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4/4/12 Anatomy of external auditory canal a review Ent Scholar

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Anatomy of external auditory canal a review
From otolaryngologist's perspective
April 3, 2012 Otology
Theexternalauditorycanalistheonlyskinlinedculdesacinthewholehumanbody.Itisknownto
performbothauditoryandnonauditoryfunctions.Theauditoryfunctionisthatitpermitsefficient
soundtransmissionfromtheenvironmenttothetympanicmembrane,selfmaintenanceofaclear
passagefortransmissionofsound.Itsnonauditoryfunctionsincludeprotectionofthemiddleearand
innerearfromtraumaandenvironmentalinsults.Thisarticledwellsindepthabouttheentiregamut
ofanatomyofexternalauditorycanal.
Introduction:
Theexternalauditorycanalistheonlyskinlinedculdesacinthewholehumanbody.Itisknownto
performbothauditoryandnonauditoryfunctions.Theauditoryfunctionisthatitpermitsefficient
soundtransmissionfromtheenvironmenttothetympanicmembrane,selfmaintenanceofaclear
passagefortransmissionofsound.Itsnonauditoryfunctionsincludeprotectionofthemiddleearand
innerearfromtraumaandenvironmentalinsults .
Fig.1:Figureshowingexternalauditorycanal
Embryology:
Theexternalcanalarisesfromthefirstbranchialcleftwhichissituatedbetweenthemandibularand
hyoidarches .Thefirstbranchialclefthasadorsalandventralcomponents.Theexternalcanal
Abstract
Anatomy of external auditory canal a review
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Authors
BalasubramanianThiagarajan
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arisesfromthedorsalcomponentwhiletheventralcomponentdisappears.Iftheventralportion
persiststhenitresultsintheformationoffirstbranchialcleftcyst .Tostartwiththeectodermofthe
firstcleftisindirectcontactwiththeendodermofthefirstpharyngealpouch,whichlatertransforms
intothemiddleearcavity.Bythefifthweekofdevelopment,mesodermisfoundgrowingbetweenthe
twolayers.Bythe8thweekofgestationprimaryexternalmeatusisformedwhenthefirstbranchial
cleftdeepenstowardsthetympaniccavity.Thisprimarymeatuscorrespondtothelateralthirdofthe
externalauditorycanal.Thisportionislatersurroundedbycartilagewhichisformedfromthe
surroundingmesoderm.Theectodermofthefirstbranchialgroovethickenandgrowmedially
towardsthetympaniccavityresultingintheformationofameatalplugorplate.Thismeatalplug
remainssoliduntilthe21stweek .Themeatalplugstartstohollowoutwhenitsinnercellsstartto
degenerate.Theexternalauditorycanalisfullycanalizedbythe28thweek .Themostmedialcells
oftheepithelialplugbecometheouterlayerofthetympanicmembrane.
Figureshowingcoronalviewofembryonicexternal
auditorycanal6thweek
Figureshowingcoronalviewofembryonicexternal
auditorycanal9thweekF
Atbirth,thetympanicmembrane,ossiclesandoticcapsuleareallofadultsize, butchangesdo
occurtotheexternalcanaltillabout9yearsofage.Inneonatesthetympanicmembraneandthe
squamousportionofthetemporalboneformtheroofoftheexternalcanal.Thetympanicringisnot
completelyfusedinferiorly,andaportionoftheflooroftheexternalcanaliscomposedofthenon
ossifiedlaminafibrosa.Thetympanicringiscompletelyfusedinferiorlybythesecondyear.Complete
ossificationofthelaminafibrosaiscompletedbythethirdorfourthyear.Failureofcomplete
ossificationintheanteroinferiorcanalresultsinabonygapknownastheforamenofHuschke.The
shapeoftheexternalcanalinaneonateisnearlystraight.Bytheageof9theexternalcanalhas
elongatedandnearlyofadultsize.
Anatomy:
Theadultexternalcanalisdividedintoanoutercartilaginousportioninitsouter1/3andbonyportion
initsinner2/3.Itmeasuresabout2.5cmsonthewhole.Theposterosuperiorwalloftheexternal
canalmeasures25mmwhereasitsanteroinferiorwallisslightlylongeri.e.measuringabout31mm
becauseoftheanteroinferiorinclinationoftheeardrum.Thecartilaginoussectionoftheexternal
canalisangledposterosuperiorly,whilethebonycanalisinclinedanteroinferiorly.These
angulationsgivethecanalasshapedcourse.Thecartilaginouscanalcanbestraightenedbypulling
thepinnaposterosuperiorlyenablingbettervisualisationoftheeardrum.
Figureshowingcoronalsectionofexternalcanalofaninfant.Theeardrumisnearlyhorizontalformingthe
medialportionofexternalcanal
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Thecondyleofthemandibleandglenoidfossaproduceaconvexityintheanteriorbonycanalwall
limitingthevisualisationoftheeardrum.Thisprominenceandthedepthoftheanteriortympanic
sulcuspredisposeforeignbodyentrapmentintheanteroinferiorportionofthemedialendofthe
externalcanal.Thenarrowestportionoftheexternalcanalisatthebonycartilaginousjunction.The
volumeoftheexternalcanalisabout0.85ml .
Theouterthirdoftheexternalcanalissurroundedbyanincompletecylinderofcartilage.This
cartilageisdeficientinitssuperiorportion.Thisdefectisbridgedbydensefibroustissuethatis
attachedtothesquamousportionofthetemporalbone.Laterallythiscartilagenousportionis
continuouswiththeconchalandtragalcartilage.Thiscartlageisattachedmediallytothebonycanal
wallwithdenseconnectivetissue.Inthecartilagenousportionanteroinferiorlyaretwohorizontal
fissuresinthecartilagenouscanaltermedthefissuresofsantorini.Thesefissuresrendermore
flexibilitytotheexternalcanal.Italsoservestoallowinfectionsandtumortopassbetweenthe
externalcanalandtheparotidgland.
Figureshowingtheorientationofexternalauditory
canalcartilage
Thebonycanaliscomposedofacompletecylinderofboneextendinglaterallyfromtheeardrum.
Theanteriorandinferiorwallsarecomposedofthetympanicportionofthetemporalboneandthe
superiorandposteriorwallsareformedbythesquamousandmastoidportionsofthetemporalbone.
Abonyridge,thetympanomastoidsuturelineisevidentintheposteriorinferiorportionofthecanal
wallduringsurgicalprocedureslikeelevationofthetympanomeatalflap.
Bloodsupplyofexternalauditorycanal :
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Laterallysuppliedbythepostauricularandsuperficialtemporalarteries.Mediallyitissuppliedby
deepauriculararterywhichisabranchoffirstportionoftheinternalmaxillaryartery.Thisdeep
auriculararterysuppliesthetympanicvascularring.Veinsfromtheexternalcanaldrainintothe
superficialtemporalandpostauricularveins.Thepostauricularveinconnectstothesigmoidsinus
viathemastoidemissaryvein,thisanastomosisprovidearouteforinfectionsoftheexternalearto
spreadtotheintracranialcavity.
Lymphaticsgenerallyfollowtheveinsanddrainintotheparotidgroupofnodes .
SensoryInnervation:
Sinceitoriginatesfrombranchialarchitisinnervatedby5th,7th,9thand10thcranialnerves.
Auriculotemporalbranchofthemandibularnerveinnervatestheanteriorportionofthepinna,tragus,
andtheanteriorwalloftheexternalcanal.Thewelloftheconchaandtheposteriorwallofthe
externalcanalreceiveinnervationfromthe7th,9th,and10thcranialnerves.Thiscomplex
innervationoftheexternalcanalaccountsforseveralclinicalfindingsinvolvingtheexternalcanal:i.e.
vesiculareruptionintheskinoftheexternalcanalwithfacialpalsyiscausedbyherpeticinfectionof
thegeniculateganglionisknownastheRamsayHuntsyndrome.Hypesthesiaoftheconchaand
externalcanalcausedbyfacialnervecompressionfromcerebellopontineangletumorsisknownas
Hitselbergerssign.Instrumentationoftheexternalcanalcancausenauseaorcoughingthrough
stimulationofthevagusnerveviatheArnoldsnerve.
Histology:
Theexternalcanalislinedentirelybykeratinisingstratifiedsquamousepithelium.Thisepitheliumisin
continuitywiththelateralsurfaceofthetympanicmembrane.Thereismarkeddifferencesinthe
morphologyoftheskinasoneprogressesfrommedialtolateralintheexternalcanal.Theskinlining
thebonycanalisverythin,measuringabout3050micronsinthickness.Thereteridgesareabsent
intheskinliningthebonyportionoftheexternalcanal.Theskinherealsolackshairandother
appendages.Theskinhereislooselyadherenttotheunderlyingbone,facilitatingeasyelevation
duringsurgery.
Figureshowingthehistologyofskinliningthe
cartilagenousportionofexternalcanal
Theskinoverthecartilagenouscanalismuchthickerandmoreadherentthantheskinofthebony
canal.Ithasnumeroushairsaswellassebaceousandceruminousglands.Therearenoeccrine
sweatglandsintheexternalcanal.Theskinliningtheexternalcanalistheonlykeratinising
epitheliumthatlackseccrineglands.Thehairsaremostnumerousatthelateralendofthecanal,
becominglessnumerousmediallyandtotallyabsentfromthebonycartiagenousjunction.
Thesebaceousglandsaresimpleorbranchedalveolarglandsemptyingtheirsecretionsinthethe
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Likethis:
Bethefirsttolikethisarticle.
baseofthehairfollicles.Theseglandsareinfactnotcapableofactivesecretionsbuttheyformtheir
secretionbypassivebreakdownofcells.
Ceruminousglandsaremodifiedapocrinesweatglands.Thereareapproximately10002000
ceruminousglandsinanear.Theseglandsaretubularandhaveductsthatopeneitherintohair
folliclesordirectlyontotheskinsurface.Theindividualceruminousglandisasimplecoiledtubular
gland.Theglandularepitheliumiscuboidalorcolumnarandhassecretorybudsextendingtothe
lumenofthetubule.
Figureshowinghistologyofdeepcanalwallskin
Theexternalcanalprovidesidealconditionforgrowthofmicroorganismsbecauseofitswarmth,
darkness,moisture,andpresenceofdebrisandnutrients.Henceitcouldevenbetermedasaskin
linedculturetube.Thenormalfloraoftheexternalcanalisstableandshownosignificantdifference
withregardtosex,climateorseasonetc.
1. Stenstrm,J.Sten:DeformitiesoftheearIn:Grabb,W.,C.,Smith,J.S.(Edited):PlasticSurgery,
Little,BrownandCompany,Boston,1979,ISBN0316322695(C),ISBN0316322687
2. http://www.drtbalu.co.in/anat_extca.html
3. KennanM.A.Embryologyanddevelopmentalanatomyoftheear.In:BluestoneCD,StoolE(eds).
Paediatricotolaryngology,Saunders,Philadelphia.19907787.
4. BelucciR.JCongenitalauralmalformations:diagnosisandtreatmentOtolaryngolClinNorthAm
198114:95124
5. YNishimura,TKumoiTheembryologicdevelopmentofthehumanexternalauditorymeatus.
Preliminaryreport.ActaOtolaryngol.:1992,112(3)496503PMID:1441991
6. ChiarellaSforza,GaiaGrandi,MiriamBinelli,DavideGTommasi,RiccardoRosati,VirgilioF
FerrarioAgeandsexrelatedchangesinthenormalhumanear.ForensicSci.Int.:2009,187(1
3)110.e17PMID:19356871
7. BlackbourneLH,AntevilJ,MooreC,eds.AnatomyRecall.Philadelphia,Pa:LippincottWilliams&
Wilkins2000.
Like
References
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5/6/12 Atrophic rhinitis Ent Scholar


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Atrophic rhinitis
A review
March 3, 2012 Rhinology
Atrophicrhinitisisachronicembarrassingdebilitatingdiseaseinvolvingnasalcavityandparanasal
sinuses.Itischaracterizedbyfoulsmellingcrusts(greenish)insidethenasalcavity.Nasalmucosa
tendstobleedwhenthesecrustsareremoved.Nasalcavityappearstobeexcessivelyroomy.Foul
stenchemanatesfromthepatient.Patientismercifullyunawareofthisstenchbecauseofthe
presenceofanosmia.Thisarticlediscussesthevariousfeaturesofthisdiseaseandthevarious
managementmodalitiesavailable.
Introduction:
Atrophicrhinitisisdefinedasachronicnasaldiseasecharacterisedbyprogressiveatrophyofthe
nasalmucosaalongwiththeunderlyingbonesofturbinates.Thereisalsoassociatedpresenceof
viscidsecretionwhichrapidlydriesupformingfoulsmellingcrusts.Thisfetidodor isalsoknownas
ozaena.Thenasalcavityisalsoabnormallypatent.Thepatientisfortunatelyunawareofthestench
emittingfromthenoseasthisdisorderisassociatedwithmercifulanosmia .Thisdiseaseisrather
rareindevelopedcountries,butarerathercommonindevelopingcountries .Nowadaysitismore
commonasasequelaeofmedicalinterventions.Overzealousturbinatesurgeryhasbeenimplicated
asaprobableiatrogeniccause.
Synonyms:
Thefollowingarethevariousterminologiesusedtoindicatethesamecondition:
1.Rhinitissicca
2.Dryrhinitis
3.Ozena
4.Opennosesyndrome
5.Emptynosesyndrome
History:
ItwasSpenserWatsonofLondonwhofirstcoinedthetermOzenatodescribethiscondition.Hewas
thefirsttodescribeclinicalfeaturesofthisdisease.Heclassifiedthisdiseaseintomild,moderateand
severevarieties.MildvarietyofatrophicrhinitisaccordingtoWatsonischaracterizedbyheavy
crusting.Thesecrustscaneasilyberemovedbynasaldouching.Moderatevarietyfeaturesanosmia
andstenchemanatingfromthenasalcavity.Severevarietyisinvariablycausedbysyphilis.Bone
Abstract
Atrophic rhinitis a review
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BalasubramanianThiagarajan
5/6/12 Atrophic rhinitis Ent Scholar
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destructionandcosmeticdeformitiesofnoseisrathercommoninthisvariety. In1876DrBernhard
Fraenkelfirstdescribedtheclassictriadofsymptomswhichwasvirtuallydiagnosticofthisdisorder.
ThistriadisstillknownasFraenkelstriadinhishonorinclude:Fetor,CrustingandAtrophyofnasal
structures.FrankBosworthin1881notedthatBreathfromthesepatientswerenotonlyunpleasant
butvirtuallyunbearable.Thesuffererpersewasmercifullyunawarebecauseofthepresenceof
anosmia.
Etiology:
Theetiologyofthisproblemstillremainsobscure.Numerouspathogens havebeenassociatedwith
thiscondition,themostimportantofthemare:
1.Coccobacillus
2.Bacillusmucosus
3.Coccobacillusfoetidusozaenae
4.Diptheroidbacilli
5.Klebsiellaozaenae.
Theseorganismsdespitebeingisolatedfromthenoseofdiseasedpatientshavenotcategorically
beenprovedasthecauseforthesame.
Otherpredisposingfactorsinclude:
1.ChronicsinusitisSSali consideredatrophicrhinitistobeinfectiveinnature.Hereportedatrophic
rhinitisin7childrenofafamilyafterachildwithatrophicrhinitisspentanightintheirhouse.Common
organismisolatedfromnasalcavitiesofthesechildrenwasKlebsiellaozenae
2.Excessivesurgicaldestructionofthenasalmucosaandturbiantes
3.Nutritionaldeficiencies:Bernat in1965demonstratedthat50%ofpatientswithatrophic
rhinitisbenefitedwithirontherapy.Hansen demonstratedsymptomaticimprovementinmajorityof
thispatientswithatrophicrhinitiswhentreatedwithvitaminA.
4.Syphilis.
5.Endocrineimbalances(Diseaseisknowntoworsenwithpregnancy/menstruation)
6.Heredity:ThiswasfirstreportedbyBartonandSibert (Autosomaldominentpatternofinheritance
identified).
7.Autoimmunedisease
8.Developmental:Hagrass reportedshortenedAnteroPosteriornasallengthsandpoormaxillary
antralpneumatizationinpatientswithatrophicrhinitis.
9.Vascular:ExcesssympatheticactivitywasobservedinthesepatientsbyRuskin
Ageofonset:
Usuallyatrophicrhinitiscommencesatpuberty.
Sexpredilection:
Femalesaremorecommonlyaffectedthanmales
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ClassificationofAtrophicrhinitis:
Primaryatrophicrhinitis:Thisclassicformofatrophicrhinitisissupposedtoarisedenovo.Thisisin
factadiagnosisofexclusion.ThistypeofatrophicrhinitisiscommoninChina,IndiaandMiddleEast.
InalmostallthesepatientsKlebsiellaozenaehasbeenisolated.
Secondaryatrophicrhinitis:Thisisthemostcommonformofatrophicrhinitisseenindeveloped
countries.Inthistypethepredisposingcauseisclearlyevident.Commoncausesofsecondary
atrophicrhinitisinclude:
1.SurgicalproceduresinvolvingnoseandparanasalsinusesTheyincludeturbinectomies,sinus
surgeries,maxillectomyetc.
2.Irradiation
3.Trauma
4.Granulomatousdiseases:IncludeSarcoidosis,LeprosyandRhinoscleroma
5.Infections:Thisincludestuberculosisandsyphilis
Clinicalfeatures:
Thepresentingsymptomsarecommonlynasalobstructionandepistaxis.Anosmiai.e.mercifulmay
bepresentmakingthepatientunawareofthesmellemanatingfromthenose.Thesepatientsmay
alsohavepharyngitissicca.Chokingattacksmayalsobeseenduetoslippageofdetachedcrusts
fromthenasopharynxintotheoropharynx.Thesepatientsalsoappeartobedejectedanddepressed
psychologically.
Clinicalexaminationofthesepatientsshowthattheirnasalcavitiesfilledwithfoulsmellinggreenish,
yelloworblackcrusts,thenasalcavityappeartobeenormouslyroomy.Whenthesecrustsare
removedbleedingstartstooccur.
Whynasalobstructioneveninthepresenceofroomynasalcavity?
Thisinterestingquestionmustbeanswered.Thenasalcavityisfilledwithsensorynerveendings
closetothenasalvalvearea.Thesereceptorssensetheflowofairthroughthisareathusgivinga
senseoffreenessinthenasalcavity.Thesenerveendingsaredestroyedinpatientswithatrophic
rhinitisthusdeprivingthepatientofthissensation.Intheabsenceofthesesensationthenosefeels
blocked.
Radiologicfeaturesofatrophicrhinitis:
Radiologicfeaturesaresimilarforbothtypesofatrophicrhinitis.Plainxraysshowlateralbowingof
nasalwalls,thinorabsentturbinatesandhypoplasticmaxillarysinuses.
CTscanfindings:
1.Mucoperiostealthickeningofparanasalsinuses
2.Lossofdefinitionofosteomeatalcomplexduetoresorptionofethmoidalbullaanduncinate
process
3.Hypoplasticmaxillarysinuses
4.Enlargementofnasalcavitywitherosionofthelateralnasalwall
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5.Atrophyofinferiorandmiddleturbinates
Fig.1:CTscannoseandsinusesinapatientwithatrophicrhinitis
Histopathologicalfeatures:
1.Metaplasiaofciliatedcolumnarnasalepitheliumintosquamousepithelium.
2.Thereisadecreaseinthenumberandsizeofcompoundalveolarglands
3.Dilatedcapillariesarealsoseen
Pathologicallyatrophicrhinitishasbeendividedintotwotypes:
TypeI:ischaracterisedbythepresenceofendarteritisandperiarteritisoftheterminalarterioles.This
couldbecausedbychronicinfections.Thesepatientsbenefitfromthevasodilatoreffectsof
oestrogentherapy.
TypeII:ischaracterisedbyvasodilatationofthecapillaries,thesepatientsmayworsenwithestrogen
therapy.Theendothelialcellsliningthedilatedcapillarieshavebeendemonstratedtocontainmore
cytoplasmthanthoseofnormalcapillariesandtheyalsoshowedapositivereactionforalkaline
phosphatasesuggestingthepresenceofactiveboneresorption.Ithasalsobeendemonstratedthat
amajorityofpatientswithatrophicrhinitisbelongtotypeIcategory.
Management:
Conservative:
NasaldouchingThepatientmustbeaskedtodouchethenoseatleasttwiceadaywithasolution
preparedwith:
Sodiumbicarbonate28.4g
Sodiumdiborate28.4g
Sodiumchloride56.7g
mixedin280mloflukewarmwater.
Thecrustsmayberemovedbyforcepsorsuction.25%glucoseinglycerindropscanbeappliedto
thenosethusinhibitingthegrowthofproteolyticorganism.
InpatientswithhistologicaltypeIatrophicrhinitisoestradiolinarachisoil10,000units/mlcanbeused
asnasaldrops.
Kemecetineantiozaenasolutionispreparedwithchloramphenicol90mg,oestradioldipropionate
0.64mg,vitaminD2900IUandpropyleneglycolin1mlofsaline.
Potassiumiodidecanbeprescribedorallytothepatientinanattempttoincreasethenasalsecretion.
Systemicuseofplacentalextractshavebeenattemptedwithvaryingdegreesofsuccess.
5/6/12 Atrophic rhinitis Ent Scholar
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Surgicalmanagement:
1.Submucousinjectionsofparaffin,andoperationsaimedatdisplacingthelateralnasalwall
medially.ThissurgicalprocedureisknownasLautenslaugersoperation.
2.Recentlyteflonstrips,andautogenouscartilageshavebeeninsertedalongthefloorandlateral
nasalwallafterelevationofflaps.
3.WilsonsoperationSubmucosalinjectionof50%Tefloninglycerinpaste.
4.Repeatedstellateganglionblockshavealsobeenemployedwithsomesuccess
5.Youngsoperation Thissurgeryaimsatclosureofoneorbothnasalcavitiesbyplasticsurgery.
