
epiglottis with the soft palate provides a immediate threat to life; upper-airway
continuous, uninterrupted airway from the blockage represents a true emergency.
nose to the bronchi. This configuration, similar Obstruction at the laryngeal level
in all mammals, is peculiarly lost in humans produced by congenital laryngeal deformities
four to six months after birth. The structural and infection are common to childhood
change provides the potential for oral development. Neoplastic obstruction of the
respiration at an early age as the larynx laryngeal aperture and vocal cord paralysis
descends in the neck with postnatal matura- are often diseases of adulthood.
342 Textbook of Ear, Nose and Throat Diseases
Foreign body in the larynx and tracheobron- change in the voice. There may occur complete
chial tree is one of the most important causes asphyxia which is further aggravated by the
of stridor and dyspnoea in infancy and child- glottic oedema.
hood. There may or may not be a history of
inhaling a foreign body. Sudden occurrence FOREIGN BODIES IN THE TRACHEA
of dyspnoea in a previously healthy child The main symptom is dyspnoea with stridor.
raises suspicion. Effects of the foreign body The changing position of the foreign body in
vary according to its size, nature and location the trachea may give rise to signs like an
in the larynx and tracheobronchial tree. audible slap and a palpatory thud. Depend-
Small and smooth metallic foreign bodies ing upon the obstruction one can hear an
such as pins allow uninterrupted passage of asthamatic type of wheeze in such cases.
air, while a larger foreign body may cause a
total occlusion of the airway. FOREIGN BODIES IN THE
The nature of the foreign body is also BRONCHUS
important. Vegetable foreign bodies like peas Foreign bodies usually get arrested in the right
and beans produce severe pneumonitis and main bronchus because it is wide and is more
are also difficult to remove. The effects on the in line with the trachea than the left main
patient and his respiratory system depend bronchus.
also on the location of the foreign body in the The immediate effect of the foreign body
respiratory tract. If the foreign body gets in the bronchus is respiratory obstruction
arrested in the larynx, it obstructs both the which could be partial or complete.
phases of respiration and rapidly produces
laryngeal oedema. In the trachea, if the foreign Partial obstruction If the foreign body is smaller
body is large, there is an equal danger of total than the size of the bronchus, initially it allows
respiratory obstruction. the passage of air in both directions with little
interference, like a bypass valve. A foreign
FOREIGN BODIES IN THE LARYNX body which is just of the size of the bronchus
A foreign body lodged in the larynx obstructs allows the flow of air only on inspiration and
inspiration as well as expiration and produces blocks the expiratory phase. It thus acts as a
Foreign Body in the Larynx and Tracheobronchial Tree 345
The larynx is supplied by the vagus. The supe- course. It hooks around the ligamentum
rior laryngeal nerve is sensory to the larynx arteriosum and then ascends back into the
but supplies motor fibres to the cricothyroid neck to supply the larynx. Figures 63.1A to C
muscle through its external laryngeal branch. show the position of vocal cords during respi-
The recurrent laryngeal nerve is sensory to the ration and phonation.
larynx below the level of the cords and also
supplies motor fibres to all laryngeal muscles Aetiology of Laryngeal Paralysis
except the cricothyroid. Laryngeal paralysis can be caused by a variety
These nerves can get involved in a variety of lesions. The sites of paralysis can be supra-
of lesions in the brain, at the base of the skull, nuclear or infranuclear. The former gives rise
in the neck and in the chest. The right to a spastic type of paralysis and because
recurrent laryngeal nerve leaves the vagus at larynx has bilateral representation in the
the level of the subclavian artery and then cortex, only a widespread lesion of the cortex
loops around it to ascend up in the tracheo- causes such paralysis (Figs 63.2A to C).
oesophageal groove to supply the larynx. The Infranuclear paralysis is common and can
left recurrent laryngeal nerve has a longer be due to following causes:
Figs 63.1A to C:Various positions of vocal cords: A. Quiet respiration. B. Deep inspiration. C. Phonation
Laryngeal Paralysis 347
Figs 63.2A to C:Positions of paralysed vocal cords: A. Unilateral abductor paralysis. B. Bilateral abductor
paralysis,and C. Unilateral paralysis with compensation by unparalysed cord
3. Schimdt’s syndrome: There is involvement also has some vocal weakness because of
of the accessory nerve (spinal and cranial paralysis of the cricothyroid muscle.
divisions) along with vagus resulting in Indirect examination reveals an oblique
paralysis of the larynx, soft palate, glottis and deviation of the posterior commis-
sternomastoid and trapezius. sure to the side of paralysis. There may be a
4. Vernet’s syndrome: Involvement of the level difference of the cords as the affected
vagus, accessory and glossopharyngeal cord lacks tension, because of cricothyroid
nerves produces features of Schimdt’s paralysis.
syndrome along with diminution of taste
Paralysis of the recurrent laryngeal nerve The
at the base of the tongue and loss of
changing positions of the vocal cords as seen
pharyngeal sensation.
on laryngoscopy in the recurrent laryngeal
5. Hughlings-Jackson syndrome: Involvement nerve paralysis have been the subject of
of the tenth, eleventh and twelfth cranial controversy.
nerves produces homolateral associated
paralysis of the larynx, soft palate, tongue Semon and Rosenback hypothesis was used to
and muscles of the neck (sternomastoid, explain the sequence of paralytic conditions
trapezius). of the vocal cord. It stated that in the course
6. Collet-Sicard syndrome: (Villaret’s syndrome): of a gradually advancing organic lesion of the
Involvement of the last four cranial nerves recurrent nerve, abductor fibres are more
and the cervical symphathetic trunk in the vulnerable to damage so the vocal cords
region of the jugular foramen produces approximate near the midline, the adduction
symptoms and signs of their paralysis. is still possible and it is only in the late stages
7. Klinkert syndrome: Involvement of the that the adductor fibres get involved and the
recurrent laryngeal nerve and phrenic cords are paralysed in the intermediate
nerve, usually at the root of the neck or position (cadaveric position), and the reverse
happens during recovery.
mediastinum produces this syndrome.
Many diverse views have been proposed
8. Ortner’s syndrome: Paralysis of the recur-
to explain the vulnerability of the abductors
rent laryngeal nerve may occur as a result
in laryngeal paralysis. However, neither
of cardiomegaly particularly because of the
separate grouping of the abductor and adduc-
dilated left atrium in mitral stenosis.
tor fibres has been demonstrated in the nerve
Paralysis of the superior laryngeal nerve Involve- trunk, nor has any other explanation been
ment of this nerve produces sensory paralysis found valid to explain the cord position on this
of the same side of the larynx. Laryngeal hypothesis.
anaesthesia and paraesthesia occur on the The opposition to this hypothesis came
side of lesion. Sometimes neuralgia is the from Wagner and Grossman. They postulated
presenting feature. Because of laryngeal that median or paramedian position of the
anaesthesia, there occur choking spells, paralysed vocal cord in recurrent laryngeal
particularly on drinking fluids. The patient nerve paralysis is due to intact function of the
Laryngeal Paralysis 349
circothyroid muscle, which is innervated by Animal studies have shown minimum tissue
the superior laryngeal nerve. response. Left in tissues for a long time, it has
The intermediate position (cadaveric not been found to be carcinogenic. Particles
position) of the vocal cord is because of com- between 50-100 microns in diameter, mixed
bined paralysis of the recurrent laryngeal with glycerine as a vehicle to form air, are used
nerve and the superior laryngeal nerve, as to make an injectable paste. Teflon is not
now the cricothyroid muscle also gets digested, absorbed or extruded as a foreign
paralysed. body. Since the average granule size is larger
It is now an accepted theory and so the than the diameter of the lymphatic drainage
laryngologist must consider mainly two channels, it remains where it has been placed.
positions, viz. paramedian and intermediate. The glycerine vehicle is soon absorbed.
The apparent small variations in these two The following instruments are used.
positions are due to compensation by the 1. Laryngoscope
normal cord across the midline or atrophy and 2. Long needle to traverse the laryngo-
scarring of the paralysed vocal cord. scope
3. Laryngoscope holder
Management of Laryngeal Paralysis 4. Screw type syringe.
The treatment in laryngeal paralysis is Local anaesthesia is used and the patient
directed towards the causative lesion and to is asked to attempt phonation.
the effects of the paralysis. Involvement of both the recurrent laryn-
Many cases of unilateral vocal cord paralysis geal nerves causes paralysis of both vocal
do not require any active treatment as there cords in the paramedian position. Tracheo-
are adequate compensatory movements by stomy is needed to relieve respiratory distress.
the normal cord, thus producing good voice. If recovery does not occur by 6 months to
1 year, the following options are considered:
Glottic rehabilitation with Teflon injection For the
return of voice, cough and laughter, the injec- 1. The patient remains with permanent tra-
tion of Teflon glycerine mixture into the vocal cheostomy. He can be fitted with a speak-
cord is a procedure that can be used. The ing valve tracheostomy tube for speech.
method has its most particular application in This tube has a valve which closes during
cases where there is a lateral lying paralysed expiration and allows the air column
vocal cord. It is also useful in building up through the cords during phonation.
functioning scars after cordectomy and may 2. Alternatively, the patient is considered for
help to correct cord deformities. surgery. Surgical procedures (cordectomy
Teflon (C2 Fu)n is a product of the research and cordopexy) are aimed at widening the
of the Manhattan project of Atomic Energy glottis.
Commission. It is one of the most non-reac- These procedures allow normal airway
tive substances known. For this reason it has through the larynx but suffer from the
been used as a graft for artery replacement. disadvantage of poor voice.
350 Textbook of Ear, Nose and Throat Diseases
Table 63.1: Differentiating points between the inferior cornu of thyroid cartilage, thus
paralysed and a fixed vocal cord widening the glottis.
