Diseases o f

EAR, N O S E A N D THROAT

FIFTH EDITION

P L Dhingra MS, D L O , M N A M S
Emeritus Consultant
Indraprastha A p o l l o Hospital, N e w D e l h i
Formerly D i r e c t o r , Professor & H e a d
Department o f Otolaryngology and
Head & Neck Surgery
Maulana Azad Medical College and
Associated L N J P & G B Pant Hospitals, N e w D e l h i

Shruti Dhingra MS ( M A M C )
Department of Otolaryngology
Postgraduate Institute o f M e d i c a l E d u c a t i o n and Research
Chandigarh, India

Assisted by

Deeksha Dhingra M D , PGDHA

T a m w o r t h Base H o s p i t a l
D e a n Street, T a m w o r t h 2 3 4 0
N S W , Australia

ELSEVIER

ELSEVIER
A division of
R e e d Elsevier India Private L i m i t e d
Diseases of Ear, N o s e and Throat, 5/e
PL Dhingra

ELSEVIER
A division of
R e e d Elsevier India Private L i m i t e d

Mosby, Saunders, Churchill Livingstone, Butterworth Heinemann and Hanley & Belfus are the Health Science imprints of Elsevier.

© 2010 Elsevier
First E d i t i o n 1992
Second E d i t i o n 1998
T h i r d E d i t i o n 2004
F o u r t h E d i t i o n 2007
Fifth Edition 2010
Reprinted 2010
Reprinted 2011
Reprinted 2012
Reprinted 2013

A l l rights reserved. N o part o f this p u b l i c a t i o n m a y be r e p r o d u c e d , s t o r e d i n a retrieval system, o r t r a n s m i t t e d i n any f o r m

or b y any means, electronic, mechanical, p h o t o c o p y i n g , r e c o r d i n g o r otherwise, w i t h o u t the p r i o r permission o f the
publisher.

ISBN: 978-81-312-2364-2

M e d i c a l k n o w l e d g e is c o n s t a n d y c h a n g i n g . A s n e w i n f o r m a t i o n b e c o m e s available, changes i n t r e a t m e n t , procedures,

e q u i p m e n t a n d t h e use o f d r u g s b e c o m e necessary. T h e a u t h o r s , e d i t o r s , c o n t r i b u t o r s a n d t h e p u b l i s h e r h a v e , as far as i t is
p o s s i b l e , t a k e n care t o e n s u r e t h a t t h e i n f o r m a t i o n g i v e n i n t h i s t e x t is a c c u r a t e a n d u p - t o - d a t e . H o w e v e r , readers are
s t r o n g l y a d v i s e d t o c o n f i r m t h a t i n f o r m a t i o n , e s p e c i a l l y w i t h r e g a r d t o d r u g dose/usage, c o m p l i e s w i t h c u r r e n t l e g i s l a t i o n
a n d standards o f p r a c t i c e . Please consult full prescribing information before issuing prescriptions for any product mentioned
in the publication.

H e a d - M e d i c a l E d u c a t i o n : Jalees F a r h a n
M a n a g i n g E d i t o r : Shabina N a s i m
Publishing Operations Manager: Sunil K u m a r
Production Manager: N C Pant

P u b l i s h e d b y Elsevier, A d i v i s i o n o f R e e d Elsevier I n d i a Private L i m i t e d .

Registered Office: 305, R o h i t House, 3 Tolstoy M a r g , N e w D e l h i - 1 1 0 001

Corporate Office: 14th H o o r , B u i l d i n g N o . 10B, D L F C y b e r City, Phase-II, Gurgaon-122002, Haryana, India.

P r i n t e d a n d b o u n d i n I n d i a a t : E I H L t d - U n i t P r i n t i n g Press. I M T , M a n e s a r , G u r g a o n .
D e d i c a t e d t o a l l m y s t u d e n t s : past, p r e s e n t a n d f u t u r e w h o are t h e i n s p i r i n g f o r c e b e h i n d t h i s w o r k .

I r e p r o d u c e b e l o w t h e i n v o c a t i o n f r o m o u r great ancient s c r i p t u r e — t h e Kathopanishad w h i c h shows the relationship

b e t w e e n the teacher and the taught.

"*TT 1^f|[TOtl i£ ?TTfnT: TTTf^T: WfnT:

"O G o d , t h e a l m i g h t y , bless us b o t h ( t h e t e a c h e r a n d t h e s t u d e n t ) t o g e t h e r , d e v e l o p us b o t h t o g e t h e r , g i v e us s t r e n g t h
t o g e t h e r . L e t t h e k n o w l e d g e a c q u i r e d b y us b e b r i g h t a n d i l l u r m n a n t , a n d s e c o n d t o n o n e . L e t b o t h o f us l i v e t o g e t h e r w i t h
l o v e , affection and h a r m o n y . O G o d , let there be physical, m e n t a l and spiritual peace.' 1
Preface

T h e fifth e d i t i o n o f the b o o k marks the 18 th

y e a r o f its p u b l i c a t i o n . W i d e a c c e p t a n c e o f t h e p r e v i o u s e d i t i o n s a n d t h e
a d v a n c e s m a d e b y t h e s p e c i a l i t y w e r e a great m o t i v a t i o n a l f o r c e t o b r i n g o u t t h i s u p d a t e d e d i t i o n .

T h e s p e c i a l i t y o f O t o l a r y n g o l o g y : H e a d a n d N e c k S u r g e r y is fast e x p a n d i n g a n d has e v o l v e d i n t o s e v e r a l s u p e r s p e c i a l i t i e s .
T o k e e p abreast w i t h these a d v a n c e m e n t s , w e h a v e r e v i s e d m a n y t o p i c s a n d i n c l u d e d n e w o n e s l i k e r a d i o f r e q u e n c y s u r -
g e r y , h y p e r b a r i c o x y g e n t h e r a p y , s n o r i n g a n d sleep a p n o e a , b o n e - a n c h o r e d h e a r i n g aids, c o c h l e a r i m p l a n t s a n d v i b r a n t
s o u n d b r i d g e . E n d o s c o p i c s u r g e r y o f n o s e a n d paranasal sinuses has e x p a n d e d i n its s c o p e b u t t h e a p p l i e d a n a t o m y o f t h i s
r e g i o n , as g i v e n i n t h e t e x t b o o k s o f a n a t o m y , does n o t f u l f i l t h e needs o f t h e e n d o s c o p i c s u r g e o n a n d t h u s r e q u i r e d r e v i s i o n ,
e x p a n s i o n a n d u p d a t i n g . M a n y n e w p h o t o g r a p h s , i l l u s t r a t i o n s , tables a n d f l o w c h a r t s h a v e b e e n a d d e d a n d s o m e o l d o n e s
replaced, t o make the b o o k student friendly and t o enhance c o m p r e h e n s i o n o f the subject.

