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Ent LQ1
Ent LQ1
ANATOMIC SUBDIVISIONS:
1. Squamous
o It forms the lateral wall of the skull and is the biggest part
2. Mastoid
o Located posteriorly and contains air cells
3. Tympanic
o Forms the bony ear canal
4. Styloid
o The elongated portion (based on the image above)
5. Petrous
o Not shown in the image above
o It contains many vital structures and is best seen in the
medial side
Lecture Discussion:
The most protuberant portion of the ear is the Pinna. It is comprised of
cartilage and skin EXCEPT for the lobule which is composed of skin and fat.
The structure of the pinna is intricate comprising of several elevations and
depressions.
Helix – outermost rim of the auricle
Lecture Discussion:
Conchae – deepest depression of the ear
A well pneumatized or well aerated mastoid will have numerous air cells as
represented here as the honeycomb-like appearance. Black representing air,
while the White septations as bone.
A diploic bone is partially pneumatized
A sclerotic bone is dense and has no air cells
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Lecturer: Dr. Cruz, Melanie Grace
External Ear – Ear Canal Innervation of the External Ear and Tympanic
EAC length: 2.5 cm Membrane:
Lateral or Outer 1/3 is VII – Sensory cutaneous branches
Cartilaginous V – Auriculotemporal nerve
o Has cerumen X – Arnold’s Nerve
glands and hair C3 – GAN
follicles C2, C3 – Lesser occipital nerve
Medial 2/3 is Bony
o No cerumen glands or hair follicles Lecture Discussion:
Isthmus – Junction It just shows that the External Ear and the Tympanic
Membrane have similar nerve innervation
o This is an anatomical constriction
Annulus Fibrosus
Fibrocartilaginous ring supporting
the Tympanic Membrane
Lies in the tympanic sulcus (groove
in the tympanic bone)
Deficient superiorly at the NOTCH
OF RIVINUS
Annulus Fibrosus
Pars Flaccida
Retracts readily if there is any absorption of air when Eustachian tube
is blocked and it bulges if there is fluid or inflammatory swelling Additional Information: Middle Ear Boundaries
Superior - TEGMEN TYMPANI (epitympanum)
within the middle ear cavity
Inferior - JUGULAR BULB (hypotympanum)
When the ear drum retracts, the short process of the malleus
Medial - PROMONTORY, OVAL WINDOW, ROUND WINDOW,
becomes prominent LATERAL SEMICIRCULAR CANAL
When it bulges, the landmarks are obliterated The footpiece of the stapes seals off the oval window.
Lateral - EAR DRUM, Scutum
Retracted Pars Flaccida Bulged Pars Flaccida Anterior - TENSOR TYMPANI, internal carotid artery, EUSTACHIAN
TUBE
Posterior – FACIAL CANAL and aditus ad antrum
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Tectorial Membrane
The membranous labyrinth contains endolymph Gelatinous structure which lies on top of OHC and IHC
AUDITORY SYSTEM
The pinna collects
sound waves.
The sound waves are
transferred to the ear
canal and into the ear
drum.
The ear drum vibration
will cause ossicular
Different Parts of the Cochlea: vibration or coupling.
SCALA VESTIBULI – above the The ossicular vibration will have what is called impedance matching.
Cochlear Duct (Perilymph) Impedance matching – efficient sound transmission
SCALA TYMPANI – below the o Without this, sound will just bounce off the oval window
Cochlear duct (Perilymph)
Vibration of ossicles ( malleus - incus - stapes)
SCALA MEDIA – endolymph
Footplate of stapes strikes the oval window
Perilymphatic displacement leads to basilar membrane displacement
Modiolus
which will cause endolyphatic compartment displacement
o Central Conical Axis
allows passage of
the auditory nerve fibers Area Ratio Lever Ratio
TM: footplate Malleus to Incus
Helicotrema
17-20:1 1.31:1
o Apex of the modiolus
Stria vascularis
Hair Cell Activity
o Blood supply of the cochlea
Stereocilia moves towards kinocilium.
There will be depolarization (180 spikes/sec).
Organ of Corti
There will be opening of gated channels.
Principal sensory
There will be influx of potassium from the endolymph.
structure in cochlea
The membrane potential will be positive once there is potassium
epithelial structure on
influx.
top of the basilar
membrane The calcium channels will be activated.
Calcium channel activation will cause calcium influx.
Hair Cells Glutamate will be released into the nerve endings.
Functions as receptor
cells that transduce mechanical movement into electrochemical Von Bekesy Travelling Wave Theory
signal Wave from cochlear base transfers to apex
o Inner Hair Cells (IHC) The motion of the basilar membrane takes the form of a traveling
Single row wave, like the one that occurs when you flick a rope
Most important sensory cells of hearing The wave oscillates at the frequency of stimulation
o Outer Hair Cells (OHC) For the Organ of Corti to be given maximal displacement, creating
3 rows COCHLEAR MICROPHONICS which is a local electrical potential
Acts as amplifiers
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It is important to note that the basilar membrane is narrow near the Blood Supply:
base of the cochlea and wide at the apex. It is also stiffer at the base INTERNAL AUDITORY ARTERY (branch of anterior inferior cerebellar
than the apex this is the reason why at the base, we can hear artery) – blood supply to the cochlea that enters into the internal
higher frequency sounds while at the apex, we can hear lower auditory canal
frequency sounds
EMBRYOLOGY AND CONGENITAL ANOMALIES
Auditory System: External Ear:
E Eight Nerve The ear starts to develop at the 3rd-7th week of gestation
Lecture Discussion:
C Cochlear Nucleus This is the auditory pathway of Modification of the surface ectoderm by which the skin is brought to
O Superior Olivary Nucleus how we are able to hear. From the functional relationships with the ossicles at the drum and the
L Lateral Lemniscus periphery, impulses will travel external canal
I Inferior Colliculus from the cochlear nerve which will
M Medial Geniculate Body go to the Eight Nerve all the way to
the Auditory Cortex
A Auditory Cortex
Balance Apparatus
3 Semicircular Canals – angular acceleration
Vestibule – linear acceleration
o Utricle – horizontal Hillocks of His
o Saccule – vertical 6 Hillocks of His
1st Branchial Arch
Semicircular Canals o 1 – Tragus
Dilated ends at the vestibule called ampulla containing crista o 2 – Helical Root
ampullaris o 3 – Helix
Cristae ampullaris contains hair cells (sensory) 2nd Branchial Arch
On top of the hair cells is a gel- like structure called cupula where it o 4 – Anti helix
is suspended to the wall of the opposite ampulla o 5 – Anti tragus
Coplanar o 6 - Lobule
o If one side is excitatory the other side is inhibitory Pinna – 1st and 2nd BA
Angular acceleration of the body causes movement of the endolymph
with the semicircular canal parallel to the rotation. ANOMALIES OF THE EXTERNAL EAR
Due to inertia, movement of endolymph causes displacement of the Maldevelopment of the 1st and 2nd arches
hair cells opposite to the direction of the acceleration stimulus. Auricular deformities are the most prominent
Torsional pendulum model Most common is a LOP EAR deformity.