Paralysed cord Fixed cord CRICOARYTENOID JOINT
1. There is bowing of The cord is straight ARTHRITIS
the cord and it and looks shortened.
appears toneless.
Arthritis of the cricoarytenoid joint causes
2. There is medial The position of the fixation of the vocal cords. The patient gives a
deviation of the arytenoid depends on history of pain in the throat and odynophagia
arytenoid cartilage the condition causing may be present. The fixed cord does not fall
on the affected side. fixation.
in a particular position as in laryngeal para-
3. Vocal cord shows a No flicker is seen.
flicker on phonation. lysis. Passive mobility test by a probe helps to
4. On probe test the No vibrations are seen. differentiate this condition from paralysis. The
paralysed cord shows joint mobility is impaired in arthritis.
vibrations.
FIXED AND PARALYSED CORD
Fixation is due to infiltration of malignancy,
Cordopexy The procedure is termed adhesions and scarring of the vocal cord.
Woodman’s operation. The larynx is exposed The important clinical signs to differentiate
laterally, the arytenoid is removed and the between the two conditions are given in
posterior end of the vocal cord is attached to Table 63.1.
64 Tracheostomy
ANATOMICAL RELATIONS OF
TRACHEA
Before considering the operative procedure
some important anatomical relations are
reviewed.
Anteriorly the trachea is covered by skin,
superficial and deep fascia, sternohyoid and
sternothyroid muscles. The isthmus of the
Fig. 64.1:Tracheostomy instruments
thyroid gland lies deep to the strap muscles
and covers the trachea from the second to the
fourth ring. Below the isthmus lies the inferior
thyroid vein. Indications for Tracheostomy
On each side of the trachea are thyroid 1. Tracheostomy may be needed to relieve
lobes enclosed in the pretracheal fascia, respiratory obstruction which may be due
carotid sheath and other greater vessels and to the following:
nerves of the neck. Posteriorly the trachea lies a. Inflammatory diseases of the upper
on the oesophagus and the recurrent laryngeal respiratory tract like acute laryngo-
nerves ascend on each side between the tracheobronchitis, laryngeal diphtheria
trachea and the oesophagus. The instruments and acute epiglottitis.
used for tracheostomy are shown in b. Impacted foreign bodies in the larynx
Figure 64.1. or trachea.
c. Trauma such as laryngeal injury,
Tracheostomy
maxillary and mandibular fractures,
This is a procedure wherein an opening is inhalation of irritant fumes or corrosive
made in the anterior tracheal wall which is poisoning causing laryngeal oedema.
brought to skin by inserting a tube. d. Angioneurotic oedema.
352 Textbook of Ear, Nose and Throat Diseases
Complications of Tracheostomy
Various complications may arise during or
after the operation. Complications that can
arise during surgery include haemorrhage
mainly due to trauma to the thyroid veins.
Fig. 64.3:Tracheostomy incisions: Horizontal Trauma during surgery may be to thyroid
incisions in elective operation gland, oesophagus, recurrent laryngeal nerve,
great vessels of the neck or the domes of the
Operative Technique pleura.
A vertical incision is given in the suprasternal Sudden decrease in PCO2 in the blood and
space extending down from the cricoid correction of hypoxia may lead to apnoea.
cartilage through the skin, subcutaneous fat
Postoperative Complications
and deep cervical fascia. The infrahyoid
muscles are exposed and separated in the 1. Surgical emphysema of the neck and chest
midline to expose the thyroid isthmus and may occur as the air may leak into the
trachea. cervical tissues.
The thyroid isthmus is either retracted or 2. Displacement of tube: Improper opening in
cut to expose the tracheal rings. An assistant the trachea, improper size and securing of
pulls the soft tissues and muscles laterally with the tube may lead to displacement of the
retractors. The cricoid cartilage is hooked up tube with the formation of a false passage.
to stabilise the trachea. 3. A high tracheostomy may damage the
An opening is made in the tracheal wall, cricoid cartilage with resultant subglottic
usually at the level of the third or fourth ring stenosis.
and the tracheostomy tube is placed in 4. Damage to tracheal rings can lead to
position and secured by tapes around the tracheomalacia.
neck. 5. Difficult decannulation: The removal of
A tracheostomy is called high when the tracheostomy tube is known as decannu-
tracheal opening is made above the thyroid lation. Decannulation is usually difficult in
354 Textbook of Ear, Nose and Throat Diseases
infants and young children perhaps A metallic tracheostomy tube has an inner
because the young child has no airway and an outer tube. The inner tube is longer
reserve. It is better to use expiratory valve than the outer one so that secretions and crusts
to begin with, thus restoring physiological form in it can be removed and the tube
expiratory thrust and stimulating the reflex reinserted after cleaning without difficulty.
for vocal cord abduction. Once this is However, they do not have a cuff and cannot
tolerated well the cannula should be produce an airtight seal.
gradually blocked and reduced in size. A nonmetallic tracheostomy tube can be of the
Factors causing difficult decannulation cuffed or noncuffed variety, e.g. rubber and
are the following: PVC tubes. Silastic cuffed PVC tubes are of
i. Persistence of the condition that special use and allow intermittent positive
originally necessitated the tracheo- pressure respiration and prevent aspiration
stomy into the trachea.
ii. Granulation around stoma
Care of Tracheostomy
iii. Oedema of the tracheal mucosa
iv. Inability to tolerate upper airway 1. Proper attention is given to the correct
resistance on decannulation positioning of the tracheostomy tube by
v. Emotional dependence on tracheo- selecting a proper sized tube and securing
stomy it with tapes around the neck.
vi. Subglottic stenosis 2. Removal of secretions: In addition to the
vii. Tracheomalacia original pathology, the tube itself irritates
viii. Incoordination of the laryngeal the mucosa and thus produces copious
secretions. The removal of secretions is
opening reflex
done by using a sterile catheter for suction.
ix. Impaired development of the larynx
Instillation of a few drops of 5 per cent
as a result of long- standing tracheo-
sodium bicarbonate or saline may cause
stomy.
thinning of secretions.
6. Pulmonary infection: Lack of proper defence
3. Cleaning of tracheostomy tube: Secretions
mechanism of the upper air passages and
deposited on the tube, dry up and form
improper care of the tracheostomy may
crusts thereby causing difficulty in
lead to pulmonary infection.
breathing. The inner tracheostomy tube is
7. Tracheal stenosis
periodically removed and cleaned, so is the
8. Fatal haemorrhage might occur due to
outer tube, if necessary.
erosion of a great vessel (innominate
4. The tracheostomy wound is properly
artery) by the tube end.
dressed to avoid infection.
5. If a cuffed tube has been used, the cuff
Types of Tracheostomy Tubes
should be periodically deflated to prevent
A tracheostomy tube may be metallic or necrosis of the mucosa and tracheal
nonmetallic. stenosis.
Tracheostomy 355
and the person cannot speak. The treatment Rhinolalia Clausa or Hyponasality
is vocal rest, speech therapy and the treatment When there is absence of nasal resonance for
of the underlying psychoneurotic problem. words like syringe which normally resonate
in the nasal cavity—the dull voice or “potato
PUBERPHONIA (MUTATIONAL in mouth” voice is produced. The cause is in
FALSE TO VOICE) the nose or nasopharynx, e.g. catarrh or com-
In boys the larynx matures at puberty as the mon cold, allergic rhinitis, polypi or growth
vocal cords lengthen and voice changes from in the nose, adenoid hypertrophy, naso-
high pitch to lower pitch—normally. In pharyngeal growth and habitual or familial
emotionally immature and psychologically speech pattern.
disturbed boys, this normal changes does not
Stammering or Stuttering
occur leading to persistence of childhood high-
pitched voice. Treatment is to train the boy to Though some children have normally dys-
produce low-pitched voice by Lustzmann’s fluency of speech between two to four years
pressure test—where thyroid prominence is of age but children feeling psychologically
insecure, or overattention of parents, imitating
pressed backwards or downwards—which
some stutters, may make this behaviour
relaxes the overstretched cords producing
pattern fixed. In early stage at grade I, the
lowpitched voice.
fluency of speech is affected and there may
Other disorders of voice though not related to
be hesitation to start the speech, or repetition
larynx are:
or prolongations or blocks in the flow of
Rhinolalia Operta or Aperta or Hypernasality speech. Later stage in grade II child develops
secondary mannerisms such as facial
It is due to defective closure of oropharynx grimacing, eye blinking and abnormal
from nasopharynx or abnormal com- movements of head, legs or arms. Stuttering
munication between the oral and nasal is cured by speech therapy and psycho-
cavities, e.g. in velopharyngeal insuffi- therapy, encouraging the child to speak nor-
ciency, cleft palate, short soft palate, wide mally without fear and tension. The parents
nasopharynx, paralysis of soft palate, and the teachers should be given proper
oronasal fistula, postadenoidectomy, education as not to overact to child’s dysflu-
habitual or familial speech pattern, etc. ency in early stages of speech development.
66 Tumours of the Larynx
The tumours of larynx can be benign or microscope. The excised tissue is sent for histo-
malignant. pathological examination as it is a premalig-
nant condition.
