ENT diseases

Disease of the Ear

Cerumen Impaction
• ear wax is a mixture of secretions from ceruminous and
pilosebaceous glands, squames of epithelium, dust, and debris
Risk Factors
• hairy or narrow ear canals, in-the-ear hearing aids, cotton
swab usage, osteomata
Clinical Features
• hearing loss (conductive)
• tinnitus, vertigo, otalgia, aural fullness
Treatment
• ceruminolytic drops (bicarbonate solution, olive oil, glycerine)
• syringing
• manual debridement
• Cerumen impaction is the most common cause of conductive
hearing loss in 15 to 50 year olds.
SYRINGING
Indications
• totally occlusive cerumen with pain, decreased hearing, or tinnitus
Contraindications
• non-occlusive cerumen, previous ear surgery, only
hearing ear, TM perforation
Complications
• failure, otitis externa, TM perforation, vertigo...
Method
• establish TM is intact
• gently pull the pinna up and back
• using warm water, aim the syringe nozzle upwards and
posteriorly to irrigate the ear canal
 Otitis Externa (OE)

Etiology
• bacteria (~90% of OE): Pseudomonas aeruginosa,
Pseudomonas vulgaris, E. coli, S. aureus
• fungus: Candida albicans, Aspergillus niger 
Risk Factors
• associated with swimming (“swimmer’s ear”)
• mechanical cleaning , skin dermatitides, aggressive scratching
• devices that occlude the ear canal: hearing aids, headphones,
etc. 
Clinical Features
• acute
• pain aggravated by movement of auricle (tragal tenderness)
• otorrhea (sticky yellow purulent discharge)
• conductive hearing loss , aural fullness 2o to obstruction of
external canal by swelling and purulent debris
• post-auricular lymphadenopathy
• complicated OE exists if the pinna and/or the periauricular soft
tissues are erythematous and swollen
• chronic
• pruritus of external ear , excoriation of ear canal
• atrophic and scaly epidermal lining , otorrhea , hearing loss
• wide meatus but no pain with movement of auricle
tympanic membrane appears normal
Treatment
• clean ear under magnification with irrigation, suction, dry
swabbing
• bacterial etiology
• antipseudomonal otic drops (e.g. gentamicin,
ciprofloxacin) or a combination of antibiotic and steroid
• do not use aminoglycoside if the tympanic membrane
(TM) is perforated because of the risk of ototoxicity
• systemic antibiotics if either cervical lymphadenopathy
or cellulitis
• fungal etiology
• repeated debridement and topical antifungals
( clotrimazol)
• analgesics
• chronic otitis externa (pruritus without obvious
infection) --> corticosteroid alone
 Malignant (Necrotizing) Otitis Externa/Skull
Base Osteomyelitis

• osteomyelitis of the temporal bone 

Epidemiology
• occurs in elderly diabetics and immunocompromised patients 
Etiology
• rare complication of otitis externa
• Pseudomonas infection in 99% of cases
Clinical Features
• otalgia and purulent otorrhea that is refractory to medical therapy
• granulation tissue on the floor of the auditory canal 
Complications
• lower cranial nerve palsies
• systemic infection
Treatment  
• imaging: high resolution temporal bone CT scan
• requires hospital admission, debridement, IV
antibiotics
 Acute Otitis Media (AOM)