W e have retained the original objectives o f the b o o k w h i c h include:

• Simple language, concise b u t c o m p r e h e n s i v e coverage.
• Clinically oriented text.
• T o p r o v i d e i n s i g h t o f t h e s u b j e c t t o M B B S s t u d e n t s w h o has t a k e n m e d i c i n e as t h e i r c a r e e r .
To f u l f i l t h e needs o f students t a k i n g v a r i o u s entrance tests t o p o s t g r a d u a t e d i p l o m a , M D / M S d e g r e e c o u r s e s o r
D i p l o m a t e National Board or other competitive examinations.
• T o p r o v i d e a f o u n d a t i o n course f o r postgraduate students w h o have j o i n e d t h e speciality t o pursue M S examination
b e f o r e t a k i n g t o l a r g e r treatises o n t h e s u b j e c t a n d a q u i c k r e v i s i o n b e f o r e exam.

W e w i l l f e e l g r a t i f i e d i f t h e p r e s e n t e d i t i o n a c h i e v e s its o b j e c t i v e a n d e n r i c h e s t h e u n d e r s t a n d i n g o f t h e s u b j e c t .

The authors w i l l welcome any suggestions and comments from teachers a n d s t u d e n t s at p l d h i n g r a @ g m a i l . c o m or

infoindia@elsevier.com.

PL Dhingra
Acknowledgements

W o r d s c a n n o t express t h e f e e l i n g s b u t s t i l l t h e y are t h e o n l y m e d i u m o f e x p r e s s i o n f o r h u m a n b e i n g s . W i t h a d e e p sense

o f g r a t i t u d e w e w o u l d l i k e t o t h a n k m a n y o f o u r c o l l e a g u e s , f r i e n d s a n d last b u t n o t t h e least o u r s t u d e n t s f o r t h e i r i n s p i r a -
t i o n , e n c o u r a g e m e n t and f e e d b a c k i n p e r s o n , t h r o u g h letters a n d the e l e c t r o n i c m e d i a . T h e w e b s i t e created f o r the f o u r t h
e d i t i o n w a s h i t b y h u n d r e d s o f s t u d e n t s f o r s u p p l e m e n t s u p d a t e d f r o m t i m e t o t i m e t o a p p r i s e us o f t h e i r n e e d s . W e would
l i k e t o t h a n k all o f t h e m . W e t h a n k i n particular:

• D r A r u n Agarwal, Dean and Director-Professor; D r A n o o p Raj, Professor and H e a d o f E N T ; D r Achal Gulati,

P r o f e s s o r ; D r J C Passey, P r o f e s s o r ; D r P K R a t h o r e , P r o f e s s o r ; D r I s h w a r S i n g h , P r o f e s s o r ; D r S h e l l y C h a d h a ; D r R a v i
M e h e r , D r V i k a s M e h r o t r a a n d the resident staff o f D e p a r t m e n t o f O t o l a r y n g o l o g y a n d H e a d & N e c k Surgery of
Maulana A z a d M e d i c a l College, N e w D e l h i f o r their constant inspiration and support.
• Faculty m e m b e r s o f D e p a r t m e n t o f E N T a n d H e a d & N e c k Surgery, U n i v e r s i t y M e d i c a l Sciences a n d G T B H o s p i t a l ,
D e l h i , i n particular D r PP Singh, Director-Professor and Head, D r L a x m i V a i d , D r H C Taneja, D r A r u n Goyal and
D r Neelima Gupta.
• T h e entire faculty o f Lady H a r d i n g M e d i c a l College, N e w D e l h i , i n particular D r J K Sahni, Director-Professor and
H e a d ; D r N M M a t h u r , Professor; D r T S A n a n d , Professor; a n d D r S u n i l K u m a r .
« D r R a m e s h C D e k a , D i r e c t o r , A l l I n d i a I n s t i t u t e o f M e d i c a l S c i e n c e s a n d also P r o f e s s o r a n d H e a d o f E N T Department;
D r S C S h a r m a , Professor; D r A l o k T h a k a r a n d D r K K Handa.
» D r A r j a n Das, Professor a n d H e a d , a n d D r N i t i n M Nagarkar, Reader, Department o f E N T , G o v e r n m e n t Medical
College, Chandigarh.
° D r M o h d Lateef, Professor a n d H e a d ; D r K a w a l j e e t a n d D r R o u f A h m e d , D e p a r t m e n t o f E N T , G o v e r n m e n t Medical
College, Srinagar.
• D r A n e c e C h a u d h a r y , Professor and H e a d , D r D i n e s h L u t h r a and D r Sunil K o t w a l , D e p a r t m e n t o f E N T , Government
Medical College, Jammu.
9
D r A n i b a n B i s w a s , K o l k a t a f o r i n s p i r i n g r e v i e w o f o u r b o o k i n Indian J Otolaryngology.
• D r K a r a n Sharma, Professor a n d H e a d , D e p a r t m e n t o f E N T , M e d i c a l College, A m r i t s a r .
• D r A m r i k S i n g h , Professor, D e p a r t m e n t o f E N T , G u r u R a m Das M e d i c a l C o l l e g e , A m r i t s a r .
• D r A K Singhal, Dean a n d Professor H e a d , D e p a r t m e n t of ENT, C H Shah M e d i c a l College, Surrender Nagar,
Gujarat.
i:
Dr RC Y a d a v , Professor and H e a d , D e p a r t m e n t o f E N T , M e d i c a l College, K o t a , Rajasthan.
• D r D D H e m a n i , P r o f e s s o r a n d H e a d , D e p a r t m e n t o f E N T , M a h a t m a G a n d h i N a t i o n a l I n s t i t u t e o f M e d i c a l Sciences,
Jaipur, Rajasthan.
• D r S y e d A b r a r Hassan a n d D r SC Sharma, D e p a r t m e n t o f E N T , J L N M e d i c a l C o l l e g e , A l i g a r h , U P .
• D r S a u r a b h V a r s h n e y , Professor a n d H e a d , D e p a r t m e n t o f E N T , H i m a l a y a n I n s t i t u t e o f M e d i c a l Sciences, D e h r a d h u n ,
Uttrakhand.
• D r R o h i t Saxena, H e a d , D e p a r t m e n t o f E N T , Santosh M e d i c a l C o l l e g e , Ghaziabad, UP.
« D r M a n i s h M u n j a l , Professor o f E N T a n d H e a d & N e c k Surgery, D a y a n a n d M e d i c a l C o l l e g e , L u d h i a n a , Punjab.
D r D a l b i r S i n g h , Associate Professor, D e p a r t m e n t o f E N T , Government Medical College and Rajendra Hospital,
Patiala, Punjab.
Acknowledgements

• D r N a r e s h Panda, Professor, a n d D r A K G u p t a , Professor, Postgraduate I n s t i t u t e o f M e d i c a l E d u c a t i o n a n d Research,

C h a n d i g a r h f o r their constant guidance a n d i n t e r a c t i o n .
• D r R K Saxena, P r o f e s s o r a n d H e a d , D e p a r t m e n t o f E N T , M e d i c a l C o l l e g e , N e p a l g a n j , N e p a l .