BENIGN TUMOURS OF THE LARYNX
The following are the benign tumours of the Multiple Papillomas of the Larynx
larynx. The multiple papillomatosis of the larynx is a
1. Papillomas disease of children. The lesions subside at
a. Solitary papilloma puberty. The aetiology of this condition is not
b. Multiple papillomas definitely known but it appears that it is of
2. Haemangioma viral origin. The disease may occur in early
3. Fibroma childhood with a definite tendency for the
4. Chondroma papillomas to disappear at puberty.
Multiple papilliomatous tumours appear
Solitary Papilloma on the vocal cords, false cords and other areas
Papilloma of the larynx is the most common of the larynx and present with multiple
benign lesion in the larynx. A solitary papil- problems. Not only do these tumours inter-
loma is common in adults, particularly in fere with laryngeal function thereby causing
males. These usually arise from the edge of hoarseness of voice and respiratory difficulty
the vocal cord in the anterior part and may but because of their multiplicity, the tumours
be pedunculated. are difficult to excise. Besides, these papil-
Indirect laryngoscopy shows a pink warty lomas have a tendency to recur and may
growth of varying size in the anterior spread to other areas of the larynx, trachea and
commissure. bronchi causing a very frustrating situation for
The main presenting symptom is hoarse- the laryngologist.
ness of voice.
Treatment
Treatment Various medical modalities of therapy like
Direct laryngoscopy and excision of the antibiotics, steroids, hormones and vaccines
papilloma is done, preferably using a have proved of no use. Repeated surgical exci-
Tumours of the Larynx 359
Squamous cell carcinoma is the most com- of cordal growth and it is very rare that a pri-
mon type of laryngeal cancer. Sarcomas are mary starts in the subglottis itself. Subglottic
very rare. cancer is difficult to diagnose, hence present
very late and spread occurs to pretracheal,
Aetiology paratracheal and mediastinal lymph nodes
The exact aetiology is not clear but carcinoma making radical cure very difficult. The prog-
nosis is bad.
is relatively common in Indians. Chronic
irritation by smoking, alcohol and chewing of Supraglottic cancer Commonly epiglottis is the
betel nut and tobacco may be contributory site of tumour in this region. Laryngeal
factors, prolonged vocal strain plays a ventricle and false cords are rare sites. The
significant role. tumours present in the late stages. Epiglottic
tumours send metastasis to both sides of the
Glottic cancer It is the most common type of
neck. Marginal zone tumours include tumours
laryngeal neoplasm in adults. It usually arises
of the tip of the epiglottis and aryepiglottic
from the free margin of the upper surface of
folds. These carry a poor prognosis because
true vocal cord in its anterior two-third (Fig.
these tumours are detected in advanced stages
66.4). The spread occurs locally along the cord
and gain an early access to the lymph nodes.
to the anterior commissure and may involve The spread of laryngeal cancer may occur
the other cord. Lymph node involvement is a directly to the adjacent tissues or through lym-
very rare phenomenon in glottic cancer as the phatics to the regional lymph nodes. Rarely
vocal cords are practically devoid of lympha- spread may occur through the blood, usually
tics. Prognosis is excellent if the tumour is to the lungs, liver and bones.
treated early.
Subglottic cancer The subglottic region is Clinical Features
usually involved by the downward extension The disease commonly affects elderly males.
Progressive continuous hoarseness of voice is
the main early symptom particularly in glottic
cancer. The other symptoms include a feeling
of discomfort in the throat, irritable cough
particularly in supraglottic growths and
haemoptysis and many times the patient
presents with features of respiratory obstruc-
tion like dyspnoea or stridor, dysphagia and
swelling in the neck in advanced cases.
The growth may be seen on indirect laryn-
goscopy or fibreoptic laryngoscopy as raised
nodular, papilliferous or an ulcerative lesion,
with or without fixation of the cords and
Fig. 66.4:Tumour confined to one vocal cord involvement of neck nodes.
362 Textbook of Ear, Nose and Throat Diseases
HEMILARYNGECTOMY
A vertical hermilaryngectomy removes half
Fig. 66.5:A. Sorenson’s, and B. Gluck’s
of the larynx, including the ipsilateral thyroid
incision for total laryngectomy
ala, arytenoid, true vocal fold, and often the
false vocal fold. Frequently, a neoglottis is 3. Preliminary tracheostomy is done before
constructed with strap muscle or a local undertaking laryngectomy.
mucosal flap to compensate for the resected 4. The procedure should preferably be done
tissue. under general anaesthesia, can be done
under local anaesthesia also.
EXTENDED PARTIAL 5. Sorenson’s and Gluck’s incisions as shown
LARYNGECTOMIES in Figure 66.5, are the usual incisions used.
Various types of extended partial laryn- 6. The skin flap is elevated, strap muscles cut,
gectomies have been designed as alternative larynx exposed, suprahyoid attachments
to the standard total laryngectomy when cut, thyroid isthmus transected in the
oncologically safe. Their presumed advantage middle exposing the trachea, pyriform
lies in improved speech without the need for mucosa elevated from the inner aspect of
a prosthesis. thyroid laminae and then the larynx is
removed either from above downwards or
Total Laryngectomy from below upwards.
The patient should be meticulously assessed 7. The pharynx is closed in layers after
before operation. He should be made to passing the Ryle’s tube.
understand what sort of life he will have after 8. Trachea is connected with the skin creat-
laryngectomy as he is going to lose his voice ing a permanent tracheostomy.
and will have a permanent tracheostomy. 9. The skin is closed after keeping the corru-
gated rubber drains.
Procedure
1. There should be no focus of infection in the Postoperative Care
nose, paranasal sinuses or in the oral 1. Care of the tracheostomy tube with pro-
cavity. per suction is important.
2. General condition of the patient should be 2. Vital signs, viz. pulse, BP and respiration
fairly good. must be monitored.
364 Textbook of Ear, Nose and Throat Diseases
3. The patient should be encouraged to sit Voice rehabilitation after total laryngectomy: It is
and to cough, so as to prevent pulmonary important to make patient to converse to make
complications. his day-to-day life purposeful. Following
4. He should be put on heavy antibiotics and methods are being used and tried:
IV fluids. a. Oesophageal speech: Patient is taught to
5. Daily dressings should be done to keep the swallow air which is held in upper oeso-
wound healthy. Stitches should be phagus and then slowly ejected from
removed on the seventh to the tenth day. oesophagus to pharynx. These patients
when trained can speak about 8-10 words
Complications by reswallowing air, voice is loud but
The following are the complications of rough.
laryngectomy: b. Artificial larynx: In patients who cannot
1. Cardiac arrest learn oesophageal speech following
2. Haemorrhage devices are used to make them speak.
3. Pulmonary embolism i. Electrolarynx: It is a small transistorised,
4. Pulmonary complications like broncho- battery operated device having a
pneumonia, and atelectasis, etc. vibrating disc which is held against the
5. Pharyngocutaneous fistula. soft tissue of neck and a low pitched
After laryngectomy the patient can be sound is produced in the hypopharynx
trained to speak by oesophageal speech, use which is further modified into speech by
of electronic larynx or by surgical procedures the tongue, teeth, palate and lips.
aimed at constructing the “neoglottis”. ii. Transoral pneumatic device: Another type
of artificial larynx is a transoral device.
ORGAN PRESERVATION THERAPY
Here vibrations produced in a rubber
In this study, laryngeal preservation was diaphragm are carried by a plastic tube
attained in 64 per cent of the patients who into the back of oral cavity where sound
received induction chemotherapy followed by is converted into speech by modulators.
radiation therapy. To date, the quality of the This is a pneumatic type of device and
speech in these organ preservation protocol uses expired air from the tracheostome
patients has been evaluated adequately. to vibrate the diaphragm.
iii. Tracheo/Oesophageal speech: Here attempt
ALARYNGEAL COMMUNICATION
is made to carry air from trachea to
There are three major methods of communi- oesophagus or hypopharynx by the
cation used by patients after undergoing a creation of a skin lined fistula or putting
total laryngectomy: artifical larynx, oeso- an artificial prosthesis. The vibrating
phageal speech, and TE speech. They all column of air entering the pharynx is
possess various advantages and disadvant- then modulated into speech. This
ages, and it is clear that the optimal method technique has the disadvantage of food
of alaryngeal speech has yet to be developed. entering the trachea. These days
Tumours of the Larynx 365
prostheses are being used to shunt air a. Mean or maximum phonation time.
from trachea to oesophagus. They have b. Spectrographic analysis, measure-
inbuilt valves which work only in one ment of fundamental frequency.
direction, thus preventing problems of c. Measurement of phonatory airflow,
aspiration. e.g. directly by pneumotachography
or indirectly by using hot wire
PHONOSURGERY anemometry.
Phonosurgery is undertaken in order to iii. Video-stroboscopy is the most useful
restore or retain the function of phonation. objective test, for preoperative and
There are multiple procedures designed to postoperative evaluation of patients with
improve the voice (phonation) in different unilateral vocal cord impairment.
conditions which affect the proper voice iv. Electromyography is a valuable test for
production (phonation). evaluating the integrity of laryngeal
These procedures may be: innervation in the presence of vocal cord
i. Microlaryngeal procedures for excision motion impairment.
of benign or malignant disease. Vocal cord augmentation or medialisation
ii. Vocal cord injection for augmentation can be done as under.
and medialisation.
iii. Laryngeal framework surgery which is Transoral Injection
further classified into four types of Transoral injection may be performed in
surgical procedures based on functional
selected patients. Topical 4 per cent lidocaine
alteration of vocal cords:
solution is applied to the pharyngeal mucosa.
a. Medial displacement
With the patient holding the tongue forward,
b. Lateral displacement
allowing indirect visualisation, the injection
c. Shortening or relaxation
is performed using a curved laryngeal needle.
d. Elongation or tensioning procedures.
Right and left needles are available so that the
iv. Laryngeal reinnervation procedures, and
bevel is directed away from the midline to
v. Reconstructive and rehabilitative
minimise the possibility of an intra-
procedures after tumour resection.
mucosal injection.
The microlaryngeal procedures have
already been discussed (Chapter 57).