Youngsmethodistoraisefoldsofskininsidethenostrilandsuturingthesefoldstogetherthus
closingthenasalcavities.Afteraperiodof6to9monthswhentheseflapsareopenedupthe
mucosaofthenasalcavitieshavefoundtobehealed.Thiscanbeverifiedbypostnasalexamination
beforerevisionsurgeryisperformed.Modificationsofthisprocedurehasbeensuggested(modified
Youngsoperation)wherea3mmholeisleftwhileclosingtheflapsinthenasalvestibule.This
enablesthepatienttobreaththroughthenasalcavities.Itisbetterifthesesurgicalproceduresare
doneinastagedmanner,whilewaitingforonenosetohealbeforeattemptingontheotherside.
Atrophicrhinitisendoscopicview
1. ZoharY,TalmiYP,StraussM,etal.Ozenarevisited.JOtol19:3459,1990
2. http://www.drtbalu.co.in/atro_rhinitis.html
3. http://www.utmb.edu/otoref/grnds/AtrophicRhinitis050330/AtrophicRhinitis050330.htm
4. Atrophicrhinitisareviewof242casesMoore,EricJ.Kern,EugeneBAmericanJournalof
Rhinology,Volume15,Number6,NovemberDecember2001,pp.355361(7)
5. DudleyJP.Atrophicrhinitis:antibiotictreatment.AmJOtolaryngol8:38790,1987
6. SsaliCH.Atrophicrhinitis.Anewcurativesurgicaltreatment.JLaryngolOtol197387:397403.
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References
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7. Bernat,I.,Ozaena,Amanifestationofirondeficiency,OxfordPergmonPress(1965)
8. HansenC.Theozenaproblem:clinicalanalysisofatrophicrhinitisin100cases.ActaOtolaryngol
198293:4614
9. Primaryatrophicrhinitis:aninheritedcondition?R.P.E.Bartona1a3andJ.R.Siberta2The
JournalofLaryngology&Otology(1980),94:pp979983CopyrightJLO(1984)Limited1980DOI:
10.1017/S0022215100089738
10. HagrassMAE,GamaeAM,elSheriefSG,etal.Radiologicalandendoscopicstudyofthemaxillary
sinusinprimaryatrophicrhinitis.JLaryngolOtol106:7023,1992.
11. Young,A(May1967)."ClosureoftheNostrilsinAtrophicRhinitis".TheJournalofLaryngology&
Otology81(5):515524.doi:10.1017/S0022215100067426.PMID6024992
5/6/12 Blow out fracture orbit Endoscopic reduction Ent Scholar
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Blow out fracture orbit Endoscopic reduction
A Novel Management Modality
May 4, 2012 Rhinology
Blowoutfractureoforbitinvolvesfractureoforbitalfloorwithoutfractureofinfraorbitalrim.Thisinjury
iscommonfromfrontalblowtoorbit.Frontalblowtoorbitcausesincreasedintraorbitaltension
causingfractureofflooroftheorbit(weakpoint)withprolapseoforbitalcontentintothemaxillary
sinuscavity.Thiscausesenophthalmosanddiplopia.Infraorbitalrimisnotinvolvedinpureblowout
fracture,itisalsoinvolvedthenitshouldbeconsideredasanimpureblowoutfracture3.Entrapment
ofinferiorrectusmusclebetweenthefracturefragmentswillcausediplopiainthesepatients.This
articlediscussesanovelendoscopicinternalreductionoffracturedfragments.Mainadvantageof
endoscopicapproachisthelackoffacialskinincision.Itiscosmeticallyacceptable.
BlowoutfractureorbitEndoscopicreductionanovelmanagementmodality
Introduction:
OrbitalfloorfractureswerefirstdescribedbyMacKenzieinParisin1884 .Smithwasthefirstto
describeentrapmentofinferiorrectusbetweenthefracturefragments.Hewasalsothefirsttocoin
thetermBlowoutfracture .Blowoutfracturecausesanincreaseintheintraorbitalvolume,this
causesenopthalmos.Entrapmentofinferiorrectusmusclecausesdiplopia.Thesepatientsusually
reporttoanopthalmologistsinceorbitalsignsandsymptomsarepredominant.Shereetalintheir
studyconcludethatnearly14%ofblowoutfracturesarecausedbycontactsportsinamilitary
population .
CaseReport:
30yearsoldmalepatientcamewithcomplaintsof:
Clinicalphotographofapatientwithblowoutfracture
orbitshowingorbitalswelling
Abstract
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BalasubramanianThiagarajan
5/6/12 Blow out fracture orbit Endoscopic reduction Ent Scholar
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1.Swellingrighteye1dayduration
2.Doublevision1dayduration
3.Bleedingfromrightnose1dayduration
Historyofinjuryonbeingstruckbyacricketball+
Hegavenohistoryoflossofconsiousness.
Onexamination:
Swellingoverupperandlowereyelidsontherightside+
Enopthalmosrighteye+
Ocularmovementsrestrictedonrightgaze
Diplopia+
Forcedductiontest+
CTscannoseandparanasalsinuses:
CoronalCTplainofnoseandsinusesshowingblow
outfracturerightorbit(classicteardropsign)
Showedevidenceofblowoutfracturerightorbit.Teardropsigncouldbeseen.
Management:
ReductionwasperformedviaCaldwelLucapproachunderendoscopicguidance.4mm30degree
nasalendoscopewasusedforthispurpose.Trapdoorfracturescanusuallybereducedwithout
resortingtoprosthesis.Sincethispatienthadatrapdoorfractureitcouldbeeasilyreducedunder
endoscopicguidance.Thereducedfracturefragmentwasstabilizedbyinflatingtheballoonoffoleys
catheterintroducedintothemaxillarysinusviainferiormeatalantrostomy.Foleyscatheterisleftin
placeforaperiodof2weeksforuniontooccur.
Pictureshowingfoleyscatheterbeingintroducedintothemaxillaryantrumviainferiormeatalantrostomy
5/6/12 Blow out fracture orbit Endoscopic reduction Ent Scholar
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Pictureshowinginflatedfoleyscatheterinsidethe
maxillaryantrum
Discussion:
Orbitalblowoutfractureiscommonlycausedbyblunttraumatotheorbit.Thisiscommonlyseenin
personsinvolvedincontactsportslikeboxing,football,rugbyetc .
Twotheoriesattempttoexplainthisinjuryphenomenon:
1.Bucklingtheory
2.Hydraulictheory
Bucklingtheory:
Thistheoryproposedthatifaforcestrikesatanypartoftheorbitalrim,theseforcesgets
transeferredtothepaperthinweakwallsoftheorbit(i.e.floorandmedialwall)viaripplingeffect
causingthemtodistortandeventuallytofracture.ThismechanismwasfirstdescribedbyLefort3.
Hydraulictheory :
ThistheorywasproposedbyPfeifferin1943.Thistheorybelievesthatforblowoutfracturetooccur
theblowshouldbereceivedbytheeyeballandtheforceshouldbetransmittedtothewallsofthe
orbitviahydrauliceffect.Soaccordingtothistheoryforblowoutfracturetooccurtheeyeballshould
sustaindirectblowpushingitintotheorbit.
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WaterHouse in1999didadetailedstudyofthesetwomechanismsbyapplyingforcetothe
cadavericorbit.Heinfactusedfreshunfixedcadaversfortheinvestigation.Hedescribedtwotypesof
fractures:
TypeI:Asmallfractureconfinedtotheflooroftheorbit(actuallymidmedialfloor)withherniationof
orbitalcontentsintothemaxillarysinus.Thisfracturewasproducedwhenforcewasapplieddirectly
totheglobe(Hydraulictheory).
TypeII:Alargefractureinvolvingthefloorandmedialwallwithherniationoforbitalcontents.This
typeoffracturewascausedbyforceappliedtotheorbitalrim(Bucklingtheory).
DiagrammaticrepresentationofBucklingtheory
Initialsignsandsymptomsofblowoutfractureinclude:
1.Immediateswellingoftheeye
2.Tendernessoverinvolvedorbit
3.Painanddifficultywitheyemovements
4.Doublevision
5.Enopthalmos
6.Numbness/tinglingoverlowereyelid,nose,upperlip
Complicationsofblowoutfracture:
1.Herniationoforbitalfatintomaxillarysinus
2.Orbitalemphysema
3.Bleedingintomaxillarysinus
4.Entrapment/ruptureofocularmuscles
5.Ischaemicmusclecontractures
6.Cellulitis
7.Diplopia
Timingforsurgicalintervention:
Thisishighlycontroversial.Someoftheauthorspreferawaitingperiodofatleast2weeksforthe
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oedematoresolvebeforeproceedingwithsurgicalreductionofthefracture.Earlyinterventionis
indicatedonlyinwhiteeyedblowoutfracturewhichiscommoninchildren.Inchildrenthebonesare
flexibleanddoesnotbreakeasilybutbends.Significantamountsoforbitaltissuemaygetentrapped
inbetweenthefracturedfragmentscausingacompromiseintheirbloodsupply.Thisconditionis
knownasthewhiteeyedblowoutfracture.Thesepatientsshouldundergoimmediatereduction.
Surgeryisindicatediftheeyehasrecessedbymorethan2mmintotheortbit,ocularmovements
restricted,persistenceofdiplopia.
Advantagesofendoscopicapproach:
1.Accuratefracturevisualization
2.Incisionsaresmall
3.Facialincisionscanbeavoided
4.Minimalsofttissuedissection
5.Hospitalstayminimized
6.Cosmeticallyacceptable
1. 1.NgP,ChuC,YoungN,SooM.Imagingoforbitalfloorfractures.AustralasRadiol.Aug
199640(3):2648
2. 2.SmithB,ReganWFJr.Blowoutfractureoftheorbitmechanismandcorrectionofinternal
orbitalfracture.AmJOphthalmol.Dec195744(6):7339
3. http://www.drtbalu.com/blow_out.html
4. 4.ShereJL,BooleJR,HoltelMR,AmorosoPJ.Ananalysisof3599midfacialand1141orbital
blowoutfracturesamong4426UnitedStatesArmySoldiers,19802000.OtolaryngolHeadNeck
Surg.2004130:164170
5. 5.BurmJS,ChungCH,OhSJ.Pureorbitalblowoutfracture:newconceptsandimportanceof
medialorbitalblowoutfracture.PlastReconstrSurg.1999103:18391849.
6. 6.RheeJS,KildeJ,YoganadanN,PintarF.Orbitalblowoutfractures:experimentalevidencefor
thepurehydraulictheory.ArchFacialPlastSurg.20024:98101.
7. 7.WaterhouseN,LyneJ,UrdangM,GareyL.Aninvestigationintothemechanismoforbital
blowoutfractures.BrJPlastSurg.199952:607612.
8. 8.MooreKL.ClinicallyOrientedAnatomy.3rded.Baltimore,MD:Williams&Wilkins1992.
9. 9.GilbardSM.Managementoforbitalblowoutfractures:theprognosticsignificanceofcomputed
tomography.AdvOphthalmicPlastReconstrSurg.19876:269280
10. 10.KaiserPK,FriedmanNJ,PinedaR.TheMassachusettsEyeandEarInfirmaryIllustrated
ManualofOpthalmology.2nded.Philadelphia,PA:Saunders2004
11. 11.LismanRD,SmithBC,RodgersR.Volkmannsischemiccontracturesandblowoutfractures.
AdvOphthalmicPlastReconstrSurg.19877:117131.
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References
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12. 12.IkedaK,SuzukiH,OshimaT,TakasakaT.Endoscopicendonasalrepairoforbitalfloor
fracture.ArchOtolaryngolHeadNeckSurg.Jan1999125(1):5963.
5/6/12 Cystic fibrosis Ent Scholar
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Cystic fibrosis
February 19, 2012 Otology
Cysticfibrosisisanautosomalrecessivedisorderaffectingtheexocrineglands.Itcausesthe
secretionsfromtheseglandstobecomethickandviscous.Thereisatendencytoinvolvemultiple
organsystems.Thisarticlediscussestheetiopathogenesis,clinicalfeaturesandmanagementofthis
problem.
Introduction:
Cysticfibrosisisanautosomalrecessivedisorderaffectingtheexocrineglands.Itcausesthe
secretionsfromtheseglandstobecomethickandviscous.Thereisatendencytoinvolvemultiple
organsystems.Commonlyinvolvedorgansystemsinclude:Nose,paranasalsinuses,gastrointestinal
tract,skinandreproductivesystem.Theincidenceisratherhighincaucasians.Figuresreportedfrom
UnitesStatesisabout1per2500livebirths .Thishighincidencehasbeenattributedtoimproved
diagnostictools.Chronicrhinosinusitisandnasalpolyposisarerathercommoninthesepatients.
Studiesrevealthattheextentofsinusdiseasemayhaveabearingonpulmonarysymptoms .
Pathophysiologyofcysticfibrosis:
Cysticfibrosisiscausedduetodefectsinvolvingcysticfibrosisgenewhichcodesfortransmembrane
conductanceregulatorprotein(CFTR)whichfunctionsaschloridechannel.Thischloridechannelis
regulatedbyCyclicAMP.Mutationsinvolvingcysticfibrosistransmembraneconductanceregulator
proteinresultsinabnormalitiesinvolvingchloridetransportacrossepithelialcells/mucosalsurfaces.
SixtypesofdefectsinvolvingCFTRgeneshavebeenidentifiedincysticfibrosis .
CompleteabsenceofCFTRproteinsynthesis
DefectivematurationandearlydegradationofCFTRprotein(themostcommonmutation)
DisorderedregulationduetodecreasedATPbindingandhydrolysis
Defectivechlorideconductance
Diminishedtranscriptionduetopromoterorsplicingabnormality
Acceleratedchannelturnoverfromthecellsurface
CFTRmutationshaveverypoorpenetrance.Thisindicatesthatgenotypedoesnotpredictthe
severityofthedisorder.
DefectiveCFTRcausesdecreasedsecretionofchlorideandincreasedreabsorptionofsodiumand
wateracrossepithelialcells.Thiscausesareductionintheheightoffluidliningtheepithelium.
Abstract
Cystic fibrosis
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BalasubramanianThiagarajan
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Thereisalsoassociateddehydrationofmucincausingittothikcn.Italsoprovestobemorestickier
thannormalmucoussecretion.Bacteriagetsadherenttothismaterialcausingsmoulderinginfection.
Secretionsintherespiratorytract,Gastrointestinaltractandsweatglandsareincreasedinviscosity
makingitdifficulttoclear.
Clinicalmanifestationsofcysticfibrosis:
Thisisdependentontheorgansinvolved.Probabledisordersinclude:
Nasalpolyposis
Sinusitis
Chronicdiarrhoea
Rectalprolapse
Pancreatitis
Cholelithiasis
Cirrhosisofliver
Pathophysiologyofsinusitisinpatientswithcysticfibrosis:
Exactmechanismisstillnotclear.Sincechlorideionscannotbeexcretedsodiumionsgets
reabsorbedexcessively.Thisincreasesthethicknessandviscosityofthemucousblanket.Normal
ciliapresentinthenoseandparanasalsinusesfinditdifficulttopushthisviscidsecretionsoutofthe
sinus/nasalcavities .Thiscausesaccumulationofmucinwithinthesinuscavity.Thisaccumulated
mucinisanexcellentculturemediumforcolonizingbacteria.Thisisoneofthemajorreasonschronic
sinusinfectionsinthesepatients.
Otherfeaturespredisposingtosinusinfectionsinthesepatientsinclude:
Ciliarydysfunction
Increasedsecretionofinflammatorymediators
Pseudomonasaeruginosacolonization
Pseudomonascolonizationofnasalcavityiscommonlyreportedinpatientswithcysticfibrosis
associatedwithnasalpolypi,whereasitisnotsocommoninpatientswithcysticfibrosiswithoutnasal
polyposis .Pseudomonasorganismsproducetoxinswhichhasdeleteriouseffectsonthenormal
ciliarybeat.Thesetoxinsinclude:HemolyzinandPyocyanin.OutofthesetwotoxinsPyocyaninslows
downtheciliarybeatappreciablycausingmucinstasiswithinnoseandparanasalsinuses.Pyocyanin
hasbeensuspectedtoplaysomeroleinthedevelopmentofnasalpolyposisinthesepatients .
Roleofallergyinthepathophysiologyofnasalpolyposisinpatientswithcysticfibrosis:
Roleofallergyinthepathophysiologyofnasalpolyposisinpatientswithcysticfibrosisisstillnotclear.
Statisticalprevalanceofatopyinpatientswithcysticfibrosisdoesnotdiffersignificantlybetween
thosewithnasalpolyposisandthosewithoutnasalpolypi .Howevercurrentstudiesrevealthat
patientswithcysticfibrosiswhomanifestwithpositiveskinpricktesthavebeenfoundtobecommonly
colonizedbypseudomonas.Asstatedpreviouslypseudomonascolonizationhasaroletoplayinthe
pathophysiologyofdevelopmentofnasalpolypiinthesepatients.Henceithasbeenwidely
postulatedwhetheritistheallergicreactionperseorallergicreactiontofungicouldbethecausefor
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nasalpolyposisinthesepatients.Allergicreactiontoaspergillusfumigatushasbeendocumentedin
patientswithbronchopulmonaryaspergillosisinpatientswithcysticfibrosis .
Pathologicaldifferencesbetweennasalpolypiinpatientswithcysticfibrosisandinthosewithout
cysticfibrosis:
Histopathologicalcharacteristicsdifferbetweennasalpolypifoundincysticfibrosisfromthoseofnon
cysticfibrosispatients.
Thetablegivenbelowprovidesjustaglimpseintothehistopathologicaldifferencesbetweenthese
twoentities.
Nasalpolypiincysticfibrosis Nasalpolypiinnoncysticfibrosispatients
Neutrophilicinfiltration Eosinophilicinfiltration
Basementmembraneofpolypthinand
delicate
Thickbasementmembrane
Submucosalhyalinizationabsent Submucosalhyalinizationpresent
Mucousglandscontainacidmucin Mucousglandscontainneutralmucin
Nasalpolypicommoninchildrenwithcystic
fibrosis
Nasalpolypiareratherrareinchildrenwithoutcystic
fibrosis
Ithasbeensuggestedthatallchildrenwithnasalpolyposisshouldundergosweattesttoruleout
cysticfibrosis.Sweatchloridelevelofmorethan60mEq/Lisconsideredtobediagnosticofcystic
fibrosis.Thisshouldeventuallybefollowedupbygenetictestingandpropercouncelling.
Roleofimagingindiagnosis/evaluationofpatientswithcysticfibrosis:
Routinexraysareofnovalueinthesepatients.CTscanofnoseandparanasalsinusesisthe
preferredradiologicalinvestigationofchoiceinthesepatients.
CTscanfindingsinclude:
Frontalsinushypoplasia
Maxillarysinusexpansionwithmedialization
Lossofmedialmaxillarywall
Mucoceleformationinmaxillarysinuses
Frontalsinushypoplasiahasbeenattributedduetodiminishedpostnatalgrowthofthesesinuses
duetothepresenceofchronicinflammation.
Management:
Medical:
Thisshouldbeconsideredtobethefirststepinaseriesofsteps.
Salineirrigation:
Regularsalineirrigationofnasalcavitiesclearsthenasalsecretions,andalsogetsridofinflammatory
mediatorsfromthenasalmucousmembrane.Crustsbecomesoftonexposuretosalineandcan
hencebeeasilyremovedafterthewash.Childrenwhounderwentregularsalinewashoftheirnasal
cavitiesonaregularbasisrarelyneededsurgeryfornasalpolyposis.
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Topicalbabyshampoolavagehasfoundfavourrecently.Ithelpsinremoving/dislodgingbiofilms
frominsidethenasalcavity .
Roleofsteroids:
Useoftopicalsteroids havebeenfoundtoplayanimportantroleinreducingthesizeofnasalpolypi
inthesepatients.Ithasbeendemonstratedinchildrenwhoareonsystemicsteroidsfortheirlung
conditionshowedasignificantreductioninthesizeofnasalpolypi.
Roleofantibiotics:
Sincepsudeomonasinfectionsplayanimportantroleinthedevelopmentofnasalpolypiinpatients
withcysticfibrosis,antibiotictherapydirectedagainstpseudomonasorganismplaysanimportant
role.TopicalTobramycincanbeusedasnasalwashinthesepatients.Thisnotonlyreducedthe
pseudomonasnasalloadbutalsocausedasignificantreductioninthesizeofnasalpolypi.Thiswas
reportedwidelybyMossetal .
RoleofDornasealpha :
Inpatientswithcysticfibrosis,alargeamountofDNAreleasedfromdegeneratingneutrophilshave
beenimplicatedasthecauseofincreasedviscosityofnasalsecretions.Dornasealphaarecombinant
humandeoxyribonucleasewhenadministeredinthesepatientshasreducedtheviscosityofbronchial
andnasalsecretions.Intranasaladministrationofthisdrughashadbeneficialeffectsinthese
patients.
RoleofIbuprofen:
Upregulationofcyclooxygenase(COX)enzymeshasbeenidentifiedinnasalpolypiofpatientswith
cysticfibrosis.Highdoseibuprofenwhichblockstheseenzymeshasshownpromiseinthesepatients.
Highdoseibuprofenhasreducedthesizeofnasalpolypiinthesepatients .
Surgery:
Roleofsurgeryinthesepatientsisonlywhenconservativemedicalmanagementfails.Majorrisk
involvedinsurgeryisduetobleeding.SincethesepatientshavevitaminKmalabsorption,coagulation
disordersarecommon.Aftersurgerynasalblockisdramaticallyreduced.Endoscopicsinussurgical
procedureshavereplacedtheconventionalpolypectomy.Recurrenceiscommoninthesepatients
evenaftersuccessfulremoval.Recurrenceiscommoninabout60%oftreatedpatients.Inpatients
withmaxillarysinusmucocelesawidemiddlemeatalantrostomywillfacilitateitsdrainage.
