Diagnosis in Otorhinolaryngology

Diagnosis in Otorhinolaryngology

(Parte 1 de 4)

T. Metin Önerci Diagnosis in Otorhinolaryngology


T. Metin Önerci

Diagnosis in Otorhinolaryngology

With 432 Figures and 62 Tables

Prof. T. Metin Önerci Hacettepe University Faculty of Medicine Dept. of Otorhinolaryngology 06100 Ankara Sihhiya Turkey metin@tr.net

ISBN: 978-3-642-00498-8e-ISBN: 978-3-642-00499-5

Library of Congress Control Number: 2009926009 Springer-Verlag Berlin Heidelberg 2009

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In preparing the material for this book, I took the advice of my students who generously shared their views and opinions with me. I was told that it would be preferable to have images of the various diseases with legends describing the disease. Students would be able to learn and retain the information more successfully if the material was accompanied by pictures and schematic drawings.

Recent advances in technology have made it possible to photograph regions that are difficult to view with the naked eye, such as the ear, nose, throat, nasopharynx, and larynx – all the areas of otorhinolaryngology. Such an illustrated text in this field is important and necessary for teaching purposes.

In this book I tried to compile images of the basic conditions that are commonly seen in general practice and to give the reader a visual survey with a brief description of the condition. I added tables and schematic drawings in order to provide practical information. It is not the purpose of this book to be a comprehensive textbook, since many textbooks are already available with more detailed information of the conditions illustrated here.

This book is primarily intended for medical students, family and general practitioners, and ENT trainees. It may also serve as basic reading material for those in allied specialties. I hope my colleagues find this book useful and it contributes toward their teaching purposes.

Ankara, Turkey T. Metin Önerci


Chapter 1 Ear

1.1 Ear Anatomy 2 1.2 ENT Examination 8 1.3 The Pinna 14 1.4 External Ear Canal 18 1.5 Otitis Media with Effusion 24 1.6 Acute Otitis Media 28 1.7 Chronic Otitis Media 34 1.8 Facial Nerve Paralysis 41 1.9 Complications of Otitis Media 43 1.10 Hearing Loss 45 1.1 Otalgia 48 1.12 Temporal Bone Fractures 50 1.13 Tinnitus 52 1.14 Vertigo 54

Chapter 2 Nose

2.1 The Common Cold and the Flu 58 2.2 Rhinitis 60 2.3 Allergic Rhinitis 65 2.4 Nasal Vestibulitis and Nasal Furunculosis and Mucormycosis 69

2.5 Sinusitis 72 2.6 Complications of Sinusitis 79 2.7 Nasal Polyposis 87 2.8 Nasal Obstruction 92 2.9 Septum 97 2.10 Epistaxis 101 2.1 Traumas 104 2.12 Dacryocystorhinostomy 110 2.13 Tumors 112

Chapter 3 Throat & Neck

3.1 Acute Tonsillopharyngitis 122 3.2 Adenoids 126 3.3 Snoring 129 3.4 Temporomandibular

Joint 132 3.5 Airway Obstructions 134 3.6 Hoarseness 137 3.7 Cysts 143 3.8 Parotid Tumors 147 3.9 Oral Cavity 151 3.10 Neck Masses 159 3.1 Neck Malignancies 168