We also express o u r g r a t i t u d e t o s e n i o r c o n s u l t a n t s o f E N T at I n d r a p r a s t h a A p o l l o H o s p i t a l , i n p a r t i c u l a r D r Ameet

Kishore FRCS-ORL (UK) for u p d a t i n g topics on cochlear implants, implantable hearing aids and BAHA and to
D r T a r u n S a h n i , Sr C o n s u l t a n t M e d i c i n e a n d H e a d , H y p e r b a r i c O x y g e n T h e r a p y U n i t f o r h i s c o n t r i b u t i o n o n h y p e r b a r i c
o x y g e n therapy i n E N T disorders.

T h a n k s are also d u e t o t h e e n t i r e t e a m o f E l s e v i e r , A d i v i s i o n o f R e e d E l s e v i e r I n d i a P r i v a t e L i m i t e d . M r S a n j a y B a n e r j e e
a n d M r S a k e t B u d h i r a j a h a d i n i t i a t e d t h e w o r k o n t h i s e d i t i o n b u t l a t e r w h e n M r V i d h u G o e l , t h e D i r e c t o r a n d D r Jalees
F a r h a n , H e a d - M e d i c a l E d u c a t i o n t o o k o v e r , t h e y g a v e us t h e u n s t i n t e d c o o p e r a t i o n t o c o m p l e t e t h e b o o k . T h e y were
i n s t r u m e n t a l i n u p - k e e p i n g t h e q u a l i t y o f p r o d u c t i o n o f t h e b o o k b e f i t t i n g t h e standards o f E l s e v i e r . H i d d e n b e h i n d t h e
flawless p r o d u c t i o n o f t h e b o o k l i e t h e d e d i c a t e d e f f o r t s a n d c o m m i t m e n t o f t h e e d i t o r o f t h e b o o k , M s S h a b i n a N a s i m
w h o deserves o u r a p p r e c i a t i o n f o r t h e h a r d w o r k .
Contents

Dedication v
Preface vii
Acknowledgements ix

S E C T I O N I: D I S E A S E S O F E A R

1 A n a t o m y o f Ear 3
2 P e r i p h e r a l R e c e p t o r s a n d P h y s i o l o g y o f A u d i t o r y and Vestibular Systems 16
3 A u d i o l o g y and Acoustics 23
4 Assessment o f H e a r i n g 25
5 H e a r i n g Loss 34
6 Assessment o f V e s t i b u l a r F u n c t i o n s 46
7 Disorders o f Vestibular System 51
8 Diseases o f E x t e r n a l E a r 54
9 E u s t a c h i a n T u b e a n d Its D i s o r d e r s 63
10 Disorders o f M i d d l e Ear 69
11 Cholesteatoma and C h r o n i c Otitis M e d i a 75
12 Complications o f Suppurative Otitis M e d i a 84
13 Otosclerosis (Syn. Otospongiosis) 97
14 F a c i a l N e r v e a n d Its D i s o r d e r s 101
15 M e n i e r e ' s Disease 111
16 T u m o u r s o f E x t e r n a l Ear 117
17 T u m o u r s o f M i d d l e Ear a n d M a s t o i d 120
18 Acoustic N e u r o m a 124
19 The Deaf Child 127
20 Rehabilitation o f the Hearing-Impaired 134
21 O t a l g i a (Earache) 143
22 Tinnitus 145

SECTION II: DISEASES O F N O S E A N D P A R A N A S A L SINUSES

23 A n a t o m y o f Nose
24 Physiology of Nose
25 Diseases o f E x t e r n a l N o s e a n d N a s a l V e s t i b u l e
N a s a l S e p t u m a n d Its Diseases
27 Acute and Chronic Rhinitis
28 G r a n u l o m a t o u s Diseases o f N o s e
Miscellaneous Disorders o f Nasal C a v i t y
 Allergic Rhinitis
Vasomotor and O t h e r Forms o f Non-allergic Rhinitis
Nasal P o l y p i
33 Epistaxis
T r a u m a t o t h e Face
A n a t o m y a n d P h y s i o l o g y o f Paranasal Sinuses
A c u t e Sinusitis
37 C h r o n i c Sinusitis
C o m p l i c a t i o n s o f Sinusitis
39 Neoplasms o f Nasal C a v i t y
N e o p l a s m s o f Paranasal Sinuses

S E C T I O N III: D I S E A S E S O F O R A L C A V I T Y A N D S A L I V A R Y G L A N D S

41 Anatomy o f Oral Cavity 227

42 C o m m o n Disorders o f O r a l Cavity 229
43 Tumours of Oral Cavity 236
44 N o n - n e o p l a s t i c Disorders o f Salivary Glands 244
45 Neoplasms o f Salivary Glands 247

S E C T I O N IV: D I S E A S E S O F P H A R Y N X

46 A n a t o m y and Physiology o f Pharynx 253

47 Adenoids and O t h e r Inflammations o f Nasopharynx 258
48 Tumours o f Nasopharynx 261
49 Acute and C h r o n i c Pharyngitis 268
50 Acute and Chronic Tonsillitis 271
51 H e a d a n d N e c k Space I n f e c t i o n s 277
52 Tumours of Oropharynx 284
53 T u m o u r s o f the H y p o p h a r y n x and Pharyngeal P o u c h 288
54 S n o r i n g a n d Sleep A p n o e a 291

S E C T I O N V: D I S E A S E S O F L A R Y N X A N D T R A C H E A

55 A n a t o m y and Physiology o f Larynx 299

56 Laryngotracheal Trauma 305
57 Acute and Chronic Inflammations o f Larynx 307
58 C o n g e n i t a l Lesions o f L a r y n x a n d S t r i d o r 314
59 L a r y n g e a l Paralysis 317
60 Benign Tumours of Larynx 322
61 Cancer Larynx 326
62 V o i c e a n d Speech Disorders 333
63 T r a c h e o s t o m y and O t h e r Procedures for A i r w a y M a n a g e m e n t 336
64 F o r e i g n B o d i e s o f A i r Passages 342

S E C T I O N VI: DISEASES O F OESOPHAGUS

65 A n a t o m y and Physiology o f Oesophagus 347

66 Disorders o f Oesophagus 349
67 Dysphagia 354
68 F o r e i g n B o d i e s o f F o o d Passage 356
 S E C T I O N VII: R E C E N T ADVANCES

69 Laser S u r g e r y 361
70 Cryosurgery 364
71 Radiotherapy i n H e a d and N e c k Cancer 366
72 Chemotherapy for H e a d and N e c k Cancer 370
73 H I V I n f e c t i o n / A I D S and E N T Manifestations 373

S E C T I O N VIII: C L I N I C A L M E T H O D S IN E N T A N D N E C K MASSES

74 Clinical Methods i n E N T 379

75 N e c k Masses 398

S E C T I O N IX: O P E R A T I V E SURGERY

76 Myringotomy 407
77 M a s t o i d Surgery 409
78 Radical Mastoidectomy 413
79 M o d i f i e d Radical Mastoidectomy 415
80 Myringoplasty 416
81 P r o o f P u n c t u r e (Syn. A n t r a l Irrigation) 418
82 Intranasal I n f e r i o r M e a t a l A n t r o s t o m y 420
83 Caldwell-Luc Operation 421
84 Submucous R e s e c t i o n o f Nasal S e p t u m ( S M R Operation) 423
85 Septoplasty 425
86 Diagnostic Nasal Endoscopy 427
87 E n d o s c o p i c Sinus Surgery 429
88 Direct Laryngoscopy 432
89 Bronchoscopy 434
90 Oesophagoscopy 436
91 Tonsillectomy 438
92 Adenoidectomy 442