CoronalCTscanofnoseandparanasalsinusesinapatientwithcysticfibrosis
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Pictureshowingnasalpolyposiswithinfected
secretionsinapatientwithcysticfibrosis
1. 1.DodgeJA,LewisPA,StantonM,WilsherJ(2007)CysticfibrosismortalityandsurvivalintheUK:
19472003.EurRespirJ29:522526
2. 2.FriedmanEM,StewartM(2006)Anassessmentofsinusqualityoflifeandpulmonaryfunctionin
childrenwithcysticfibrosis.AmJRhinol20:568572
3. 3.RoweSM,ClancyJP.Advancesincysticfibrosistherapies.CurrOpinPediatr.Dec
200618(6):60413.
4. RutlandJ,ColePJ.Nasalmucociliaryclearanceandciliarybeatfrequencyincysticfibrosis
comparedwithsinusitisandbronchiectasis.Thorax.198136:654658.
5. HenrikssonG,WestrinKM,KarpatiF,WikstromAC,StiernaP,HjelteL(2002)Nasalpolypsin
cysticfibrosis.Clinicalendoscopicstudywithnasallavagefluidanalysis.Chest121:4047
6. 6.WilsonR,PittT,TaylorG,WatsonD,MacDermotJ,SykesD,RobertsD(1987)Coleinhibitthe
References
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beatingofhumanrespiratoryciliainvitro.JClinInvest79:221229
7. 7.HadfieldPJ,RoweJonesJM,MackayIS(2000)Theprevalenceofnasalpolypsinadultswith
cysticfibrosis.ClinOtolaryngolAlliedSci25:1922
8. 8.ShoseyovD,BrownleeKG,ConwaySP,KeremE(2006)Aspergillusbronchitisincysticfibrosis.
Chest130:222226
9. 11.ChiuSG,PalmerJN,WoodworthBA,DoghramjiL,CohenMB,PrinceA,CohenMA(2008)
Babyshampoonasalirrigationsforthesymptomaticpostfunctionalendoscopicisinussurgery
patient.AmJRhinol22:3437
10. 9.HadfieldPJ,RoweJonesJM,MackayIS(2000)Aprospectivetreatmenttrialofnasalpolypsin
adultswithcysticfibrosis.Rhinology38:6365
11. 10.MossR,KingV(1995)Managementofsinusitisincysticfibrosisbyendoscopicsurgeryand
serialantimicrobiallavage.ArchOtolaryngolHeadNeckSurg121:566572
12. 12.CimminoM,NardoneM,CavaliereM,PlantulliA,SepeA,EspositoV,MazzarellaG,RaiaV
(2005)Dornasealfaaspostoperativetherapyincysticfibrosissinonasaldisease.ArchOtolaryngol
HeadNeckSurg131:10971101
13. 13.LindstromDR,ConleySF,SplaingardML,GershanWM(2007)Ibuprofentherapyandnasal
polyposisincysticfibrosispatients.JOtolaryngol36:309314
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Deiaed Naal Sepm and i managemen
A aigh naal epm i ahe ae
March 21, 2012 Rhinology
Introduction:
Nasalcavityisdividedintotwoportionsbythepresenceofamidlinenasalseptum.Thenasalseptum
hastwocomponentsi.e.Bonyandcartilaginousones.Bonycomponentsofnasalseptuminclude:
1.PerpendicularplateofethmoidsuperiorlyItarticulateswiththecribriformplateofethmoid.
TraumaticmanipulationofperpendicularplateofethmoidcanleadtoCSFleak.Ifthisportionofnasal
septumisthecausefornasalobstructionthenitshouldberemovedbysharpdissectionratherthan
bytwistingandpullingitout.
2.VomerInferoposteriorportionofnasalseptumisformedbythisbone.Itisakeelshapedbone
extendingfromsphenoidboneposteriorlyandsuperiorlyfromthenasalcrestsofmaxillaandpalatine
bone.
3.Nasalcrestofpalatineboneintheposteriorportionofnasalseptum
4.Nasalcrestofmaxillaformingtheinferiorportionofnasalseptum
5.Anteriornasalspineformsanteroinferiormostportionofnasalseptum
6.Nasalspineoffrontalboneformstheanterosuperiorportionofnasalseptum
Cartilaginousportionofnasalseptuminclude:
1.Septalcartilageforminganteriorportionofnasalseptum
2.Medicalcrusofalarcartilage
3.Vomeronasalcartilage:Thisthinstripofcartilageliesbetweencartilaginousnasalseptumandthe
vomer
Fig.1:Anaomofnaalepm
Deiaed Naal Sepm and i managemen
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BalasubramanianThiagarajan
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Septaldeviation:
Varyingdegreesofseptaldeviationshavebeendocumentedatbirth.Thesedeviationshavea
tendencytoaccentuateasthechildgrows .Adotcentralnasalseptumisaclinicalcuriosity.
Eventhoughseptaldeviationsarecommontheyareusuallynotsevereenoughtocausesymptoms .
Etiologyofseptaldeviation:
DirecttraumaManyseptaldeviationsarearesultofdirecttraumaandthisisfrequentlyassociated
withdamagetootherpartsofthenosesuchasfracturesofnasalbone.Fracturesinvolvingnasal
bonesarethecommonestfracturesinvolvingthefacialskeleton.Nearly40%ofnasalseptalfractures
areunidentifiedduringclosedreductionoffracturesinvolvingnasalbones.Theseunrecognized/
untreatedseptalfracturesusuallycauseseptaldeviationsatalaterdate .Fracturesinvolvingnasal
bonesareratheruncommoninchildrenundertheageof5.Theincidenceofnasalbonefractures
progressivelyincreasesasthechildgrowsolder.Thepeakoccursaroundtheageof30 .Studies
stresstheimportanceofidentifyingseptalmucosatearduringclinicalexaminationofthesepatients.
Almostallpatientswithseptalmucosaltearfollowingnasalbonefractureinvariablyhaveassociated
fracturesofnasalseptumalso.
Fig.2:Naaldefomiihepaldeiaion
folloingama
BirthmouldingtheorManypatientswithseptaldeviationdonotgivehistoryoftrauma.Birth
1
2
3
4
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mouldingtheorywaspropoundedbyGray.Accordingtohimabonromalintrauterineposturemay
resultincompressionforcesactingonthenoseandupperjaws.Displacementofseptumcanoccurin
thesepatientsduetotorsionforcesthatoccurduringparturition.Dislocationsaremorecommonin
primiparaandwhenthesecondstageoflabourlastedformorethan15minutes.Dislocationsare
generallytotherightinthecaseofleftoccipitoanteriorpresentationsandtotheleftwithright
occipitoanteriorpresentations.Subsequentgrowthofnoseaccentuatestheseasymmetries.
DifferentialgrowthbetweennasalseptumandpalateThisisthemostacceptabletheorytoday.
Whenthenasalseptumgrowsfasterincertainindividualsthanthepalatethenthenasalseptum
startstobuckleunderpressure.
Fig.3:Bcklingofnaalepm
Figureshowingunusualgrowthpatternsbetween
nasalseptumandpalatecausingbucklingofnasal
septum
Pathophysiology:
Deformityofnasalseptummaybeclassifiedinto:
1.Spurs
2.Deviations
3.Dislocations
SpursThesearesharpangulationsseeninthenasalseptumoccuringatthejunctionofthevomer
below,withtheseptalcartilageand/orethmoidboneabove.Thistypeofdeformityistheresultof
verticalcompressionforces.Fracturesthatoccurthroughnasalseptumduringinjurytothenosemay
alsoproducesharpangulations.Thesefractureshealbyfibrosisthatextendtotheadjacent
mucoperichondrium.Thisincreasesthedifficultyofflapelevationinthisarea.
Fig.4:Sepalp
Endoscopicview
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DeviationsMaybeCshapedorSshaped.Thesecanoccurineitherverticalorhorizontalplane.It
mayalsoinvolvebothcartilageandbone.
DislocationsInthisthelowerborderoftheseptalcartilageisdisplacedfromitsmedialpositionand
projectsintooneofthenostrils.
Inpatientswithseptaldeviationacompensatoryhypertrophyoftheturbinatesandbullamayoccuron
thesideoppositetothedeviation.Ifcompressionforcesareinvolvedtheseptaldeviationsareoften
asymmetricalandmayalsoinvolvethemaxilla,producingflattentingofthecheek,elevationofthe
flooroftheaffectednasalcavity,distortionofthepalateandassociatedorthodonticabnormalities.
Themaxillarysinusisusuallyslightlysmallerontheaffectedside.
Anteriorseptaldeviationsareoftenassociatedwithdeviationsintheexternalnasalpyramid.
Deviationsmayaffectanyofthethreeverticalcomponentsofthenosecausing:
1.Cartilaginousdeviations
2.TheCdeviation
3.TheSdeviation.
Cartilaginousdeviations:
Inthesepatientstheupperbonyseptumandthebonypyramidarecentral,butthereisadislocation/
deviationofthecartilaginousseptumandvault.
TheCdeviation:
Herethereisdisplacementoftheupperbonyseptumandthepyramidtoonesideandthewholeof
thecartilagenousseptumandvaulttotheoppositeside.
TheSdeviation:
Herethedeviationofthemiddlethird(theuppercartilaginousvaultandassociatedseptum)isopposite
tothatoftheupperandlowerthirds.Withdeviationsofthenose,thedominantfactoristhepositionof
thenasalseptum,hencetheadageastheseptumgoes,sogoesthenose.Thefirststep,therefore
intreatingthetwistednoseistostraightentheseptum,andifthisobjectiveisnotachieved,thereis
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nohopeofsuccessfullystraighteningtheexternalpyramid.
Effectsofseptaldeviation:
NasalobstructionThisisalwaysfoundonthesideofthedeviation,andcanalsobepresentonthe
oppositesideasaresultofhypertrophicchangesoftheturbinates.
MucosalchangesTheinspiratoryaircurrentsareabnormallydisplacedandfrequentlygets
concentratedonsmallareasofnasalmucosa,producingexcessivedryingeffect.Crustingwilloccur
andtheseparationofthecrustsoftenproducesulcerationandbleeding.Sincetheprotectivemucous
layerislosttheresistancetoinfectionisreduced.Themucosaaroundaseptaldeviationmay
becomeoedematousasaresultofBernouillisphenomenon.Thisoedemafurtherincreasesnasal
obstruction.
Fig.5:Componenofnaalepm
Fig.6:Shapeddeiaionofnaalepm
caingeenaldeiaionofnoe
Cshapeddeviationofnasalseptumcausingexternaldeviationofnose
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NeurologicalchangesPressuremaybeexertedbyseptaldeviationsonadjacentsensorynerves
canproducepain.ThiswasfirstexplainedbySluderandtheresultantconditionbecameknownas
theanteriorethmoidalnervesyndrome.Inadditiontothesedirectneurologicaleffects,reflex
changesperhapsmayresultfromseptaldeformitieswhichaffectthenasopulmonaryandnasal
reflexes.
Symptoms:
Thesymptomscausedbyseptaldeviationsareentirelytheresultoftheireffectsonnasalfunction.
Thedominentsymptombeingnasalobstruction,butthisisrarelysevereenoughtocauseanosmia.
Signs:
Septaldeviationsareevidentonanteriorrhinoscopy.Thisshouldbedonewithouttheuseofnasal
speculumbecausetheinsertionofspeculumissufficienttostraightenthenasalseptum.Whenthetip
ofthenoseisliftedseptaldeviationbecomeevident.Nasalobstructionmayalsobepresentonthe
oppositeside(paradoxicalnasalobstruction).Thisisduetothepresenceofhypertrophiedturbinates.
Ifthehypertrophyislimitedtoturbinatemucosaalonethenitwillshrinkwhendecongestantdrugsare
usedinthenasalcavity.Ifthehypertrophyisbonythendeconstantdropsisuseless.
Septaldeviationsintheregionofthenasalvalveareacausethegreatestobstruction,sincethisisthe
narrowestpartofthenasalcavity.Thiscanbeidentifiedbythecottletest.Apositivecottletestwill
confirmthefactthatnarrowingispresentinthenasalvalvearea.Thisisdonebyaskingthepatientto
pullthecheekoutwardsandthismanuverissupposedtoopenuptheareathusreducingtheblock.
Theseptumshouldnotbeconsideredinisolationanditisnecessarytodoacarefulexaminationof
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thelateralwallofthenasalcavity.Wheneversinuscomplicationslikesinusitisissuspecteddueto
obstructiontothedrainagechannelofthesinusesbythedeviationxraysinusmustbetaken.
Septaldeviationinnewbornisassociatedwithasymmetryofthenostrils,anobliquecolumellaandtip
whichpointsinthedirectionwhichisoppositetothedeviation.Mostofthesepatientsarediagnosed
bytheuseofGraysstruts.Thesestrutsare4mmwideand2mmthickandafterlubrication,are
insertedintothenostrilsandthengentlypushedbackwardsalongthefloorofthenasalcavity,
huggingthenasalseptum.Normallythesestrutscanbeintroducedforadistanceof45cms,butin
casesofseptaldeviationafrankobstructionisencountered,usually12cmsfromthenostril.
RoleofImaging:
CTscancanplayaroleinidentifyingseptalfractures.Thesefracturesmaynotbeevidentinroutine
radiographsoffaciomaxillaryregions.
Sincefracturesinvolvingnasalboneshavebeenimplicatedascommoncauseforseptaldeviations
classificationinvolvingnasalbonefractureswillhaveabearingonmanagementmodality.
Strancsclassificationofnasalfractures :
Laeabie:
Uiaeaaabefaceihdeeifbe
Uiaeadeeiadaeaiaifhecaaeaaabe
Biaeaaabeieeihfacigfhefacefhe
aia
FaTe:
1:Deeedeiaiedafheeaabehe
aiaieTe
2:Faeigfhecaiagiadbce,eaface,ad
iaaacaijieTe
3:Seeecaefheaabeadeaeacaiageih
eecigfhee.Aciaediacaiaadbiaijieacc
Cottlehasclassifiedseptaldeviationsintothreetypes:
Simpledeviations:Herethereismilddeviationofnasalseptum,thereisnonasalobstruction.Thisis
thecommonestconditionencountered.Itneedsnotreatment.
Obstruction:Thereismoreseveredeviationofthenasalseptum,whichmaytouchthelateralwallof
thenose,butonvasoconstrictiontheturbinatesshrinkawayfromtheseptum.Hencesurgeryisnot
indicatedeveninthesecases.
Impaction:Thereismarkedangulationoftheseptumwithaspurwhichliesincontactwithlateral
nasalwall.Thespaceisnotincreasedevenonvasoconstriction.Surgeryisindicatedinthese
patients.
Mladinasclassificationofseptaldeviation :
TypeI:Mildanteriordeviationnotcompromisingnasalfunction.Thispresentsasaunilateralridge
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alongthenasalvalvearea.Itdoesnotinvolvethewholelengthofnasalseptumandisnotincontact
withthelateralnasalvalvethenasalairwayisnotcompromisedinanyway.
TypeII:Anteriorverticaldeviationcompromisingnasalairway.Thereisunilateralverticalridgeinthe
nasalvalveareacompromisingnasalairway
TypeIII:Posteriorverticaldeviation.Inthisconditiontheunilateralverticalridgeliesnexttothehead
ofthemiddleturbinate
TypeIV:Sshapedseptaldeviation
TypeV:Horizontalspurispresentinthenasalseptumalwaysincontactwiththelateralnasalwall.
TypeVI:TypeVdeviationwithadeephorizontalgutterintheoppositeside
TypeVII:Crumpledseptum
Indicationsforsubmucousresectionofnasalseptum:
1.Markedseptaldeviationoccurringbehindtheverticallinepassingbetweenthenasalprocessesof
thefrontalandmaxillarybones.Thisdeviationmustbethecauseforthepatientssymptoms.
2.Closureofseptalperforations
3.Sourceofgraftingmaterial
4.Toobtainsurgicalaccessinhypophysectomy,andvidianneurectomy
FigureshowinginwhichtypeofdeviationSMR
shouldbedoneSurgicallytheseptumisdividedinto
anteriorandposteriorsegmentsbyaverticalline
passingbetweenthenasalprocessesoffrontaland
maxillaybones
Procedure:
Submucosalresectionofnasalseptumisideallyperformedunderlocalanaesthesia.4%xylocaineis
usedastopicalanestheticagentbynasalpacking.2%xylocaineisusedasinfiltrativeanesthetic
agent.Itismixedwith1in1lakhadrenaline.Infiltrationisdoneatthemucocutaneousjunctionon
bothsidesjustbehindthecolumella.Thefloorofthenasalcavityisalsoinfiltratedontheconcave
side.KilliansincisionispreferredforSMRoperations.Killiansincisionisthecommonlyusedincision.
Itisanobliqueincisiongivenabout5mmabovethecaudalborderoftheseptalcartilage.
Thecartilagenousandbonynasalseptumisexposedbyelevationofmucoperichondrialand
mucoperiostealflapsonbothsides.Thisisdonebyslicingtheseptalcartilagejustabovethe
columellatoaccesstheoppositeside.Flapsareelevatedonbothsidesofthenasalseptum.the
cartialgeisfullyexposedfrombothsidesandisremoveusingaLucsforcepsoraBallangersswiwel
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knife.Theflapsareallowedtofallbackinplaceandwoundisclosedwithcatgut.Bonydeviations
alongthefloorofthenoseifanyarealsochissledoutbeforewoundclosure.
SMRshouldnotbeperformedinchildrenbecauseitmayaffectgrowth.
ComplicationsofSMR:
1.Septalhematoma
2.Septalabscess
3.Septalperforation
4.Nasaldeformitiesduetoexcessiveremovalofdorsalstrutoftheseptum
5.Removalofthecolumellacartilagewillcausepigsnoutdeformity
Diagramshowingvarioustypesofincisionsusedin
septalsurgery
Figureshowingvarioustunnelsraisedina
septoplastysurgery
Septoplasty:
Thisisamoreconservativeprocedure.TheanesthesiaisthesameasdescribedforSMRoperation.
Theincisionisalwayssitedontheconcavesideoftheseptum.Freershemitransfixationincisionis
preferred.Thisismadeatthelowerborderoftheseptalcartilage.AunilateralFreersincisionis
sufficientforseptoplasty.Threetunnelsarecreatedasshowninthefigure.
Exposure:Thecartilagenousandbonyseptumareexposedbyacompleteelevationofamucosal
flapononesideonly.Sinceflapisretainedontheoppositesidethevascularityoftheseptumisnot
compromised.
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Likehi:
Bethefirsttolikethisarticle.
Mobilisationandstraightening:Theseptalcartilageisfreedfromallitsattachmentsapartfromthe
mucosalflapontheconvexside.Mostofthedeviationsaremaintainedbyextrinsicfactorssuchas
caudaldislocationofcartilagefromthevomerinegroove.Mobilisationalonewillcorrectthisproblem.
Whendeviationsareduetointrinsiccauseslikethepresenceofhealedfracturelinethenitmustbe
excisedalongwithastripofcartilage.Bonydeviationsaretreatedeitherbyfractureandrepositioning
orbyresectionofthefragmentitself.
Fixation:
Theseptumismaintainedinitsnewpositionbysuturesandsplints.
AdvantagesofFreersincision:
1.Theincisioniscitedoverthickskinmakingelevationofflapeasy.
2.Thereisminimalriskoftearingtheflap
3.Thewholeofthenasalseptumisexposed.
4.IfneedarisesRhinoplastycanbedonebyextendingthesameincisiontoafulltransfixationone.
UseofWrightssuturetopreventoverlap
AdvantagesofSeptoplasty:
1.Moreconservativeprocedure
2.Performedeveninchildren
3.Lessriskofseptalperforation
4.Lessriskofseptalhematoma
1. GrayL.P.Deviatednasalseptum.Incidenceandetiology.Ann.otol.Rhinol.Laryngol.87spp150
(1978)pp320
2. http://www.drtbalu.co.in/dns.html
3. MooreCC,MacDonaldI,LathamR,BrandtMG.Septopalatalprotractionforcorrectionofnasal
Like
Refeence
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septaldeformityincleftpalateinfants.OtolaryngolHeadNeckSurg2005133(6):94953.
4. AtighechiS,BaradaranfarMH,AkbariSA.Reductionofnasalbonefractures:acomparativestudy
ofgeneral,local,andtopicalanesthesiatechniques.JCraniofacSurg200920(2):3824.
5. StrancMF,RobertsonGA:Aclassificationofinjuriesofthenasalskeleton.AnnPlastSurg2:468
474,1979
6. ClinicalManifestationsinDifferentTypesofNasalSeptalDeviationYousifEbrahimChalabietal
TheNIraqiJMedDecember20126(3)2429
2/9/12 Hyperbaric oxygen therapy Recent advances in otolaryngology
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Hperbaric ogen therap
Concept's and mths
February 9, 2012 Laryngology
Introduction:
Hyperbaricoxygentherapyisdefinedasadministrationof100%oxygentoapatientplacedinsidea
chamberpressurisedtogreaterthan1atmosphereatsealevel .Localapplicationofoxygenunder
highpressurewithoutcompletelyenclosingthepatientisnotconsideredtobehyperbaricoxygen
therapy.
Histor:
Hyperbaricoxygentherapyisnotanewconcept.Thisconcepthistoricallycanbetracedbackto
1600.ThefirsthyperbaricchamberwasconstructedbyBritishclergymanHenshaw .Hecalledthe
chamberdomicilium.Thischamberwaspressurizedanddepressurizedusingbellows.In1670Robert
Boyleobservedthattheeyeofasnakecouldexpressgasbubblethroughthecornea.Onobserving
thisphenomenonheconcludedthattissuesundergoingrapiddecompressioncausesexpressionof
bubblesofpreviouslydissolvedgases.ThispromptedhimtoformulatethefamousBoyleslaw,which
statesAtconstanttemperaturethevolumeandpressureofgasareinverselproportional.
Henshawusedhisdomiciliumtofacilitatedigestion,tofacilitatebreathing,preventionofrespiratory
infections.Thischamberprovidedonlyatmosphericairunderhighpressureasoxygenwasnot
discoveredtill1773byCarlWilhemSheeley.ThetermoxygenwascoinedbyAntoineLavoiseronlyin
1777. FrenchsurgeonFontainewasthefirsttobuildapressurisedmobileoperatingroomin1879 .
HeusedNitrousoxideasanaestheticagentandbeleivedhyperbaricoxygenchambershelpedin
betterpatientanesthesia.