Laryngoscopic Injection
Patient Evaluation and Selection Ideally, the procedure is performed under
Degree of impairment may be determined by: local anaesthesia to monitor the changes in
i. Subjective criteria based on the patient’s vocal quality during injection. When local
symptoms, e.g. breathiness, aspiration or anaesthesia is inadequate, the injection may
exertional intolerance. be performed under general anaesthesia with
ii. Objective criteria obtained through jet ventilation using the Sanders device,
various tests like: avoiding the use of an endotracheal tube.
366 Textbook of Ear, Nose and Throat Diseases
Superior laryngeal nerve blocks with lidocaine new. In selected patients, medialisation can be
should be avoided, as they will alter vocal cord accomplished quickly and effectively in the
tension due to cricothyroid muscle paralysis office setting. These procedures are relatively
and adversely affect voice quality. simple and yield immediate results with little
First cord is lateralised exposing the discomfort to the patient.
ventricle, the laryngeal needle is inserted When vocal cord paralysis has been found
lateral to the vocal cord 2 mm deep. to be permanent, Teflon may be used to
Teflon or Gelfoam paste is injected at single medialise the vocal cord. If recovery of vocal
click interval. It is must to wait after each click cord function is likely, Teflon is contra-
as there is continued extension of material for indicated and alternative methods must be
several seconds. A second injection is made considered. Gelfoam may be used as a tem-
lateral to vocal cord at the junction of anterior porising measure in this setting. The use of
and middle thirds. After injection a spatula is Gelfoam injection as a trial before Teflon
used to massage the vocal cord to distribute injection should be discouraged, as this will
the material more evenly. The laryngoscope result in redundant surgical procedures.
is relaxed and patient asked to phonate. There Percutaneous injections may be performed
are some complications of vocal cord without sedation using local anaesthesia
injections like: alone. Flexible fibreoptic laryngoscope is
required to visualise position and adequacy
i. Excessive and incorrect placement of
of injection, given their advantage and ease
injected material.
of performance, percutaneous injections are
ii. Inspiration with obstruction.
becoming the airway management is a
iii. Phonation with vocal cord overlap.
potential problem, injection in a controlled
iv. Teflon granuloma.
setting during direct laryngoscopy should be
Percutaneous medialisation by injection
considered.
should be considered in patient with short life
A distinction should also be made between
expectancy and aspiration or severe
vocal cord medialisation and intrachordal
dysphonia.
injection. With injection for medialisation, the
material is injected lateral to the vocal muscle
Vocal Cord Medialisation by Injection leaving the mucosa overlying the vocal cord
The use of injectable material for vocal cord unaltered.
medialisation remains a standard procedure
Medialisation Thyroplasty
for laryngeal rehabilitation. In the absence of
arytenoid ankylosis and when adequate It has been introduced in 1915 by Payr:
residual vocal cord structure remains to allow 1. It is performed with local anaesthesia with
needle placement for augmentation, mediali- minimal or no discomfort to the patient.
sation of a paralysed vocal cord by injection 2. Patient positioning is more anatomic,
using Gelfoam or Teflon. Recently transoral allowing better assessment of voice during
and percutaneous approaches have added a the procedure.
Tumours of the Larynx 367
quadrants of the window to determine the iv. Airway obstruction: Airway compromise
optimal position. Smaller or larger templates is a potential problem require in patient
may be selected as needed. Once the appro- observation for a minimum of 24 hours.
priate size and position have been determined,
the retractors are replaced and the implant is Management of Bilateral Vocal Cord
inserted and secured with the corresponding Movement Impairment with Airway
shim. Obstruction
If the window is fashioned correctly, the The least invasive of the lateralising proce-
shim will fit securely preventing migration of dures involves endoscopic surgery. An
the implant. The wound is then litigated with arytenoidectomy may be performed through
antibiotic solution. A one-fourth penrose drain the laryngoscope. Lateralisation of the vocal
is placed deep to the strap muscles and cord by suture placement is an alternative
brought out through the incision. Strap procedure. The laser has been suggested as a
muscles and platysma are approximated with method for excising a portion of the vocal
4-0 chronic suture and skin is closed with a cord. Although this method has proved
running 4-0 nylon suture. A dry fluff comp- successful in removing the anterior two-thirds
ression dressing is applied for 24 hours, at of the vocal cord, the posterior third repre-
which time the penrose is removed. Decadron sented by the arytenoid is more difficult to
is given preoperatively to minimise oedema remove successfully with the CO2 laser.
and prophylactic.
Elevate Pitch
It is better to use the largest prosthesis
possible while maintaining quality of voice. Lengthening the vocal cord and elevating
Overmedialisation is supported by Isshiki et vocal pitch may be achieved by advancing the
al (1989), who found deterioration in voice anterior commissure or by cricothyroid
quality overtime as intraoperative oedema approximation lengthening procedures have
resolved in the postoperative period. Where been advocated for vocal cord bowing
early medialisation is performed, muscle resulting from ageing or trauma, postsurgical
atrophy may also result in voice deterioration defects, androphonia, and gender transfor-
postoperatively. Minimising operative time is mation. An alternative approach to elevate
critical in obtaining optimal results. pitch is to decrease vocal cord mass, thereby
Fabricating implants before the procedure and increasing the frequency of vibratory cycle.
rapid determination of size and position will Decreased vocal cord mass may be achieved
facilitate the procedure. by removing tissue with the CO2 laser or by
Complication associated with type I mechanically inactivating the vocal muscle.
thyroplasty include: Other techniques designed to decrease mass,
i. Penetration of the endolaryngeal including vocal cord stripping, laser
mucosa, wound injection. vaporisation, and steroid injection, are less
ii. Chondritis well controlled and may potentially result in
iii. Implant migration or extrusion, and deterioration of vocal quality.
Tumours of the Larynx 369
muscle incised superficially. The muscle and a tongue-shaped flap of the full thickness
pedicle is sutured in place using the previously of the posterior tracheal wall is raised basing
placed stay sutures. superiorly about 1.5 cm inferior to the upper
cut margin of the trachea. This is the future
Reconstruction and Rehabilitative neoepiglottis. The base is about 1.5 cm and
Procedures after Laryngectomy height of the flap is 1.5 cm. The inferior margin
Since most of the patients who have a total is rounded. An endotracheal tube is fenes-
laryngectomy are elderly their motivation to trated passed through the cricopharyngeal
attend speech therapy classes and practise ring into the oesophagus with the fenestra
oesophagus speech is very low, hence neo- looking forward. A transverse incision of
glottis operations are performed for them 1.5 cm is made on the fenestra through the
initially a fistula used to be made between anterior wall of the base of the neoepiglottis.
trachea and oesophagus. Later different tubes The tube protects the posterior oesophageal
were made in the form of tunnels from the wall from possible injury by the knife. Two
base of tongue to the trachea or between the anchoring silk stitches are applied to the
trachea and oesophagus. The aim was to allow anterior oesophageal wall, just lateral to the
air to go up but to prevent fluid coming down ends of the transverse incision. Another
other external devices like electric larynx were anchoring stitch is applied to the lower end
used to produce speech. of the neoepiglottis in order to facilitate its
In the process of neoglottis formation introduction into the oesophagus through the
Blom-Singer valve and Panje valve gave some transverse cut. A small cartilage bar (1 cm long
promising results. and 2-3 mm thick) is cut out from the uninvol-
ved thyroid ala and is placed transversely on
Operative Procedure the anterior oesophageal wall just below the
transverse cut. The oesophageal mucosa is
A preliminary low tracheostomy is performed everted and brought down over the bar and
since a good length of supratracheostomal stitched to the raw anterior oesophageal wall
trachea is required for constructing the with 4-0 vicryl, thus completely submerging
neoepiglottis from its posterior wall. A routine the bar. The semirigid lower margin of the
total or Kitamuras supracricoid laryngectomy transverse cut with its mucosa-lined cartilage
(1970) with or without radical neck dissection bar is meant to work as the vocal cord. A long
is carried out leaving a long trachea above the artery forceps is introduced through the
tracheostome. cricopharyngeal sphincter into the oeso-
The trachea is separated from the oeso- phagus and the tip is shown at the transverse
phagus by blunt and sharp dissections for cut. The anchoring thread of the neoepiglottis
about 4 cm taking care not to perforate is introduced through the transverse cut and
through the posterior membranous wall is caught by the artery forceps placed in the
of trachea. In that case neoepiglottis cannot be oesophagus while the assistant gently pulls
constructed. The trachea is retracted anteriorly the oesophageal anchoring silks superiorly,
Tumours of the Larynx 371
laterally and anteriorly to stabilise the the neck with an adhesive tape. After 3 weeks
anterior oesophageal wall in order to facili- the sheet is removed by pulling on the thread.
tate the introduction of the neoepiglottis into This is meant to prevent possible adhesions
the oesophageal lumen. The forceps in the and stenosis of the neoglottis. Two wedges are
oesophagus is pushed downwards thus taking removed from the lateral upper cut margin of
along with it the neoepiglottis through the the trachea is closed 2-0 vicryl stitches. So the
transverse cut into the oesophagus. While tracheal lumen ends in a cul-de-sac at its upper
doing this manoeuvre, the trachea is pushed end. The pharynx and the skin wounds are
backwards and held in apposition with the closed in the usual way after inserting a
anterior oesophagus and thus the tracheal nasogastric feeding tube and Redevac
fenestra, resulting from raising the neoepi- drainage. The patient is put on antibiotics and
glottis, is closed by the anterior oesophageal metronidazole for 2 weeks. Oral feeds are
wall. The adjacent tracheal and oesophageal started on the tenth day after test feed. The
walls are stitched to each other with 2-0 vicryl silastic sheet is removed after three weeks. A
in order to prevent relative movements fenestrated plastic or metal tracheostomy
between the trachea and oesophagus. The tube, preferably with a speaking valve, is
anchoring stitches and the forceps are inserted and the patient is asked to phonate
removed. A rectangular silastic sheet (5 cm by closing the tracheostomy tube with his finger
1.5 cm) is introduced through the neoglottis, (if it is an ordinary tube) and he does it
situated between the mucosal surface of the immediately. The phonetic steam, being
neoepiglottis and the mucosa lined inferior obstructed by the upper end of the cul-de-sac,
margin of the transverse cut, into the passes through the neoglottis into the oeso-
oesophagus from the tracheal aspect and left phagus and upwards through the pharynx
in situ for 3 weeks and anchored by a silk stitch and the oral cavity for articulation. He is
to its tracheal end and brought out through advised to talk, talk and talk which would
the tracheostome and secured to the skin of keep the neoglottis patent.