MACROTIA – abnormally large ear
Utricle and Saccule MICROTIA – abnormally small ear
Linear acceleration in relation to ANOTIA – absence of ear
gravity
Ear Canal Atresia/Stenosis - Partial or complete stenosis of the ear
Contains macula canal.
Hair cells suspended in a Rudimentary ear appendages
gelatinous matrix
Failure to fuse of the Hillock of His leads to
Otoliths (CaCO3) crystals are formation of pre-auricular sinus cyst
suspended on top of the otolithic
membrane
Vestibular Function:
Vestibule-ocular reflex - stabilize eye gaze
Vestibulocolic reflex – posture and gait
Vestibulospinal reflex - posture and gait, extension of limbs
ANS – adjust hemodynamic reflex maintaining cerebral perfusion
Cerebellum – coordination and adaptation of vestibular reflex
Cortex – perception of movement and orientation
Stimulation of the vestibular organs result in neural excitation that travels via
the vestibular nerve to the 4 vestibular nuclei in the brain
Nystagmus
A Reflex Eye Movement elicited upon stimulation of the semicircular
canals
Jerk Nystagmus: Slow and Fast Phases
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Topic: Ear Anatomy, Physiology, Embryology and Congenital Anomalies
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Trisomy 18 E
“Edward’s Syndrome”
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Topic: Diseases of the External Ear, Middle Ear and Mastoid
Lecturer: Dr. Uy, Sidney
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Topic: Diseases of the External Ear, Middle Ear and Mastoid
Lecturer: Dr. Uy, Sidney
Diffuse Otitis Externa (Swimmer’s Ear) 4.) Herpes Zoster Oticus (Ramsay Hunt Disease)
Swimmer’s ear Viral infection of external ear
Usually affects patients that went swimming in a water that is Manifestations:
dirty with ear trauma. o Facial nerve paralysis
o Otalgia or ear pain
The whole ear canal is inflamed o Herpetic eruptions in the auricle and
Occurs commonly during hot, humid weather aggravating factor surrounding area
Etiology is Pseudomonas aeruginosa
Manifestations: Treatment:
o Severe pain o Since it is a viral infection, its treatment is symptomatic.
o Tragal tenderness o It usually resolves on its own but it takes a long time.
o Swelling of canal Self-limiting
o Patient may present with scanty discharge o Pain relievers can be given.
o Normal or slight hearing loss due to the swelling of ear canal o Steroids are given to accelerate the inflammation of the ear.
o Lymphadenopathy can be present in severe cases.
Neck nodes or Cervical lymph nodes 5.) Perichondritis
Effusion of serum or pus between the perichondrium
Treatment: and the ear cartilage
o Ear wick is used since the ear canal is very inflamed and is It has the appearance of “cauliflower ear” which is
almost closing. very common among boxers.
o Otic drops It is due to regular trauma or inflammation
Antibiotics & Steroids Manifestations:
o Severity will determine if there is a need to give oral antibiotics o Red, tender, warm and swollen auricle
Penicillins
Macrolides – if allergic to penicillins Management:
Quinolones o Antibiotics are given either orally or parenterally
o Topical medications if there are external lesions
3.) Otomycosis (Fungi) o Otic drops can be given.
Fungal infection of the ear canal o Antibacterial ointments with steroids
Common in o Evacuation of fluid through 2 big incisions then bolster packing
immunocompromised patients afterwards
Also common in patients with o Excision of necrotic cartilage
poor hygiene
Common etiologies are EAR MALFORMATIONS
Pityrosporum and Aspergillus Lop ears Excessively protruding ears
(A. niger and A. flavus) Anotia Congenitally absent ear
Manifestations: Microtia Congenitally small ear
o Itchiness Macrotia Congenitally big ear
o Patient may sometimes present with ear blockage because the Atresia Ear did not form
molds of the fungus are embedded in the ear canal.
o Patient may present with dry ear.
o In physical examination with otoscopy:
Blackish spores with hyphal elements can be seen.
It has a “wet newspaper” appearance
Management:
o Regular ear cleaning
o All the hyphal elements must be removed inside the ear canal
because the patient will not recover even if otic drops are given
but still there are hyphal elements left inside the ear canal.
o Otic drops are given once all the hyphal elements have been
removed.
o Antifungal otic drops given usually for 2 weeks
Candibec solution, Kenacomb otic are brand names of GRADING OF EAR MALFORMATIONS
the antifungal otic drops Grade 1 Smaller than normal but the ear has mostly normal anatomy
Their generic name is Clotrimazole Part of the ear looks normal, usually the lower half
Grade 2
The canal may be normal, small or completely closed
o Acidification is done for easier eradication of the fungi Just a small remnant of peanut shaped skin and cartilage
Grade 3
There is no canal, which is called “aural atresia”
Complete absence of both external ear and ear canal
Grade 4
Also called “anotia”
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Topic: Diseases of the External Ear, Middle Ear and Mastoid
Lecturer: Dr. Uy, Sidney
Management:
o Usually, excision is done if not infected. Darwin’s Tubercle Keloid Scarring
o If infected, antibiotics (macrolides or beta lactams are given).
o If there is an abscess, drainage must be done. BENIGN SKIN LESIONS
o The whole sinus tract must be removed. Sun damaged skin
Solar Keratosis
Painless
Lecture Discussion: Management of Preauricular Sinus Scaly
Proper treatment is surgical excision. If left untreated, a Type II Preauricular “Cutaneous horn”
sinus would cause recurrent infections, and sometimes abscess. To prevent No treatment is usually done
those from happening you have to tell the patient to undergo surgical You can advise to undergo
excision. cryotherapy or excision of
the solar keratosis
ACCESSORY AURICLE (SKIN TAG)
Nothing is done Seborrheic Keratosis
It does not need surgery. Round
It can be removed through surgery (for Dark
patients who are vain) “liver spots”
Sun damage
No treatment is usually done
You can advise to undergo
EXTERNAL EAR TUMORS cryotherapy or excision of
Single, rounded growth with bony peduncle the seborrheic keratosis
to inner 3rd of the bony canal
Osteoma If symptomatic and causes recurrent Tophi
infections, it can be removed.