OrwillCunninghamProfessorofanesthesia(1928)ranaHyperbaricoxygenhospitalinLawrence
Kansas.HechristeneditasSteelBallHospital.Thissocalledhyperbaricoxygenhospitalwassix
storieshighand64feetindiameter.Thishospitalcouldachievepressurelevelsof3atmospheres .
Cunninghamclaimedexcellentresultsandheusedthischambertotreatpatientswithspanish
influenza whichwasrampantduringthefirstworldwarinUnitedstates.Twoyearslaterthishospital
wascloseddownandscrappedforlackofscientificevidence.
Militaryfoundauniqueuseforhyperbaricoxygenchambers.PaulBertdemonstratedexcessoxygen
saturationcausedgrandmalseizuresinhumans.Navyusedthischambertoquantifydifferent
exposuretimestooxygenatvaryingdepthsthatcouldleadtoseizuresinhumans.
From1930onwardsoxygensupplementationwasusedtomanageacutedecompressionsickness.
Oxygenwhenrespiredatveryhighpressuresmanagestodisplacenitrogenaccumulatedfromthe
tissue.Useofhyperbaricoxygenconsiderablyhelpstoreducethetimetakentotreatdecompression
sickness.In1935,Behnkeshowednitrogentobethecommoncauseofnarcosisinhumansduring
Hperbaric Ogen Therap
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decompressionsickness.BehnkeandShawsuccessfullyusedhyperbaricoxygentotreat
decompressionsickness.
IndicationsofHperbaricogentherap:
1.Arterialairorgasembolism
2.Acutebloodlossanaemia
3.Carbonmonoxidepoisoning,cyanidepoisoning,andsmokeinhalation
4.Compromisedskingraftsandflaps
5.Crushinjury
6.Decompressionsickness
7.Tofacilitateenhancedwoundhealing
8.Gasgangrene
9.Necrotisingsofttissueinfections
10.Radiationnecrosis:Osteoradionecrosis,softtissueradionecrosis,cariesinradiatedbones
11.Refractoryosteomyelitis
12.Refractorymycosis
13.Thermalburns
Mechanismofaction:
1.Hyperoxygenationisachievedbyfirstcompletelysaturatingthehemoglobinandthenby
increasingtheamountofoxygendissolvedintheplasma.Thisincreasesthedistanceofoxygen
diffusesawayfromthecapillaries.Thisisthreetimeshigherthanundernormalconditions.
2.VasoconstrictionVasoconstrictioncausedbyhyperbaricoxygentherapydoesnotreduce
oxygenation,onthecontraryithasabeneficaleffectofreducingedemainskingraftsandflaps.
3.AnitmicrobialactivityHyperbaricoxygentherapyisbactericidialtoobligateanaerobes.Italso
increasestheabilityofpolymorphstokillbacteria.Itisalsoknowntoinhibitandinactivatethetoxins
releasedbyclostridiumwelchi,therebypreventinggasgangrene.
4.PressureeffectsHyperbaricoxygenisusedtoreducethesizeofgasbubble.Becauseofthis
featureitisthetreatmentofchoiceindecompressionsickness.
5.Neovascularisation
6.Fibroblasticproliferation
7.Improvedfunctioningofosteoblastsandosteoclasts
8.Increasedredcelldeformability
Gamobag :
In1990Gamowdevisedaportablehyperbaricchamberwhichcouldgeneratepressureslessthan
1.5Atmospheres.Thisbagisstillbeingusedbyhighaltitudeclimberstocombatlowairpressuresat
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highaltitudes.
ComplicationsofHperbaricogentherap:
1.MiddleearbarotraumaThiscanoccurifthepatientisunabletoequalisethemiddleear
pressure.Thiscomplicationcanbebestavoidedbytheuseofsystemicandtopicalnasal
decongestantsbeforeproceedingwithhyperbaricoxygentherapy.Ifthisconditionoccursthen
myringotomyshouldberesortedtowithouthesitation.
2.MyopiaThisistemporaryandreversesbacktonormalaftercessationoftreatment.
3.Pneumothoraxcanoccurifdecompressionoccurtoorapidlyorifthepatientholdsthebreath
duringdecompression.
4.OxygeninducedseizuresThiscomplicationisveryrare.Thesepatientsshouldbegivenvitamin
Ebeforetreatmenttoprotectagainstsuperoxideradicals.Oxygeninducedseizurescanbestopped
byallowingthepatienttobreathnormalair.Oxygeninducedseizuresarenotknowntocause
permanentneurologicalsequlae.
Howtoadministerhyperbaricoxygen?
Hyperbaricoxygenisadministeredbyplacingthepatientinsideoxygenchambers.Twotypesof
chambersarecommonlyusedforhyperbaricoxygentherapy.1.Monoplaceand2.Multiplace
chambers.Inboththesechambersfacilitiesareprovidedformonitoringthevariousvitalbody
parameterslikeheartrate,bloodpressureandbloodoxygenlevelsetc.Facilitiesareprovidedfor
intravenousadministrationofdrugsandfluids.
Monoplacechamber:Here100%pressurisedoxygenisutilized.Patientaloneisplacedinthistypeof
chamber.Thereisnospaceforattendants.Thepatientisplacedaloneinsidethischamber.This
chamberishencenotusefulincriticallyillpatients.
Multiplacechamber:Thesechambersarepressurisedwithair.Patientsinsidethischamberare
administered100%oxygenviaafacemaskorhood.Thesechambersallowoneormoreattendants
insidethem.Thisfeatureisadvantageousintreatingseriouslyillpatients.
Regardlessofthetypeofchamberusedthefollowingfactorsmustbeconsidered:
1.Theamountofpressureused.
2.Durationofthetreatment.
3.Howoftenthetreatmentisrepeated.
Toavoidoxygentoxicitythetreatmentdurationshouldnotexceed120minutes.Thesaferangebeing
90120minutes.Thepressureusedisabout2atmospheres.Whenapatientsconditionrequire
multiplehyperbaricoxygentreatmentsperday,aminimumdurationof6hoursbetweenthemisa
must.
Indications:
1.Radiationinducedsofttissuenecrosis:Hyperbaricoxygentherapypromotesneovascularisation.
Hypoxiaiscorrectedandwoundhealsfaster.
2.Osteoradionecrosis:Hyperoxygenationandneovascularisationhelpsintreatingthisdifficult
condition.Hyperbaricoxygentreatmentisaneffectiveadjuvanttoantibioticsinmanagingthis
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Likethis:
Behefiolikehiaicle.
condiion.
3.Peenionofmandiblaoeoadionecoi
4.Ineaingnecoiingofieinfecion
5.Inmanagemenofmalignanoiieena
6.Canbeedinmanagemenoffngalinfecionofheadandneck.Thihaapoenaleaan
adjncoheeglaanifngalagen.
7.Managmenofacebloodloanaemia
8.Canbeedoalagecompomiedkingafandflap
9.Canbeedaanadjncinhemanagemenofpaienihbn
10.Canbeedomanageaiogaembolim
Contraindicationsforhperbaricogentherap:
Absolutecontraindications:
1.Pnemohoa
2.Plmonadamage
Relativecontraindications:
1.Plmonablla
2.Seiediode
3.Paienonhighdoeofeoid
4.Chonicobcieplmonadiode
5.Recenmocadialinfacion
6.Paienihclaophobia
Fig.1:ImageofHperbaricchamber
ImageofHpebaicogenchambe
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1. 1.hp://.dbal.co.in/hpe_o.hml
2. 2.HenhaIN,SimponA.CompeedAiaaTheapeicAgeninheTeamenof
Conmpion,Ahma,ChonicBonchiiandOheDieae.Edinbgh:ShelandandKno
1857.
3. 3.KindallE,WhelanH.HpebaicMedicinePacice.2Nded.Flagaff,AZ:BePblihing
Compan2004:chap1,18,19,20,25,29,30.
4. 4.hp://hpebaicopion.com/edcaion/hbo_hio.php
5. 5.Aebach,PalSDonne,HoadJ.Wei,EicA.(2008).FieldGideoWildene
Medicine,3dEdiion.MobEleie.ISBN9781416046981.
5/6/12 Huge rhinolith nasal cavity an interesting case report and a review of literature En
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Huge rhinolith nasal cavity an interesting case
report and a review of literature
May 5, 2012 Rhinology
Rhinolithsarecalcareousdeposits(stonelike)insidethenasalcavity.Thesestonelikestructuresare
highlyfriableandmaycrumblewhencrushed.Thisinterestingcasereportdiscussesapatientwitha
hugerhinolithinsidethenasalcavity.Rhinolithssincetheycrumbleeasilycanberemovedafter
crushingwithalucsforcepsviathenasalcavity.Sincetherhinolithinthispatientwasverylarge
extendinguptothechoanaitwasremovedvialateralrhinotomyapproachinordertoavoidexcessive
injurytonasalmucosaduringtheprocessofremoval.
Hugerhinolithnasalcavityaninterestingcasereportandareviewofliterature
Introduction:
Rhinolithsarealsoknownasnasalcalculiarecalcareousdepositspresentinsidethenasalcavity .
Rhinolithsareoftwotypes:ExogenousandEndogenous.
Exogenousrhinolith:Ifconcretionsoccuraroundaimpactedforeignbodythenitisconsideredtobe
exogenousinnature.Thesecalcareousdepositsaroundintranasalforeignbodiesisthemost
commonvarietyofrhinolith .
Endogenousrhinolith:Ifconcretionsoccuraroundbloodclot/inspissatedforeignbodythenitis
consideredtobeendogenousinnature.
Thisconditioniscommonlydiagnosedbyhistoryandanteriorrhinoscopy .Thisconditioniscommon
inadultsandelderlyindividuals.Unilateralfoulsmellingbloodtingednasaldischargeinanadult
shouldalwaysraisesuspicionofrhinolith.Sincerhinolithsarecommonlyseenintheanteriornasal
cavity,anteriorrhinoscopicexaminationofnoseclinchesthediagnosis .
Patientswithrhinolithusuallypresentwith:
1.Unilateralnasalobstruction
2.Unilateralfoulsmellingbloodtingednasaldischarge
3.Hardmassinsidethenasalcavity
CaseReport:
60yearsoldmalecamewithcomplaintsof
1.Rightsidednasalblock3years
2.Foulsmellingbloodtingeddischargerightnose3years
Abstract
1
2
3
4
Authors
BalasubramanianThiagarajan
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3.Rightsidedheadacheonandoff4years
Anteriorrhinoscopy:
Dirtywhiteirregularhardmasscouldbeseenoccupyingtheentirerightnasalcavity.Thesamemass
wasfoundpushingthenasalseptumtotheleftside.Themasswasfoundtobegrittyonprobing.The
probecouldbepassedallaroundthemass.
Anteriorrhinoscopyshowingrhinolith
CTscan:
AxialandcoronalCTscanshowedradioopaqueirregularmassoccupyingtheentirerightnasal
cavity.
CoronalCTscanofnoseandsinusesshowing
rhinolith
AxialCTofnoseandsinusesshowingrhinolith
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Management:
Sincethemasswasquitelargeandwasextendinguptotheposteriorendofmiddleturbinateitwas
decidedtoremoveitusinglateralrhinotomyapproachinordertopreventdamagetonasalmucosa.A
pervianaturalisapproachwasnotconsideredbecausethemasswasconsiderablyhard(notfriable)
andwaslarge.
Undergeneralanesthesia,usingMooreslateralrhinotomyapproachthenasalcavitywasentered.
Themasswasremovedcompletelyandthewoundwasclosedinlayers.
Discussion:
ThetermrhinolithisderivedfromGreek(rhinonoselithosstone).Itisconsideredtobearather
rareconditioni.e.About1in10,000otolaryngologypatients .ItwasBertholinwhofirstgavethe
accuratedescriptionofthisconditionin1654 .Rhinolithsareusuallyirregularbrownish/grey
coloredmassespresentintheanteriorportionofthenasalcavity.
Forsomeunknownreasonmalesseemtobecommonlyaffectedthanfemales .Theexact
pathogenesisinvolvedinthedevelopmentofrhinolithisstillnotknown.Ithasbeensuggestedthat
impactedforeignbody/mucousplugs/bloodclotmayinciteinflammatoryreactionandstimulate
depositionofmineralsandsalts.Thesaltswhichgetsdepositedaroundthenidusisderivedfrom
nasalsecretions,tearandinflammatoryexudate .Thenidusofrhinolithisusuallyaforeignbody .
Evengauzeswabsinadvertentlyleftinsidethenasalcavityfollowingsurgeryhasbeenknownto
causerhinolith.Radiologyisusuallydiagnostic.Typicalradiologicalpictureisradioopacitywith
sometimescentralopacity.Thecentralradiolucencycouldbeduetothepresenceoforganicmaterial
whichcouldhaveformedthenidusforrhinolith.ThisdescriptionwasfirstgivenbyMacIntyre in
1900.CTscanusuallycannotdifferentiaterhinolithfromothercalcifiedmasses.
Differentialdiagnosisofrhinolithinclude:
Hemangioma
Osteoma
Calcifiedpolyp
Chondroma
Osteosarcoma
Conclusion:
Thiscaseisbeingpresentedbecauseofitslargesize,lackoffriabilityandthesurgicalapproach
whichwasresortedtoinordertoremoveit.Lateralrhinotomyapproachwasresortedtoinorderto
preventmucosaldamagewhichcouldoccurifremovalisattemptedpervianaturalis.
1. 1.http://www.drtbalu.co.in/rhinolith.html
2. 2.TuranA,GozuACleftlip/nosedeformityandrhinolithPlasReconstrSurgery200411307980
3. 3.AksungurEH,BinokayFBArhinolithwhichismimickinganasalbenigntumorEur.JRadiol1999
31:535
5
2
3
1 5
6
References
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4. 4.GiantRhinolithwithnasopharyngealextensionaRareCaseReportBimalKumarSinha,
SangeethaBhandaryPakistanJournalofotolaryngology200521:4243
5. 5.SinhaVRaneARazdan(1995)RhinolithSurgicalJournalofNorthIndia11(1):8182
6. 6.RoyalSAGardnerRE.RhinolithiasisanunusualpaediatricnasalmasspaediatrRadiol199828
5455
3/30/12 Malignant otitis externa a review of current literature Ent Scholar
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Malignant otitis externa a review of
current literature
Difficult to diagnose and troublesome to treat
January 17, 2012 Otology
Malignantotitisexternaisaseveredebilitatingdisorderthatinvolvestheexternalauditorycanal.The
termMalignantOtitisExternaisactuallyamisnomer.Ithasbeencoinedtoindicatethedestructive
capabilitiesofthisdisorder.Thisarticlediscussesetiopathogenesis,diagnosticproblemsandvarious
managementmodalitiesavailabletomanagethesame.
Thisarticlewasnotfundedbyanyagency.
BalasubramanianT
Introduction:
Malignantotitisexternaisainflammatorydisorderinvolvingtheexternalauditorycanalcausedby
pseudomonasorganism.Majorityofthesepatientsareelderlydiabetics.Thisconditionistermedas
malignantotitisexternabecauseofitspropensitytocausecomplications.Hencethetermmalignant
mustnotbeconstruedinahistologicalsense.ThisconditionwasfirstdescribedbyMeltzerand
Kelemenin1959
ItwasChandlerin1963whocoinedthetermMalignantotitisexterna .Thisconditioncommonly
affectselderlydiabeticswhohavedecreasedimmunity.Studiesrevealthatitismorecommonamong
insulindependentdiabetics.CurrentliteraturealsoreportsafewcasesofMalignantotitisexterna
involvinginfants/younginsulindependentdiabetics.Theaimofotolaryngologististodifferentiatethis
conditionfromthatofrealmalignancyi.e.Squamouscellcarcinoma.Currentlyfluoroquinoloneshold
lotsofpromiseinmanagingthesepatients.
History:
1838Toulmouschreportedthefirstcaseofotitisexterna
1959Meltzerreportedacaseofpseudomonasosteomyelitisoftemporalbone
1968Chandlerdiscussedthevariousclinicalfeaturesanddescribeditasadistinctclinicalentity
Abstract
Funding Statement
Malignant otitis externa a review of current literature
1
2
3
4
Authors
BalasubramanianThiagarajan
3/30/12 Malignant otitis externa a review of current literature Ent Scholar
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Epidemiology:
Thetypicalpatientwithmalignantotitisexternaisanelderlydiabetic,withmalesoutnumbering
femalesbytwicethenumber.Thiscouldbeduetothepossibilityofmalesbeingmoreproneto
secretewaxwhicharemoreacidicinnature.Malignantotitisexternaisveryrareinchildrenif
presentitwillbeassociatedwithmalnutritionorHIVinfection.
Pathophysiology:
Malignantotitisexternaisknowntoaffecttheexternalauditorycanalandtemporalbone.The
causativeorganismbeingpseudomonasaeruginosa.Thesepatientsareinvariablyelderlydiabetics.
Thisdisorderusuallybeginsasotitisexternaandprogressestoinvolvethetemporalbone.Spreadof
thisdiseaseoccursthroughthefissuresofSantoriniandosteocartilagenousjunction.Thisdisorder
couldbecausedbyacombinationofpoorimmuneresponseandpeculiarcharacteristicsofthe
offendingmicrobe.
Immunityisreducedinpatientswith:
1.Diabetesmellitus
2.Bloodcancer
3.HIVinfections
4.Patientsonanticancerdrugs
Diabeticmicroangiopathyplaysavitalroleinthereductionoftissueperfusioncausingopportunistic
infectionsinvolvingthearea .RubinidentifiedtriggeringfactorforMalignantotitisexternainmore
than60%ofcases.Hewasabletoelicithistoryofattemptsatremovingwax,useofearbudsetc .
Itshouldalsoberememberedthatdiabeticpatientshaveimpairedphagocytosis,poorleukocytic
response,andimpairedintracellulardigestionofbacteria.Diabeticpatientssecretewaxwhichhas
lesslysozymecontentthannormaltherebyreducingtheeffectivenessofwaxasanantimicrobial
agent.
Pseudomonasaeruginosaisagramnegativeaerobewithpolarflagella.Itisfoundontheskin.It
invariablybehaveslikeanopportunisticpathogen.Thepathogenicityofthisorganismisduetoability
tosecreteexotoxinandvariousenzymeslikelecithinase,lipase,esterase,proteaseetc.Sincethis
organismisclothedbyamucoidlayeritisresistanttodigestionbymacrophages.
Clinicalfeatures:
Thepatientgiveshistoryoftrivialtraumatotheearoftenbyearbuds,followedbypainandswelling
involvingtheexternalauditorycanal.Painisoftenthecommoninitialpresentation.Itisoftensevere,
throbbingandworseduringnights.Itneedsincreasingdosesofanalgesics.Onexamination
granulationtissuemaybeseenoccupyingtheexternalcanal.Itoftenbeginsatthebonycartilaginous
junctionoftheexternalcanal.Dischargeemanatingfromtheexternalcanalisscantyandfoul
smellinginnature.Whenthedischargeisfoulsmellingitindicatestheonsetofosteomyelitis.
Ironicallythepatientdoesnothavefeverorotherconstitutionalsymptoms.
Otoscopy:Revealsgranulationtissueatthebonycartilaginousjunction.Theeardrumisusually
normal.Theexternalauditorycanalskinissoggyandedematous.
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Cranialnervepalsiesarecommonwhenthediseaseaffectstheskullbase.Thefacialnerveisthe
mostcommonnerveaffected.Asthediseaseprogressesthelowerthreecranialnervesareaffected
closetothejugularforamen.
Intracranialcomplicationslikemeningitisandbrainabscessarealsoknowntooccur.
Fig.1:Facialpalsy
Malignantotitisexternawithlowermotorneurontype
facialpalsy
CreativeCommons,BalasubramanianThiagarajan
drtbalu.
Spreadofinfection:
Spreadofinfection:
1.Inferiorlythroughthestylomastoidforamentoinvolvethefacialnerve.
2.Anteriorlytotheparotid
3.Posteriorlytothemastoidandsigmoidsinus
4.Superiorlytothemeningesandbrain
5.Mediallytothesphenoid
6.Spreadthroughvascularchannelsarealsocommon
RoleofImagingindiagnosis:
1.Conventionalradiologyisofnouseinthediagnosis
2.CTscan isusefulinassessingboneinvolvement
3.MRIscanisusefulinassessingsofttissueinvolvement
4.RadionucleotidescanusingTechnitium99helpsinthediagnosis.Thisisreallyusefulduringthe
veryearlystages ofthisdisorder.FixationofTechnitiumcorrelateswithhighdegreeofosteolytic
activitywhichiscommonlyseeninthesepatients.Thistestishighlyaccurate100%butitsspecificity
isratherlow .Gallium67scintigraphyisveryusefulforprognosticevaluationbecauseofitshigh
specificity .
LevensonscriteriaindiagnosingMalignantotitisexterna:
1.Refractoryotitisexterna
2.Severenocturnalotalgia
3.Purulentotorrhoea
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Likethis:
Bethefirsttolikethisarticle.
4.Granulationtissueintheexternalauditorycanal
5.Growthofpseudomonasaeruginosafromexternalcanal
6.Presenceofdiabetes/Immunocompromisedstate
Radiologicalstaging:
Grade Diagnosticcriteria
I Diseaselimitedtosofttissuenotinvolvingbonerefractorytostandardantibiotictherapyfor
morethan4weeks
II EarliestformofMalignantotitisexternawithinvolvementofMastoidbone
III Malignantotitisexternaextendingmediallytoinvolvepetrousportionoftemporalbone
IV MOEextendingmediallytoinvolvethepetrousapexorwithcranialnerveinvolvementor
preadanteriorlytoinvolvethefacialbones,posteriorlytoinvolvetheoccipitalbone,
orspreadtothecontralateralbaseofskull
Fig.2:Externalcanalgranulation
ExternalcanalgranulationinapatientwithMalignant
otitisexternaStagingandclassification:
Stage Ga67 TC99 ExtentofDisease
I + Softtissue(Necrotising
Otitis)
II + + Ear&Mastoid(Skullbase
osteomyelitis)
III + + Extensiveskullbase
osteomyelitis
Management:Extensivesurgicalprocedureshave
failedmiserablytocurethiscondition.Theroleof
surgeryisconfinedtoonlyexclusionofmalignancy
bybiopsy.Wounddebridementisapossibilityin
advancedcases.Medicalmanagement:
Carbenicillin,Pipercillin,Ticarcillincanbeused.