93 Radiology in E N T 444

APPENDICES

Appendix I : Some Memorable Nuggets for R a p i d R e v i e w 457

A p p e n d i x EI: I n s t r u m e n t s 463
Appendix I I I 476

Index 477
Diseases of Ear

1. Anatomy o f Ear 3
2. Peripheral Receptors and Physiology o f Auditory and Vestibular Systems 16
3. Audiology and Acoustics 23
4. Assessment o f Hearing 25
5. Hearing Loss 34
6. Assessment o f Vestibular Functions 46
7. Disorders o f Vestibular System 51
8. Diseases o f External Ear 54
9. Eustachian Tube and Its Disorders 63
10. Disorders o f Middle Ear 69
11. Cholesteatoma and Chronic Otitis Media 75
12. Complications o f Suppurative Otitis Media 84
13. Otosclerosis (Syn. Otospongiosis)
14. Facial Nerve and Its Disorders 101
15. Meniere's Disease 111
16. Tumours o f External Ear 117
1 7. Tumours o f Middle Ear and Mastoid 1 20
18. Acoustic Neuroma 124
19. The Deaf Child 127
20. Rehabilitation o f the Hearing-Impaired 134
21. Otalgia (Earache) 143
22. Tinnitus 145
A n a t o m y o f Ear

T h e ear is d i v i d e d i n t o :
1. Auricle or Pinna
E x t e r n a l ear
2. M i d d l e ear T h e e n t i r e p i n n a , e x c e p t its l o b u l e , a n d t h e o u t e r p a r t o f
. . I n t e r n a l ear o r t h e l a b y r i n t h . e x t e r n a l a c o u s t i c c a n a l are m a d e u p o f a f r a m e w o r k o f a
s i n g l e p i e c e o f y e l l o w elastic c a r t i l a g e c o v e r e d w i t h s k i n .
T h e l a t t e r is c l o s e l y a d h e r e n t t o t h e p e r i c h o n d r i u m o n its
THE EXTERNAL EAR
l a t e r a l surface w h i l e i t is s l i g h t l y l o o s e o n t h e m e d i a l s u r -
f a c e . T h e v a r i o u s e l e v a t i o n s a n d depressi ons s e e n o n t h e
T h e e x t e r n a l ear consists o f t h e (i) a u r i c l e o r p i n n a , ( i i ) l a t e r a l surface o f p i n n a are s h o w n i n F i g . L I B .
external acoustic canal a n d (iii) t h e t y m p a n i c m e m b r a n e T h e r e is n o c a r t i l a g e b e t w e e n t h e tragus a n d crus o f t h e
(Fig. 1.1A). h e l i x , a n d t h i s area is c a l l e d t h e incisura terminalis (Fig. 1.1C).

B Triangular fossa

Antitragus

F i g u r e 1.1

( A ) T h e ear a n d its d i v i s i o n s . ( B ) T h e elevations a n d depressions o n t h e lateral surface o f p i n n a . ( C ) T h e a u r i c u l a r c a r t i l a g e .

A n i n c i s i o n m a d e i n t h i s area w i l l n o t c u t t h r o u g h t h e c a r -
3. T y m p a n i c M e m b r a n e or the Drumhead
t i l a g e a n d is u s e d f o r e n d a u r a l a p p r o a c h i n s u r g e r y o f t h e
e x t e r n a l a u d i t o r y c a n a l o r t h e m a s t o i d (see page 4 1 0 ) . Pinna
I t f o r m s t h e p a r t i t i o n b e t w e e n t h e e x t e r n a l a c o u s t i c canal
is also t h e s o u r c e o f several g r a f t m a t e r i a l s f o r t h e s u r g e o n .
a n d t h e m i d d l e ear. I t is o b l i q u e l y set a n d as a r e s u l t , its
C a r t i l a g e f r o m t h e tragus, p e r i c h o n d r i u m f r o m t h e tragus
p o s t e r o s u p e r i o r p a r t is m o r e l a t e r a l t h a n its a n t e r o - i n f e r i o r
o r c o n c h a , a n d fat f r o m t h e l o b u l e are f r e q u e n t l y u s e d f o r
p a r t . I t is 9 - 1 0 m m t a l l , 8 - 9 m m w i d e a n d 0 . 1 m m t h i c k .
r e c o n s t r u c t i v e s u r g e r y o f t h e m i d d l e ear. T h e c o n c h a l c a r -
T y m p a n i c m e m b r a n e can be d i v i d e d i n t o t w o parts:
t i l a g e has also b e e n u s e d t o c o r r e c t t h e depressed nasal
b r i d g e w h i l e t h e c o m p o s i t e grafts o f t h e s k i n a n d c a r t i l a g e
(a) Pars Tensa
f r o m t h e p i n n a are s o m e t i m e s u s e d f o r r e p a i r o f d e f e c t s o f
It forms most o f tympanic membrane. Its p e r i p h e r y is
nasal ala.
t h i c k e n e d to f o r m a fibrocartilaginous r i n g called the annu-
lus tympanicus w h i c h f i t s i n t h e t y m p a n i c sulcus. T h e cen-
2. External A c o u s t i c (Auditory) C a n a l t r a l p a r t o f pars tensa is t e n t e d i n w a r d s at t h e l e v e l o f t h e
t i p o f m a l l e u s a n d is c a l l e d t h e umbo. A b r i g h t c o n e o f l i g h t
It extends f r o m the b o t t o m o f the concha t o the t y m p a n i c c a n b e seen r a d i a t i n g f r o m t h e t i p o f m a l l e u s t o t h e p e r i p h -
m e m b r a n e a n d m e a s u r e s a b o u t 2 4 m m a l o n g its p o s t e r i o r ery i n the anteroinferior quadrant (Fig. 1.2).
w a l l . I t is n o t a s t r a i g h t t u b e ; its o u t e r p a r t is d i r e c t e d
u p w a r d s , b a c k w a r d s a n d m e d i a l l y w h i l e its i n n e r p a r t is (b) Pars Flaccida (Shrapnel's Membrane)
directed downwards, forwards and medially. Therefore, to
T h i s is s i t u a t e d a b o v e t h e l a t e r a l p r o c e s s o f m a l l e u s bet-
see t h e t y m p a n i c m e m b r a n e , t h e p i n n a has t o b e pulled
w e e n the n o t c h o f R i v i n u s and the anterior and posterior
u p w a r d s , b a c k w a r d s a n d l a t e r a l l y so as t o b r i n g t h e t w o
m a l l e a l f o l d s ( e a r l i e r c a l l e d t h e m a l l e o l a r f o l d s ) . I t is n o t so
parts i n a l i g n m e n t .
taut a n d m a y appear s l i g h t l y p i n k i s h . V a r i o u s l a n d m a r k s
T h e c a n a l is d i v i d e d i n t o t w o p a r t s : (a) c a r t i l a g i n o u s a n d
seen o n t h e lateral surface o f t y m p a n i c m e m b r a n e are
(b) b o n y .
s h o w n i n Fig. 1.2.