Due to gout
Usually, no treatment is done.
Painless, smooth, uric acid
Dense
crystals subcutaneously
Exostosis Rounded protuberance of hypertrophic canal
deposited
bone
Can be resolved by treatment
Resembles a pimple inside the ear canal
of the gout
Can be big or small
Ear Polyps
Can sometimes be infected
Keloid Scarring
Surgically removed
Darwin’s Tubercle Thickening on the helix at the junction of the
upper and middle thirds
Carcinomas of the Ear Basal cell carcinoma
Squamous cell carcinoma
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Topic: Diseases of the External Ear, Middle Ear and Mastoid
Lecturer: Dr. Uy, Sidney
Management:
DISEASES OF THE TYMPANIC MEMBRANE
Tympanosclerosis o If it is an inactive type, there is no treatment done.
o Antibiotics are given for actively draining infections.
o Oral antibiotics may be given if it is severe
Retracted drum
Bullous or Hemorrhagic Myringitis
o There are blebs or bullae in the ear drum
o Ear drum is not perforated.
Ear drum is retracted o The ear drum may contain serous fluid, blood or both.
inwards o Ear drum may appear red or purple.
o Usually caused by Mycoplasma pneumoniae
Management:
o Antibiotic ear drops (PND otic drop)
Bulging drum
o Pricking of blebs
Fine needle or knife
Swollen ear drum
Can be due to tumor or
otitis media
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Topic: Diseases of the External Ear, Middle Ear and Mastoid
Lecturer: Dr. Uy, Sidney
Manifestations:
o Otophony/Autophony – the patient hears his own respiration
o Sensation of ear fullness
o “plugged up” feeling
Physical Examination:
o Drum is thin & atrophic
o Drum moves in & out with respiration
Schwartze Sign:
Management:
o You do myringotomy
o Insertion of ventilation tube
To equalize the pressure between the middle ear and
external ear
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Topic: Diseases of the External Ear, Middle Ear and Mastoid
Lecturer: Dr. Uy, Sidney
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Topic: Diseases of the External Ear, Middle Ear and Mastoid
Lecturer: Dr. Uy, Sidney
Chronic Otitis Media & Mastoiditis continued….. TUMORS OF THE MIDDLE EAR
Manifestations: Originates from the glomus bodies that
relate to the jugular bulb in the floor of the
Otorrhea Glomus Jugulare or
middle ear, or from nerve distributions from
o Purulent Glomus Tympanicum
the middle ear
o Mucoid (active secretory glands)
Highly vascular tumor, bulging purplish
o Foul-smelling, putrid & dirty yellow (cholesteatoma) mass (Brown’s sign)
o Thin, watery (TB) It sometimes extends out of the ear.
Due to ear drum perforation, patient has conductive hearing loss. Carcinoma of the Ear Most common malignant tumors of the
Pain may be rare but may indicate complication. middle ear are adenoid cystic CA and
Vertigo – erosion of semicircular canals adenocarcinoma.
Perforation
o Marginal & attic (cholesteatoma) Management:
o Multiple (TB) Surgery
Chemotherapy
Management:
o Conservative
Keep water out of the ear.
Cleaning with hydrogen peroxide or alcohol
Antibiotic drops
Usually what is given is quinolone otic
drops/ofloxacin otic drops. Sometimes you can
also give oral antibiotics – quinolones
(ciprofloxacin/levofloxacin)
o Surgery
Tympanoplasty – to restore hearing
You are creating a new ear drum
3.) Cholesteatoma
Found in chronic otitis media & chronic mastoiditis
Keratinizing squamous epithelium (skin) entrapped in the middle ear &
mastoid
Increases in size and erodes the bone
Damage the ossicles
Press on the facial nerve
Treated by mastoidectomy
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Topic: Diseases of the Inner Ear
Lecturer: Dr. Caluag, Jim
Acute Stage:
It starts with the ACUTE STAGE which is characterized by the invasion If SNHL (sensorineural hearing loss) or vertigo is present, MODIFIED
of pus cells. RADICAL MASTOIDECTOMY must be done to eradicate Mastoid and
Middle Ear Diseases
The acute stage is characterized by a stormy period lasting for 1-2
weeks wherein the vestibular symptoms peaks for the first few days
Complications:
then gradually subsides after a week.
The most serious stage is the ACUTE STAGE because during this stage,
When diffuse suppurative labyrinthitis occurs unilaterally, the patient
complications may occur by the spread of the infection to adjacent
has severe vertigo and the patient cannot stand or sit upright.
regions such as to the internal auditory canal along the nerves and the
The patient must lie quietly on the side of the diseased ear which is
vessels or to the cochlear aquiduct.
completely deaf.
Common complication is Septic Meningitis
Slight head and body movements cause the patient to vomit.
o Extradural and cerebellar abscesses as well as sinus
The surroundings seem to spin in the direction from the normal to the
thrombosis are possibilities
diseased side.
The patient is very incapacitated to cooperate with tests that suggest a
diagnosis of the basic clinical picture.
