Otorhinolaryngology

What is otorhinolaryngology?• Otorhinolaryngology: the study of the

ear, nose, and throat – Derives from oto = ear; rhino = nose; and

laryn = throat

• Otolaryngology: abbreviated, most-commonly used form

• Otolaryngologists (ENT physicians) are trained in both medicine and surgery.

Anatomy of the Ear • Two sensory systems:

– Auditory system: detection of sound– Vestibular system: maintains equilibrium

• The Outer Ear– Pinna or auricle: Visible part of the ear– External auditory canal: Tubular passage

leading inward to the eardrum– Tympanic membrane (eardrum)

• The Middle Ear– Lies inside the skull with only small layer of bone

separating it from the brain– The ossicular chain: Malleus (hammer), incus (anvil),

and stapes (stirrup), called ossicles that connect the eardrum to the middle ear and derived from Latin terms that describe their shapes

– Oval window: Covers opening to the inner ear– The eustachian tube: Equalizes air pressure

• The Inner Ear – Also called the labyrinth, a word meaning “a

complex system of paths and tunnels.”– Hearing: The cochlea and organ of Corti – Balance: The utricle, saccule, and three

semicircular canals

• The Nose – Components:

• Nasal bone • Upper jaw bone (maxilla) • Nasal septum made of bone and cartilage separating

right and left nostrils

• Paranasal sinuses – “Sinus” means a hollow cavity or space in bone

or other tissue. “Nasal sinus” is an air-filled, mucus-lined cavity within the cranial or facial bone

• Maxillary sinuses (cheeks) • Ethmoid sinuses (bridge of nose) • Frontal sinuses (forehead)• Sphenoid sinuses (behind nose deep in skull)

• Nares – name given to two nasal cavities

• Concha, or nasal turbinate – a long, narrow shelf-like structure in the nose which helps trap particles entering the nasal cavity– Three nasal turbinates on the sidewall of the

nose (superior, middle, and inferior turbinate)

• The Throat (pharynx) – Nasopharynx (behind nose) and extends to the

uvula, the fleshy mass hanging form the soft palate

– Oropharynx (back of mouth) and includes soft palate, tonsils, posterior third of the tongue and posterior wall of the throat

– Hypopharynx (bottom of pharynx), the part of the throat that connects to the esophagus

• The Larynx: A tube-shaped structure leading from the pharynx to the trachea (wind pipe)

– Epiglottis – a lid-like flap of cartilage that opens and closes to help direct food and liquid into the esophagus and protect the airway during swallowing

– Thyroid cartilage – largest cartilage of the thyroid, also called the “Adam’s apple”

– Cricoid – lies below thyroid cartilage and encircles the airway

– Arytenoids – paired cartilages lying on top of cricoid– Corniculate and cuneiform cartilages – strengthen the

entrance of the larynx

• Vocal anatomy – Vocal cords (or vocal folds or true vocal folds) –

two elastic folds of mucous membrane stretched horizontally across the larynx, involved in voice production

– False vocal folds – second set of folds above the true vocal folds. Role in voice production is minimal

– Glottis – the gap between the vocal folds

The Process of Hearing • Air conduction:

– Sounds captured by the pinna. – Pass through the external auditory canal – To the tympanic membrane – To the ossicles in the middle ear– To the cochlea in the inner ear and relayed to the

brain

• Bone conduction: – Sound is carried directly to cochlea from vibrations of

bone, bypassing outer and middle ear

Common Otolaryngologic Diseases and Treatments

• Rarely fatal but can be quite debilitating– Nasal disorders can make breathing and

talking difficult– Ear disorders can disturb hearing and

equilibrium– Throat ailments can cause difficulty

eating, breathing, and talking

Ear Disorders • Otitis Media: infection/fluid in the middle ear

– Eustachian tube becomes inflamed from a cold or infection

– Treatments: • Antibiotics for infection (amoxicillin, ampicillin) for

infection of ear canal or for otitis externa, or swimmer’s ear, an infection of the external auditory canal

• Myringotomy – surgical incision into the tympanic membrane to relieve pain and drain fluid

• Tympanostomy tube – (pressure-equalization or PE tube) inserted to help drain the fluid

• Vertigo – Sudden, brief feelings of dizziness and confusion with change in position of the head

– Benign paroxysmal positional vertigo (BPPV) is most common form

– Called “hallucination of movement” causing sensation of room spinning

– Treatments:• Antibiotics to eliminate underlying infection• Medication to treat dizziness (Antivert)• Radiation or surgery for vertigo caused by strokes or

tumors

• Ménière disease: a balance disorder of the middle ear – First described by French physician Prosper

Ménière in 1861– Period episodes of vertigo, with hearing loss,

tinnitus, and sensation of fullness or pressure– No known cause or cure– Treatments to control symptoms:

• Reducing retention of fluids• Medications used to treat vertigo

• Cholesteatoma: a sac of debris or dead cells that accumulates in the middle ear – Can destroy bones o the middle ear if not

treated and cause central nervous system complications such as brain abscess and meningitis

– Treatments: • Ear cleaning and drainage of debris and fluid• Antibiotics to control infection• Surgical removal if large