(a) Cartilaginous Part

Layers of Tympanic Membrane
I t f o r m s o u t e r o n e - t h i r d (8 m m ) o f t h e c a n a l , C a r t i l a g e is
T y m p a n i c m e m b r a n e consists o f t h r e e l a y e r s :
a c o n t i n u a t i o n o f the cartilage w h i c h f o r m s the f r a m e w o r k
o f the pinna. I t has two deficiencies—the "fissures of (i) O u t e r e p i t h e l i a l l a y e r , w h i c h is c o n t i n u o u s w i t h t h e

Saniorim' i n this part o f the cartilage and t h r o u g h t h e m t h e skin l i n i n g the meatus.

p a r o t i d or superficial m a s t o i d i n f e c t i o n s can appear i n t h e (ii) I n n e r m u c o s a l l a y e r , w h i c h is c o n t i n u o u s w i t h the

c a n a l , o r v i c e versa. T h e s k i n , c o v e r i n g t h e c a r t i l a g i n o u s m u c o s a o f t h e m i d d l e ear.

c a n a l is t h i c k a n d c o n t a i n s c e r u m i n o u s a n d p i l o s e b a c e o u s
g l a n d s w h i c h secrete w a x . H a i r is o n l y c o n f i n e d t o the Shrapnell's
Lateral process
o u t e r canal a n d t h e r e f o r e f u r u n c l e s (staphylococcal infec- of malleus membrane
t i o n o f h a i r f o l l i c l e s ) are seen o n l y i n t h e o u t e r o n e third Anterior
Posterior
o f the canal. malleol fold
malleol fold

(b) Bony Part

Shadow of
I t f o r m s i n n e r t w o - t h i r d s (16 m m ) . S k i n l i n i n g the b o n y incudostapediol
c a n a l is t h i n a n d c o n t i n u o u s o v e r t h e t y m p a n i c m e m b r a n e . joint
I t is d e v o i d o f h a i r a n d c e r u m i n o u s g l a n d s . A b o u t 6 m m
Pars tensa
lateral t o t y m p a n i c m e m b r a n e , the b o n y meatus presents a Shadow of
n a r r o w i n g c a l l e d t h e isthmus. Foreign bodies l o d g e d medial round window

t o t h e i s t h m u s , g e t i m p a c t e d , a n d are d i f f i c u l t t o r e m o v e .
Cone of light
A n t e r o - i n f e r i o r part o f the deep meatus, b e y o n d the i s t h -
m u s , p r e s e n t s a recess c a l l e d t h e anterior recess w h i c h acts as Annulus
a c e s s p o o l f o r d i s c h a r g e a n d d e b r i s i n cases o f e x t e r n a l a n d tympanicus

middle ear i n f e c t i o n s . A n t e r o - i n f e r i o r p a r t o f t h e bony

canal may present a deficiency (foramen of Huschke) in Figure 1.2
c h i l d r e n u p t o t h e age o f f o u r o r s o m e t i m e s i n a d u l t s , p e r -
L a n d m a r k s o f a n o r m a l t y m p a n i c m e m b r a n e o f r i g h t side.
m i t t i n g infections to and f r o m the parotid.
(iii) M i d d l e f i b r o u s l a y e r , w h i c h encloses t h e h a n d l e of External Auditory Canal
m a l l e u s a n d has t h r e e t y p e s o f f i b r e s — t h e r a d i a l , c i r -
(i) A n t e r i o r w a l l and roof: a u r i c u l o t e m p o r a l (V_).
cular and the parabolic.
(it) Posterior wall and floor: a u r i c u l a r b r a n c h o f vagus

F i b r o u s layer i n t h e para flaccida is t h i n a n d n o t o r g a n i s e d (CN X).

i n t o v a r i o u s f i b r e s as i n pars tensa. (iii) P o s t e r i o r w a l l o f t h e a u d i t o r y c a n a l also r e c e i v e s s e n -

sory fibres o f C N V I I t h r o u g h auricular b r a n c h of
v a g u s (see H i t z e l b e r g e r s i g n o n p a g e 124).
Relations of External Acoustic Meatus

Tympanic Membrane
S u p e r i o r l y : M i d d l e c r a n i a l fossa
(i) A n t e r i o r h a l f o f lateral surface: a u r i c u l o t e m p o r a l ( V ) . 3

P o s t e r i o r l y : M a s t o i d a i r cells a n d t h e f a c i a l n e r v e
(ii) P o s t e r i o r h a l f o f lateral surface: auricular branch of
Inferiorly: Parotid gland
vagus ( C N X ) .
Anteriorly: Temporomandibular j o i n t
(iii) Medial surface: Tympanic branch of C N IX
P o s t e r o s u p e r i o r p a r t o f d e e p e r canal n e a r t h e t y m p a n i c
(Jacobson's n e r v e ) .
m e m b r a n e is r e l a t e d t o t h e m a s t o i d a n t r u m . " S a g g i n g " of
this area m a y b e n o t i c e d i n a c u t e m a s t o i d i t i s (see p a g e 8 6 ) .

THE MIDDLE EAR

Nerve S u p p l y of the External Ear

T h e m i d d l e ear t o g e t h e r w i t h t h e e u s t a c h i a n t u b e , a d i t u s ,
Pinna
a n t r u m a n d m a s t o i d a i r cells is c a l l e d t h e middle ear cleft ( F i g .
(i) Greater auricular nerve ( C ) 2 3 supplies m o s t o f t h e 1.4). I t is l i n e d b y m u c o u s m e m b r a n e a n d f i l l e d w i t h air.
m e d i a l surface o f p i n n a a n d o n l y p o s t e r i o r part o f the T h e m i d d l e ear e x t e n d s m u c h b e y o n d t h e l i m i t s o f t y m -
l a t e r a l surface ( F i g . 1.3). p a n i c m e m b r a n e w h i c h f o r m s its l a t e r a l b o u n d a r y a n d is
(ii) Lesser o c c i p i t a l ( C , ) s u p p l i e s u p p e r p a r t o f m e d i a l sometimes d i v i d e d i n t o (i) mesotympanam (lying opposite
surface. t h e pars tensa), ( i i ) epitympanum o r t h e attic ( l y i n g above
(iii) A u r i c u l o t e m p o r a l ( V ) s u p p l i e s t r a g u s , crus o f h e l i x t h e pars tensa b u t m e d i a l t o S h r a p n e l l ' s m e m b r a n e a n d t h e
a n d the adjacent part o f the h e l i x . b o n y l a t e r a l a t t i c w a l l ) , ( i i i ) hypotympanum (lying below
(iv) A u r i c u l a r b r a n c h o f vagus ( C N X ) , also called A r n o l d ' s t h e l e v e l o f pars tensa) { F i g . 1 . 5 ) . T h e p o r t i o n o f m i d d l e
n e r v e , supplies t h e c o n c h a a n d c o r r e s p o n d i n g emi- ear a r o u n d t h e t y m p a n i c o r i f i c e o f t h e e u s t a c h i a n t u b e is
n e n c e o n t h e m e d i a l surface. sometimes called the protympanum.
(v) Facial nerve, which is d i s t r i b u t e d w i t h fibres of M i d d l e ear c a n b e l i k e n e d t o a s i x - s i d e d b o x w i t h a
a u r i c u l a r b r a n c h o f vagus, supplies the c o n c h a a n d roof, a floor, m e d i a l , lateral, a n t e r i o r a n d posterior walls
retroauricular groove. (Fig. 1.6).