67 Block Dissection
of the Neck
Many carcinomas of the head and neck sooner Radical Neck Dissection
or later metastasise to the lymph nodes of the
It consists of removal of all lymph node groups
neck which form a barrier that prevents
(level I-V) and all three nonlymphatic struc-
further spread of the disease for many months.
tures (spinal accessory nerve, sternocleido-
The standard operation for dealing with meta-
mastoid muscle and internal jugular vein).
static glands in the neck is that of radical neck
dissection described by Crile in 1906. In this
Modified Radical Dissection
operation the different groups of deep cervical
lymph nodes, internal jugular vein, sterno- It consists of removal of all lymph node groups
cleidomastoid muscle, submandibular with preservation of one or more nonlym-
gland, tail of the parotid and the accessory phatic structures. In type 1, the spinal acces-
nerve are removed en bloc with the primary sory nerve is preserved. In type II, the spinal
tumour, if possible. Hence, the operation is accessory and the IJV are preserved and in
also called block dissection of the neck. The type III, all the three structures are preserved
block neck dissection is elective when no palp- and this is known as funtional neck dissection.
ably enlarged lymph nodes are present,
definitive or therapeutic when enlarged Selective Neck Dissection
lymph nodes are present, and functional when It consists of preservation of one or more
the sternocleidomastoid muscle and internal
lymph node groups and all three nonlympha-
jugular vein are preserved.
tic structures. The dissections are named
American Academic Committee for head
according to the lymph node group removed.
and neck surgery and oncology has adopted
the following classification for various neck
Extended Radical Neck Dissection
dissections.
1. Radical neck dissection It consists of removal of all the structures
2. Modified radical neck dissection resected in radical neck dissection and one or
3. Selective neck dissection more additional lymph node groups (levels VI
4. Extended radical neck dissection. orVII)or nonlymphatic structures. Neck
Block Dissection of the Neck 373
THYROID 4. Lymphadenoid
5. Inflammatory.
The thyroid gland mainly develops from the
6. Malignant disease
median bud of the pharynx (thyroglossal
a. Carcinoma
duct) which passes from the foramen caecum
b. Reticulosarcoma
at the base of the tongue to the isthmus of
c. Secondary neoplasms
the thyroid gland. A lateral bud from the
fourth pharyngeal pouch of each side amal-
gamates with it and completes the Nodular Goitre
corresponding lateral lobe. It can be sporadic or endemic.
Treatment
Partial thyroidectomy is the treatment of
choice.
Retrosternal Goitre
Complications
1. Pressure upon the trachea—dyspnoea,
tracheal shift
2. Secondary thyrotoxicosis—Iodine base-
down
3. Malignancy—in 8 per cent cases. Fig. 68.2:Huge multinodular goitre
Thyroid 377
nodule, but the rest of the gland may also High-risk tumours including the papillary and
contain microscopic nodules. This type of follicular carcinomas greater than 1cm in size
tumour spreads mostly by direct invasion and are also treated with local thyroidectomy, as
lymphatics. are the tumors associated with significant
multifocality, local or distant spread. Patients
Follicular carcinoma This is a typically encap-
under 16 years with a diagnosis of diffe-
sulated tumour with minimal invasive
rentiated thyroid cancer should be regarded
characteristics. This type of tumour spreads
as high-risk, and are usually best treated
mainly by blood to bones or viscera and less
aggressively. The intermediate group of
so by lymphatics.
thyroid malignancy of the differentiated type
Medullary carcinoma It is the tumour of para- may either be treated by lobectomy or by
follicular or ‘C’ cells, and is of neuroecto- total thyroidectomy and if recurrence occurs
dermal origin. It presents as a single hard following the conservative surgery further
nodule and may spread to any group of treatment (complete thyroidectomy) is likely
lymph nodes in the neck. to be curative. The intermediate group of
All the types of tumours may cause symp- patients consists of a low-risk patient (female
toms due to pressure on or direct involve- under 45 years) with high-risk tumour or a
ment of trachea, recurrent laryngeal nerve, high risk patient with low-risk tumour
oesophagus and neck veins. (including papillary carcinoma of less than 1
cm in size). Low-risk patient with a low-risk
Treatment tumour is treated with lobectomy. Tumours
Thyroid neoplasms are treated by surgery of the isthmus can be treated by an isthmusec-
(thyroidectomy) supplemented by radio- tomy and a 1cm margin.
iodine (I 131 ) and external radiotherapy
depending upon the stage of disease. The Follicular Adenocarcinoma
patient is put on thyroid hormone replace- The management of follicular adenocarci-
ment therapy after surgery. noma is very similar to that of papillary
tumours. The main stay of treatment is
TREATMENT POLICY surgery. The neck and mediastinum are
managed as for papillary carcinoma.
Papillary Adenocarcinoma
Subsequently ablation of any thyroid
A patient with papillary adenocarcinoma with remnants is performed, followed in 3 months
a large mass in one lobe of the thyroid asso- by screening for residual disease in the neck
ciated with metastatic lymph nodes in the neck or distant metastasis. Hurthle cell cancers
requires a total thyroidectomy and neck should be managed as follicular cancers.
dissection. Treatment strategy for differen-
tiated (papillary and follicular) thyroid cancer Medullary Carcinoma
in high-risk patients including all males and The principal treatment advised for the
females over 45 years is total thyroidectomy. patient with medullary carcinoma is total
Thyroid 379
thyroidectomy and removal of any enlarged with thyroid lymphoma. Thyroidectomy is,
lymph node masses. There is no role for therefore, sometimes indicated (but not
elective neck surgery. Palpable disease usually feasible), so that radiotherapy
requires modified radical or radical neck remains the principal treatment for this
dissection. The operation is extended into condition. Patients with high grade histology
superior mediastinum if necessary. As these and more advanced disease should, in
tumours arise from parafollicular cells, it is addition, receive appropriate chemotherapy,
not surprising that they do not concentrate if permitted by their general condition.
radio-iodine. Postoperative radio therapy is
indicated if there is any suggestion of Anaplastic Tumours
macroscopic residual disease in the neck and/
or multiple large nodal metastasis with A biopsy is mandatory to confirm that a
extracapsular extension. patient suspected to have an anaplastic
carcinoma does not have lymphoma which
Thyroid Lymphoma may be curable. Sometimes isthmus may need
Although no surgery other than biopsy is to be divided and tracheostomy performed
usually considered to be necessary for if there is airway obstruction. Regression may
lymphoma at other sites, surgical removal of be achieved by radical radiotherapy, but
bulky disease has been shown to improve early recurrence is the rule, leading almost
both local control and survival in patients inevitably to death within 6-12 months.
69 Bronchoscopy
The endoscopic examination of the bronchi subglottis, trachea and bronchi. Forceps of
is necessary for various diagnostic and various shapes are available for endobron-
therapeutic purposes. chial manipulation. The instruments used for
bronchoscopy and oesophagoscopy are
Indications shown in Figure 69.1.
Bronchoscopic procedure may be needed for Contraindications for Bronchoscopy
the following: 1. Diseases of the cervical spine, where it
1. Examination of the bronchial tree in may be impossible to pass a rigid metallic
patients, who present with abnormalities tube.
like unexplained lung shadows on X-ray, 2. Vascular tumours like aneurysms of aorta.
haemoptysis, collapse of the lung, slowly 3. Fulminating suppurative pneumonitis or
resolving pneumonia. morbid condition of the patient.
2. For biopsy of an endobronchial growth.
3. For removing foreign bodies from the Procedure
bronchus. Bronchoscopy can be done under local or
4. For bronchial aspiration in cases of lung general anaesthesia. The patient lies in supine
abscess and aspiration pneumonia.
The examination is carried by a rigid
metallic tube which has arrangements for
lighting and aspiration. The bronchoscope has
side holes to allow respiration to take place
through the bronchi which are not occupied
by the bronchoscope.
The bronchoscopes are of various sizes
designed to fit the bronchi at various ages as
the bronchi do not allow over distension.
Bronchoscopic telescopes are available and Fig. 69.1:Instruments used for bronchoscopy
allow a more detailed magnified view of the and oesophagoscopy
Bronchoscopy 381
SURGICAL ANATOMY
Oesophagus is a fibromuscular tube about
25 cm long extending from the cricopharyn-
geal sphincter to the cardia of the stomach.
In an adult 4 cm of this tube lies below the
diaphragm. The musculature of the upper
one-third is striated and that of the lower
two-third is smooth. It is lined by squamous
epithelium and the portion below the level
of the diaphragm is lined by gastric type of
mucosa (without oxyntic or peptic cells).