1.1 Ear Anatomy 2

1.2 ENT Examination 8 1.3 The Pinna 14

1.4 External Ear Canal 18

1.5 Otitis Media with Effusion 24

1.6 Acute Otitis Media 28

1.7 Chronic Otitis Media 34 1.8 Facial Nerve Paralysis 41

1.9 Complications of Otitis Media 43 1.10 Hearing Loss 45

1.1 Otalgia 48 1.12 Temporal Bone Fractures 50

Chapter 1

2 Chapter 1 Ear

1.1 Ear Anatomy a c

Malleus Incus

Stapes Styloid

Stylohyoid ligament

Hyoid bone

Fig. 1.1.1 (a) The ear is divided into three compartments: external, middle, and inner. The pinna is composed of cartilage covered by skin. The shape of the cartilage is very important, since it gives the shape of the auricle. Any necrosis of the cartilage may lead to cosmetic deformity. The external auditory canal measures approximately 2.5 cm. The outer one-third is cartilaginous and the inner two-thirds is bony. There is a narrowing at the bone–cartilage junction which causes foreign bodies to get stuck in this area. The skin of the bony part is very thin lying on the periosteum and does not contain glands, hair follicles, and any adnexal structures. There are two or three fissures in the cartilaginous external auditory canal which are called “Santorini fissures.” These fissures provide a potential route for the spread of infection from the external ear to the parotid area or infratemporal fossa and also of tumors from the parotid area to the external ear. The eustachian tube connects the middle ear to the nasopharynx. The posterior one-third of the adult eustachian tube is bony and lies within the petrous portion of the temporal bone. The anterior two-thirds is cartilaginous. In adults the tube lies at an angle of 45° in relation to the horizontal plane, whereas this inclination is only 10° in infants. The tube is longer in the adult than in the infant and young child. (b) Illustration showing the organs of hearing and the cerebellum. Sound waves are channeled by the pinna (visible part of the ear) into the auditory canal (pink) toward the eardrum. The eardrum transmits the vibrations to three tiny bones – the malleus, incus, and stapes – in the middle ear. The stapes passes the vibrations to the inner ear structures (purple), the semicircular canals and the cochlea (spiral). Auditory sensations are picked up by the cochlear nerve (yellow) and transmitted to the medulla (brainstem), the thalamus, and ultimately the cerebral cortex (visual photos). (c) The external and middle ear develop from the branchial apparatus. The middle ear cavity is derived from the endodermal first branchial cleft. The inner ear develops from the otic placode. The first arch, or Meckel’s cartilage, contributes to the malleus and the incus. The tensor tympani muscle derives from the first branchial arch and is innervated by the nerve of the first branchial arch, which is mandibular branch of the trigeminal nerve. The second branchial arch, or Reichert’s cartilage, contributes to the suprastructure of the stapes. The stapes muscle is innervated by a facial nerve, which is the nerve of the second branchial arch. The chorda tympani nerve, a branch of the facial nerve (second arch nerve), joins the first arch nerve to the mandibular lingual nerve. The footplate of the stapes is derived from the otic capsule. Thus, a congenital abnormality can occur in one part while the other parts may develop normally

1.1 Ear Anatomy 3

Fig. 1.1.3 The external auditory canal is not straight. To see the tympanic membrane, the ear canal should be straightened by pulling the auricle posteriorly and superiorly in adults (but inferiorly in infants)

Fig. 1.1.2 The innervation of the auricle is by the greater auricular nerve (C3), the lesser occipital nerve (C2, 3), the auriculotemporal nerve (V3), and sensorial branches of the VII and X cranial nerves

Fig. 1.1.4 (a, b) The tympanic membrane is elliptical and slightly conical in shape. The apex of this cone, the umbo, marks the inferior part of the manubrium. The diameter of the tympanic membrane measures approximately 9 m (9–10 vertical; 8–9 horizontal). The surface area is 85–90 m. The tympanic membrane is composed of three layers: an outer epidermal layer, an inner mucosal layer, and a middle fibrous layer. The area above the short process of the malleus is known as pars flaccida and the area below as pars tensa. The pars flaccida does not have a middle fibrous layer, therefore it is flaccid. The pars tensa thickens peripherally forming the tympanic annulus. The tympanic annulus does not exist superiorly around the pars flaccida. There is a light triangle in the anterior–inferior quadrant of the tympanic membrane. The position of this triangle changes superiorly and becomes shorter when the tympanic membrane is retracted

Light cone b

4 Chapter 1 Ear

Fig. 1.1.6 Due to the differences in the physical properties of air and water, sound vibrations in the air are largely reflected away from the surface of water (9.9% of the energy of air-borne sound is reflected away), with only 0.1% entering the water. Although the surface area of the tympanic membrane is 85–90 m, the effective vibrating area of the tympanic membrane is 5 m. The surface area of the footplate is 3.2 m. The ratio of the surface areas of the tympanic membrane and the footplate is 5/3.2 = 17.1. This represents the hydraulic ratio of the tympanic membrane and stapes footplate, producing an increase force at the oval window of 17 times for the human ear, since the sound pressure level is equal to the force divided by the surface area (P = F/a). The final transformer ratio of the human tympanic membrane and ossicular chain is the product of the lever ratio of 1.3 times the hydraulic ratio of 17, which equals 2. This gain compensates the loss due to the air–bone difference

Fig. 1.1.5 False-color scanning electron micrograph (SEM) of the three smallest bones in the human body responsible for conduction of sound waves in the middle ear. At the top left is the malleus (hammer), which strikes the incus (anvil – right of malleus); the incus is joined to the stapes (stirrups), which conducts sound toward the inner ear. Sound waves enter the ear through the external auditory meatus and cause the eardrum to vibrate. Vibrations from the eardrum are passed to the malleus and then the stapes via the incus. The stapes transmits the vibrations to the fluid-filled cochlea of the inner ear where the vibrations are converted to nerve impulses. Lever effect: the manubrium mallei is 1.3 times longer than the long process of the incus. This difference in the lengths of the manubrium mallei and long process of the incus contributes a lever factor of 1.3 to increase the intensity of the sound (visual photos)