Auriculotemporal nerve (V3)

Lesser occipital nerve

Great auricular
nerve (C 3) 2(

CN VII & X

Great auricular nerve

CN VII & X

Figure 1.3

Nerve s u p p l y o f p i n n a . ( A ) Lateral surface o f p i n n a . ( B ) M e d i a l o r c r a n i a l surface o f p i n n a .

 Attic
Latera
Antrum A d i h j s

Anterior
Eustachian tube

Figure 1.6

W a l l s o f m i d d l e ear a n d the s t r u c t u r e s related t o t h e m .

Mastoid air cells 1 . Canal for tensor t y m p a n i 7. Facial nerve
2. O p e n i n g o f e u s t a c h i a n tube 8. P y r a m i d
Figure 1.4 3. O v a l w i n d o w 9. A d i t u s
4. Round w i n d o w 10. C h o r d a t y m p a n i
M i d d l e ear c l e f t .
5. Processus c o c h l e a r i f o r m i s 11. Carotid artery
6. H o r i z o n t a l canal 1 2. j u g u l a r b u l b

Lateral attic wa

s u m m i t o f w h i c h appears t h e t e n d o n o f t h e stapedius m u s -
c l e t o get a t t a c h m e n t t o t h e n e c k o f stapes. Aditus, an
Epitympanum
opening through which attic communicates with the
a n t r u m , lies a b o v e t h e p y r a m i d . F a c i a l n e r v e r u n s i n t h e
p o s t e r i o r w a l l j u s t b e h i n d t h e p y r a m i d . Facial recess o r t h e
posterior sinus is a d e p r e s s i o n i n t h e p o s t e r i o r w a l l l a t e r a l t o
t h e p y r a m i d . I t is b o u n d e d m e d i a l l y b y t h e v e r t i c a l p a r t o f
Mesotympanum
V l l t h nerve, laterally b y the c h o r d a t y m p a n i and above, b y
the fossa i n c u d i s (Fig. 1.7). Surgically, facial recess is
i m p o r t a n t , as d i r e c t access c a n b e m a d e t h r o u g h t h i s i n t o
the m i d d l e ear without disturbing posterior canal wall
Hypotympanum
( i n t a c t c a n a l w a l l t e c h n i q u e , see p a g e 8 2 ) .

T h e m e d i a l w a l l ( F i g . 1.8) is f o r m e d b y t h e l a b y r i n t h . I t
Figure 1.5
presents a b u l g e c a l l e d promontory w h i c h is d u e t o t h e basal
D i v i s i o n s o f m i d d l e ear i n t o e p i - , m e s o - a n d h y p o t y m p a n u m . c o i l o f c o c h l e a ; oval window i n t o w h i c h is f i x e d t h e f o o t -
p l a t e o f stapes; round window o r t h e fenestra c o c h l e a e w h i c h
is c o v e r e d b y t h e s e c o n d a r y t y m p a n i c m e m b r a n e . Above
T h e r o o f is f o r m e d b y a t h i n p l a t e o f b o n e c a l l e d t e g m e n t h e o v a l w i n d o w is t h e canal for facial nerve. Its b o n y cover-
t y m p a n i . I t also e x t e n d s p o s t e r i o r l y t o f o r m t h e r o o f o f t h e i n g m a y sometimes be congenitally dehiscent and the nerve
a d i t u s a n d a n t r u m . I t separates t y m p a n i c c a v i t y f r o m the m a y lie exposed m a k i n g it v e r y vulnerable to injuries or
m i d d l e c r a n i a l fossa. i n f e c t i o n . A b o v e t h e c a n a l f o r f a c i a l n e r v e is t h e promi-
n e n c e o f lateral semicircular canal. Just a n t e r i o r t o the o v a l
The floor is also a t h i n plate o f b o n e w h i c h separates t y m -
w i n d o w , t h e m e d i a l w a l l presents a h o o k - l i k e p r o j e c t i o n
p a n i c c a v i t y f r o m the j u g u l a r b u l b . S o m e t i m e s , i t is c o n g e n i -
called t h e processus cochleariformis. The tendon o f tensor
tally d e f i c i e n t a n d t h e j u g u l a r b u l b m a y t h e n p r o j e c t i n t o t h e
t y m p a n i takes a t u r n h e r e t o get a t t a c h m e n t t o t h e n e c k o f
m i d d l e ear; separated from t h e c a v i t y o n l y b y t h e m u c o s a .
m a l l e u s . T h e c o c h l e a r i f o r m process also m a r k s t h e l e v e l o f
T h e a n t e r i o r w a l l has a t h i n p l a t e o f b o n e w h i c h sepa- t h e g e n u o f t h e facial n e r v e w h i c h is a n i m p o r t a n t l a n d -
rates t h e c a v i t y f r o m i n t e r n a l c a r o t i d a r t e r y . I t also has t w o m a r k f o r s u r g e r y o f t h e facial n e r v e . M e d i a l t o t h e p y r a m i d
openings; the l o w e r o n e f o r the eustachian tube and the is a d e e p recess c a l l e d sinus tympani w h i c h is b o u n d e d b y
u p p e r o n e f o r t h e canal o f tensor t y m p a n i muscle. t h e subiculum b e l o w a n d t h e ponticulus above (Fig. 1.7).

T h e p o s t e r i o r w a l l lies close t o t h e m a s t o i d a i r cells. I t T h e l a t e r a l w a l l is f o r m e d l a r g e l y b y t h e t y m p a n i c m e m -

p r e s e n t s a b o n y p r o j e c t i o n c a l l e d t h e pyramid t h r o u g h the b r a n e a n d t o a lesser e x t e n t b y t h e b o n y o u t e r a t t i c w a l l
 Anatomy of Ear

Figure 1.7

( A ) Facial recess lies lateral a n d sinus t y m p a n i m e d i a l t o t h e p y r a m i d a l e m i n e n c e a n d v e r t i c a l p a r t o f t h e f a c i a l nerve. (B) Exposure

o f f a c i a l recess t h r o u g h p o s t e r i o r t y m p a n o t o m y as seen at m a s t o i d surgery.