At birth the greatest diameter of the
empty oesophagus is 5 mm, at one year of
life it is 9 mm, at five years of life it is 15 mm,
and it is 20 mm in adult. After distention it
Fig. 70.1: Showing various constrictions of
increases about 30 mm. oesophagus
There are three physiological constrictions
in the oesophagus at the level of 15, 25, 40 Nerve Supply
cm from the upper incisor tooth (Fig. 70.1). The parasympathetic nerve supply is medi-
They are the sites of anatomical narrowing ated by the vagus through the extrinsic and
where difficulties may be experienced in the intrinsic nerve plexuses. The intrinsic plexus
passage of instruments and where foreign has no Meissner’s network which is present
bodies may be arrested. They are also the elsewhere throughout the alimentary canal,
sites of predilection for benign strictures and and Auerbach’s plexus is present in the lower
for carcinoma of the oesophagus. two-thirds only. Sympathetic supply is by
384 Textbook of Ear, Nose and Throat Diseases
nerves surrounding the vessels which supply A radiolucent foreign body in the oeso-
the oesophagus. phageal lumen may be demonstrated on
screening by giving the patient a piece of
INVESTIGATIONS FOR AN cotton impregnated barium to swallow,
OESOPHAGEAL DISEASE which gets arrested at the site of the foreign
The following investigations are undertaken body.
in an oesophageal disorder: Cine-radiography Image intensification with
i. Radiography cine-radiography is an improvement over the
ii. Endoscopy barium swallow examination. It is particu-
iii. Oesophageal pressure study. larly helpful in abnormal patterns of degluti-
tion such as cricopharyngeal spasm.
Radiological Investigation
1. X-rays of the chest and neck (AP and lateral Barium Meal X-ray of the Oesophagus
view) are helpful to diagnose conditions
X-ray films taken during barium screening
like foreign bodies in the oesophagus and
are helpful in determination of the site of
oesophageal rupture with complications.
holdup and to note the extent of the obstruct-
2. Barium screening: It is a common investi-
ing lesions like tumour or stricture. Spillage of
gation required for an oesophageal
barium into the lungs suggests a tracheo-
disease.
oesophageal fistula.
During screening, the passage of a mouth-
The mucosal irregularity and diverticulum
ful of barium from mouth to the stomach is
are demonstrated. Extraluminal pressure on
followed and the following points are noted.
the oesophagus by an enlarged atrium, aorta
a. Physiological constrictions.
or a mediastinal tumour may be evident as
b. Pathological dilatations, constrictions,
an area of compression and displacement.
webs, filling defects or holdups and the
exact site of the constriction, stricture or
holdup. Oesophageal Pressure Study
c. The type and amplitude of peristaltic Manometric pressure studies of the oeso-
waves and competence of the oesophago- phagus have been done and found useful in
gastric sphincter. neuromuscular disorders affecting peristal-
d. Any diversion of normal flow. sis.
71 Common Oesophageal
Diseases in ENT Practice
Indications for surgery Surgical exposure is the oesophagus. Repair follows by the
needed in the following: formation of granulation tissue. It is important
i. Progressive surgical emphysema. to note that the granulation tissue does not
ii. Evidence of pleural effusion. function like damaged muscle tissue. Instead,
iii. Worsening of the patient’s general healing occurs by dense scar tissue which
condition. forms the stricture. Strictures due to corrosive
iv. Formation of a mediastinal abscess. burns are usually single although these may
be multiple. “Skip areas”, virtually free of
Corrosive Injury of the Oesophagus involvement, are noted in multiple strictures.
Corrosive poisoning may be accidental or These are explained on the basis of spasm and
suicidal and is caused by swallowing acids or peristalsis.
alkalies. It results in severe burns with Clinical Features
consequent local oedema and disturbances of
acid-base balance. There is a history of swallowing of a corrosive
It is, however, the late changes that are of liquid. There occurs intense pain and difficulty
importance surgically. The degree and extent in swallowing. The acute symptoms subside
of these changes are proportionate to the within 2 to 3 weeks followed by apparent
amount and concentration of the corrosive improvement. However, within a few weeks
fluid swallowed. In addition, the presence or the patient presents with dysphagia and
absence of vomiting or regurgitation of the regurgitation. Barium meal X-ray reveals the
ingested material is of considerable character of the stricture, its severity, location,
significance, thereby causing second exposure extent and whether it is single or multiple.
chemical trauma. Typically a corrosive stricture is single,
involving a large segment of the oesophagus.
Pathology of Stricture Formation
Treatment of Corrosive Burns of Oesophagus
Initially cellular death takes place. This area Immediate attention is given to the general
is surrounded by an intense zone of condition like maintenance of fluid and
inflammation. Necrotic tissue sloughs out electrolyte balance and preservation of ade-
during the first week, leaving behind an ulce- quate airway. Systemic antibiotics are given
rated surface. The level of tissue necrosis to control the infection.
depends upon the nature of the corrosive
ingested. Alkalis cause liquefication necrosis Prevention of Stricture Formation
and therefore a deeper level of tissue injury
and are thus associated more with perfo- As soon as the patient’s general condition
rations of the oesophagus. Acids on the other allows, a Ryle’s tube is passed down the gullet.
hand cause coagulative necrosis and as such It not only maintains the lumen during the
although the burns are severe tend to be healing stage but also helps in feeding the
confined to the superficial muscular coats of patient.
Common Oesophageal Diseases in ENT Practice 387
Aetiology
Children are usually in the habit of swallow-
ing anything they can get hold of. Similarly,
foreign body lodgement is common in the
elderly because of improper mastication and
week propulsive movements of the gullet.
Loose fitting artificial dentures may be
swallowed during mastication or sleep.
Certain oesophageal conditions like benign
strictures or malignancy and sites of anato-
mical narrowing of the oesophagus may arrest
Fig. 71.1: X-ray of the soft tissues of the neck showing
a foreign body. a radiopaque foreign body (needle) in the upper
oesophagus
Clinical Features
The patient, if an adult, usually gives a history
of having swallowed a foreign body. If the
foreign body is arrested in the upper part of
the oesophagus, the patient is very often able
to localise the pain and site of the lodgement
of the foreign body. If the foreign body is lower
down, localisation is vague. Dysphagia is
another important symptom of foreign body
in the oesophagus and should raise the
suspicion, particularly in children.
A detailed examination of the pharyngeal
wall, tonsils, valecullae and pyriform fossae
should be carried out.
Plain films of the neck and chest are taken.
Ideally both the anterioposterior and lateral
views are taken to know the exact location and
disposition of the foreign body (Figs 71.1 to
71.3).
Foreign bodies in the oesophagus, parti-
cularly flat objects like coins lie in the coronal
plane in contrast to laryngeal or tracheal Fig. 71.2: Shadow of a foreign body
foreign bodies which lie in the sagittal plane. (meat bolus) at the cricopharynx
390 Textbook of Ear, Nose and Throat Diseases
3. Perioesophagitis
4. Perforation
5. Paraoesophageal abscess.
Treatment
Foreign bodies in the oesophagus should
always be removed. It is not good to wait and
allow the foreign body to pass down as it may
get arrested leading to fatal complications.
Though foreign body removal is an
emergency, the surgeon must have a know-
ledge of the location and disposition of the
foreign body so that he selects the proper
endoscopic instruments and orients himself to
the situation.
Fig. 71.3: X-ray of the chest showing
Oesophagoscopy for removal of the
50 paisa coin in the oesophagus
foreign body can be done under local and
If the foreign body is not visualised, screen- general anaesthesia. If the size of the foreign
ing of the chest and abdomen is done to note body is bigger than the diameter of the
whether it has passed down. oesophagoscope, then after having caught the
In case of nonopaque foreign bodies, a little foreign body, all three articles, the foreign
barium sulphate is given and its passage down body, forceps and oesophagoscope are
the oesophagus is observed. Barium may be removed as a single unit.
held up or the flow of barium may be split at With all long foreign bodies, the aim is to
the site of the foreign body. Sometimes a little search the proximal end. In case of pins and
cotton soaked in barium paste or a gelatin needles, their point must be searched for.
capsule filled with barium is swallowed and The mortality which may follow the failure
its arrest in the oesophagus on the foreign to remove a foreign body does not justify the
body noted. However, if the clinician is still violent method of its removal and no harm
in doubt, oesophagoscopy should be done to should be done, if one cannot remove the
be sure regarding the presence or absence of foreign body.
the foreign body. Dentures in the oesophagus present many
problems. They often have sharp edges and
Complications
associated metallic hooks which cause their
Complications of foreign body in oesophagus impaction. Hence, such cases should be
include the following: properly studied before attempting hapha-
1. Impaction of foreign body zard removal. They may require division by a
2. Oesophagitis sheer before they can be removed.
Common Oesophageal Diseases in ENT Practice 391
Fig. 71.4: Barium X-ray of the oesophagus showing Fig. 71.5: Barium X-ray of the oesophagus
irregular narrowing with dilatation above (malignancy) (rat-tail deformity due to malignancy)
Oesophagoscopy allows proper visualisation of given to relieve them. If the growth lies below
the obstructing lesion. the level of the thoracic inlet, endoluminal
Proliferative or ulcerative lesions and areas plastic tubes may be inserted through the
of mucosal irregularity are looked for an growth area to maintain patency. Soutter’s or
endoscopy. The extent or spread, its site and Mousseu-Barbin tubes may be used for
distance from the upper incisor teeth is providing nutrition. Feeding gastrostomy
noted. Mobility of the oesophagus seen on may be only choice in very advanced lesions.
inspiration, may be absent. Biopsy from the
suspected lesion is confirmatory. Surgery Oesophagogastrectomy for growths
involving the lower end of the oesophagus
Treatment offers better chances of survival provided the
The prognosis of oesophageal cancer at pre- patient presents early.
sent is poor. Majority of the cases are Involvement of the bronchial tree and
inoperable. The symptoms present late, and, recurrent laryngeal nerve indicate an
many times only palliative radiotherapy is inoperable growth.