- is acute inflammation of middle ear  

Epidemiology
• 60 to 70% of children have at least 1 episode of AOM
before 3 years
• 18 months to 6 years most common age group
• peak incidence January to April
• one third of children have had 3 or more episodes by age
3 
Etiology
• S. pneumoniae – 35% of cases (incidence decreasing due to vaccine)
• H. influenzae – 25% of cases
• M. catarrhalis – 10% of cases
• S. aureus and S. pyogenes (all beta-lactamase producing)
anaerobes (newborns) , gram negative enterics (infants) , viral 
Predisposing Factors
• eustachian tube dysfunction/obstruction
• swelling of tubal mucosa
• obstruction/infiltration of eustachian tube ostium
   disruption of action of:
• cilia of Eustachian tube
• mucus secreting cells
• capillary network that provides humoral factors, PMNs,
phagocytic cells
• Immunosuppression/deficiency due to chemotherapy,
steroids, diabetes mellitus, hypogammaglobinemia
Pathogenesis
obstruction of Eustachian tube --> air absorbed in middle ear -->
negative pressure (an irritant to middle ear mucosa) --> edema
of mucosa with exudate/effusion --> infection of exudate from
nasopharyngeal secretions
Clinical Features
• triad of otalgia, fever (especially in younger children), and CHL
• rarely tinnitus, vertigo, and/or facial nerve paralysis
• otorrhea if tympanic membrane perforated
• pain over mastoid
• infants/toddlers
• ear-tugging
• hearing loss, balance disturbances (mild)
• irritable, poor sleeping
• vomiting and diarrhea
• anorexia
• otoscopy of tympanic membrane
• Hyperemic, bulging TM
• loss of landmarks: handle and short process of malleus not visible
Treatment
• antibiotic treatment hastens resolution – 10 day course
• 1st line:
• amoxicillin 40 mg/kg/day divided into two doses
• if penicillin allergic: macrolide (clarithromycin, azithromycin),
trimethoprim-sulphamethoxazole

• 2nd line (for amoxicillin failures):

• double dose of amoxicillin (80 mg/kg/day), amoxicillin-clavulinic acid
• Cephalosporin : cefuroxime , ceftriaxone
• symptomatic therapy
• antipyretics/analgesics (e.g. acetaminophen)
***** AOM deemed unresponsive if clinical
signs/symptoms and otoscopic findings persist beyond 48
hours of antibiotic treatment
Complications of AOM CNS
•otologic meningitis
•TM perforation  brain abscess
•chronic suppurative OM facial nerve paralysis
•ossicular necrosis other 
•cholesteatoma mastoiditis and
•persistent effusion (often labyrinthitis
leading to hearing loss) sigmoid sinus
thrombophlebitis
 Otitis Media with Effusion (OME)

• presence of fluid in the middle ear without signs or

symptoms of ear infection
Epidemiology
• not exclusively a pediatric disease
• follows AOM frequently in children:
• middle ear effusions have been shown to persist
following an episode of AOM for 1 mos in 40% of
children, 2 mos in 20% and 3+ mos in 10%
Clinical Features
• fullness – blocked ear
• hearing loss , tinnitus
• pain, low grade fever
• otoscopy of tympanic membrane
• discolouration – amber or dull grey with “glue” ear
• meniscus fluid level
Treatment
• expectant – 90% resolve by 3 months
• ventilating tubes to equalize pressure and drain ear 
Complications of Otitis Media with Effusion (OME)
• hearing loss, speech delay, learning problems in young children
• chronic mastoiditis
• ossicular erosion
• cholesteatoma especially when retraction pockets involve pars
flaccida or postero-superior TM
• retraction of tympanic membrane, atelectasis, ossicular fixation
 Cholesteatoma

- Is a cyst composed of keratinizing squamous epithelium in an abnormal

place (e.g. middle ear, mastoid, temporal bone) 
• Congenital
• Acquired (more common)
• generally occurs as a consequence of otitis media and chronic
Eustachian tube dysfunction
• frequently associated with retraction pockets in the pars flaccida and
marginal perforations of the tympanic membrane
• the associated chronic inflammatory process causes progressive
destruction of surrounding bony structures 
Clinical Features
• symptoms
• history of otitis media (especially if unilateral), ventilation tubes, ear surgery
• progressive hearing loss (predominantly conductive although may get sensorineural
hearing loss in late stage)
• otalgia, aural fullness, fever
• signs
• retraction pocket in TM, may contain keratin debris
• TM perforation
• granulation tissue, polyp visible on otoscopy
• malodorous, unilateral otorrhea
Complications
ossicular erosion: conductive hearing loss
• facial paralysis
• Meningitis
• sensorineural hearing loss from inner ear erosion
• sigmoid sinus thrombosis
• dizziness from inner ear erosion or labyrinthitis
• intracranial abscess (subdural, epidural, cerebellar)
• temporal bone infection: mastoiditis, petrositis
Investigations  
• CT scan 
Treatment
• there is no conservative therapy for cholesteatoma
• surgical: mastoidectomy , tympanoplasty ,ossicle
reconstruction 
 Mastoiditis