MacEwen's triangle

Spine of Henle

Figure 1.9

M a c E w e n ' s ( s u p r a m e a t a l ) t r i a n g l e . It is b o u n d e d by t e m p o r a l
line ( a ) , p o s t e r o s u p e r i o r s e g m e n t o f b o n y externa! a u d i t o r y
c a n a l ( b ) a n d the line d r a w n as a t a n g e n t t o the externa! c a n a l

Figure 1.8 ( c ) . It is an i m p o r t a n t l a n d m a r k t o l o c a t e the m a s t o i d a n t r u m

in m a s t o i d surgery.
M e d i a l w a l l o f m i d d l e ear.
1. Promontory 7. P o n t i c u l u s
2. Processus c o c h l e a r i f o r m i s 8. Sinus t y m p a n i
3. C N V I I 9. S u b i c u l u m
4. Oval w i n d o w 10. R o u n d w i n d o w r o o f is f o r m e d b y t h e tegmen antri w h i c h is a c o n t i n u a t i o n
5. H o r i z o n t a l c a n a l 1 1 . T y m p a n i c plexus o f t h e t e g m e n t y m p a n i a n d separates i t f r o m t h e m i d d l e
6. P y r a m i d c r a n i a l fossa. T h e l a t e r a l w a l l o f a n t r u m is f o r m e d b y a
p l a t e o f b o n e w h i c h is o n a n a v e r a g e 1.5 c m t h i c k i n t h e
a d u l t . I t is m a r k e d e x t e r n a l l y o n t h e s u r f a c e o f m a s t o i d b y
c a l l e d t h e scutum. T h e tympanic membrane is s e m i t r a n s -
suprameatal (MacEwen's) triangle ( F i g . 1.9).
p a r e n t a n d f o r m s a ' w i n d o w ' i n t o t h e m i d d l e ear. I t is
p o s s i b l e t o see s o m e s t r u c t u r e s o f t h e m i d d l e ear t h r o u g h
the n o r m a l t y m p a n i c m e m b r a n e , e.g. t h e l o n g process o f
Aditus ad Antrum
incus, incudostapedial j o i n t and the r o u n d w i n d o w .

A d i t u s is a n o p e n i n g t h r o u g h w h i c h t h e a t t i c c o m m u n i -
Mastoid Antrum cates w i t h t h e a n t r u m . T h e b o n y p r o m i n e n c e o f t h e h o r i -
z o n t a l c a n a l lies o n its m e d i a l side w h i l e t h e fossa i n c u d i s ,
I t is a large, a i r - c o n t a i n i n g space i n t h e u p p e r p a r t o f m a s t o i d t o w h i c h is a t t a c h e d t h e s h o r t process o f i n c u s , lies l a t e r a l l y .
and communicates w i t h t h e a t t i c t h r o u g h t h e a d i t u s . Its Facial n e r v e courses j u s t b e l o w t h e aditus.

f
 ( v i i ) t i p cells w h i c h are q u i t e l a r g e a n d l i e m e d i a l a n d
I T h e M a s t o i d a n d Its A i r C e l l S y s t e m ( F i g . 1.10) |
lateral t o the digastric r i d g e i n the t i p o f m a s t o i d .
( v i i i ) m a r g i n a l cells ( l y i n g b e h i n d t h e sinus p l a t e a n d m a y
T h e m a s t o i d consists o f b o n e c o r t e x w i t h a " h o n e y c o m b "
extend i n t o the occipital bone).
o f a i r cells u n d e r n e a t h . D e p e n d i n g o n d e v e l o p m e n t o f a i r
(ix) s q u a m o s a l cells ( l y i n g i n t h e s q u a m o u s p a r t o f t e m -
cell, three types o f m a s t o i d have b e e n described.
poral bones).
(i) Wcll-pneumatised or cellular. M a s t o i d cells are well
Abscesses m a y f o r m i n r e l a t i o n t o these a i r cells a n d m a y
d e v e l o p e d a n d i n t e r v e n i n g septa are t h i n .
s o m e t i m e s b e l o c a t e d far f r o m t h e m a s t o i d r e g i o n .
(is) Diploetk. M a s t o i d consists o f m a r r o w spaces a n d a
f e w a i r cells.
Development of Mastoid
( i i i ) Sclerotic or acellular. There are n o cells o r marrow
spaces. M a s t o i d develops f r o m the squamous a n d petrous bones.
T h e p e t r o s q u a m o s a l s u t u r e m a y persist as a b o n y p l a t e —
W i t h a n y t y p e o f m a s t o i d p n e u m a t i s a t i o n , a n t r u m is a l w a y s
t h e Korner's septum, separating superficial squamosal cells
p r e s e n t . I n s c l e r o t i c m a s t o i d s , a n t r u m is u s u a l l y s m a l l a n d
f r o m t h e d e e p p e t r o s a l cells. K o r n e r ' s s e p t u m is s u r g i c a l l y
t h e s i g m o i d sinus is a n t e p o s e d .
i m p o r t a n t as i t m a y cause d i f f i c u l t y i n l o c a t i n g t h e a n t r u m
D e p e n d i n g o n t h e l o c a t i o n , m a s t o i d air cells are d i v i d e d
a n d t h e d e e p e r cells; a n d thus m a y lead to incomplete
into:
r e m o v a l o f disease at m a s t o i d e c t o m y ( F i g . 1 . 1 1 ) . M a s t o i d
(i) z y g o m a t i c cells ( i n t h e r o o t o f z y g o m a ) . a n t r u m c a n n o t b e r e a c h e d unless t h e K o r n e r ' s s e p t u m has
(ii) t e g m e n cells ( e x t e n d i n g i n t o t h e t e g m e n t y m p a n i ) . been removed.
( i i i ) p e r i s i n u s cells ( o v e r l y i n g t h e sinus p l a t e ) .
(iv) r e t r o f a c i a l cells ( r o u n d t h e f a c i a l n e r v e ) .
(v) p e r i l a b y r i n t h i n e cells (located above, below and [ O s s i c l e s o f the Middle E a r (Fig. 1.12) [

b e h i n d t h e l a b y r i n t h , s o m e o f t h e m pass t h r o u g h t h e
a r c h o f s u p e r i o r s e m i c i r c u l a r c a n a l . T h e s e cells m a y T h e r e are t h r e e ossicles i n t h e m i d d l e e a r — t h e malleus,

c o m m u n i c a t e w i t h the petrous apex). i n c u s a n d stapes.

(vi) p e r i t u b a l ( a r o u n d the eustachian tube. A l o n g with T h e malleus has h e a d , n e c k , h a n d l e ( m a n u b r i u m ) , a l a t -

h y p o t y m p a n i c cells t h e y also c o m m u n i c a t e w i t h t h e e r a l a n d a n a n t e r i o r process. H e a d a n d n e c k o f m a l l e u s l i e
petrous apex). i n t h e a t t i c . M a n u b r i u m is e m b e d d e d i n t h e f i b r o u s l a y e r

Squomosa

Mastoid antrum

Sinodural angle

Zygomatic

Periantra!

Perisinus

Retrofccial

Tip cells

Figure 1.10

A i r cells in t h e t e m p o r a l b o n e .
 Anatomy of Ear

Squamosal cells
Korner's Petrosal cells
Septum
/
Antrum

Figure 1.11

K o r n e r ' s s e p t u m ( A ) as seen o n m a s t o i d e x p l o r a t i o n , ( B ) in c o r o n a l section o f m a s t o i d ; in its presence there is d i f f i c u l t y in l o c a t i n j

t h e a n t r u m w h i c h lies deep t o i t .