Caloric tests reveals impaired vestibular response
Labyrinthitis should be differentiated from brain lesions
In labyrinthitis, labyrinthine nystagmus occurs for a few weeks and
then subsides whereas in a brain lesion nystagmus is noted for a
much longer duration
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Topic: Diseases of the Inner Ear
Lecturer: Dr. Caluag, Jim
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Topic: Diseases of the Inner Ear
Lecturer: Dr. Caluag, Jim
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Topic: Diseases of the Inner Ear
Lecturer: Dr. Caluag, Jim
o CNS disorders Any disorder that causes unilateral reduction in vestibular function may
A neural apparatus central to the cochlea can be the origin cause vertigo
of tinnitus. Cerebello-pontine angle lesion affecting the 8th The best way to establish whether vestibular activity is reduced,
nerve trunk directly generates a minor high pitched tinnitus vestibular function is measured by Caloric Test done by tilting the
not usually localized to the ear patient’s head 60 degrees backward and irrigating the ear with cold
water, a horizontal nystagmus of 1-3 minutes duration occurs with fast
Treatment for Tinnitus: component towards the opposite side
Correction for a known cause is the most effective positive treatment Most patients have very active response and the characteristic of
since therapy can be aimed specifically. nystagmus must be noted
A bedside clock radio, loudly ticking alarm clock or a fan provides There are 3 characteristic of nystagmus exhibited by the patient:
ambient noise to mask the ringing at bedtime. 1. Vertical nystagmus – indicates brain lesion
Tranquilizers and sedatives may be initially used but should be 2. Horizontal nystagmus – indicates that there is
discontinued as the patient becomes more adjusted to the symptoms. labyrinthine lesion
The patient should be informed that there are no miracle drugs or 3. Rotary nystagmus – means that the vertigo is systemic
surgical procedures for tinnitus. in origin
If there is an accompanying hearing loss, wearing hearing aids will
increase ambient sound to mask the tinnitus. Vertigo due to CENTRAL DISORDERS – central vertigo may be due to:
o Multiple sclerosis
o Acoustic neuromas
o Seizures
o Basilar insufficiency
o Vascular accidents
Several conditions affect the vertebral basilar arterial system and may
cause vertigo
Cervical Spondylitis
May cause compression on the Basilar Artery resulting to vertigo
Another condition is insufficient blood supply to the basilar system
Chronic ischemia of the vertebral basilar arterial system due to
Atherosclerosis produces vertigo
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Topic: Diseases of the Inner Ear
Lecturer: Dr. Caluag, Jim
Vestibular Neuronitis
Also known as epidemic labyrinthitis because it sometimes seems to
occur in epidemic form
Patient presents with intermittent vertigo.
Examination shows normal hearing but with a reduced caloric reaction
Thought to be due to a virus that attacks the ganglion of the vestibular
nerve but attacks the whole vestibular labyrinth
Thought to be due to the activation of Human Herpes simplex virus
Medications are supportive but not specific.
A self-limiting
Management:
o Treatment after an early diagnosis is preferably surgical.
o Radiotherapy is a useful pre and post-operative adjunct
therapy.
Management:
o Diuretics are given to reduce the swelling of the membranous
labyrinth.
o It has the same principle of management with glaucoma.
o Sedatives
o Central vasodilators
o Antiemetics
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Topic: Basic Audiology
Lecturer: Dr. See, Nixon
Figure Above: Figure Above: Basic Audiometer & Head Phone, Bone Vibrator
The low frequency tuning forks (C-128, C-256) they have a rounded tip on Head phone – we use the headphone for air conduction testing
top which we call “Dampers,” these are there to prevent the production of Bone vibrator – we use it for bone conduction testing
overtones when you overstimulate the tuning fork by hitting it too much.
Below it are your “Tines or Prongs/Tongs,” then the “Body” and the “Stem
or Neck.”
Underneath is the “Hilt or Base” part of the tuning fork that should touch
the patient’s head
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Topic: Basic Audiology
Lecturer: Dr. See, Nixon
For bone conduction testing, since we are vibrating the right mastoid the Lecture Discussion: 5 up 10 down rule
whole skull will vibrate as well as the non-tested ear (the left ear) patient For example you give stimulus at 0 dB, the patient did not respond. Give
will also be responding to that = false positive result another 10 dB, the patient did not respond. And then when you give it 30 dB,
the patient responded that is not yet the threshold of the patient. You
follow the 5 up 10 down rule:
Cross Hearing: So you decrease 30 dB to 20 dB, the patient did not respond. Add
o Patient respond to the test signal on the non-tested ear another 5 (=25 dB), if the patient did not respond then add another
To eliminate the cross hearing or interaural attenuation 5. If the patient responded again at 30 dB that means that it
we give another sound that is complex (a hissing sound to would be the threshold of the patient at 1000 Hz by air conduction
distract the non-tested ear so that the patient will
concentrate in responding to the interrupted tone given on The next test would be at 2000 Hz then followed by 4000 Hz, 8000 Hz, then
the tested ear) go back to the low frequency (500 Hz, 256 Hz). After getting the result by Air
The stimulus on pure tone audiometry is a series of pure conduction, you proceed with the same technique by Bone conduction
tone (interrupted tone) testing. The results can be placed on an audiogram
Masking:
o Obscuring one sound by another sound
The sound you hear here is like that of in the T.V. when
stations are off
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Topic: Basic Audiology
Lecturer: Dr. See, Nixon
Sensory Neural Hearing Loss: both BC and AC are the same and neither
is normal
Interpretation:
Normal: when bone conduction and air conduction thresholds are
between 0-20 dB
Lecture Discussion: If both AC and BC threshold are both abnormal but this
time there is a gap of more than 10 dB a mixed type of hearing loss (you
cannot diagnose this by tuning fork test)
Lecture Discussion: If the bone conduction thresholds are within normal, and
the air conduction is below normal this represent a conductive type
hearing loss
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Topic: Basic Audiology
Lecturer: Dr. See, Nixon
Confirmatory Test
ABR – Auditory Brainstem Evoked Response audiometry
ASSR – Auditory Steady State Response Audiometry
Lecture Discussion: Type Ad
It has the same pressure on both external and middle ear but the tympanic
membrane will move very loosely at 0 pressure because there’s no limitation
or restriction on the movement by the ossicles. This can be seen on patient
with ossicular chain discontinuity
Type As
o Very low compliance at ambient pressure
o Seen in ossicular fixation
Lecture Discussion:
This is a schematic diagram of impedance audiometry. The external ear is
totally sealed off, no sound or pressure or stimulus can get in without being
measured and no sounds or echoes can come out without being measured
as well
Lecture Discussion: Type As
1. Tympanometry Similar with the first two types, the movement of the tympanic membrane is
Is an indirect measure of the compliance (mobility) of the tympanic seen on 0 pressure. But it is now limited or restricted. This are usually seen if
membrane under conditions of (+), (-) or normal pressures the ossicular chain has a problem like fixation because of recurrent middle
Lecture Discussion: ear infection.