• infection of mastoid air cells, most commonly seen

approximately two weeks after onset of untreated
or inadequately treated acute suppurative otitis
media
Etiology
• acute mastoiditis caused by the same organisms as
AOM: S. pneumonia , S. pyogenes , S. aureus, H.
influenza
Clinical Features
• classic triad
• otorrhea
• tenderness to pressure over the mastoid
• retroauricular swelling with protruding ear
• fever, hearing loss ,TM perforation (late)
• radiologic findings: opacification of mastoid air cells by
fluid and interruption of normal trabeculations of cells
Treatment
• IV antibiotics and ventilating tubes - usually all that is
required acutely
• cortical mastoidectomy
• debridement of infected tissue allowing aeration and
drainage
• requires lifelong care
Facial nerve paralysis

Causes
• Bell’s palsy(50%)
• Trauma(20%)
• Otitis media…
 Bell’s palsy

• Rapid onset, minimal associated symptoms &

spontaneous recovery
• Improvement in 3 weeks in 85 % of cases
• The longer the delay, the greater the sequale
• Recent evidences suggest it is Herpes simplex
mononeuritis
Palsy is not Bell’s if any of the following occur
• Sign of tumor/vescicle
• Temporal bone infection/trauma
• Multiple CN involvement/ palsy at birth
• Signs of CNS lesion
Treatment
• Steroids
• Acyclovir
• Surgical decompression
• Eye care
 Otosclerosis

• is fusion of stapes footplate to oval window so that it cannot

vibrate 
• Otosclerosis is the second most common cause of conductive
hearing loss in 15 to 50 year olds (after cerumen impaction).
Etiology
• autosomal dominant, variable penetrance approximately 40%
• female > male, progresses during pregnancy (hormone
responsive) 
Clinical Features
• progressive conductive hearing loss first noticed in teens and
20’s (may progress to sensorineural hearing loss if cochlea
involved)
• tinnitus
***tympanic membrane is normal
Treatment
• Surgical
 Disease of the Inner Ear

Congenital Sensorineural Hearing Loss

Prenatal TORCH Infections
• toxoplasmosis, rubella, cytomegalovirus (CMV), herpes simplex,
others (e.g. HIV
• Perinatal
- Rh incompatibility
- anoxia
- hyperbilirubinemia
- birth trauma (hemorrhage into inner ear
• Postnatal
- meningitis
- mumps
-Measles
• Congenital SNHL is decreasing in incidence due to the
availability of vaccines & improved neonatal care. 
• 50 to 75% of newborns with sensorineural hearing loss have
at least one risk factors
 Presbycusis

Definition
• sensorineural hearing loss associated with aging (5th and 6th decades)
• Presbycusis is the most common cause of sensorineural hearing loss.
Etiology
• hair cell degeneration
• age related degeneration of basilar membrane
• cochlear neuron damage
• ischemia of inner ear
Clinical Features
• progressive, gradual bilateral hearing loss
• recruitment phenomenon: inability to tolerate loud sounds
tinnitus
Treatment
• hearing aid
 Drug Ototoxicity

Aminoglycosides
• toxic to hair cells by any route: oral, IV, and topical (only if
the TM is perforated)
• destroys sensory hair cells – outer first, inner second
• ototoxicity occurs days to weeks post-treatment
• streptomycin and gentamicin (vestibulotoxic), kanamycin
and tobramycin (cochleotoxic)
• daily dosing presents less risk than divided daily
doses
• duration of treatment is the most important
predictor of ototoxicity
• treatment: immediately stop aminoglycosides
 Noise-Induced Sensorineural Hearing Loss

Pathogenesis
• 85 to 90 dB over months or years causes cochlear damage
• early-stage hearing loss at 4000 Hz (because this is the resonance frequency
of the temporal bone) , extends to higher and lower frequencies with time
• speech reception not altered until hearing loss >30 dB at speech frequency,
therefore considerable damage may occur before patient complains of
hearing loss
• difficulty with speech discrimination, especially in situations with
competing noise
Limits of Noise Causing Damage
• continuous sound pressure >85 dB
• single sound impulse >135 dB
 Diseases of the oral cavity & oropharynx