1.1 Ear Anatomy 5

Fig. 1.1.8 The inner ear comprises the cochlea and the labyrinth. The labyrinth consists of three semicircular canals (superior, posterior, and lateral) and two otolithic organs (utricle and saccule). The utricular duct and the saccular duct join to form the endolymphatic duct

Fig. 1.1.9 The cochlea has three fluid-filled compartments: the scala tympani, the scala vestibuli, and the scala media, which contains the organ of Corti (courtesy of Paparella, Paparella otopathology lab director) a b

Fig. 1.1.7 (a–c) The temporal bone contains the ear. It has five parts: the bony external ear canal, the styloid process, the squamous portion, the petrous portion, and the mastoid process. There are suture lines between these various portions such as the petrotympanic fis- sure, petrosquamous suture, tympanosquamous suture, tympanomastoid suture etc. The mastoid process is not present at birth, which makes the facial nerve very superficial

6 Chapter 1 Ear

Fig. 1.1.10 Inner ear organ of Corti. Color SEM of a section through the human inner ear, showing the organ of Corti (spiral organ). At the top right can be seen four rows of hair cells, supported by pillar-like Dieter cells. Each hair cell contains up to 100 individual hairs. The hairs translate mechanical movement caused by their displacement by sound waves into electrical impulses, which are transmitted to the brain via the cochlear nerve (visual photos)

Fig. 1.1.1 Sensory hair cells in the ear. Color SEM of hair cells in the cochlea, the inner ear’s auditory sense organ. The crescent-shaped areas across the center are numerous stereocilia, and are located on top of supporting hair cells. Sound waves entering the inner ear displace the fluid that surrounds the stereocilia, causing them to bend. This triggers a response in the hair cells, which release neurotransmitter chemicals that generate nerve impulses. The nerve impulses travel to the brain along the auditory nerve. This process can transmit information about the loudness and pitch of a sound. Magnification: ×2,0 when printed 10 cm wide (visual photos)

1.1 Ear Anatomy 7

Fig. 1.1.12 Balancing stone from inner ear. Color SEM of crystals of calcium carbonate on the surface of an otolith. An otolith or otoconium is a calcified stone that is found in the otolith organs of the inner ear. They are attached to sensory hairs, and, when the head tilts, the movement of the stones causes nerve impulses that form the basis of the sense of balance. In humans, otoconia can range in size from 3 to 30 µm (millionths of a meter) across (visual photos)

Anatomic features of the ETInfantsAdults Length of tubeShorterLonger Lumen Smaller Wider Angle of tube to horizontal plane10°45° Mucosal folds Greater Lesser

Table 1.1.1 Differences between anatomy of the eustachian tube (ET) in infants and adults

8 Chapter 1 Ear

1.2 ENT Examination

Tuning Fork Tests

Weber Test

Tuning fork tests are generally performed with a 512-Hz fork. The vibrating fork is placed on the patient’s forehead. Sound lateralized to the poor hearing ear indicates a conductive hearing loss. Sound lateralized to the better hearing ear suggests a sensorineural hearing loss in the opposite ear.

Rinne Test

The vibrating fork is placed first on the mastoid bone. When the patient no longer hears, the tuning fork is brought 1 cm away from the external meatus. The result is expressed as “Rinne positive” when sound is heard longer by air, and “Rinne negative” when sound is heard longer by bone. Normally the sound of the fork is perceived louder when placed in front of the ear canal (Rinne positive).

False Rinne

When the fork is placed on the bone, the vibrations are conducted by bones of the skull to both cochleas. A patient with a total loss of hearing in one ear can hear the sound in the better ear by bone cross-conduction if the fork is placed on the mastoid bone of the diseased ear. The patient does not hear when the fork is brought in front of the external meatus after sound is no longer heard by mastoid bone conduction. The result is reported as a negative Rinne indicating the presence of conductive hearing loss, when in fact a false-negative Rinne has occurred.

Fig. 1.2.1 Pathologies in the external and middle ear cause conductive hearing loss

Fig. 1.2.2 Pathologies in the inner ear and the hearing nerve cause sensorineural hearing loss

(Parte 1 de 4)