If you have a middle ear fluid, the tympanic membrane is bulging or under
The tympanic membrane will be able to move freely if the pressure
pressure. For sure it will not be able to move either on positive or negative
in the external ear is the same as the pressure in the middle ear
pressure
because they are both open to the atmosphere
Type B (Flat)
Purpose:
o Little or no change in middle ear compliance
o TM mobility
o Impacted cerumen, perforated ear drum, with middle ear fluid,
o Middle ear pressure
TM perforation
o TM perforation
o Patency of the eustachian tube
Procedure:
o Acoustic energy ( 45 db SPL) is introduced into the ear.
Some are absorbed, others are reflected back (echoes)
and measured by another channel
Tympanogram
Type A (Normal)
o Maximum compliance of tympanic membrane at 0 pressure Lecture Discussion: Type B
Impacted cerumen, perforated ear drum, etc all these situations there will
be no movement of the tympanic membrane at all. So when you try to do
tympanometry, the graph will be very flat
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Topic: Basic Audiology
Lecturer: Dr. See, Nixon
Lecture Discussion:
Since the acoustic reflex is reflexive and bilateral, then we can take
advantage of this characteristic. We can do acoustic reflex contralaterally or
ipsilaterally.
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Topic: Basic Audiology
Lecturer: Dr. See, Nixon
PEDIATRIC AUDIOMETRY
Behavioral Audiometry
o Newborn to 24mos of age
o Difficult to handle and inconsistent
o replaced by BERA
Play audiometry -2-4 years old
Speech audiometry
Objective audiometry
o Impendance Audiometry
o BERA
o Otoacoustic Emission test
The smaller it is, the more expensive your hearing aid will be but not
necessarily they are the most with important features. Every features that
you add on the hearing aid will entail another expense on the price of the Picture Above:
hearing aid
This is the reason why we see patient with facial nerve problem as well
(besides hearing problems). As the facial nerve exits the brainstem it enters
AUDITORY BRAINSTEM EVOKED RESPONSE
the internal auditory canal that is already part of your temporal bone so 70%
Also called ABR (Auditory Brainstem Reflex) or BERA (Brainstem Evoked of the peripheral fiber of the facial nerve is within ENT.
Response Audiometry)
Represent electrical response of CN VIII and some portions of the brain After it has passed through the internal auditory canal, it gives a peripheral
to auditory stimulus after being sensed by the inner ear branch to your lacrimal gland thru the greater petrosal nerve to control
80 dB above threshold click stimulus at fixed repetitions e.g. 11/sec or lacrimation. It turns back and down towards the middle ear giving a branch
33/sec until 2000 click response have been average to your stapedial muscle. Then again, it turns back going to the mastoid. The
Electrodes on mastoid vs. forehead EEG pattern circled portion in this diagram is part of your middle and your mastoid. Along
Series of waves ( I-VIII) are produced I and II are from the cochlea the mastoid it will give another branch which is the chorda tympani towards
Results: latency of each wave and interwave your tongue and your submandibular and sublingual gland. Before it exits the
stylomastoid foramen and give the famous 5 peripheral muscular innervation
Lecture Discussion:
What is important are the early waves because your ABR was designed to
diagnose Cerebellopontine angle tumors. If we look at the sensitivity and
specificity of this test, it is at 95%. It is a very reliable test. Likewise, this ABR
is used as a mandatory confirmatory test for hearing evaluation in infants
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Topic: Basic Audiology
Lecturer: Dr. See, Nixon
In case the patient has LMN paralysis blocking both upper and lower Maximal Stimulation Test
contralateral face, it will receive the same innervation also on the ipsilateral Is a crude test. An electrode is placed on the cheek
upper face but since this will also be blocked, then the patient has a total and electrical stimulation is given. This is quite
paralysis on the opposite, it will be 70% ENT. painful to the patient
o Salivation
Cannulation of the Wharton’s Duct
25% difference is significant
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Topic: Basic Audiology
Lecturer: Dr. See, Nixon
2.) Infections
Herpes zoster Oticus
Middle ear Infections
3.) Trauma
Temporal Bone Fracture
o Longitudinal – parallel to the temporal bone
Delayed complete paralysis
Full recovery
o Transverse - perpendicular fracture
25% full recovery
Greater chance of permanent paralysis
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Topic: Anatomy of the Nose and Paranasal Sinuses
Lecturer: Dr. Caluag, Jim
The internal nose is largely filled with the nasal septum and the
turbinates.
Turbinates are also known as conchae
Superiorly:
o The upper rigid part of the nose is composed of the frontal The nasal septum and turbinates have regular spaces in between
process of the maxilla which is also known as the nasal them which form the so-called “flues” or the spaces for the flow of
pyramid or the bridge of the nose. air.
The nasal pyramid or the nose bridge is where The horizontal spaces next to the nasal septum are known as the
glasses/spectacles are placed when a person is wearing one common meatuses which are straight and parallel with the surface.
Superior, Middle and Inferior Meatus
o Together with the frontal process of the maxilla which makes o Potential spaces lying between the superior, middle and
up the nasal pyramid are the nasal bone plates fused together. inferior turbinates
Inferiorly: o The WIDEST portion is the INFERIOR MEATUS
o The lower part of the nose is formed by a group of cartilages o The combined volume of these spaces is approximately
15-20 cc.
consisting of the:
o The volume on either side is approximately 7-10 cc.
Lateral nasal cartilage
o MIDDLE MEATUS – where the ostium of the frontal,
Medial and lateral dura of the greater or major
maxillary and anterior ethmoid sinuses drains
alar cartilages o SUPERIOR MEATUS – is where the posterior ethmoids
Free margin of the septal cartilage and sphenoid sinuses drains
Connective tissue covering the whole nose. o INFERIOR MEATUS – where the nasolacrimal duct opens
o The septal cartilage is part of the nasal septum.