• Hearing loss – Conductive: Outer or middle ear; treatable– Sensorineural: Inner ear; not treatable– Mixed: Combination of both types

• Treatments for Hearing Loss:– Removal of debris buildup in the ear– Treatment of infection with antibiotics– Hearing aids– Cochlear implant

Nasal Disorders • Deviated septum: An abnormal

configuration of the cartilage that divides the two sides of the nose, causing breathing difficulties and repeated sinus infections

• Treatment:– Septoplasty: A reconstructive procedure where

malformed portions of the septum are removed or readjusted to straighten the deviation of the nose and improve breathing

• Chronic sinusitis: continuous inflammation of sinuses – Treatments: Goal is to improve sinus

drainage and curing chronic infections • Antibiotics for infections• Nasal steroid sprays to clear congestion • Endoscopic sinus surgery (ESS) – removing

blockages in the sinuses to allow proper drainage out of the nose and improve breathing

• Epistaxis: Nosebleed where lining of the nose is irritated or broken down enough to cause bleeding

– Treatments: • Packing to stop bleeding • Cauterization of bleeding vessels, called electrocautery

or nasal cautery using silver nitrate to stop bleeding and then application of cautery to stop bleeding in larger vessels

• Reconstruction of nasal septum in more severe cases

• Nasal polyps: Fleshy outgrowths in the nose as a result of inflammation

– Treatments: • Corticosteroids and nasal sprays to reduce inflammation• Surgical removal of the polyps

• Obstructive sleep apnea (OSA): A condition of interrupted breathing during sleep

• From Greek word apnea which means “without breath or air”

• Caused by obstruction of airway in several possible sites or collapse of airway muscles during sleep

• Hypopnea: A decrease in the rate and depth of breathing that is not as severe as apnea

Disorders of the Throat

• Treatments for Sleep Apnea:– Significant weight loss– Oral appliances (mandibular advance device) – a mouth

guard to move the jawbone forward and open the airway or tongue-retaining device to pull tongue forward and eliminate airway obstruction

– Continuous positive airway pressure (CPAP) and bi-level machine – blows air under pressure into the nose via nose mask to keep airway open and unobstructed

– Bi-level machine (BiPAP) – blows air at two different pressures

• Surgical Treatments for Sleep Apnea– Uvulopalatopharyngoplasty (UPPP) – tissues at

the back of the throat are removed, including uvula, tonsils, and parts of the soft palate, widening airway

– Somnoplasty – Radiofrequency waves are used to target tissues that need shrinking, resulting in overall reduction in tissue volume and a wider airway

• Laryngopharyngeal reflux disease (LRD): Backflow of acid into esophagus

• Symptoms: Chronic cough; hoarseness, and sometimes aspiration of acid into the trachea (laryngospasm).

• Indications: Pachydermia or cobblestoning (abnormal thickening of the larynx), swelling of vocal cords, or ulcers on vocal cords

– Treatments:

• Behavior and diet modification

• Acid reflux medications (Nexium, Prilosec, Zantac)

• Vocal cord paralysis: Inability to move the muscles that control the vocal cords

• Possible Causes: head trauma, stroke, tumor, or viral infection

• Treatments:

• Voice therapy for the paralysis

• Phonosurgery to improve vocal cord function

Diagnostic Studies and Procedures

• Acoustic Studies – Purpose: To evaluate overall hearing

function– Otologic Examination:

• Visual examination of outer ear and eardrum, called otoscopy

• Valsalva maneuver – an attempt to forcibly exhale while keeping the mouth and nose closed

• Audiometry – testing used to identify and diagnose hearing loss

• Intensity of sound measured in decibels (dB) and frequency of sound measured in Hertz (Hz), or cycles per second

– Pure Tone Audiometry: sounds and pitches record audio thresholds

– Tympanometry: air pressure evaluates middle ear function

• Air and Bone Conduction Studies– Also called “tuning fork tests” because vibrating

tuning forks are placed in contact with the head to test hearing

• Rinne test – compares bone conduction to air conduction by placing tuning fork against the bone behind the ear

• Weber test – evaluates bone conduction by placing tuning fork at various points along the midline of the skull and face

• Otoacoustic emissions (OAE) – used to assess the integrity and function of outer hair cells in the inner ear (commonly used for newborns)

• Brainstem Auditory Evoked Response Test (BAER) – analyzes brain’s response to sound

• Nasal Studies

– Nasal endoscopy, also called rhinoscopy

– Used to evaluate chronic and recurrent acute sinusitis

– Small abnormalities can be identified and cultures can be taken for examination

– Imaging studies used to view paranasal sinuses for abnormalities: CT, MRI

• Laryngeal Studies

– Indirect laryngoscopy, also called “mirror exam” of vocal folds using a mirror and reflected light

– Direct (fiberoptic) laryngoscopy, using a long, thin tube to get a more magnified view of structures

– Videostroboscopy, uses a strobe light combined with laryngoscopy to allow slow-motion view of vibrating vocal folds with images recorded on videotape

– Polysomnography (also called sleep study): Measures variables obtained and recorded during sleep