Acute Tonsillitis
Etiology
• Group A beta-hemolytic streptococcus and Group G streptococcus
• S. pneumonia, S. aureus, H. influenzae, M. catarrhalis  
Clinical Features
• symptoms
• sore throat
• dysphagia, odynophagia, trismus
• malaise, fever
• otalgia (referred)
• signs
• tender cervical lymphadenopathy especially submandibular,
jugulodigastric
• tonsils enlarged, inflammation ± exudates/white follicles 
• strawberry tongue, scarletiniform rash (scarlet fever)
• palatal petechiae (infectious mononucleosis) 
Investigations
• CBC
. 
Treatment
• bed rest, soft diet, ample fluid intake
• analgesics and antipyretics
• antibiotics
• 1st line penicillin or amoxicillin (erythromycin if penicillin allergic) x 10
days
• rheumatic fever risk emerges approximately 9 days after the onset
of symptoms: antibiotics are utilized mainly to avoid this serious sequela
and to provide earlier symptomatic relief
• no evidence for the role of antibiotics in the avoidance of post-streptococcal
glomerulonephritis
Complications
• deep neck space infection
• abscess: peritonsillar, intratonsillar
• sepsis
• glomerulonephritis
Adenoid hypertrophy
• Increase in size with allergy
and repeated URTI
• Clinical features
• Nasal obstruction
• Adenoid facies
• Hyponasal voice
• OSA
• Rhinitis/sinusitis
• PND and cough
• Recurrent OM
 Adenoid Hypertrophy
adenoidal hypertrophy
ANTIGEN EXPOSURE and cellular response

continued exposure
of antigen in trapped nasopharyngeal obstruction
secretions and inspissation of secretions

resolution of acute infection

immunologic memory
established
Adenoid Hypertrophy

• Indications for surgery

• OSA, cor pulmonale
• Chronic nasopharyngitis
• CSOM
• Recurrent AOM
• Suspect malignancy
• Chronic sinusitis
• Contraindications to surgery
• Bleeding disorder
• Cleft palate
Tonsil Hypertrophy
Indications for Tonsillectomy

• Absolute
Relative
• OSA, cor pulmonale
Tonsillar hypertrophy
• Suspect malignancy Recurrent tonsillitis

• Hemorrhagic Complications of tonsillitis

tonsillitis

• Severe dysphagia
- Recurrent Acute Tonsillitis (adults and children)
◦ 7 episodes within 1 year
◦ 4 -5 episodes per
year x2 years
◦ 3 episodes per year x3 years
Obstructive sleep apnoea syndrome
(OSAS)
• Definitions
• Apnoea
• Cessation of airflow at nostrils for 10 seconds or longer
• Apnoea index
• Number of apnoeas per hour of sleep
• Hypopnoea
• Reduction in airflow associated with desaturation
• Sleep apnoea syndrome
• 30 or more apnoeic episodes during a 7-hour sleep
Causes of OSAS

• Nose
• Polyps
• Deviated nasal septum
• Pharynx
• Adenoidal hypertrophy
• Nasopharyngeal tumor
• Large palatine/lingual tonsils
• Retropharyngeal mass
• Large tongue
• Obesity
 Clinical features
• Frequent wakening and
disturbed sleep pattern
• Snoring
• Sign of partial airway
obstruction
• Apnoeic episodes
• Daytime somnolence
Signs
Poor nasal airway
Mouth breathing
Noisy respiration
Grossly hypertrophic
tonsils
Short, thick neck
Obesity
Complications of OSAS:
Pulmonary hypertension,
RHF, COR pulmonale
 Special investigations

• Lateral neck X-ray, CXR, ECG Surgical

• Nasendoscopy Adenotonsillectomy
Treatment Tracheostomy
• Conservative
• Dietary modification
• Nasopharyngeal airway
• CPAP (continuous positive
airway pressure)
 Malignant tumors of the oral cavity