The columella is formed by the: III. Septum
o Lower margins of the septal cartilage Practically divides the nasal cavity into two nearly equal compartments
o Anterior nasal spine (covered with skin) Also known as the internal nasal skeletal framework
o Medial portion of the two greater (major) alar cartilages Composed of 6 structures: a single cartilage and 5 bones
Composition:
The nostrils are formed by the two major (greater) alar cartilages which
o Quadrangular cartilage
are flexible plates bent in such a way that they tend to form the lateral o Perpendicular plate of the ethmoid bone
and medial walls of the nares o Vomer
o Rostrum of the sphenoid
II. Internal Nose o Crest of the palate
o Crest of the maxilla
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Topic: Anatomy of the Nose and Paranasal Sinuses
Lecturer: Dr. Caluag, Jim
IV. Turbinates The sphenoid sinus occupies the sphenoid bone and
Septal deviations due to abnormal growth that may interfere with the Sphenoid Sinus extends to the wings of the sphenoid, the clinoid
nasal airflow must be surgically corrected process and the lateral margin of the pterygoid plates
The turbinates are areas of erectile tissue (cavernous venous spaces) on Housed in the ethmoid labyrinth medially bounding
both sides of the nasal septum serving to adjust their size in varying the orbital cavity
Anterior
atmospheric conditions and they are also known as nasal radiators. It is separated by a thin plate of bone known as the
and
They have a rich blood supply. lamina papyracea which is normal dehiscent in the
Posterior
pediatric age group. That’s why in pediatric patient
The inferior and middle turbinates are long fleshy bodies that hang Ethmoids
they would orbital complications (e.g. orbital
downwards occupying the lateral nasal wall. They extend horizontally
cellulitis) if their ethmoid sinus infection would extend
to almost the full length of the lateral nasal wall. through the lamina papyracea
They are supplied with erectile tissue or cavernous venous spaces that
serve to adjust their size. Sinuses present at birth: Maxillary and Ethmoids
They act as radiators of the nose and they are subserved with a rich The frontal sinus is not yet developed and the sphenoid sinus is
blood supply. rudimentary
The mucous membrane of the respiratory tract lines the nasal cavity,
sinuses, nasopharynx, Eustachian tubes, middle ear space, and mastoid
down to the respiratory bronchioles
The pharynx- lined by squamous epithelium
Pseudostratified columnar ciliated epithelium – lines the respiratory
epithelium composed of long columnar cells surmounted by cilia of
about 100 to a cell underlain with 3-4 layers of replacement cells
Pseudostratified cuboidal epithelium – surfacely lines the paranasal
sinuses with only 1-2 layers of replacement cells
The Cilia of the epithelium are uniform in length
The glands and blood vessels in the stroma of the submucosae vary in
Hiatus Semilunaris number and in size in direct proportion of the air flow and they furnish
In the middle meatus, the ostia of the frontal, maxillary and anterior the mucous blanket
ethmoids opens into the HIATUS SEMILUNARIS These glands are tubular and racemose, containing serous and mucosal
cells
Ethmoidal Bullae
A vestigial structure that arises from the fusion of the ethmo-
C. Olfactory Epithelium
turbinals that carry olfactory epithelium in lower animals but not in
The olfactory epithelium is of high cylindrical type with distinct basal
man
cells in which the upper surface of the cell of the olfactory epithelium
It is found in the upper margins of the hiatus semilunaris
appears different from that of the respiratory portion.
Ethmo-turbinals 3 types of cells makes up the olfactory epithelium:
Well-developed in lower animals which carry olfactory epithelium 1. Cuboidal cells forming the basal layer
in which some lies within the frontal and sphenoidal sinuses 2. Tall cylindrical supporting cells
Man has a relatively rudimentary sense of smell and the olfactory 3. Sense cells
epithelium is confined to the uppermost middle area of the nasal
septum Olfactory Sense Cells
They are bipolar nerve cells that form a tract coming from the central
B. Paranasal Sinuses nervous system.
The paranasal sinuses are irregularly shaped air spaces that lie adjacent They are evenly distributed among the supporting cells.
to the nose.
All sinuses vary in size, shape, configuration and symmetry. Olfactory Vesicle
They are air cavities bounded by bones that are embedded within the From the distal end of these olfactory sense cells, a modified dendrite
skull. will be protruding above the surface epithelium giving rise to the
OLFACTORY VESICLE.
Lies between the outer and inner table of the frontal
bone with which the floor serves as the roof or ceiling At the surface of the olfactory vesicle, there are 6-8 motile cilium and
Frontal Sinus at the proximal end the cilium tapers to a smooth thin filament which
of the orbit
The superior wall of the orbit makes up its floor. is about 1 micron in diameter and this will make up the axon.
Occupies majority of the maxillary bone It will join with other similar axons giving rise to the OLFACTORY
Extends from the orbit and serves as the orbit’s roof NERVES
or ceiling down to the apices of the molars in which The axons are collected together to pass through the Cribriform plate
some of the molars protrude particularly the into the Olfactory bulb to form a synapse with the dendrites of the
premolars or the first and second molar tooth root mitral cells
Maxillary Sinus protrudes into the sinus cavity
(Antrum of Axons of these mitral cells forms the Olfactory Tract going into the CNS
Highmore)
Lies beneath the maxillary bone wherein the floor of to connect with numerous nuclei
the orbit makes up its roof and the apices of the
molars serve as its floor.
Traumatic tooth extraction of 1st or 2nd upper molar
would lead to sinusitis due to a presence of oroantral
fistula
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Topic: Anatomy of the Nose and Paranasal Sinuses
Lecturer: Dr. Caluag, Jim
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Topic: Anatomy of the Nose and Paranasal Sinuses
Lecturer: Dr. Caluag, Jim
EMBRYOLOGY Failure of the buco-nasal membrane to rupture before birth will give
A. Nose rise to a congenital condition known as congenital choanal atresia
The nose forms BETWEEN THE 4TH and 8TH WEEK OF EMBRYONIC LIFE
(AOG) and continuously undergoes changes even in adulthood. The ANTERIOR PORTION of the palate will undergo SPONTANEOUS
o During early embryonic development, there are 5 BRANCHIAL OSSIFICATION.