Thirdandforthgenerationcephalosporinscanbe
used.Ciprofloxacillinindosesof1.5g2.5g/day
individeddosescanbeadministeredforaperiodof
2weeks.Gentamycincanalsobeadministered
parenterallyindosesof80mgivtwotimesadayin
adults.
Copyright,BalasubramanianThiagarajan,drtbalu.
Creativecommons
IacknowledgeDrRGeethaforpublishingthisarticle.
Like
Acknowledgements
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1. Malignantotitisexterna
ReferenceLink
2. MeltzerPE,KelemanG.Pyocyaneousosteomielitisofthetemporalbone,mandible,andzygoma.
Laryngoscope.195969:130016
3. ChandlerJR.Malignantexternalotitis.Laryngoscope.196878:125794.
4. CeruseP,ColleauxB,TruyE,DisantF,MorgonAH,LahnecheB.Malignantexternalotitis.
Aproposof7recentcases.AnnOtolaryngolChirCervicofac.1993110:3326.
5. CohenD,FriedmanP.Thediagnosticcriteriaofmalignantexternalotitis.JLaryngolOtol.
1987101:21621.
6. RubinJ,YuVL,KamererDB,WagenerM.Auralirrigationwithwater:apotentialpathogenic
mechanismforinducingmalignantexternalotitis?AnnOtolRhinolLaryngol.199099:1179.
7. GrandisJR,CurtinHD,YuVL.Necrotizing(malignant)externalotitis:prospectivecomparisonof
CTandMRimagingindiagnosisandfollowup.Radiology.1995196:499504.
8. HardoffR,GipsS,UriN,FrontA,TamirA.SemiquantitativeskullplanarandSPECTbone
scintigraphyindiabeticpatients:differentiationofnecrotizing(malignant)externalotitisfromsevere
externalotitis.JNuclMed.199435:4115.
9. StokkelMP,BootCN,VanEckSmitBL.SPECTgalliumscintigraphyinmalignantexternalotitis:
initialstagingandfollowup.Casereports.Laryngoscope.1996106:33840.
10. Malignantotitisexterna:AnAustraliancaseseriesRonaldChin,PhoebeRoche*,Elizabeth
Sigston,NeilValanceRoyalCollegeofSurgeonsIreland,Otolaryngology,BeaumontHospital,Dublin,
Irelandthesurgeonxxx(2011)1e5
References
5/6/12 Mucocele of middle turbinate an interesting case report and literature review Ent
1/3 wordpress.com//mucocele-of-middle-turbinate-an-interesting-case-report-and-lite
Mucocele of middle turbinate an interesting
case report and literature review
May 1, 2012 Rhinology
Abstract:
Conchainvolvingmiddleturbinateisacommonoccurence .Reviewofliteratureputstheincidence
anywherebetween1440%.Thisisaninterestingcasereportofmucoceleinvolvingmiddle
turbinateconcha.Pneumatizationofmiddleturbinateisknownasconchabullosa .Conchabullosa
actuallyisaradiologicaldiagnosis .Mucocelescantechnicallyarisefromaconchabullosaifits
outflowchannelisobstructed.Thisisofcourseratherrare.Thiscasereportdiscussesacaseof
mucoceleinvolvingapneumatizedmiddleturbinate.
Introduction:
Mucoceleisdefinedasacystwithoutepitheliallining.Thisisactuallyapathologicaldefinition.
Ironicallymucocelesinvolvingparanasalsinusesdohaveamucosalliningandhenceareconsidered
tobetruemucousretentioncystscausedduetoobstructiontothenormaldrainageofglandular
secretions .Conchabullosaiscausedbyanteriorethmoidalaircellmigrationintothemiddle
turbinate.Whenpresentthislargeaircelldrainsintothefrontalrecessareacommonly.Bolgerinhis
classictreatisedividedconchabullosaintothreegroups :
1.Lamellartype
2.Bulboustype
3.Extensiveconchabullosa
Lamellartypeofconchabullosa:
Thisisactuallypneumatizationofverticallamellaofthemiddleturbinate
Bulboustypeofconchabullosa:
Thisispneumatizationofthebulbousportionofthemiddleturbinate
Extensiveconchabullosa:
Thisinvolvespneumatizationofbothverticalandbulbousportionsofmiddleturbinate.Thisisrather
extensiveformofconchaandiscommonlyassociatedwithseptaldeviationtotheoppositeside.
Casereport:
32yearsoldfemalepatientpresentedwithcomplaintsof:
Leftnasalcavityobstruction3monthsduration
Leftsidedheadache3months
Shegavenohistoryofbleedingfromthenasalcavity.
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2/3 wordpress.com//mucocele-of-middle-turbinate-an-interesting-case-report-and-lite
Anteriorrhinoscopyshowinghugeconchabullosain
therightnasalcavity
CoronalCTscanshowingahugeconchabullosaon
theleftsidewithfluidlevel
Management:
Patientwastakenupforsurgery.Endoscopicconchaplastywasperformed.Theentiremiddle
turbinatewhichwaspneumatizedwasfoundtobefilledwithpentupmucoussecretion.
Anteriorrhinoscopy:
Reddishmasscouldbeseenoccupyingtheentireleftnasalcavity.
Coughimpulsewasnegative.
Masswassensitivetotouch.
Probecouldbepassedaroundthemassexceptlaterally.
Discussion:
Eventhoughtheincidenceofconchabullosaisrathercommon,itisrareformucoceletooccurin
them.Studiesrevealthatconchabullosahasitsownmucociliaryclearancemechanisms.Commonly
itdrainsintothefrontalrecessareaandrarelyviathelateralsinus.Anyobstructiontotheirdrainage
channelscanpotentiallyleadtoformationofmucoceles .Wheninfectedthesemucocelescan
becomepyocelestoo .
Imageshowingconchabeingopenedfilledwithmucoiddischarge
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Conclusion:
Eventhoughconchabullosaisrathercommon,infectionsinvolvingthemleadingtotheformationof
mucocelesareratherrare.CTimagingalwaysclinchesthediagnosis.Thiscaseisreportedforits
rarityandtocreateawarenessaboutthiscondition.
1. SazgarAA,MassahJ,SadeghiM,etal.TheIncidenceofConchaBullosaandtheCorrelationwith
NasalSeptalDeviation.BENT20084(2):8791
2. ZinreichSJ,MattoxDE,KennedyDW,etal.Conchabullosa:CTevaluation.JComputAssist
Tomogr198812:77884
3. BalasubramanianThiagarajan.Mucocelesofparanasalsinuses[Internet].Version26.EntScholar.
2012Mar7.Availablefrom:http://entscholar.wordpress.com/article/mucocelesofparanasalsinuses/.
4. ZinreichS,AlbayramS,BensonM,OliverioP.Theostiomeatalcomplexandfunctionalendoscopic
surgery.In:SomP,ed.HeadandNeckImaging.4thed.StLouis:Mosby,2003149173
5. BolgerWE,ButzinCA,ParsonsDS.Paranasalsinusbonyanatomicvariationsandmucosal
abnormalities:CTanalysisforendoscopicsinussurgery.Laryngoscope1991101:5664.
6. UnluHH,AkyarS,aylanR,NalaY.Conchabullosa.JOtolaryngol199423:237.
7. LidovM,SomPM.Inflammatorydiseaseinvolvingaconchabullosa(enlargedpneumatizedmiddle
nasalturbinate):MRandCTappearance.AJNRAmJNeuroradiol199011:9991001.
References
3/7/12 Mucoceles of paranasal sinuses Ent Scholar
1/6 entscholar.wordpress.com/article/mucoceles-of-paranasal-sinuses/
Mcoceles of paranasal sinses
March 7, 2012 Rhinology
Mucocelesaregraduallyexpandinglesioninvolvingparanasalsinuses.Thisisusuallycauseddueto
obstructiontothenormaldrainagechannelsofparanasalsinusesleadingontopentupsecretions
withinit.Thesepatientsclassicallydontpresentwithsymptomspertainingtonoseandsinusesbut
withophthalmologicalsignsandsymptoms.Theyinvariablypresenttotheopthalmologistbefore
findingtheirwaytoanotolaryngologist.
Definition:
Amucoceleisdefinedasmucousfilledepitheliumlinedsac.Mucocelescommonlyinvolveethmoidal
andfrontalsinuses.Mucocelesarecommonlycausedduetoobstructiontodrainagechannelof
paranasalsinuses.Theseexpansilecysticmassesaresometimesfilledwithmucopurulentsecretions
.Sometimesassociatedbonedestructionisalsoevident .
Mucocelesarerathercommoninfrontalsinuses.Nextcomestheethmoidalsinuses.Isolated
mucocelesinvolvingethmoidalsinusesareratherrare .Theyalwaysoccurincombinationwith
frontal/sphenoidmucoceles .
Histor:
ThetermmucocelewasfirstcoinedbyRolletin1896.OnodifirstdescribedhistologyofMucocelein
1901.
Classificationofsurgicalapproachesusedinthemanagementofmucocelesofparanasalsinuses:
ITransnasalapproaches:ThisincludeEndoscopicsinussurgery,Microscopicsinussurgery,Trans
sphenoidalapproach.
Etiopathogenesis:
Mucoceleshavebeenpostulatedtoformduetoobstructionofsinusostiafollowingchronicinfections
/allergicreactionsinvolvingparanasalsinuses .Previoustrauma/surgerycanalsocause
obstructiontosinusoutflowchannelscausingformationofmucoceles.Ethmoiodalmucocelesif
presentinisolationcouldbecausedbyendoscopicethmoidectomy.Somestudieshave
reportedoccurrenceofisolatedethmoidalmucoceleseven10yearsaftersurgery .Paranasal
sinusescontinuestoexpandslowlyowingtopentupmucoussecretions.Thesemucocelesarelined
bydilatedciliatedcolumnarepitheliumwhichsecretemucouscausingexpansionofthecyst.
Continuingexpansionofthiscystputspressureonthebonywallsofparanasalsinuses,causingbony
erosionandremodeling.Uncheckedextensionofsinuscavitycancauseextensionofmucoceleinto
orbit,nasopharynxandcranialcavity .Inadditiontopressurechangesinflammatorymediatorslike
Abac
Mcocele of paanaal ine
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prostaglandins,interleukinsandtumornecrosisfactorpresentwithinmucocelesalsocontributeto
theirexpansioncapability .
Threemaintheoriesofpathogenesisofmucoceleformationhasbeenpostulated :
1.Pressureerosion
2.Cysticdegenerationofglandulartissue
3.Activeboneresorptionandregeneration
PathogenesisofMucoceleformation
Sitesinvolvedbmucoceles:
1.Anteriorethmoid
2.Frontal
3.Maxilla
4.Posteriorethmoid
5.Sphenoid
About60%ofparanasalsinusmucocelesarepresentinthefrontoethmoidalregion .
Relationshipbetweenendoscopicsinussurgerandmucoceleformation:
Endoscopicsurgerycancausemucoceleformationduetoadhesionsdevelopinginthemiddle
meatus.Thiscomplicationcanbepreventedbytakingcarenottodamagenormalmucosa.Retention
ofhealthymucosainthemiddlemeatalareapreventsadhesionsfromoccurring.Meticulouspost
operativeendoscopiccleaningofcrustswillhelpinminimizingadhesionformation.Routinemiddle
turbinateexcisionwhileperformingendoscopicsinussurgerywaspreviouslyconsideredtominimize
adhesionsfromoccurringinthemiddlemeatusarea.Adhesionscanstillforminotherareasofnasal
cavity.Infactadhesionscanformbetweenremnantmiddleturbinateandlateralnasalwall .Studies
haverevealedthatitcouldtakeanywherebetween510years beforemucoceledevelops,henceit
isimportanttoelicithistoryofparanasalsurgeryinthesepatients.
Clinicalfeatures:
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Usuallypatientswithmucocelesinvolvingparanasalsinusesdonthavenasal/sinussymptoms.Only
symptomstheypresentwithareophthalmologicalinnature.
Proptosiscausedduetofrontoethmoidalmucocele
Proptosiswithfistulafrontalboneareadueto
frontoethmoidalmucocele
1.Pain:Thisiscommonlyperiorbitalinnature.Thisiscausedbyinflammationandstretchingofnasal
andsinusmucosa,rarelyfromdura.Painisusuallytransmittedbytrigeminalnerve .
2.Progressiveproptosis
3.Visualdisturbances(diplopia)/blurringofvision:Thisiscausedbyerosionofthebonycasing
aroundopticnerve.Anyfurtherexpansionofmucocelewillcausecompressionofopticnerve
compromisingitsbloodsupply.Infectionsfrommucocelecanreachtheopticnervewhenthebony
casingaroundtheopticnerveisbreachedbytheenlargingmucocele .
4.Epiphora
5.Impairedocularmobility
Roleofradiologindiagnosisofmucoceles:
Radiologicalimagesofsinusesdemonstratethinningandexpansionofaffectedparanasalsinus
walls.Sinusesaffectedbymucocelesusuallyappearshomogenousandairless.Plainxrayof
paranasalsinusmucocelesshowthefollowingfeatures:
1.Softtissuedensitymassseenobliteratingsinuses
2.Expansionofparanasalsinus
3.Evidenceofbonethinninganderosion
CTscanshowslesionswithgreaterclarity.Preciseextensionofthelesioncanbeassessedby
studyingCTscanimages.Scansrevealwelldefinedexpansilelesionwithobliterationofparanasal
sinusaircellcavities.
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CoronalCTNoseandparanasalsinusshowingexpansilelesioninvolvingleft
frontoethmoidalregion.
CTnoseandsinusesshowingexpansilelesion
involvinganteriorethmoidandfrontalsinuses.
Sizeoftheswelling(external)causedbyfrontoethmoidalmucocelesincreasesinsizegradually.The
rateofexpansionoffrontoethmoidalmucoceleisacceleratedifsecondaryinfectionispresentwithin
mucocele .
ClassificationofFrontalmucocele:
Frontalmucoceleshavebeenclassifiedinto5typesdependingonitsextent.
TypeI:Inthistypethemucoceleislimitedtothefrontalsinusonlywithorwithoutorbitalextension.
TypeII:Herethemucoceleisfoundinvolvingthefrontalandethmoidalsinuseswithorwithoutorbital
extension.
TypeIIIa:Inthistypethemucoceleerodestheposteriorwallofthefrontalsinuswithminimalorno
intracranialinvolvement.
TypeIIIb:Inthistypethemucoceleerodestheposteriorwallwithmajorintracranialextension.
TypeIV:Inthistypethemucoceleerodestheanteriorwallofthefrontalsinus.
TypeVa:Inthistypethereiserosionofbothanteriorandposteriorwallsoffrontalsinuswithoutor
minimalintracranialextension.
TypeVb:Inthistypethereiserosionofbothanteriorandposteriorwallsoffrontalsinuswithamajor
intracranialextension.
Management
Mucocelesareideallymanagedsurgically.Beforetheadventofendoscopicprocedures,External
frontoethmoidectomywasconsideredtobetheidealmanagementmodality.
Classificationofsurgicalapproaches:
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Likehi:
Bethefirsttolikethisarticle.
I.Transnasalapproach:
Endoscopicsinussurgery
Microscopicsinussurgery
Transsphenoidalapproach
II.Externalapproaches:
CaldwelLucapproach
Osteoplasticfrontalsinussurgery
ExternalEthmoidectomy
Lateralrhinotomy
Craniofacialresection
Endoscopicproceduresarecurrentlythecommonlyusedsurgicalapproachinmanagingmucoceles.
Figureshowingmucousextrudingfrommucoceleon
beingincised..
CaldwelLucsurgicalprocedure
Like
Refeence
3/7/12 Mucoceles of paranasal sinuses Ent Scholar
6/6 entscholar.wordpress.com/article/mucoceles-of-paranasal-sinuses/
1. CanalisRF,ZajtchukJT,JenkinsHA.Ethmoidalmucoceles.ArchOtolaryngolHeadNeckSurg
104:286291,1978.
2. NatvigK,LarsenTE.Mucocelesoftheparanasalsinus.JLaryngolOtol92:10751082,1982.
3. EvansC.Aetiologyandtreatmentoffrontoethmoidalmucocele.JLaryngolOtol95:361375,1981.
4. LaiPC,LiaoSL,JouJR,etal.Transcaruncularapproachforthemanagementoffrontoethmoid
mucoceles.BrJOphthalmol200387:699703.
5. ChristmasDA,MiranteJP,YanagisawaE.Isolatedethmoidsinusmucocele.ENTRhinoscopic
Clinic200275960.
6. BusabaNY,SalmanSD.Ethmoidmucoceleasalatecomplicationofendoscopicethmoidectomy.
OtolaryngolHeadNeckSurg2003128:51722.
7. Sinusmucocele:NaturalhistoryandlongtermrecurrencerateM.DevarsduMayne,A.Moya
Plana,D.Malinvaud,O.Laccourreye,P.BonfilsEuropeanAnnalsofOtorhinolaryngology,Headand
Neckdiseases(2012)
8. https://sites.google.com/site/drtbalusotolaryngology/rhinology/mucocele
9. LaiPC,LiaoSL,JouJR,etal.Transcaruncularapproachforthemanagementoffrontoethmoid
mucoceles.BrJOphthalmol200387:699703.
10. ConboyPJ,JonesNS.Theplaceofendoscopicsinussurgeryinthetreatmentofparanasalsinus
mucoceles.ClinOtolaryngol200328:20710.
11. HarElG.Endoscopicmanagementof108sinusmucoceles.TheLaryngoscope.2001111:2131
4.
12. MoriyamaH,HesakaH,TachibanaT,HondaY.Mucocelesofethmoidandsphenoidsinuswith
visualdisturbance.ArchOtolaryngolHeadNeckSurg1992118:1426.
13. LaiPC,LiaoSL,JouJR,etal.Transcaruncularapproachforthemanagementoffrontoethmoid
mucoceles.BrJOphthalmol200387:699703.
14. YumotoE,HyodoM,KawakitaS,AibaraR.Effectofsinussurgeryonvisualdisturbancecaused
bysphenoethmoidmucoceles.AmJRhinol199711:33743.
3/30/12 Nasal polyposis in children Ent Scholar
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Nasal polyposis in children
A review article
January 17, 2012 Rhinology
Thisarticlediscussesvariouscausativefactorsofnasalpolyposisinchildren.Itisareviewof
literatureonthissubject,supplementedbytheauthorspersonalexperience.Eventhoughnasal
polyposisisratheruncommoninchildren,whenpresenttheyshouldbethroughlyinvestigatedtorule
outothersinisterlesions.Imaginghasavitalroletoplayindiagnosisofthesepatients.Antrochonal
polypiscurrentlythecommonestnasalpolypseeninchildren.
Thisarticlewasnotfundedbyanyagency
Introduction:
Studiesrevealthateventhoughnasalobstructionanddischargearecommoninchildren,nasal
polyposis isratheruncommon.Majorityofnasalpolypiinchildrenarecausedbyinfectionand
inflammationofnasal/sinusmucosallining.Amongthetypesofnasalpolyposisseeninchildren
about1/3ofthesepatientshaveantrochoanalpolyp .
Causesofnasalpolyposisinchildren:
Antrochoanalpolyp
Inflammatorypolyp
Polypduetocysticfibrosis
Antrochoanalpolyp:
Synonyms:Antrochoanalpolyp,Killianspolyp ,Nasalpolyp.
Palfyn describedthefirstcaseofantrochoanalpolyp1n1753.Sincehefoundthepolypfillingthe
nasopharynxandextendingbelowuvulahethoughtthatitcouldhavearisenfromthechoana.Killian
in1906demonstratedthatthispolyparosefrommaxillarysinusantrum.AccordingtoStammberger
70%ofantrochoanalpolypexitedoutofthemaxillarysinusantrumviatheaccessoryostium .
Definition :
Antrochoanalpolypisabenignsolitarypolypoidallesionarisingfromthemaxillarysinusantrum
causingopacificationandenlargementofantrumradiologicallywithoutanyevidenceofbone
destruction.Iteixtstheantrumthroughtheaccessoryostiumreachesthenasalcavity,expands
Abstract
Funding Statement
Nasal polyposis in children
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Authors
BalasubramanianThiagarajan
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posteriorlytoexitthroughthechoanaintothepostnasalspace.
Incidence:
Itcommonlyaffectsyoungchildrenandadolescents.
Etiopathogenesis:
Antrochoanalpolypissaidtooriginateinthemaxillaryantrumduetoinflammation .Thiscondition
hasbeencommonlydocumentedonlyinnonatopicpersons .Itsetiologyisstillunknown.
Varioustheorieshavebeenproposedtoaccountforthepathogenesisofthisdisorder:
Proetztheory :
Proetzsuggestedthatthisdiseasecouldbeduetofaultydevelopmentofthemaxillarysinusostium,
sinceitwasalwaysbeenfoundtobelargeinthesepatients.Hypertrophicmucosaofmaxillary
antrumsproutsoutthroughthisenlargedmaxillarysinusostiumtogetintothenasalcavity.The
growthofthepolypisduetoimpedimenttothevenousreturnfromthepolyp.Thisimpedimentoccur
atthelevelofthemaxillarysinusostium.Thisvenousstasisincreasestheoedemaofthe
polypoidmucosatherebyincreasingitssize.
Bernoullisphenomenon:Pressuredropnexttoaconstrictioncausesasuctioneffectpullingthesinus
mucosaintothenose.Accordingtothistheorythereisapressuredropatthelevelofinfundibular
areacausingarelativenegativepressure.Thisnegativepressureissufficienttocauseprolapseof
maxillaryantralmucosaintothenasalcavity.Thisprolapsedmucosalliningbeginstoenlargeinsize
duetooedematousreactioncausingformationofpolypoidaltissue.