72 Oesophagoscopy
Endoscopic inspection of the oesophagus is Boyce’s position with the neck flexed and the
known as oesophagoscopy. The procedure head extended at the atlanto-occipital joint. A
may be needed for diagnostic or therapeutic piece of gauze protects the teeth on the upper
purposes. jaw and retracts the upper lip.
The oesophagoscope is held by the right
Indication hand and guided forwards gently by the left
1. Diagnostic indications thumb so that it is passed through the oral
a. Foreign body in the oesophagus cavity on the right side of the tongue, pharynx
b. Stricture of the oesophagus and along the right pyriform fossa till the
c. Growth in the oesophagus cricopharynx is visualised. After a little pause,
d. Oesophageal varices the cricopharyngeal sphincter relaxes and the
e. Tracheo-oesophageal fistula. oesophagoscope is passed down again with
2. Therapeutic indications very gently movement taking care of the
a. Removal of foreign bodies anatomical curves of the oesophagus, and
b. Bouginage to dilate stricture or spasm visualising the lumen for any abnormality like
c. Sclerotherapy of oesophageal varices narrowing, bulging, varices, stricture or
d. Endoscopic excision of pharyngeal growth. The direction of the tip of the
pouch. oesophagoscope should be towards the left
anterior superior iliac spine because in the
Contraindications to Oesophagoscopy
lower-third, the oesophagus is directed
a. Aneurysm of aorta forwards and curves towards the left to join
b. Severe spinal deformities or cervical the cardiac end of the stomach.
spondylosis
c. Mediastinal growth Complications of Oesophagoscopy
d. Trismus. Oesophageal perforation usually results if the
oesophagoscope is passed forcibly or an
Technique attempt to remove the foreign body is made
The procedure can be done under local or without exactly knowing its position and
general anaesthesia. The patient is kept in nature.
394 Textbook of Ear, Nose and Throat Diseases
1. For children 10 × 8 mm 35 mm 35 mm
Chevalier Jackson 7 mm 35 mm 35 mm
2. For middle of 15.6 mm 55 mm 35 cm
oesophagus 13.6 mm
3. Adult size full lumen 17.6 × 15.6 mm 60 mm 45 mm
it has minimal tendency to scatter in soft Safety Precaution in the Use of Laser
tissue. a. Education of staff : The surgeon, anaes-
In the ENT region laser has been success- thesiologist, nursing and operation theatre
fully used for: personnel should be educated in laser
i. Nose, e.g. papillomas, rhinophyma, safety.
telangiectasis, nasal polypi, choanal b. Protection of eyes: Protective eye glasses
atresia, turbinectomy. It is very beneficial specific for the wave length of laser being
in patients with bleeding dyscrasias and used should be worn by the personnel to
coagulopathies. prevent accidental burns to the cornea or
ii. Oral cavity, e.g., multiple areas of leuko- retina.
plakia, erythroplakia, small superficial Patient’s eyes should also be protected
cancers, debulking of large recurrent or by a double layer of saline-moistened
inoperable tumours. Advantages are eyepads.
transoral approach, precision surgery, c. Protection of other exposed areas: All exposed
haemostasis and less postoperative skin and mucous membranes of the patient
oedema and pain. not in surgical field should be protected
iii. Oropharynx, e.g. tonsillar and pharyn- by saline soaked towels, pads or sponges
which are kept wet by moistening them
geal tumours. Laser tonsillectomy is
periodically. Teeth should also be
done in cases of coagulopathies or hyper-
protected.
tension.
d. Evacuation of smoke: Two separate suctions,
iv. Larynx, e.g. papilloma larynx, laryngeal
one for the blood and the other for smoke
web, subglottic stenosis, capillary
and steam which is produced by
haemangioma. In adults it has been used
vaporisation of tissues, should be used.
for vocal nodule, leukoplakia of cord,
e. Anaesthetic gases and equipment: Only non-
papilloma, polypoid degeneration of inflammable gases like halothane or
cord, endoscopic laser arytenoidectomy, enflurane should be used. When using CO2
malignant T1 lesions of the vocal cord. laser, red rubber or silicone tube should be
v. Trachea and bronchi, e.g. recurrent wrapped by reflective metallic foil. Cuff
papillomatosis, tracheal stenosis, should be inflated with methylene/blue
granulation tissues and bronchial coloured saline and protected with saline
adenoma, debulking of obstructive soaked cottonades.
malignant lesions of trachea and bronchi. The safest tube to use with Nd-YAG laser
vi. Plastic surgery e.g. benign and malignant is colourless or white polyvinyl or silicone
tumours of skin, vaporisation of naevi endotracheal tube that does not have any
and tattoos. black or dark lettering or a lead lines marking
vii. Neuro-otology, e.g. removal of acoustic along the side. Negligence in these precautions
neuromas, stapedectomy . can cause endotracheal tube fires.
74 Principles of Radiotherapy
(iii) epithelial cells, (iv) endothelial cells of iii. Linear accelerator, betatron or microtron.
blood vessels, pleura and peritoneum, These megavoltage machines work on
(v) connective tissue cells, (vi) muscle cells, electricity and produce radiation of
(vii) bone cells, and (viii) nerve cells. There is 4.25 mV.
no difference in the absorption of radiation in iv. Radioactive material like cesium 137, in
the bone and soft tissues. The maximum the form of pellets, iridium 192 in the
ionisation in a cobalt beam takes about 4-5 mm form of wire, gold 198 and iodine 125 in
below the skin, thus reducing skin reaction the form of grains or seeds.
and simplifying the technique.
OPTIMUM DOSE OF RADIOTHERAPY
Modes of Radiotherapy The optimum dose of radiation for radio-
therapy depends upon the following:
1. External beam therapy or teletherapy: In this
1. Size of the tumour
therapy photon (X-rays and gamma rays),
2. Relative depth in the body
or electron (from linear accelerator, 3. The anatomical site
betatron and microtron) are used and 4. Its relative radiosensitivity
projected to the target area through the 5. The period of its evolution
skin. 6. Composition of the tissues of the tumour
2. Brachytherapy: Here radioactive materials bed.
are used and placed in close contact with In medical therapeutics the dose of drug is
tumour mass. These may be applied in the based upon either the age or the weight of the
form of: patient, while in radiotherapy the concen-
a. A mould tration in a particular organ or part of the body
b. Interstitial implant in the form of radio- is considered as the result of radiation depends
active needles, wires, seeds, or fibrous upon the dose absorbed by the tissues treated.
inserted into the tumour mass. So radiological units have adopted the “rad”,
c. Intracavitary implants—the radioactive a unit of radiation absorbed dose. Previously “Y”
material is kept in a hollow cavity near (roentgen) was the unit of measurements after
the tumour mass e.g. maxillary antrum Professor Roentgen, it is still being used as a
or nasopharynx. measure of radiation energy absorbed in a
given mass of air at a specified point under
Sources of Radiation can be specified condition. Dose in ‘Y’ can be
i. Kilovoltage machines—producing converted into rads. Lately, gray (Gy) has been
X-rays of 50-400 kV and were previously used as an international unit of radiation,
used through superficial or orthovoltage one Gy equals 100 rads.
X-ray machines.
ii. Cobalt 60—Mostly used in head and DOSAGE DISTRIBUTION IN TISSUES
neck tumours. It produces 1.2 mV OF VARYING COMPOSITION
energy, but needs replacements after five Absorption of radiation by matter depends
years because of natural decay time. upon its atomic weight, so absorption atomic
Principles of Radiotherapy 399
weight of 40 should be different from that Half-life Radium has a half-life of about 1600
which is absorbed by soft tissues, e.g. fat, years. Half-life of P32 is 14 days, J 131 is 8
muscles, etc. which are composed of days and Au 198 is 207 days.
hydrogen, oxygen, carbon, nitrogen with
Units The unit of radioactivity is a curie,
atomic weight of 1-16 only. So the distribution
smaller unit millicurie (mc).
of dose will vary with the nature of tissues in
the path of radiation. The magnitude of this
USES OF RADIOTHERAPY
variation depends on the quality of radiation
used. This discrepancy is overcome by using 1. Supportive therapy: Radiotherapy can be
radiations produced at high KVS equivalent supportive to surgery preoperatively or
to 3004 MCV. Now telecobalt 60 beta unit or postoperatively, e.g. in cancer stomach,
a linear accelerator is used. colon, rectum, bronchogenic carcinoma,
Radioactivity If the nucleus of an atom is osteogenic sarcoma, fibrosarcoma, liposar-
unstable, it ultimately breaks down or disinte- coma, myosarcoma, carcinoma larynx,
grates, ejecting part of the nuclear contents. laryngopharynx, paranasal sinus, etc.
Three types of radiation are involved: It is used to make surgical procedures
1. Alpha (α)—2 protons and 2 neutrons. It is easier and safer by reducing the chances
absorbed by a sheet of paper. of dissemination or reducing the size of the
2. Beta (β)—an electron. It penetrates a few tumour and its vascularity.
millimeters of body tissue. 2. Curative therapy: This is possible in early
3. Gamma (γ)—an electromagnetic vibration. cancers of the skin, cheek, lip, anterior two-
It is identical with an X-ray and may pene- thirds of tongue, arms, bladder, intrinsic
trate well beyond the thickness of the body. cancer of larynx, maxillary antrum, penis
Natural radioactivity Radium disintegrates and cervix uteri. About 80 per cent of
naturally, emitting all three types of radiation. patients can be cured.