• Synonymous with SCC b/c it constitute 95% of cases

• Adenoid cystic carcinoma, sarcomas & liposarcoma, Lymphomas &
malignant melanoma
• Kaposi sarcoma , NHL in HIV infected patients
• SCC
• 4% & 2% of all cancers in males & females respectively
• Men affected 2-3 than women
• Average age at diagnosis is 60 years
• Incidence increases with age
• 75% occur in 10% of mucosal surface
- Areas of salivary flow & pooling
- Lateral tongue, retro molar trigone,
gingivobuccal sulcus
Incidence of SCC in the oral cavity by site
 Etiology

• Well established causes

- Tobacco(80-90% of cases)
- Alcohol
- Synergistic effect
- Poor oral hygiene
- Pipe smoking & sun exposure
- Recent studies suggest HSV 1,HPV 2, 11, 16
 Clinical features

• Majority present as ulcer

• Lump in the lip/oral cavity
• White/red patches in the oral cavity
• Palpation yield more information than inspection alone
• Others suggesting malignant growth
- Unusual pain or bleeding
- Difficulty/pain with chewing/swallowing
- Change in fit of dentures
- Referred otalgia, change in voice
 Lab & imaging

• CBC
• Blood chemistry including LFTs
• CT/MRI
• CXR to r/o metastasis
Treatment
-Antibiotics
-surgery , radiation
 Diseases of the nose & PNS

Allergic Rhinitis
• rhinitis characterized by an IgE-mediated hypersensitivity to foreign
allergens
• acute-and-seasonal or chronic-and-perennial
• perennial allergic rhinitis often confused with recurrent colds
Etiology
• when allergens contact the respiratory mucosa, specific IgE antibody is
produced in susceptible hosts
• concentration of allergen in the ambient air correlates directly with the
rhinitis symptoms
Epidemiology
• age at onset usually <20 years
more common in those with a personal or family Hx of
allergies
Clinical Features
• nasal: obstruction with pruritus, sneezing
• clear rhinorrhea (containing increased eosinophils)
• itching of eyes with tearing , frontal headache and pressure
• mucosa – swollen, pale, and “boggy”
• seasonal (summer, spring, early autumn)
• pollens from trees
• lasts several weeks, disappears and recurs following year at same
time
• perennial
• inhaled: house dust , wool, feathers, foods, tobacco, hair, mould
• ingested: wheat, eggs, milk, nuts
• occurs intermittently for years with no pattern or may be constantly
present
Diagnosis
• history & direct exam
Treatment
• education: identification and avoidance of allergen
• antihistamines e.g. diphenhydramine
 Vasomotor Rhinitis

• neurovascular disorder of nasal parasympathetic

system affecting mucosal blood vessels
• nonspecific reflex hypersensitivity of nasal mucosa
• caused by
• temperature change
• alcohol, dust, smoke
• stress, anxiety, neurosis
• endocrine – hypothyroidism, pregnancy, menopause
• Para sympathomimetic drugs
Clinical Features
• chronic intermittent nasal obstruction, varies from side to
side
• rhinorrhea: thin, watery
• nasal allergy must be ruled out
• mucosa and turbinate swollen, pale between exposure
• symptoms are often more severe than clinical picture
suggests
Treatment
• elimination of irritant factors
• parasympathetic blocker
• steroids (e.g. beclomethasone, fluticasone)
• symptomatic relief with exercise (increased
sympathetic tone)
 Atrophic rhinitis

- Atrophic mucosa on septum , turbinates & lateral nasal walls

- Can occur with out ozena
- Can be associated with ozena( thick adherent, green/yellow nasal crusts usually
accompanied by noticeable odour)
- Transformation of epithelium to keratinizing squamous epithelium
Aetiology
- Nutritional deficiencies
- Bacterial
- Iatrogenic
- Multiple cautery
- Total turbinectomy...
Treatment
- Saline rinse
- Antibiotic for chronic sinusitis
Rhinitis medicamentosa
- Rebound congestion following prolonged use of topical
decongestants
- Patients respond by increasing dose
- Prolonged hypoxia leading to fibrosis, metaplasia, loss of
cilia
Management
• Stop topical decongestant
• Treat primary disease than symptom alone
• Replace it with saline sprays