Mucopolysaccharidechanges:Jaksonpostulatedthatchangesinmucopolysaccharidesoftheground
substancecouldcausenasalpolyp.Thesechangesleadtowaterretentionwithinthesubmucosal
compartmentcouldleadtopolypformation.
Millstheory:
Millspostulatedthatantrochonalpolypcouldbemaxillarymucoceleswhichcouldbecauseddueto
obstructionofmucinousglands.
Ewingstheory:Ewingssuggestedthatananomalywhichcouldoccurduringmaxillarysinus
developmentcouldleaveamucosalfoldclosetotheostium.Thisfoldcouldlaterbeaspiratedintothe
sinuscavityduetotheeffectsofinspiredaircausingthedevelopmentofantrochonalpolyp.
Vasomotorimbalance:Thistheoryattributespolypformationduetoautonomicimbalance.
Infections:Recurrentnasalinfectionshavealsobeenpostulatedasthecausefornasalpolyp.This
theorysuggeststhatacinousmucousglandswithinthemaxillarysinuscavitygetsblockeddueto
infection/inflammtioninvolvingthemucousliningofthesinuscavity.Thisleadstotheformationofa
cysticlesionwithinthemaxillarysinuscavity.Thiscystgraduallyenlargestooccupythewholeofthe
maxillarysinuscavity.Itexitsthesinuscavitybyenlargingtheaccessoryostiumandentersthenasal
cavity.Usuallythesecystsarisefromtheanteroinferior/medialwallofmaxillary
antrum.MacroscopicallytheportionofA/Cpolypwithinthemaxillaryantrumiscysticinnature,while
thecomponentthathasprolapsedviatheaccessoryostiumissolidinnature.
Possiblereasonsforposteriormigrationofantrochoanalpolyp:
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Classicallyantrochonalpolyppresentsposteriorly.Thepolypcouldbeclearlyseenoccludingthepost
nasalspace.Possiblereasonsforthisposteriorpresentationinclude :
1.Theaccessoryostiumthroughwhichthepolypgetsoutofthemaxillaryantrumis
presentposteriorly.
2.Theinspiratoryaircurrentismorepowerfulthantheexpiratoryaircurrentthereby
pushesthepolypposteriorly.
3.Thenaturalslopeofthenasalcavityisdirectedposteriorly,hencethepolyp
alwaysslipsposteriorly.
4.Theciliaoftheciliatedcolumnarepithelialcellsliningthenasalcavityalways
beatsanteroposteriorlypushingthepolypbehind.
Histology:
Showsrespiratoryepitheliumovernormalbasementmembrane.Theinterstitiallayerisgrossly
oedematous,withnoeosinophils.Theinterstiallayercontainsotherinflammatorycells.
Clinicalfeatures:
Thisdisorderiscommonlyunilateral.Bilateralantrochoanalpolypisveryrarecondition.Onlyafew
handfulofsuchcaseshavebeenreportedinliteraturesofar.
1.Unilateralnasalobstruction
2.Unilateralnasaldischarge
3.Headache(mostlyunilateral)
4.Epistaxis
5.Sleepapnoea
6.Rhinolaliaclausaduetopresenceofpolypinthepostnasalspace
7.Difficultyinswallowingifthepolypextendsintotheoropharynx
Fig.1:Antrochoanalpolyp
ThisisanendoscopicimageofantrochoanalpolypAnteriorrhinoscopymay
showthepolypasglisteningpolypoidalstructures.Theywillbeinsensitiveto
touch.thisfeaturehelpstodifferentiateitfromahypertrophiednasalturbinate.
Postnasalexaminationwillshowthepolypifextendingposteriorlyatthelevel
ofchoana.Ifitfillsupthenasopharynxitwillbevisiblethere.Xrayparanasal
sinuseswillshowahazymazillaryantrum.CTscanofparanasalsinusesis
diagnostic.Itwillshowthepolypfillingthemaxillaryantrumandexitingout
throughtheaccessoryostiumintothenasalcavity.CoronalCTscanshowing
antrochoanalpolypCoronalCTPlainTheantrochoanalpolypisdumbbell
shapedwiththreecomponentsi.e.antral,nasalandnasopharyngeal.
Treatment:Thisisasurgicalproblem.Formerlyitwastreatedbyavulsionof
thepolyptransnasally.Thismethodledtorecurrences.Acaldwelluc
approachwaspreferredinpatientswithrecurrences.Incaldwellucprocedure
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inadditiontothepolypectomy,themaxillaryantrumisenteredviathecanine
fossaandtheantralcomponentiscompletelyexcised.Endoscopicapproach:
Withtheadventofnasalendoscopethisapproachisthepreferredone.Using
anendoscopeitisalwayseasytocompletelyremovethepolypoidtissue.The
uncinateprocessmustalsobecompletelyexcised.Endoscopicapproachhas
theadvantageofacompletesurgicalexcisionwithnegligiblerecurrancerates.
AntrochoanalpolypinthechoanaEndoscopicviewofchoanalportionof
antrochoanalpolypBalasubramanianthiagarajan,drtbaluCreativecommons
Differencesbetweenantrochoanalpolyp/Ethmoidalpolyp
Antrochoanalpolyp Ethmoidalpolyp
Solitary Multiple
Arisesfrommaxillaryantrum Arisesfromethmoidalaircells
Hasthreecomponents Hasonlyonecomponent
Infectionplaysaroleinitspathogenesis Allergyissupposedtoplayarole
Commoninadolescents Commoninadults/elderly
CoronalCTscanshowingantrochoanalpolyparisingfrommaxillaryantrum
exitingoutofaccessoryostiumandenteringthenasalcavity
Balasubramanianthiagarajan,drtbaluCreativecommons
Copyright,Balasubramanianthiagarajan,drtbalu.
CreativecommonsCopyright,Balasubramanianthiagarajan,drtbalu.
CreativecommonsCopyright,Balasubramanianthiagarajandrtbalu.
Creativecommons
Recentadvances:
CurrentresearchinvolvingNitricoxidehasthrownlightintothepossibleetiopathogenicfactors
involvedinthegenesisofantrochonalpolyp.Nitricoxidehavebeenshowntoplayamajorrolein
nonspecificimmunereactionsandinflammationinavarietyoftissues.Endogenousnitricoxideis
synthesizedfromLargeninebytheeffectofnitricoxidesynthase.Thisallimportantnitricoxide
synthaseexistsinthreeforms:
1.Endothelialnitricoxidesynthase
2.Neuronalnitricoxidesynthase
3.Induciblenitricoxicsynthase
OutofthesethreetypestheInduciblenitricoxidesynthasehasbeendetectednotonlyinepithelium
butalsoinmacrophages,fibroblasts,neutrophils,endotheliumandvascularsmoothmuscle.
Studieshaverevealedthatantrochoanalpolyptissuecontainedmorenitricoxidethannormaltissues.
Increasednitricoxideproductioncouldbefromepithelial/inflammatorycells.Amonginflammatory
cellseosinophilsplayanimportantroleinproductionofnitricoxide.Studieshavealsorevealedthat
Induciblenitricoxidesynthaseplayanimportantroleinthepathogenesisofantrochonalpolyp.
Sphenochoanalpolypisanotherrareunilateralnasalpolypthatpresentsposteriorlyoccludingthe
choana.Infactthisconditionshouldbedifferentiatedfromantrochoanalpolyp.
Cysticfibrosis:
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Thisisanotherconditionthatcancausenasalpolyposisinchildren.Thesechildrenpresentwith:
Pneumonia
Pancreaticinsufficiency
Meconiumileus
Rectalprolapse
Biliarycirrhosis&portalhypertension
Thisgeneticdisorderisknowntoaffectapproximately1in2500livebirths.Thesepatientshave
abnormalcholoridetransport,whichisactuallycausedbydefectivechloridechannelconductance
whichisactuallyregulatedbycyclicAMP.Thisdisorderiscausedbymutationinvolvingchromosome
7whichcodesforchloridechannelprotein.
Attemptstoseekevidenceinadultpatientswithnasalpolyposisforthepresenceofcysticfibrosishas
notbeenfruitful .
Theincidenceofnasalpolyposisinpatientswithcysticfibrosisrangesbetween1540%.Thisisa
highvariationconsideringthefrequencyofnasalpolyposisinchildren .Patientswithcysticfibrosis
invariablydevelopnasalpolyposisaftertheir5 yearorbeforetheyreach20yearsofage .
StudiesperformedbyTossetallhavenotdemonstratedanymorphological/histologicaldifferences
betweennasalpolypoidaltissuebetweencysticfibrosisandnoncysticfibrosisgroups.Thisactually
pointstowardsthecommonunderlyingcommonpathogenesis.
Roleofsweattestinthediagnosisofcysticfibrosis:
Thisisactuallythegoldstandardtestinthediagnosisofcysticfibrosis.
Sweattestisusuallydoneintheforearm.Itcanalsobedoneonthethighs.
Stimulationofsweatproduction:
Thisisactuallythefirststepinsweattest.Electrodescontainingpilocarpineisplacedovertheskin.
Smallcurrentispassedthroughtheelectrodessothatpilocarpinewillenterskinandstimuate
secretionofsweat.Thiscurrentisactuallynotpainfulbutcausesatinglingsensation.Afterabout10
minutestheelectrodesareremovedandafilterpaperpatchknownassweatpatchisusedtocollect
sweat.Chloridelevelsinsweatofpatientswithcysticfibrosisissupposedtobeveryhigh.
Seatchlorideranges:
Lessthan30=normal
3059=Borderline
60andaboveisindicativeofcysticfibrosis
ScreeningforthepresenceofAF508genecouldserveasapointerfordiagnosingcysticfibrosis.
Serumlevelsofimmunoreactivetrypsinogenhasbeenfoundtobeelevatedininfantswithcystic
fibrosis.
Characteristicfeatureofsinusitisinthesepatientsistherangeofmicrobesthathavebeenisolatedby
culturingthesecretions.Theseorganismsinclude:Psuedomonasaeruginosa,andstaphylococcus
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aureus.
Majornasalsymptomsseeninthesepatientsinclude:
Nasalblock
Mucopurulentsecretions
Headache
Medicalmanagementhasaverylimitedroletoplayinthemanagmentofchronicsinusitisinpatients
withcysticfibrosis.Onlyroleplayedbyantibioticsinthesechildrenistolimitthedamagedueto
repeatedlowerairwayinfections.Colonizationoflowerrespiratorytractbypseudomonasis
commonlyseeninthesepatients.Nasaldouchingifpreformedrepeatedlywillhelpinminimizing
thesecoloniesbeingformedinthelowerairway.
Encephaloceles/Meningoceles:
Thesearecongenitalneuraltubedefectspresentingaspolypoidalmassesinsidethenasalcavity.It
isimperativetodifferentiatetheselesionsfromnasalpolypi.Theselesionscanbeidentifiedbythe
presenceofcoughreflex.Thesemasseschangeinsizeaccordingtothephasesofrespiration.
HighresolutionCTscanimagesandMRIimageshelpsinthediagnosisofthiscondition.After
excisionofthesemassesthedefectintheskullbaseshouldbeclosedusingathreelayergraft.This
willhelpinavoidingtroublesomeCSFleakswhicharecommoninthesepatientsfollowingsurgery.
NasalpolyposisassociatedwithPrimaryciliarydyskinesia:
Thisconditionwhenassociatedwithbronchiectasisandsitusinversustotalisitisknownas
kartagenerssyndrome.Thesepatientshaveunrelentingnasaldischargewithoutanysymptomfree
interval.Sincenasalmucosalciliarybeatissuboptimalinthesepatientssaccharinclearancetestwill
helpindiagnosingthisconditon.
Saccharintest:
Thistestisperformedbyplacinga1mmdiametersaccharinetabletjustbehindtheanteriorendof
inferiortubinate/correspondingareaofnasalseptum.Patientisaskedtositquietyleaningforward.
Patientisinstructednottosnifforattempttoclearthenose.Thetimetakenforperceptionof
saccharinetasteafterplacementinthenasalcavityisrecorded.Saccharineisdissolvedinthe
mucouslayerandistransportedposteriorlytothenasopharynxbythenasalmucosalciliary
clearancemechanism.Averagesaccharineclearancetimeis715minutes.Inpatientswithprimary
ciliarydyskinesiatheclearancetimecouldwellbeinexcessof1hour.
FESSisuselessinthesepatients,becauseciliarymechanismisnotgoingtobecomenormal
followingsurgery.
Allergicfungalsinusitis:
Thisisanoninvasivedisorder.Commonlycausedbyaspergillusinfection.Itisseenin
immunocompetentindividuals.Thesepatientspresentwithunilateralnasalpolyposiswithpresenceof
greenishwhitecrusts.
References:
JonesNS(1999)Currentconceptsinthemanagementofpaediatricrhinosinusitis.JLaryngolOtol
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Likethis:
Bethefirsttolikethisarticle.
113:19
FreitasMR,GiestaRP,PinheiroSD,SilvaVC(2006)Antrochoanalpolyp:areviewofsixteencases.
RevBrasOtorrinolaryngol(EnglEd)72(6):831835
DiagnosisandtreatmentofkillinaspolypusinganasalendoscopeLinChuangErBiYanHouKeZa
Zhi.1999Feb13(2):7980.
http://www.drtbalu.com/ac_polyp.html
StammbergerandHawke1993EssentialsofendoscopicsinussurgeryMosbyyearbook
http://www.scribd.com/doc/48796994/acpolypEbooktitledAntrochoanalpolyp
MinYG,ChungJW,ShinJS(1995)Histologicalstructureofantrochoanalpolyps.ActaOtolaryngol
115:543547
IrvingRM,McMahonR,ClarkR,JonesNS(1997)Cysticfibrosistransmembraneconductance
regulatorgenemutationsinseverenasalpolyposis.ClinOtolaryngol22:519521
HenrikssonG,WestinKM,KarpatiF,WikstromCC,StiernaP,HjelteL(2002)Nasalpolypsincystic
fibrosis:clinicalendoscopicstudywithnasallavagefluidanalysis.Chest121:4047
GysinC,AlothmanGA,PapsinBC(2000)Sinonasaldiseaseincysticfibrosis:clinicalcharacteristics,
diagnosis,andmanagement.PaediatrPulmonol30:481489
DrRGeethaforpublishingthisarticle
Like
Acknowledgements
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Preventing nerve damage during
thyroid surgeries
Tips and Tricks
April 18, 2012 Laryngology
Introduction:
Thyroidglandisintimatelyrelatedtotwoimportantnervesthatcontrolvoicei.e.Superiorlaryngeal
andrecurrentlaryngealnerves.Surgeonwhooperatesonthryoidshouldalwayskeepinmindthe
unpleasantmorbiditycausedbyinadvertantinjurytothesenervesduringsurgery.Thyroidsurgeryis
oneofthecommonlyperformedsurgicalproceduresthesedays .
Canthethyroid
glandwheninthestateofenlargementberemoved?Ifasurgeonshouldbesofoolhardy
astoundertakeit..everystephetakeswillbeenvironedwithdifficulty,everystrokeofhis
knifewillbefollowedbyatorrentofbloodandluckyitwouldbeforhimifhisvictimlives
longenoughtoenablehimtofinishhishorridbutchery.Nohonestandsensiblesurgeon
wouldeverengageinitSamuelGross1848.Thingshavemovedalongwaysincethefamousquote
ofGross.
Withthecommonavailabilityofstateofthearthaemostatslikebipolarcautery,Radiofrequency
cauteryandharmonicscalpelsmoreandmoresurgeonsareemboldenedtoventureintothisfield.It
isslowlybecomingaborderzonewheresurgeonsofvariousspecialitiesattempttotransgress
(Generalsurgeons,otolaryngologistsandsurgicalendocrinologists).Currentlyavailablestateofthe
artcauterydeviceslikeLigaSure /Harmonicscalpel havereallymadesurgeonsjobinsecuring
haemostasisduringthissurgeryrealeasy.LotofcreditshouldgotoTheodarKocherwhoshowed
thatmorbidity/mortalitycanbesignificantlyreducedifmeticulousdissectionandpreciseligationof
bloodvesselsiscarriedout.Underhishandsthemortalityratecamedowntolessthan1%.Hewas
awardedtheNobelPrizeinrecognitiontohiscontributiontotheknowledgeofthyroidgland.Afterhim
itwaslefttoBillrothtocarrythetorchofknowledgefurther.
CausesofIncreasedmorbidityandmortalityduringthyroidsurgeries:
Haemorrhage
Asphyxia
Airembolism
Infections
Preventing nerve damage during thyroid surgeries
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Almostallofthesehavebeenconqueredbyinnovationsinthefieldofanaesthesiologyandsurgical
instrumentation.Excellentexposureandmeticuloushaemostasiswillgoalongwayinhelpingto
reducethecomplicationsofthryoidsurgery.Itisimperativeonthepartofthesurgeontorecognize
thepotentialcomplicationsofthissurgicalprocedureandtakeadequatestepstoreducetheir
incidenceintheinterestofthepatient.Bloodlessfieldwillhelpthesurgeontoidentifyvitalstructures
likerecurrentlaryngealnerves,parathyroid,andsuperiorlaryngealnerves.
Commonlyinvolvednervesduringthyroidsurgeriesinclude:
Recurrentlaryngealnerves
Superiorlaryngealnerves
Recurrentlaryngealnervesarecloselyrelatedtotheinferiorvascularpedicleofthyroidgland(inferior
thyroidartery)andsuperiorlaryngealnervesarerelatedtothesuperiorvascularpediclei.e.superior
thyroidvessels.Injuriesinvolvingrecurrentlaryngealnervesaremoresinisterinnatureandcan
causemorbiditiesrangingfromaspirationtostridor.Bestwaytoavoidinjuriestorecurrentlaryngeal
nerve(moreimportant)ofthetwoistoidentifythenerveinallcases .
Recurrentlaryngealnerveinjury:
Recurrentlaryngealnerveinjuriesaremorecommoninthyroidsurgeriesperformedfor:
Thyroidcarcinoma
ToxicgoitreDuetoincreasedvascularitywhichobscuresthenerveduetoexcessivebleeding
RecurrentgoitreDuetoadhesionsandanatomicaldisplacements
Clinicalfeaturesofrecurrentlaryngealnerveinjuries :
Imageshowingleftvocalcordparalysisfollowing
injurytoleftrecurrentlaryngealnerve
Unilateralrecurrentlaryngealnerveinjury:
Isthemostcommonsituationencountered.Leftcordisaffectedcommonlythantherightastheleft
vagusnervetakesamoretortuouscourse.Tostartwiththevoiceisbreathy,butthenormalvocal
cordstartstocompensatesoon.Theairwayisadequateandthereisnostridorinthesepatients.On
indirectlaryngoscopicexaminationtheaffectedcordcouldassumeanyofthe6positionsdescribed
above.Thecordmayappearnottomove,whiletheoppositecordwillcompensateforthelackof
mobility.
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Thesepatientshaveabreathyvoice.Thebreathinessofvoiceiscausedbyglotticchinkwhichallows
airtoescapewhenthepatientattemptstospeak.Normalvoiceproductionisdependentonproper
glottalclosureresultingfrombilateraladductionofthevocalcords.Thisadductionofvocalfolds
combinedwithsubglotticairpressurecausesthevocalfoldstovibratecausingphonation.
Bilateralrecurrentlaryngealnerveinjury:
Thisisthemostdreadedcomplicationofthyroidsurgeries.Thesepatientsmanifestwithstridorand
tracheostomyneedtobeperformedinordertosecuretheairway.Thisiscommonlyseenasa
sequeletototalthyroidectomy.Voiceisnormalinthesepatients.
Tipsforavoidinginjurytorecurrentlaryngealnerveduringthyroidsurgery:
1.Detailedanatomicalknowledgeofrecurrentlaryngealnerveanditsvaryingrelationshipswiththat
ofinferiorthyroidartery
2.Temptationtormassligatethepedicles(inferior)especiallyshouldberesisted
3.Ligaturesshouldstayasclosetothethyroidglandaspossiblealways
4.Recurrentlaryngealnerveshouldbeidentifiedbeforesecuringinferiorthryoidvessels
5.Haemostasisshouldbemeticulouslymaintainedatalltimesinordertoprovidegoodsurgicalfield
foridentifyingthenerve
6.Indirectlaryngoscopyshouldalwaysbeperformedbeforesurgeryinthesepatientstoknowthe
preoperativevocalcordstatus
7.Firsttimeisthebesttimeforsurgery.Alwayscomplete/ensurecompleteremovalofthedisease
theveryfirsttime.Attemptsatrevisionsurgeryisalwaysfraughtwithdangerstotherecurrent
laryngealnerve.
8.CommonsiteofinjurytorecurrentlaryngealnerveisclosetotheBerrysligament.Thiscanbedue
toexcessivetraction,nervegettingcaughtwithinligatures,nervebeinginjureddueto
electocoagulation.
9.Abranchedrecurrentlaryngealnerveismoreproneforinjuryduringsurgery
Roleofinferiorthryoidarteryinidentifyingrecurrentlaryngealnerve:
Theinferiorthyroidarteryanditsbranchesareintimatelyassociatedwiththerecurrentlaryngeal
nerve.Thisrelationshipisatthejunctionofmiddleandlowerthirdofthyroidgland.Theleftrecurrent
laryngealnerveascendsatadepthoftracheooesophagealgrooveorslightlylateraltoitatthelower
poleofthyroidgland.Thenerveontheleftsidecrossesdeeptotheinferiorthyroidartery/inbetween
itsterminalbranches.Itisrarelyseeninaplanesuperficialtotheartery.
Therightrecurrentlaryngealnerveissomewhatlateralinpositionatthelowerpoleofthethyroid
gland.Itcoursesmoreobliquely.Thisisaverycommonareaofinjurytorightrecurrentlaryngeal
nerveduringthyroidsurgery.Innumerablenumberofvaryingrelationshipswithinferiorthyroidartery
hasbeendescribed .Itishenceprudenttolookforthenerveunderthearteryratherthansupericial
toitasthisscenarioisveryrare.