The beta rays are adequately screened off by Curative heavy doses of radiation of
0.5 mm of platinum for radium needles. about 6000 (γ) in 4-6 weeks are given as
Radon is a radioactive gas produced from external radiation for a period of 120-186
the radioactive decay of the element radium, hours when radium needles are used.
which is itself a decay product of either 3. Palliative therapy: Where the growth has
uranium or thorium. This can be inserted into already extended much or nature of the
capillary tubing, cut into short lengths, called disease is bad, palliative therapy can be
‘seeds’. given as in cancers of the posterior
Artificial radioactivity Any substance can be one-third of tongue, pharynx, vagina,
made radioactive by irradiating it. Bombard- embryonal tumours and in Hodgkin’s
ment suffered by atoms of the material irradi- disease. X-rays of 200-400 kV are used,
ated may alter some of their nuclei, rendering generally 3000, and are effective in
them unstable and hence radioactive. 3 weeks.
400 Textbook of Ear, Nose and Throat Diseases
Cancer of the larynx: If limited to one infections, blood dyscrasias and rarely
cord, it can be successfully treated by the acute transverse myelitis.
following: ii. Late complications can be—xerostomia,
i. Beam directed X-ray therapy is atrophy of skin, subcutaneous fibrosis,
highly satisfactory. teeth decaying, trismus due to tempo-
ii. Small multiple fields. romandibular joint fibrosis, bone
iii. With radium by Finzi Hammer ope- necrosis, retinopathy, cataract, thyroid or
ration. pituitary deficit and radiation induced
Doses of 6000 (γ) are given in 5-6 weeks. malignancy.
4. Symptomatic therapy: Radiotherapy is
Patient Care during Radiotherapy
useful but of limited value in the following
cases: (i) hypernephroma, (ii) carcinoma of As patient shows certain reactions during and
ovary, (iii) extrinsic carcinoma of larynx, after radiotherapy special care is to be taken
(iv) carcinoma bladder, (v) carcinoma oeso- for:
phagus, and (vi) bronchogenic carcinoma, i. Nutrition—if patient can swallow nicely,
and (vii) isolated bone metastasis. his diet should be supplemented by more
5. Radiotherapy is useful in the following benign proteins, vitamins, iron and minerals. If
conditions. facing difficulty in swallowing, naso-
1. Inflammatory conditions gastric tube feeding should be done. If
2. Ankylosing spondylitis blood counts fall, substitute blood or
3. Certain benign pathological states of platelet transfusion should be given.
the uterus and ovaries. ii. Oral hygiene—dental check up is must
and due care to be given for proper oral
Complications of Radiotherapy cleaning and care for candidiasis, thrush
or ulcers e.g. stomatitis and glossitis
Complications of radiotherapy depend on: treated by local application of nystatin
a. Site of radiation or clotrimazole. No spices, smoking,
b. Total dose delivered. High total dose alcohol or irritants to be taken.
causes complications iii. Skin reaction is often seen during
c. Daily fraction of radiation—Large daily radiotherapy though with megavoltage
fractions cause more complications. therapy reaction is very less. However
Complications may be: patient should take following precau-
i. Early or tions for irradiate skin e.g., skin to be
ii. Late kept dry, no soap or water washing to
i. Early complications can be—radiation be done, avoiding exposure to sunlight
sickness like loss or appetite, nausea and or heat and wet shaving, or plaster
occasional vomiting, dryness of mucous dressing or irritants. Topical application
membrane, skin reactions like erythema, of antibiotic or antiallergic ointments
dry or wet desquamation, oedema of may be used and the area covered with
mucosa e.g., laryngeal oedema, fungal soft silk.
75 Syndromes in
Otorhinolaryngology
Therapy Therapy
Costen’s Syndrome
Chorda tympani Syndrome
Symptoms
Symptoms
• Pain in the temporomandibular joint with
• Sweating in the submental region. referred otalgia.
• Tinnitus and feeling of muffling in the ears.
Aetiology
• It is due to misdirection of fibres of chorda Signs
tympani nerve after regeneration. • Malocclusion of temporomandibular joint.
Syndromes of Otorhinolaryngology 405
Aetiology Symptoms
• It is caused by the thalidomide, if used by • Flushing and sweating of face during
pregnant ladies during first trimester. swallowing.
Syndromes of Otorhinolaryngology 407
Signs Therapy
• Gustatory flushing and sweating of face in • Plastic surgery of ear and face.
the area of auriculotemporal nerve.
Gradenigo’s Syndrome
Aetiology
Symptoms
• It is caused due to disturbance between
sympathetic and parasympathetic fibres • Otorrhoea
after parotidectomy or injury to parotid • Diplopia
gland. • Retro-orbital pain or facial pain.
Therapy Signs
Signs Diagnosis
• Blindness • X-ray chest (PA view).
• Ophthalmoplegia • X-ray PNS (Water’s view).
• Pain in the distribution of 5th cranial nerve.
Klinkert’s Syndrome
Aetiology
• It is paralysis of recurrent laryngeal nerve
• It is caused by extension of nasopharyn- and phrenic nerve.
geal carcinomas intracranialy. • Sympathetic paralysis may also be asso-
Therapy ciated.
• Radiotherapy. Aetiology
Signs Aetiology
• Sinusitis. • Hereditary disorder.
• Dextrocardia
• Cong. bronchiectasis Laurence-Moon-Biedl Syndrome
• Situs inversus
• Cystic fibrosis of pancreas. Symptoms
• Visual disturbances.
Aetiology • Gait disturbances.
• Developmental abnormality. • Voice disorders (remains high pitch).
410 Textbook of Ear, Nose and Throat Diseases
Signs Signs
• Always familial but never hereditary. • High arched palate
• Pigmentary degeneration of retina. • Perceptive deafness
• Mental retardation. • Convergent squint
• Hypogenitalism. • Long tappering fingers
• Polydactyly. • Some toes are bigger, some are small.
• Obesity.
• Cerebellar ataxia and pituitary Melkersson’s Syndrome
dysfunction.
Symptoms
Treatment • Bilateral facial weakness (may be familial).
• Male hormones. • Swelling of the upper lip.
Aetiology Treatment
• Spasm of internal auditory artery. • Same as for Bell’s palsy (steroids and
electric stimulation of facial nerve on
Therapy paralysed side).
• Antihistamines, e.g. phenargan.
• Vasodilators, e.g. nicotinic acid. Ménière’s Syndrome
Symptoms
Marfan’s Syndrome
• Paroxysmal attacks of vertigo.
Symptoms • Deafness and tinnitus.
• Deafness • Heaviness in head.
• Diplopia. • Nausea and vomiting.
Syndromes of Otorhinolaryngology 411
Symptoms Treatment
• Swelling of salivary glands and lacrimal • Hearing aid.
glands.
Morgagni’s Syndrome
• Dryness of mouth.
• Frontal intimal hyperostosis.
Signs
Ortner’s Syndrome
• Symmetrical enlargement of salivary
(Cardio-vocal syndrome)
glands.
• Narrowing of palpebral fissure. Symptoms
• Parchment like dryness of mouth. • Hoarseness of voice.
• Usually associated with sarcoidosis. • Aphonia.
412 Textbook of Ear, Nose and Throat Diseases
Signs Thorax
• Paralysis of left recurrent laryngeal nerve, • Congenital heart disease like PDA and
aphonia is present when patient turns his VSD.
head to left. This is due to lack of compen-
satory movement of right vocal cord in this Abdomen and Pelvis
position, signs of mitral valve disease. • Polycystic kidney, bicornuate uterus,
cryptorchidism.
Aetiology
• Paralysis of left recurrent laryngeal nerve Hand and Feet
secondary to mitral valve disease. • Polydactyly, hyperconvex finger nails,
Therapy simian crease.
Aetiology Treatment
• Abnormal development of first and second • No specific treatment
branchial arches. • Eye baths and shades
• TAB vaccine.
Ramsay-Hunt Syndrome
(Hunt’s Syndrome) Schmidt’s Syndrome
Symptoms
Symptoms
• Pain in the ear
• Loss of taste on anterior 2/3rd of tongue • Hoarseness of voice
• Facial weakness • Nasal twang with regurgitation.
• Deafness
• Vertigo. Signs
Aetiology Symptoms
Therapy Signs
• Deafness. • Deafness
• Neurological signs due to medullary
Signs infarction.
• Hypertelorism (Broad nasal root).
• Congenital perceptive deafness. Aetiology
• Heterochromia iridia. • Thrombosis of posterior inferior cerebel-
• Frontal bosses. lar artery.
• White fore lock.
• Hypertrichosis of medial portion of eye- Treatment
brows.
• Anticoagulants.
Aetiology
Wernicke’s Syndrome
• Hereditary familial disorder (dominent).
Symptoms
Wallenberg’s Syndrome
(Autosomal Dominant) • Vertigo
Symptoms • Pain on moving the eyeball.
• Dysphagia Signs
• Vertigo
• Nystagmus.
• Diplopia
• Ophthalmoplegia.
• Imbalance
• Ataxia.
• Nystagmus
• Muscular paralysis. Aetiology
Aetiology • Acute thiamine deficiency.
• It occurs due to occlusion of posterior
inferior cerebellar artery or its branch Therapy
supplying lower part of brain-stem. • Thiamine in large doses.
420 Textbook of Ear, Nose and Throat Diseases
Fig. 76.13: Mastoid gouge Fig. 76.18: St. Clair-Thompson’s nasal speculum
Common ENT Instruments 423
Fig. 76.44: Chevalier-Jackson oesophagoscope Fig. 76.49: Boyle- Fig. 76.50: Tongue
Davis mouth gag plate with throat suction
Fig. 76.56: Adenoid curette with cage Fig. 76.60: Blunt tracheal hook