ARCHES in the UPPER END of the embryo that only exist for a The POSTERIOR PORTION of the palate that did not undergo
period of 2 WEEKS before it starts to DEGENERATE. OSSIFICATION will develop to become the SOFT PALATE.
The olfactory sac grows POSTERIORLY between the MEDIAN NASAL
PROCESS and FRONTO-NASAL PROCESS compressing a portion of the
FRONTO-NASAL PROCESS giving rise to the NASAL SEPTUM which
should undergo SPONTANEOUS FUSION with the PALATE.
B. Palate
The development of the paranasal sinuses remain a mystery.
As the face grows down and forward in a much more rapid rate than
cranium growth, the ossified materials in these bones are removed to
be used in forming the rapidly growing facial bones.
As these ossified materials are being removed, the nasal mucous
The region ANTERIOR TO THE FOREBRAIN develops to become the membrane is sucked into the resulting bony spaces resulting to BONY
FRONTO-NASAL PROCESS in which the ANTERIOR FACE, NOSE and RESORPTIONS taking place in the MAXILLA, FRONTAL, ETHMOID and
JAWS develop. SPHENOID BONES while simultaneously, the MUCOUS MEMBRANE
o At the LATERAL portion of the FRONTO-NASAL PROCESS, from the nose advances intending to occupy these areas.
secondary processes develop and they are the RIGHT and LEFT As a result, the sinuses are irregular in size, shape, location, symmetry,
MEDIAN NASAL PROCESS. number, anatomic placement.
They vary greatly in every individual.
The sinuses on either side are assymetrical
While the maxillary and mandibular processes grow MEDIALLY, from SPECIAL DIAGNOSTIC PROCEDURES FOR THE NOSE AND PARANASAL
the LATERAL MAXILLARY PROCESS, the LATERAL NASAL PROCESS SINUSES
arises. A. Radiographic Examinations
Between the LATERAL and MEDIAN NASAL PROCESS, PITS form which I. Caldwell View
eventually develop as the ANTERIOR NARES. Also known as FOREHEAD-NOSE VIEW
The PREMAXILLA which is derived from the FRONTO-NASAL PROCESS This view helps to further evaluate the status of
will eventually fuse with the MAXILLARY PROCESS and gives rise to the the MAXILLA, MAXILLARY and FRONTAL SINUS,
UPPER JAW and UPPER LIP. ETHMOID AIR CELLS, LAMINA PAPYRACEA and
During the 7TH and 8TH WEEK AOG, most of the PALATE is formed by FRONTO-ZYGOMATIC SUTURE.
the MEDIAN and the LATERAL PALATINE PROCESS which is also derived
from the MAXILLARY PROCESS. II. Water’s View
During the 8TH WEEK, the PREMAXILLA will eventually FUSE with the Also known as CHIN-NOSE VIEW or OCCIPITO-
PALATE in which their fusion is INCOMPLETE and the separation MENTAL VIEW
between them develops to become the INCISIVE FORAMEN. Requested to further evaluate the status of the
The premaxilla is the anatomical landmark that most surgeons use ORBIT, ORBITAL CAVITY, INFERIOR ORBITAL
to classify whether a cleft palate is complete or incomplete. RIM, FRONTAL PROCESS OF THE MAXILLA,
If a congenital cleft palate traverses the incisive foramen, it is NASAL BONES (NASAL PYRAMID), NASAL
labeled as complete cleft palate and its surgical procedure is SEPTUM, NASAL CAVITY, MAXILLA, ZYGOMA,
uranoplasty
ZYGOMATIC ARCH, SYMPHYSIS MENTI, ANGLE
If a congenital cleft palate do no traverse the incisive foraman, it is
OF THE MANDIBLE and CORONOID PROCESS OF
labeled as incomplete cleft palate and its surgical procedure is
THE MANDIBLE
called staphylorraphy
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Topic: Anatomy of the Nose and Paranasal Sinuses
Lecturer: Dr. Caluag, Jim
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Topic: Anatomy of the Nose and Paranasal Sinuses
Lecturer: Dr. Caluag, Jim
GENETIC DEFECTS SEEN AT BIRTH Stenosis of the nostrils is due to failure of resolution of the
Hamartoma epithelium plug of the nostril occurring in the 6th fetal month
Hemangioma
Wardenburg’s Syndrome Factors Associated with Deformities of the Nose and Septum During the Active
Period of Growth:
Dental misalignment especially those affecting the upper incisor teeth
Deviations of the teeth from the midline associated with dental
Exhibits a wide and flat nose malocclusion
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Topic: Diseases of the Nose and Paranasal Sinuses
Lecturer: Dr. Hernandez, Josefino
Nose
Turbinates
Are bony structures attached to the lateral nasal wall
Septum You can see here that the cribriform plate separates the nasal cavity
Divides the nose into 2 from the orbit and through small openings, the olfactory nerve endings
Mucosa pass through to reach the upper third of the nasal cavity which is the
With erectile tissue covered with Pseudostratified ciliated columnar olfactory area. As we sniff more air, it reaches that area so that we can
epithelium significant for mucociliary clearance which propels smell the substance or particle we try to sniff
mucous from anterior going posteriorly into the nasopharynx
PARANASAL SINUSES
Paired:
o Frontal
o Maxillary
o Ethmoids
Anterior
Posterior
o Sphenoid
When we exhale we can note that the air flow is more turbulent
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Topic: Diseases of the Nose and Paranasal Sinuses
Lecturer: Dr. Hernandez, Josefino
This is the mucociliary clearance involving the frontal sinus. So you can
have secretions moving up superiorly, medially and eventually going
lateral then medially, inferiorly and exits the natural ostium into the
This is the image we see when we do endoscopy. From the front we can
frontal recess. But take note that some of the secretions will revert back
see here S – septum. Mt – middle turbinate that is attached superiorly
to the mucociliary pathway
to the cribriform plate. It – inferior turbinate. Between the two
turbinates is the space ~ middle meatus where you find the UP –
Drainage:
unicinate process as well as the B – ethmoidal bulla which is part of the
Inferior meatus
ethmoid air cells
o Nasolacrimal canal through the valve of Hasner
When a patient cries, some of the tears will enter the
Ethmoidal Infundibulum
punctum and nasolacrimal canal exits into the nose
Middle meatus
o Frontal sinus: 4-7 ml
o Maxillary sinus: 15 ml
o Anterior ethmoid air cells
Superior meatus
o Posterior ethmoid air cells
Sphenoethmoidal recess
o Sphenoid: 7 ml
MUCOCILIARY CLEARANCE
Cottle’s Maneuver
The cottle’s maneuver is a test in which the cheek on the side to be
evaluated is gently pulled laterally with one to two fingers to open the
valve. This test is used to determine if the most significant site of nasal
obstruction is at the valve or farther inside the nasal cavity
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Topic: Diseases of the Nose and Paranasal Sinuses
Lecturer: Dr. Hernandez, Josefino
EXTERNAL DISEASES OF THE NOSE o It can also trigger asthma in asthmatic patients.