Commonrelationshipofrecurrentlaryngealnervetoinferiorthyroidartery :
Therecurrentlaryngealnervehassignificantbutvaryingrelationshipwiththeinferiorthryoidartery.
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Ontheleftside,therecurrentlaryngealnervepassesbehindtheinferiorthyroidarteryin50%ofthe
casesandanteriortothearteryin20%ofcasesandmaylieinbetweenthebranchesoftheinferior
thyroidarteryin30%ofcases.Ontherightsidesincetherecurrentlaryngealnerveapproachesthe
traceoesophagealgroovemorelaterally,theserelationsaredifferentontherightside.Inhalfofthe
casestherecurrentlaryngealnervepassesbetweenthedistalbranchesoftheinferiorthyroidartery,
in30%ofpatientsitmaylieanteriortotheartery,andin20%ofcasesitmayliedeeptotheinferior
thyroidartery.
FigureshowingInferiorthyroidvessels
Identificationofinferiorthyroidartery,carefulligationofallitsbranchesclosetotheglandratherthan
awayfromitisveryhelpfulinpreventingdamagetorecurrentlaryngealnerveandinferiorparathyroid
glands.Inrarecasesthenervecanbranchbelowtheinferiorthyroidarteryandinthisscenarioitis
safeforthesurgeontoassumeallthesebranchestobemotorbranchestothelarynxandtakeextra
caretoavoiddamagetothem.Inferiorthyroidartery(abranchfromthethyrocervicaltrunk)appears
frombeneaththecarotidsheathonlywhenthethyroidglandisretractedmediallyandthejugularvein
retractedlaterally.Thismaneuverputsstraininthearteryandhelpsinbettervisualization.Before
enteringthethyroidglanditdividesintothreebranchesinferior,posteriorandinternal.Thisartery
alsosuppliestheinferiorparathyroidgland.
RelationshipofrecurrentlaryngealnervetoBerrysligament:
AlsoknownassuspensoryligamentofBerry.Thisligamentattachestheposteromedialaspectof
thyroidglandtothesidesofcricoidcartilageandfirsttwotrachealrings.Itisthisveryattachmentthat
isresponsiblefortheupanddownmobilityofthyroidglandwhichoccursduringswallowing.
Thisisarathercrucialarea.Therecurrentlaryngealnerveisembeddedclosetotheposteriorportion
ofBerrysligamentandisproneforinjurywhenthisligamentissectionedinordertofreethegland
fromitsattachment.Inferiorlaryngealarteryliesposteriortorecurrentlaryngealnerveinthisarea.
BleedersformBerrysligamentshouldnotbeclampedblindlybeforeidentifyingrecurrentlaryngeal
nerve.
Atthelevelofmiddlethirdofthyroidglandtherecurrentlaryngealnerveissituatedclosetothe
capsuleofthegland.Incaseswithpathologicalenlargementofthyroidglandsthisnervemaybe
enclosedwithinthethyroidcapsuleitselfbeforeenteringthelarynx.Itismoreproneforinjuryinlarge
swellingsinvolvingthyroidgland.
Medialretractionofthyroidlobemakesthenervemorevulnerableduringthyroidsurgeries.This
maneuverstretchestheinferiorthyroidarteryanditsbranchesdisplacingthenerveanteriorlyinthe
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tracheooesophagealgrooveexposingittodanger.
FigureshowingBerrysligamentandrecurrent
laryngealnerve:^Berrysligament*Recurrent
laryngealnerve
Cricoarytenoidjointasamarkerforthelocationofrecurrentlaryngealnerve:
Therecurrentlaryngealnerveentersthelarynxdeeptotheinferiorconstrictormuscleandposterior
tothecricoarytenoidjoint.Insidethelarynxitdividesintoasensoryandmotorbranches.The
anteriorlydirectedmotorbranchismadeupof1000axons.About250oftheaxonsinnervatethe
cricoarytenoidmuscle,sinceitisthesoleabductorofthevocalfold.Thetrachea,oesophagusand
pyriformsinusesreceivetheirsensoryfibersfromtheposteriordivisionoftherecurrentlaryngeal
nervebeforeenteringthelarynx.
Recurrentlaryngealnervecanalsobedamagedifitsbloodsupplyiscompromisedduringsurgery.
Thebloodsupplytotherecurrentlaryngealnervecomesfromtheinferiorthyroidartery.Thefeeding
branchesareusuallyanteriortothenerve.Distally,theinferiorlaryngealartery,aterminalbranchof
theinferiorthyroidartery,supplytherecurrentlaryngealnerve.Itisalwaysprudenttoligatethe
inferiorthyroidarteryclosertotheglandafterithasgivenoffthebranchtotherecurrentlaryngeal
nerve.
Alwaysconsidernonrecurrentlaryngealnerve:
Nonrecurrentlaryngealnervearisesdirectlyfromvagusnerveintheneck.Henceitisnotfoundin
theusualposition(i.e.Closetotheinferiorthyroidartery).Nonrecurrentlaryngealnerveisavery
rareanamolymorecommonontherightside(0.50.6%) .Itisextremelyrareontheleftside
(0.004%).Atpresentthereisnowayofidentifyingthisanamolypreoperativelywithacceptable
degreeofaccuracy.IfCTscanneckshowsretrooesophagealsubclavianarterythenthiscondition
shouldbesuspected .
ImageshowingNonrecurrentlaryngealnerve
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Useofoperatingloupe:
Operatingloupeswithatleast4timesmagnificationwithagoodworkingdistanceisarealboontothe
headandnecksurgeonwhileperformingthyroidsurgeries.Routineuseofoperatingloupeswill
minimizerisktotherecurrentlaryngealnerveduringthryoidsurgeries.
Figureshowingoperatingloupe
Superiorlaryngealnerve :
Thisnerveisalsoproneforinjuryduringthyroidsurgeries.
Anatomicallysuperiorlaryngealnerveisoneofthebranchesofvagusnerve.Paralysisinvolvingthis
nerveisfrequentlyoverlookedbecauseofcomplexclinicalpicture.Functionallyspeakingthesuperior
laryngealnervefunctioncanbedividedintosensoryandmotorcomponents.Thesensorifunction
providesavarietyofafferentsignalsfromsupraglotticlarynx.Motorfunctioninvolvesmotorsupplyto
ipsilateralcricothyroidmuscle.
Roleofcricothyroidmuscleonphonation:
Contractionofcricothyroidmuscletiltsthecricoidlaminabackwardatthecricothyoridjointcausing
lengthening,tensingandadductionofvocalfoldscausinganincreaseinthepitchofthevoice
generated.
Diagnosisofsuperiorlaryngealnerveparalysisisbasedlargelyonsymptomatologyandclinical
suspicion.
Symptoms:
1.Raspyvoice
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2.Voicefatigue
3.Volumedeficit
4.Lossofsingingvolume
Kiernerclassifiedthesuperiorlaryngealnerveinto4typesdependingontherelationshipofits
externalbranchtothesuperiorpoleofthyroidgland.
TypeInerve:Inthistypetheexternalbranchofsuperiorlaryngealnervecrossesthesuperiorthyroid
arteryabout1cmabovethesuperiorpoleofthyroidgland.
TypeIInerve:Inthistypetheexternalbranchofsuperiorlaryngealnervecrossesthesuperiorthyroid
arterywithin1cmofthesuperiorpoleofthyroidgland.
TypeIIInerve:Inthistypetheexternalbranchofsuperiorlaryngealnervecrossesthesuperior
thyroidarteryundercoverofthesuperiorpoleofthyroidgland.
TypeIVnerve:Inthistypetheexternalbranchofsuperiorlaryngealnervedescendsdorsaltothe
superiorthyroidarteryandcrossesitsbranchesjustsuperiortotheupperpoleofthyroidgland.
Awarenessoftheseanatomicalvariationswillhelpthesurgeoninpreservingthisbranchduringhead
andnecksurgeries.
Classificationofvariousanatomicaltypesofsuperiordivisionofexternallaryngealnerve:
Superiorlaryngealnerveishighlyvulnerableduringligationofsuperiorpedicleofthyroidgland.
Routineidentificationofthisnerveisratherdifficultwithoutdissectingthroughpharyngealconstrictors.
Innearly20%ofcasesitisnotlocatedclosetotheligationpointofsuperiorpoleofthyroidatall.
Henceroutineidentificationofthisnerveduringthyroidsurgeryhasnotbeenadvocated.Itissafeto
ligatesuperiorthyroidarteryasclosetothesuperiorpoleofthyroidglandaspossible.Itisinfactsafer
toidentifythebrancesofsuperiorthyroidarteryandavoidligatingthemaintrunkasinmajorityof
casessuperiorlaryngealnerveliesratherclosetothemaintrunk.
Useofnervestimualtors:
Eventhoughnervemonitorsandstimulatorshavebeenadvocatedtheirusefulnessstillremainshighly
questionable.Onestudyreportsthattheywereableuseitonlytoidentifysuperiorlaryngealnerve.It
didnotactuallyaidintheanatomicaldissectionofrecurrentlaryngealnerve .
1. AlSobhiSS.ThecurrentpatternofthyroidsurgeryinSaudiArabiaandhowtoimproveit.Ann
SaudiMed2002MayJul22(34):256257.
2. HallgrimssonP,LovnL,WesterdahlJ,BergenfelzA.(2008).Useoftheharmonicscalpelversus
conventionalhaemostatictechniquesinpatientswithGravediseaseundergoingtotalthyroidectomy:
aprospectiverandomisedcontrolledtrial.LangenbecksArchSurg.2008Sep393(5):67580.Epub
2008Aug2.
12
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3. DilekON,YilmazS,DegirmenciB,etal.(2005).Theuseofavesselsealingsysteminthyroid
surgery.ActaChirBelg.2005105:369372.
4. SosaJA,BowmanHM,TielschJM,PoweNR,GordonTA,UdelsmanR.Theimportanceof
surgeonexperienceforclinicalandeconomicoutcomesfromthyroidectomy.AnnSurg1998
Sep228(3):320330.
5. LamadW,RenzK,WillekeF,KlarE,HerfarthC.Effectoftrainingontheincidenceofnerve
damageinthyroidsurgery.BrJSurg1999Mar86(3):388391.
6. TYBOOKT1VocalcordparalysiscurrentmanagementtrendsA1Thiagarajan,B.UR
http://books.google.co.in/books?id=4sES5R0pJjcCPBGeethaRER
7. ReedAERelationsofinferiorlaryngealnervetoinferiorthyroidartery.AnatRec194385:17.
8. http://www.drtbalu.com/app_anarecner.html
9. MUludag,AIsgor,GYetkin,BCitgez(2009)Anatomicvariationsofthenonrecurrentinferior
laryngealnerve.BMJCaseRep.27March2009.
10. AbboudB,AouadR.Nonrecurrentinferiorlaryngealnerveinthyroidsurgery:
reportofthreecasesandreviewoftheliterature.JLaryngolOtol.2004:118:13942.
11. https://sites.google.com/site/drtbalusotolaryngology/Home/laryngology/superiorlaryngealnerve
paralysis
12. Nervestimulationinthyroidsurgery:isitreallyuseful?LochWilkinsonTJ,StalbergPL,SidhuSB,
SywakMS,WilkinsonJF,DelbridgeLW.LochWilkinsonTJ,StalbergPL,SidhuSB,SywakMS,
WilkinsonJF,DelbridgeLW.ANZJSurg.2007May77(5):37780.
5/6/12 Rhinosporidiosis Ent Scholar
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Rhinosporidiosis
A review
February 23, 2012 Rhinology
Definition:
Rhinosporidiosishasbeendefinedasachronicgranulomatousdiseasecharacterisedbyproduction
ofpolypsandothermanifestationsofhyperplasiaofnasalmucosa.Theetiologicalagentis
Rhinosporidiumseeberi.
Rhinosporidiumseeberi:wasinitiallybelievedtobeasporozoan,butitisnowconsideredtobea
fungusandhasbeenprovisionallyplacedunderthefamilyOlipidiaceae, orderchritridialesof
phycomyetesbyAshworth.MorerecentclassificationputsitunderDRIPSclade.Evenafterextensive
studiesthereisnoconsensusonwhereRhinosporidiummustbeplacedintheTaxonomic
classification.IthasnotbeenpossibletodemonstratefungalproteinsinRhinosporidiumevenafter
performingsensitivetestslikePolymerasechainreactions .
History :
1892Malbranobservedtheorganisminnasalpolyp
1900Seeberdescribedtheorganism
1903OKineleydescribeditshistology
1905Minchin&FanthamstudiedOKineleystissueandnamedtheorganismasRhinosporidium
Kinealyi
1913ZSchokkereportedsimilarorganisminhorsesandnameditRhinosporidiumequi
1923Ashworthdescribeditslifecycle
1924Forsythdescribedskinlesion
1924Thirumoorthyreportedthefirstfemalepatient
1936CefferiestablisedtheidentityofR.SeeberiandR.Equi
1953Demellowdescribedthemodeofitstransmission
IncidenceandGeographicaldistribution:
Ofallthereportedcases95%werefromIndiaandSrilanka.AnallIndiasurveyconductedin1957
revealedthatthisdiseaseisunknowninstatesofJummu&Kashmir,Himachalpradesh,Punjab,
Haryana,andNorthEasternstatesofIndia.InthestateofTamilNadu4endemicareas havebeen
identifiedinthesurvey,(Madurai,Ramnad,Rajapalayam,andSivaganga).Thecommon
denominatorintheseareasisthehabitofpeopletakingbathincommonponds.
Theoriesofmodeofspread:
1
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Authors
BalasubramanianThiagarajan
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1.Demellowstheoryofdirecttransmission
2.AutoinoculationtheoryofKarunarathnae(responsibleforsatellitelesions)
3.Haematogenousspreadtodistantsites
4.Lymphaticspreadcausinglymphadenitis(rarity)
DemellowstheoryofdirecttransmissionThistheorypropoundedbyDemellowhaditsacceptance
forquitesometime.Hepostulatedthatinfectionalwaysoccuredasaresultofdirecttransmissionof
theorgansim.Whennasalmucosacomesintocontactwithinfectedmaterialwhilebathingincommon
ponds,infectionfounditswayintothenasalmucosa.
Karunarathnaeaccountedforsatellitelesionsinskinandconjunctivalmucosaasaresultofauto
inoculation.
Rhinosporidiosisaffectingdistantsitescouldbeaccountedforonlythroughhaematogenousspread.
KarunarathnaealsopostulatedthatRhinosporidiumexistedinadimorphicstate.Itexistedasa
saprophyteinsoilandwaterandittookayeastformwhenitreachedinsidethetissues.This
dimorphiccapabilityhelpedittosurvivehostileenvironmentsforalongperiodoftime.
ReasonsforendemicityofRhinosporidiosis :
IthastobeexplainedwhythisdiseaseisendemicincertainpartsofSouthIndiaandinthedryzone
ofSrilanka.Ifstagnantwatercouldbethereasonthenthechemicalandphysicalcharacteristicsof
thewaterneedstobedefined.Inadditionotheraquaticorganismsmayalsobeplayinganimportant
synergisticreaction.Thisaspectneedtobeelucidated.Textbookofmicrobilogyisrepleatewith
examplesofsuchsynergismi.e.lactobacilluswithtrichomonas,andWolbachiawithfilarial
nematodes.
Hostfactorsresponsibleforendemicity:Eventhoughquitealargenumberofpeoplelivinginthe
endemicareastakebathincommonpondsonlyafewdevelopthedisease.Thisindicatesa
predisposing,thoughobscurefactorsinthehost.Bloodgroupstudiesindicatethatrhinosporidiosisis
commoninpatientswithgroupO(70%),thenexthighincidencewasingroupAB.Jainreportedthat
bloodgroupdistributionistoovariabletodrawanyconclusion.Largerseriesmustbestudiedforany
meaningfulanalysis.HLAtypingalsomustbestudied.Thepossibilityofnonspecificimmune
reactivityespeciallymacrophagesinprotectingtheindividualfromRhinosporidiumseeberimustbe
considered.
Lifecycle:(Ashworth)Sporeistheultimateinfectingunit .Itmeasuresabout7microns,aboutthe
sizeofaredcell.Itisalsoknownasaspherule.Ithasaclearcytoplasmwith1520vacuolesfilled
withfoodmatter.Itisenclosedinachitinousmembrane.Thismembraneprotectsthesporefrom
hostileenvironment.Itisfoundonlyinconnectivetissuespacesandisrarelyintracellular.
LifecycleofRhinosporidiumseeberi(Old)
6
7
2
4
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Thesporeincreasesinsize,andwhenitreaches5060micronsinsizegranulesstartstoappear,
itsnucleuspreparesforcelldivision.Mitosisoccursand4,8,16,32and64nucleiareformed.Bythe
time7thdivisionoccursitbecomes100micronsinsize.Afullymaturesporangiameasures150
250microns.Maturesporesarefoundatthecentreandimmaturesporesarefoundintheperiphery.
Thefullcycleiscompletedwithinthehumanbody.
Lifecycle(recent):Sincerhinosporidiumseeberihasdefiedalleffortstocultureit,anydetail
regardingitslifecyclewillhavetobetakenwithapinchofsalt.Thislifecyclehasbeenpostulatedby
studyingthevariousformsofrhinosporidiumseenininfectedtissue.
Trophozoite/JuvenilesporangiumItis6100micronsindiameter,unilamellar,stainspositivewith
PAS,ithasasinglelargenucleus,(6micronstage),ormultiplenuclei(100micronsstage),lipid
granulesarepresent.
Intermediatesporangium100150micronsindiameter.Ithasabilamellarwall,outerchitinous
andinnercellulose.Itcontainsmucin.Thereisnoorganisednucleus,lipidglobulesareseen.
Immaturesporesareseenwithinthecytoplasm.Therearenomaturespores.
Maturesporangium100400micronsindiameter,withathinbilamellarcellwall.Insidethe
cytoplasmimmatureandmaturesporesareseen.Theyarefoundembeddedinamucoidmatrix.
Electrondensebodiesareseeninthecytoplasm.Thebilamellarcellwallhasoneweakspotknown
astheoperculum.Maturationofsporesoccurinbothcentrifugalandcentripetalfashion.Thisspot
doesnothavechitinouslining,butislinedonlybyacellulosewall.Thematuresporesfindtheirway
outthroughthisoperculumonrupture.Thematuresporesonrupturearesurroundedbymucoid
matrixgivingitacometappearance.ItishenceknownasthecometofBeattee
Maturesporesgiverisetoelectrondensebodieswhicharetheultimateinfectiveunit.
LifecycleofRhinosporidiumSeeberi(New)
1Trophozoite(juvenilesporangium)
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2&3Immaturebilamellarsporangia
4a&4bintermediatesporangiawithcentrifugalandcentripetalmaturationofendospores
5Maturesporangiumwithsporesexitingthroughtheoperculum
6Freeendosporewithresidualmucoidmaterialgivingitacometlikeapperance(cometofBeattie)
7aFreeelectronbody(ultimateinfectiveunit)
7bFreeelectrondensebodysurroundedbyotherelectrondensebodieswhicharenutritive
granules
ClincialclassificationofRhinosporidiosis:
1.Nasal
2.Nasopharyngeal
3.Mixed
4.Bizzarre(ocularandgenital)
5.Malignantrhinosporidiosis(cutaneousrhinosporidiosis)
Commonsitesaffected:
Nose78%
Nasopharynx68%
Tonsil3%
Eye1%
Skinveryrare
Fig.1:Oropharyngealrhinosporidiosis
Fig.2:Nasopharyngealrhinosporidiosis
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Grossfeaturesofrhinosporidiosis:
Lesionsinthenosecanbepolypoidal,reddishandgranularmasses.Theycouldbemultiple
pedunculatedandfriable.Theyarehighlyvascularandbleedeasily.Theirsurfaceisstuddedwith
whitishdots(sporangia).Theycanbeclearlyseenwithahandlens.Thewholemassiscoveredby
mucoidsecretion.Therhinosporidiuminthenoseisrestrictedtothenasalmucousmembraneand
doesnotcrossthemucocutaneousbarrier.
Histopathologyofnasalrhinosporidiosis:
Thereispapillomatoushyperplasiaofnasalmucousmembranewithrugaeformation.Theepithelium
overthesporangiaisthinnedout,foreignbodygiantcellscanbeseen.Accumulationofmucousin
thecryptsseenwithincreasedvascularity.Theincreasedvascularityisresponsibleforexcessive
bleedingduringsurgery.Increasedvascularityisduetothereleaseofangiognenesisfactorfromthe
rhinosporidialmass.Rhinosporidialsporesstainwithsudanblack,Bromphenolblueetc.
Fig.3:RhinosporidiosisHistopathology
Endosporulation :
EndosporesrepresentasexualsporesofRhinosporidiumseeberi.Afternucleardivisioninthejuvenile
sporangia,endosporesareforrmedbycondensationofcytoplasmaroundthenucleiwiththe
formationofcellwalls.Thisprocessisknownasendosporulation.Theseendosporeshavebeen
postulatedtodevelopfromtheinnersporangialwall.Endosporesareliberatedfromthesporangium
bybingshotoutfromthesporangiumafteritsrupture(assuggestedbyBeattee),orthroughthe
operculumassuggestedbyAshworth,orbyosmoticmechanismassuggestedbyDemello.
2
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Endosporesarethickwalledmeasuringabout7micronsindiameter,roundinshapeandstainswith
PAS.Ithasavesicularnucleusandagranularcytoplasm.Theperipheralcytoplasmisvacuolated
containingdeeplystainingbodiescalledasspherules.Thesebodiesgivethesporeamorullated
appearanceandhencethetermsporemorullae.
Featuresofrhinosporidiosis:
Thecardinalfeaturesofrhinosporidiosisare:
1.chronicity
2.recurrenceand
3.dissemination.
Thereasonsforchronicityare
1.AntigensequestrationThechitinouswallandthickcelluloseinnerwallsurroundingthe
endosporesisimpervioustotheexitofendosporalantigensfrominside,andisalsoimpermeableto
immunedestruction.Howeverthissequesteredantigenmaybereleasedafterphagocytosis.
2.AntigenicvariationRhinosporidialsporesexpressvaryingantigenstherebyconfusingthewhole
immunesystemofthebody.
3.Immunesuppression?possiblereleaseofimmunosuppressoragents
4.ImmunedistractionStudiesofimmunecellinfiltrationpatternhaveshownthatimmunecell
infiltrationhasoccurredinareaswheretherearenospores,suggestingthattheseinfiltratesreached
theareainresponsetofreeantigenreleasedbythespores.Thisservesasadistraction.
5.Immunedeviation
6.Bindingofhostimmunoglobins
Treatment:
Surgeryisthetreatmentofchoice.Rhinosporidialmasscanberemovedintranasally,theonly
problembeingbleeding.PostoperativelythepatientisstartedonT.Dapsone indoseof100mg/
dayforaperiodof6months.
Unsolvedproblems:
HabitatBreedsinponds(highlytheoretical,sporeshavenotbeenisolatedfrompondsevenon
intenseeffort)
LifecycleIntheabsenceofviablewaystoculturetheorganismthelifecycleremainshighly
speculative
Pathogenicitydoesnotfullfillanyofthe4criteriallaiddownbyKochregardingtheinfectivity
Morphology
1. SeeberGR.Unneuvoesporozoarioparasitodelhombre:doscasosencontradesenpolipos
nasales.Thesis,UniversidadNacionaldeBuenosAires.1900.
9
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2. http://drtbalu.co.in/rhinosporidiosis.html
3. @article{{JORL}{19},author={Thiagarajan,B.},title={RhinosporidiosisourExperience},journal=
{Otolaryngologyonlinejournal},volume={1},number={1},year={2011},url=
{http://jorl.net/index.php/jorl/article/view/19/2}}
4. AshworthJH.OnRhinosporidiumseeberiwithspecialreferencetoitssporulationandaffinities.
TransRSocEdinburgh.192353:301342.
5. FredricksDN,JolleyJA,LeppPW,KosekJC,RelmanDA.Rhinosporidiumseeberi:ahuman
pathogenfromanovelgroupofaquaticprotistanparasites.EmergInfectDis.MayJun
20006(3):27382.
6. DeMello,MT(1949):RhinosporidiosisMycopathologia4,342348
7. ThepathologyofrhinosporidiosisW.A.E.KarunaratneArticlefirstpublishedonline:9JUN2005
DOI:10.1002/path.1700420121
8. MosesJS,ShanmughamA,KingslyN,etal.Epidemiologicalsurveyofrhinosporidiosisin
KanyakumaridistrictofTamilNadu.Mycopathologia.Mar1988101(3):1779
9. JobA,VenkateswaranS,MathanM,KrishnaswamiH,RamanR.Medicaltherapyof
rhinosporidiosiswithdapsone.JLaryngolOtol.Sep1993107(9):80912
3/16/12 Septal Hematoma? Ent Scholar
1/4 entscholar.wordpress.com/?post_type=article&p=261&preview=true
Sepal Hemaoma?
Naal defomiie ae j aond he cone
March 16, 2012 Rhinology
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3/16/12 Septal Hematoma? Ent Scholar
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3/16/12 Septal Hematoma? Ent Scholar
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2/8/12 Tests for Malingering Recent advances in otolaryngology
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Tests for Malingering
Identifing non organic hearing loss
February 6, 2012 Otology
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Testsformalingering:
VoicetestsforMalingering:
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2/8/12 Tests for Malingering Recent advances in otolaryngology
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Thesearesimpletoperform.
Erhardtstest:Thistestisbasedontheprincipleevenwithaheadshadoweffectsoundcaneasily
beconductedthroughbone.Thistesthelpsinthedetectionoffeignedtotalunilateralhearingloss.
Occusionofearwillcauseattenuationof30dB.Thistestisperformedwiththepatientseyesclosed.
Soundisprojectedtotheclosednormalear.Evenwiththeheadshadoweffectpatientshouldbeable
tohearthespokenwordasexternalcanalocclusioncasuesonlyabout30dBdampeningofsound.If
thepatientdenieshearingspokenwordthenthistestformalingeringispositive.
Lombardstest:ThistestisbasedonLombardsprinciple.Thisprinciplesaysthatoneraiseshis/
hervoicewhenspeakinginnoisyenvironment.Whileperformingthistest,thepatientisallowedto
readabook.Noiseisintroducedintotheear.Thenoiseisgraduallyincreasedtillthepatientraises
his/hervoiceorstopstheprocessofreading.Ifthereisnochangeinvoiceloudnesslevelthepatient
doesnothavefunctionalhearingdefect.
HummelDoubleconversationtest:
Whentwodifferentvoicesareappliedtotwoearsitcauseslotsofconfusiontothepatient.Ifoneear
isdeafthenthepatientisnotconfusedbytwodifferentquestionsbeingprojectedtotwoearssince
oneearisdeaf,whereasinmalingeringthesincethepatienthasnormalhearinginbothearsit
causeslotsofconfusion.Amalingererwontrespond.
Delayedspeechfeedbacktest:Inthistestthepatientissubjectedtospokenwordswhoseoutput
isdelayedby200milliseconds.Thelevelatwhichitcauseddifficultyinspeakingisobserved.This
testispositiveinmalingerers.
TwotubetestofTeuber:
ThisisactuallyamodificationofHummeldoubleconversationtest.Thistestisperformedusingtwo
tubescoupledwitheachother.Examinerholdsoneendofbothtubesandstartsspeakingtoit.By
alternatecompressionofthetubeheisabletoconfusethemalingerertoexposehisdesigns.
Stethoscopetest:Inthistest,oneearpieceofthestethoscopeisclosedwithwaxandusedonthe
sideofdeafness.Thefunnelshapedchestpieceisusedtotalktothepatient.Themalingerergets
confusedandcannottellwhetherheishearingontheright/leftside.
Erhardtstest:Thistestisalsoknownasloudvoicetest.Innormalpersonwhentheearisoccluded
withafinger,itdampensthesoundbutitcanstillbeheard.Malingereroftendenieshearingthe
soundevenwhenitisloudest.
DoerfflerStewarttest:Thistestisbasedonthefactthatpersonswithnormalhearingraisetheir
voiceinthepresenceofbackgroundnoise.Thistestcanbeperformedintwoways:Thepatientis
madetoreadapassagefromabook,whilemaskingnoiseisfedintothesocalleddeafear.Inthe
caseoftruedeafness,themaskingnoisehasnoeffectonthevoiceuntilitreachesthethresholdof
deafness.Thepatientmayalsobeaskedtolistentospokenvoiceinsteadofreadingfromabook.
Tuningforktestsformalingering:
Stengerstest:ThistestisbasedonStengersphenomenon.Instengersphenomenonwhena
listenerispresentedwiththesametypeofsoundinbothearshe/shewillhearasinglesound,that
tooonlyintheearwhichitislouder.
Procedure:Twotuningforkswithfrequencyof512Hzarekeptequidistantlyfrombothears,one
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Likethis:
Bethefirsttolikethisarticle.
shouldbeabletohearequallywellineitherside.Inmalingeringsayi.e.leftear,evenifthetuningfork
ismovedtooclosetotheleftear,thepatientdeniesthatheishearingintherightsidealso.
Tealstest:Inthistestavibratingtuningforkisappliedoverthemastoidprocessofthesocalled
deafear,thepatientacceptstohearit.Thenthepatientisblindfoldedandwithanonvibratingforkon
themastoidprocess,themalingeringpatientclaimstohearthesound.
ChimaniMoosstest:ThisisnothingbutavariationofWeberstest.NormallyinWeberstestthe
patienthearsthebestintheoccludedear.In,malingeringthepatientwillnotaccepttohearbetterin
theoccludedear.
Puretoneaudiometry :
Whileperformingpuretoneaudiometrythefollowingfeaturesifpresentaresuggestiveofmalingering:
Variableresponsetostimuli:Duringpuretoneaudiometrypatientsusuallycomeoutwithuniform,
repeatableresponse.Inmalingerersthisresponseisnotuniformandhighlyvariable.
Variationsbetweenclinicallyobservabledeafnessanddegreeofpuretoneaudiometryhearingloss
Airconductionshadowtests:Maximuminterauralattenuationforanyfrequencyisabout85dB,
averageattenuationacrossvariousfrequencieswouldbe63dB.Henceunmaskeddifference
betweentwoearswhichexceeds80dBforanyfrequencyor70dBoverarangeoffrequenciesis
suggestiveofnonorganichearingloss
Boneconductionshadowtests:Maximalboneconductiontranscranialhearinglosshasbeen
foundtobelessthan15dB.Adifferenceofunmaskedboneconductionhearingthresholdbetween
bothearsofmorethan15dBshouldpointtowardsmalingering.
Stengerstest:ThistestisbasedonTarchanowphenomenonwhichstatesthatwhenpuretonesof
equalintensitiesarepresentedbilaterally,theyarefusedintoasingletoneinthemidline.A
malingererisnotawareofthisandhencewouldreporthearingloss/lateralisationofthestimuli.
Auditoryreflexthreshold:Innormalindividualsthestapedialreflexiselicitedat70100dB.Ifa
malingerersaysheistotallydeafandifthisreflexiseliciteditissuggestiveofmalingering
.Bekesyaudiometry:Thisusescontinuousandpulsedtonetracings.Thenormalgraphrecorded
maybeinterleaved/continuoustracingsbelowpulsedtonetracings.Inpatientswithnonorganic
hearinglosswillhaveoppositecurvestheirpulsedtracingsaretrackedbelowthecontinuous
tracings.ThistypeofcurveisknownasTypeVBekesypattern.
Lengthenedofftimetest:LOT:ConventionalBekesyaudiometryusespulsedtonesthatareonand
offforequalamountsoftime(200millisecondsonand200millisecondsoff).TheLOTisatestfornon
organichearinglossthatusesBekesyaudiometryinwhichthepulsedtoneshaveanofftimethatis
lengthenedfrom200msto800ms.InadditiontheLOTusesfixedfrequencyratherthansweep
frequencytracings.Inthistestthecontinuoustracingiscomparedtothepulsedtracingthatis
obtainedwithatonethatpulsesatarateof200msonand800msoff.TheLOTincreasesthedegree
towhichthepulsedtracingfallsbelowthecontinuoustracinginmalingerers.
4
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2/8/12 Tests for Malingering Recent advances in otolaryngology
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1. 1.HinchcliffeJClinicaltestsofauditoryfunctionintheadult.Audiology1974:3:34951
2. 2.PsychogenicHearingLosswithPanicAnxietyAttackaftertheOnsetofAcuteInnerEarDisorder
ShigehitoMori,ShigeharuFujieda,TakehitoYamamoto,NoboruTakahashi,TakehisaSaito,Hitoshi
SaitoORL200264:4144(DOI:10.1159/000049268)
3. 3.McDermottBE,FeldmanMD(2007)."Malingeringinthemedicalsetting".PsychiatrClinNorth
Am30(4):64562.doi:10.1016/j.psc.2007.07.007.PMID17938038
4. 4.ScreeningtestsfornonorganichearinglossLtColA.K.MethaMJAFI2000567981
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2/13/12 Tuning Fork tests Ent Scholar
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Toning Iork tests
A review
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2/13/12 Tuning Fork tests Ent Scholar
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ItwasE.SchmalzanotologistfromDresdenGermanyin1845 introducedthetuningforktestin
otologywhichhelaternamedasWeberinhonorofWeber.Hewasthefirsttoclaimthediagnostic
possibilityofusingatuningfork.Thisachievementdidnotattractthatmuchattentionduringhistimes.
ItwaslaterlefttoTondroff whostressedtheimportanceoftuningforkasadiagnostictoolinthe
fieldofotology.
Tondroffbyhisclassicstudiesofferedthemostdetailedandcompleteexplanationoftheworking
mechanismofboneconductionhearing.Tondroffidentifiedfourmajorboneconductioncomponents :
1.Middleearinertia
2.Middleearcompliance
3.Innerearcompression
4.Roundwindowrelease
Commonlyperformedtuningforktests :
Tuningforktestsareperformedinordertosubjectivelyassessapersonshearingacuity.Thistest
caninfactbeperformedbyusingtuningforksofthefollowingfrequencies(254Hz,512Hz,and1024
Hz).Frequenciesbelow254Hzarebetterfeltthanheardandhencearenotused.Sensitivityfor
frequenciesabove1024Hzisratherpoorandhenceisnotused.
Prerequisitesforanidealtuningfork:
1.Itshouldbemadeofagoodalloy
2.Itshouldvibrateatthespecifiedfrequency
3.Itshouldbecapableofmaintainingthevibrationforonefullminute
4.Itshouldnotproduceanyovertones
Methodologyofusingtuningfork:
Thetuningforkmustbestruckagainstafirmsurface(rubberpad/elbowoftheexaminer).Thefork
shouldbestruckatthejunctionofupper1/3andlower2/3ofthefork.Itisthisareaoftheforkwhich
iscapableofmaximumvibration.
Thevibratingforkshouldbeheldparalleltotheacousticaxisoftheearbeingtested.
Advantagesoftuningforktests:
1.Easytoperform
2.Canevenbeperformedatbedside
3.Willgivearoughestimateofthepatientshearingacuity
Thefollowingtestscanbeperformedusingatuningfork:
1.Rinnetest
2.Webertest
3.ABCtest
3
3
4
5
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4.Bingtest
5.Politzertest
6.BingEntotictest
7.Stengerstest
8.Gelletest
9.ChimaniMoostest
Rinnetest:
Rinnestest:isatuningforktestusedtoclinicallytesthearingdeficienciesinpatients.Itisdesignedto
compareairconductionwithboneconductionthresholds.Undernormalcircumstances,air
conductionisbetterthanboneconduction.
Ideally512tuningforkisused.Itshouldbestruckagainsttheelboworkneeofthepatienttovibrate.
Whilestrikingcaremustbetakenthatthestrikeismadeatthejunctionoftheupper1/3andlower2/3
ofthefork.Thisisthemaximumvibratoryareaofthetuningfork.Itshouldnotbestruckagainst
metallicobjectbecauseitcancauseovertones.Assoonastheforkstartstovibrateitisplacedatthe
mastoidprocessofthepatient.Thepatientisadvisedtosignalwhenhestopshearingthesound.As
soonasthepatientsignalsthatheisunabletoheartheforkanymorethevibratingforkistransferred
immediatelyjustclosetotheexternalauditorycanalandisheldinsuchawaythatthevibratory
prongsvibrateparalleltotheacousticaxis.Inpatientswithnormalhearingheshouldbeabletohear
theforkassoonasitistransferredtothefrontoftheear.ThisresultisknownasPositiveRinnetest.
(Airconductionisbetterthanboneconduction).Incaseofconductivedeafnessthepatientwillnotbe
abletoheartheforkassoonasitistransferredtothefrontoftheear(Boneconductionisbetterthan
airconduction).ThisisknownasnegativeRinne.Itoccursinconductivedeafness.Thistestis
performedinboththeears.
Ifthepatientissufferingfromprofoundunilateraldeafnessthenthesoundwillstillbeheardthrough
theoppositeearthisconditionleadstoafalsepositiveRinne.
UseofRinnetestinquantifyingconductivedeafness:
Conductivedeafnessofmorethan25dBisindicatedbynegativeRinnewith512Hzfork,whileitis
positivefor1024Hz.IfRinneisnegativefor256,512and1024Hzthenconductivedeafnessshould
begreaterthan40dB.
Webertest:
Isatuningforktest(quick)usedtoassesshearinglevelsinanindividual.Thiscaneasilydetect
unilateralconductiveandunilateralsensorineuralhearingloss.ThistestisnameafterErnstHeinrich
Weber(17951878).Thistestisideallyperformedataboneconductionlevelof4050dBhearing
thresholdlevels.Anyincreaseinthislevelwouldleadtodistortion.
Procedure:
Tuningforksused256Hz/512Hz
Commonlyusedfrequencyis512Hz.
Avibratingforkisplacedovertheforehead/vertex/chinofthepatient.Thepatientshouldbe
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instructedtoindicatewhichearhearsthesoundbetter.Innormalearandinbilateralequallydeaf
earsthesoundwillbeheardinthemidline.Thistestisverysensitiveinidentifyingunilateral
deafness.Itcanpickoutevena5dBdifferencebetweentheears.
Theory:
Apatientwithaunilateral(onesided)conductivehearinglosswouldhearthetuningforkloudestin
theaffectedear.Thisisbecausetheconductionproblemmaskstheambientnoiseoftheroom,whilst
thewellfunctioninginnerearpicksthesoundupviathebonesoftheskullcausingittobeperceived
asaloudersoundthanintheunaffectedear.
Inadequacies:
Thistestismostusefulinindividualswithhearingthatisdifferentbetweenthetwoears.Itcannot
confirmnormalhearingbecauseitdoesnotmeasuresoundsensitivityinaquantitativemanner.
Hearingdefectsaffectingbothearsequally,asinPresbycusiswillproduceanapparentlynormaltest
result.
AbsoluteBoneconductiontest:
Thistestisperformedtoidentifysensorineuralhearingloss.Inthistestthehearinglevelofthepatient
iscomparedtothatoftheexaminer.Theexaminershearingisassumedtobenormal.Inthistestthe
vibratingforkisplacedoverthemastoidprocessofthepatientafteroccludingtheexternalauditory
canal.Assoonasthepatientindicatesthatheisunabletohearthesoundanymore,theforkis
transferredtothemastoidprocessoftheexaminerafteroccludingtheexternalcanal.Incasesof
normalhearingtheexaminermustnotbeabletohearthefork,butincasesofsensorineuralhearing
losstheexaminerwillbeabletohearthesound,thenthetestisinterpretedasABCreduced.Itisnot
reducedincaseswithnormalhearing.
Bingtest:
Thisisactuallyamodificationofweberstest.Thevibratingforkisplacedoverthemastoidprocess
andwhenitceasestobeheardtheexaminersfingerisusedtooccludetheexternalauditorycanal.
Innormalindividualsthesoundwillbeheardagain.Thisisbecausebyoccludingtheexternal
auditorycanaltheexaminerispreventingsoundfromescapingviatheexternalcanal.Theexternal
auditorycanalactsasaresonatingchamber.Ifthevibratingforkisnotheardagainaftertheexternal
canalisoccludedthenitisconstruedthatthemiddleearconductionisthecausefordeafness.In
patientswithpronounceddeafnessifthevibratingforkisheardafterocclusionofexternalcanalthen
deafnessisconstruedtobeduetolabyrinthinecauses.
Politzertest:
Inthistestthevibratingforkisheldinfrontofopenmouthandthepatientisaskedtoswallow.Ifthe
Eustachiantubesarepatulousthensoundwillbeintensifiedduringswallowing.Ifonlyonetubeis
patulousthensoundwillbeaccentuatedonlyinthatear.Sometimesnormalpersonstoomaynot
hearthevibratingfork.
BingEntotictest:
Hypotheticallythistestissupposedtodifferentiatebetweendeafnessduetoankylosisoffootplateof
stapesfromthatofconditionsinterferingwithmobilityofotherossicles.Thistestisactuallyofhistoric
valueonly.Eustachiancatheterispassedandtooneofitsendsisattachedaspeakingtube.Ifthe
patientisabletoheartheforkbetterviathistubethanthatfromtheexternalauditorycanalthen
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Likehi:
Bethefirsttolikethisarticle.
middleearossiclesotherthanfootplateofstapesissupposedtobeatfault.
Stengerstest:
Thistestisperformedtoidentifyfeignedhearinglossandmalingering.Thistestisbasedonthe
auditoryphenomenonknownasStengersprinciple.Thisprinciplestatesthatwhentwosimilar
soundsarepresentedtobothearsonlythelouderofthetwowouldbeheard.Patientsusuallyarenot
awareofthisphenomenon.Whentwosimilartuningforksofsamefrequenciesaremadetovibrate
andheldsimultaneouslyintheacousticaxisofbothearsonlythelouderforkwillbeheard.Loudness
ofvibratingforkcanbeadjustedbyadjustingthedistanceoftheforkfromtheexternalcanal.Usually
thevibratingforkisheldclosertotheallegedlydeafearofthepatient.Thepatientwillnot
acknowledgehearinginthatear.AccordingtoStengersprincipleheshouldbeabletohearthe
louderfork.Ifthehearinglossinworseearisgenuine,patientwillrespondtothesignalpresentedto
thebetterear.ThisisknownasnegativeStengerstest.Feigningpatientwillnotacknowledge
hearingwhenloudersoundispresentedtotheworseear.ThisisknownaspositiveStengerstest.
Gelletest:
Inthistest,theairpressureintheexternalcanalisvariedusingaSieglesspeculum.Thevibrating
forkisheldincontactwiththemastoidprocess.Innormalindividualsandinthosewithsensorineural
hearingloss,increasedpressureintheexternalmeatuscausesadecreaseintheloudnessofthe
boneconductedsound.Instapesfixationnoalterationinthehearingthresholdisevident.
ChimaniMoostest:
ThisisactuallyamodificationofWebertest.Whenthevibratingforkisplacedonthevertex,the
patientindicatesthathehearsitinthegoodearandnotinthedeafear.Themeatusofthegoodear
isthenoccluded.Agenuinedeafpatientwillstillbeabletolateralizethesoundtothegoodear,
whereasamalingererwilldenyhearingthesoundatall.
1. HistoryoftuningforkIIFeldmannHLaryngorhinootologie.1997May76(5):31826.
2. http://www.hps.cam.ac.uk/whipple/explore/acoustics/historicalnotes/
3. TschiassnyK.Tuningforktests.Ahistoricalreview.AnnOtolRhinolLaryngol.194655:433430.
4. KhannaS,TonndorfJ,QuellerJ.Mechanicalparametersofhearingbyboneconduction.JAcoust
SocAm.197660:139154.
5. https://sites.google.com/site/drtbalusotolaryngology/otology/tuningforktests
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