Nasal Vestibulitis o If there is obstruction of the ostium, secretions cannot come
o Infection of the skin of the nasal out so there is impaired mucociliary clearance which will
vestibule eventually lead to bacterial overgrowth on the secretions
o Staphylococci is the most which will cause the patient to develop bacterial
common organism rhinosinusitis.
o Could be secondary to trauma or
frequent nasal manipulation Classification of Rhinitis:
Allergic Infectious Others
Nasal Furunculosis Can be intermittent Can be acute or Can be Non-allergic,
o Infection of the nasal hair follicle or persistent. chronic Non-infective,
oftentimes caused by Staphylococcus Recurrent rhinitis idiopathic, NARES, etc
aureus due to an IgE
o Could be secondary to plucking of nasal mediated reaction
vibrissae (hair) of the nasal mucosa
to allergens
Infection of the external nose can progress to cellulitis or cavernous sinus
1. Allergic Rhinitis
thrombosis
Allergic rhinitis is now classified as intermittent or persistent.
Treatment: Intermittent allergic rhinitis
Consists of analgesics, warm compress and antibiotics directed against o Involves having signs and symptoms less than 4 days per week
staphylococcus or less than 4 weeks.
o In intermittent type, either of the 2 given criteria is sufficient
to be able to diagnose a patient as having an intermittent type
RHINITIS
of allergic rhinitis.
Simply means inflammation of the nose
Inflammation of the lining mucosa of the nose characterized by one or
Persistent allergic rhinitis
more of the following symptoms:
o Involves having signs and symptoms more than 4 days per
o Nasal congestion
These 4 are the cardinal signs week and more than 4 weeks.
o Rhinorrhea
and symptoms of rhinitis o For persistent allergic rhinitis, the 2 given criteria should both
o Sneezing
be present in order for a patient to be diagnosed as having
o Itchiness
persistent allergic rhinitis.
Nasal congestion must be differentiated from nasal obstruction. Allergic rhinitis can be further classified as mild, moderate or severe.
o Nasal congestion may result to nasal obstruction but the The infection will not affect the sleep as well as
problem is usually not permanent. Mild
daily activities (e.g. work or school) of the patient.
o Nasal obstruction is used to identify more permanent
Will affect the daily activities of the patient
conditions such as nasal polyps and tumors as well as
Sleep disturbance
septal deviation. Moderate
Impairment of school or work
o Nasal congestion is applied to rhinitis and sinusitis.
Troublesome symptoms
Rhinorrhea nasal discharge that can be clear/watery or Will affect the daily activities of the patient
mucopurulent Sleep disturbance
o Clear/Watery we attribute it to viral rhinitis, Severe
Impairment of school or work
allergic rhinitis, non-allergic rhinitis
Troublesome symptoms
o Mucopurulent we attribute it to bacterial
infections (e.g. acute bacterial sinusitis)
ARIA: The New Classification
Rhinitis may appear to be a simple disorder, but it can lead to more
serious problems if overlooked and left untreated
Sequelae of Rhinitis:
o If the rhinitis lasts longer than 10 days, the patient may
develop sinusitis.
o If the rhinitis persists, it may actually affect the Eustachian tube
connected to the middle ear so the patient will develop otitis
media.
There will be inflammation of the Eustachian tube mucosa
so air will not reach the middle ear and there will eventually
be fluid behind the middle ear prompting patient to
develop otitis media
Causes of Allergic Rhinitis:
o Mucopurulent discharge coming from the sinuses which Allergic rhinitis can be provoked by exposure to allergens in the
contains bacteria can be propelled posteriorly and it will reach environment.
the oropharyngeal area and patient can develop Examples of allergens are pollens (tree such as alder, hazel oak, elm and
tonsillopharyngitis. birch grass, weed), house and dust mites, animal danders, cockroaches
o This infection may further go down to develop laryngitis which and certain mold species.
presents with hoarseness. These are the common causes of allergic rhinitis.
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Topic: Diseases of the Nose and Paranasal Sinuses
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Linea nasalis
o Dorsal crease develops due to nasal salute
Dennie’s line
o An accentuated line or atopic pleat of the lower eyelid Take note: as an individual drug, the best medication is intranasal
corticosteroids followed by oral antihistamines
Pathogenesis of Allergic Rhinitis:
For nasal obstruction – best drug is intranasal decongestant
Sometimes may need more than 1 medication to improve their condition
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Effects of Antihistamines Effects of Nasal Steroids Comparison of Common Colds and Allergic Rhinitis:
Relieve pruritus Degree of inhibition of early phase
Prevent sneezing reaction
Decrease thin secretions Primary effect on suppression of late
Does not improve phase reaction
congestion Reduction of non-specific activity
Inhibition of effects of cytokines
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Topic: Diseases of the Nose and Paranasal Sinuses
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Topic: Diseases of the Nose and Paranasal Sinuses
Lecturer: Dr. Hernandez, Josefino
Management:
Wide excision of the carcinoma or maxillectomy
There must be a margin
We want to catch patients with malignancy early. Early diagnosis should
result in better prognosis
Modalities of treatment:
o Surgery
o Radiotherapy
o Chemotherapy
Surgery and postoperative radiation therapy may result in improved
local control, absolute survival, and complications when compared
with radiation therapy alone
SUMMARY
Disorders of the Nose and Paranasal Sinuses result in congestion and
obstruction of the nasal cavity which can result in problems in olfaction
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