Malleus Incus

Short process

Long process

culnr process

Head
Anterior crus

Posterior crus

Footplate
Figure 1.12

Ear ossicles a n d t h e i r p a r t s .

o f the tympanic membrane. The lateral process f o r m s a T h e ossicles c o n d u c t s o u n d e n e r g y from the tympanic
k n o b - l i k e p r o j e c t i o n o n the o u t e r surface o f t h e t y m p a n i c membrane t o the oval w i n d o w and then to the inner
m e m b r a n e a n d gives a t t a c h m e n t t o the a n t e r i o r a n d p o s t e - ear f l u i d .
rior malleal (malleolar) folds.

T h e incus has a b o d y a n d a s h o r t process, b o t h o f w h i c h

lie i n the attic, a n d a l o n g process w h i c h hangs v e r t i c a l l y
a n d a t t a c h e s t o t h e h e a d o f stapes.
T h e s t a p e s has a h e a d , n e c k , a n t e r i o r a n d p o s t e r i o r c r u r a
a n d a f o o t p l a t e . T h e f o o t p l a t e is h e l d i n t h e o v a l w i n d o w
by annular ligament.
Intratympanic Muscles
T h e r e are t w o m u s c l e s — t e n s o r tympani and the stapedius;
t h e f o r m e r attaches t o t h e n e c k o f malleus a n d tenses t h e
t y m p a n i c m e m b r a n e w h i l e t h e latter attaches t o t h e n e c k o f
stapes a n d helps t o d a m p e n v e r y l o u d sounds t h u s p r e v e n t i n g
n o i s e t r a u m a t o t h e i n n e r ear. S t a p e d i u s is a 2 n d a r c h m u s -
Blood Supply of Middle Ear
c l e a n d is s u p p l i e d b y a b r a n c h o f C N V I I w h i l e tensor
t y m p a n i develops from t h e 1st a r c h a n d is s u p p l i e d b y a
M i d d l e ear is s u p p l i e d b y six arteries, o u t o f w h i c h t w o are
branch o f mandibular nerve (V,).
the m a i n , i.e.

(i) A n t e r i o r tympanic branch o f maxillary artery w h i c h

| Tympanic Plexus | supplies t y m p a n i c m e m b r a n e .

(ii) Stylomastoid branch o f posterior auricular artery

I t lies o n t h e p r o m o n t o r y a n d is f o r m e d b y (i) t y m p a n i c w h i c h s u p p l i e s m i d d l e ear a n d m a s t o i d a i r cells.

branch o f glossopharyngeal and (ii) s y m p a t h e t i c fibres

F o u r m i n o r vessels are:
f r o m the plexus r o u n d the internal carotid artery. T y m p a n i c
p l e x u s supplies i n n e r v a t i o n t o t h e m e d i a l surface o f the i | Petrosal branch o f middle meningeal artery (runs

tympanic membrane, t y m p a n i c c a v i t y , m a s t o i d a i r cells a l o n g greater petrosal nerve).

a n d t h e b o n y e u s t a c h i a n t u b e . I t also carries secretomotor (ii) S u p e r i o r t y m p a n i c b r a n c h o f m i d d l e m e n i n g e a l artery

fibres f o r the p a r o t i d g l a n d . Section o f t y m p a n i c b r a n c h o f t r a v e r s i n g a l o n g t h e canal f o r t e n s o r t y m p a n i m u s c l e .

glossopharyngeal n e r v e can be carried o u t i n the m i d d l e ( i i i ) B r a n c h o f artery o f p t e r y g o i d canal (runs a l o n g eusta-

ear i n cases o f F r e y ' s s y n d r o m e . chian tube).

C o u r s e o f s e c r e t o m o t o r fibres to the p a r o t i d : (iv) T y m p a n i c branch o f internal carotid.

I n f e r i o r s a l i v a r y n u c l e u s —> C N I X —*• T y m p a n i c b r a n c h
Veins drain i n t o pterygoid venous plexus and superior
—*• T y m p a n i c plexus —* Lesser p e t r o s a l n e r v e —> O t i c
petrosal sinus.
g a n g l i o n - > A u r i c u l o t e m p o r a l n e r v e —> P a r o t i d g l a n d .

Lymphatic Drainage of Ear

| C h o r d a Tympani Nerve J
Lymphatics from t h e m i d d l e ear d r a i n i n t o r e t r o p h a r y n -
I t is a b r a n c h o f t h e f a c i a l n e r v e w h i c h e n t e r s t h e m i d d l e geal a n d p a r o t i d n o d e s w h i l e t h o s e o f t h e e u s t a c h i a n tube
ear t h r o u g h p o s t e r i o r c a n a l i c u l u s , a n d r u n s o n t h e m e d i a l d r a i n i n t o r e t r o p h a r y n g e a l g r o u p (see T a b l e 1.1).
surface o f the t y m p a n i c m e m b r a n e b e t w e e n t h e h a n d l e o f
malleus a n d l o n g process o f i n c u s , a b o v e t h e a t t a c h m e n t of
t e n d o n o f t e n s o r t y m p a n i . I t carries taste from anterior THE INTERNAL EAR
t w o - t h i r d s o f t o n g u e a n d supplies s e c r e t o m o t o r fibres to
the s u b m a x i l l a r y a n d s u b l i n g u a l salivary glands. T h e i n t e r n a l ear o r t h e l a b y r i n t h is a n i m p o r t a n t o r g a n o f
h e a r i n g a n d b a l a n c e . I t consists o f a b o n y a n d a m e m b r a -
n o u s l a b y r i n t h . T h e m e m b r a n o u s l a b y r i n t h is f i l l e d w i t h a
| Lining o f the Middle Ear Cleft | clear fluid called endolymph while the space between
m e m b r a n o u s a n d b o n y l a b y r i n t h s is f i l l e d w i t h p e r i l y m p h .
M u c o u s m e m b r a n e o f t h e n a s o p h a r y n x is c o n t i n u o u s w i t h
t h a t o f t h e m i d d l e ear, a d i t u s , a n t r u m a n d t h e m a s t o i d a i r
cells. I t w r a p s t h e m i d d l e ear s t r u c t u r e s — t h e ossicles, m u s -
Table 1.1 L y m p h a t i c d r a i n a g e o f ear
cles, l i g a m e n t s , a n d n e r v e s — l i k e p e r i t o n e u m w r a p s v a r i -
ous viscera i n the abdomen—raising several folds and Area Nodes
d i v i d i n g t h e m i d d l e ear i n t o v a r i o u s c o m p a r t m e n t s . M i d d l e
C o n c h a , t r a g u s , fossa Preauricular a n d p a r o t i d
ear c o n t a i n s n o t h i n g b u t t h e air; a l l t h e s t r u c t u r e s l i e o u t s i d e t r i a n g u l a r i s a n d external nodes
the m u c o u s membrane. cartilaginous canal
H i s t o l o g i c a l l y , the eustachian t u b e is l i n e d b y c i l i a t e d
Lobule and antitragus Infra-auricular nodes
e p i t h e l i u m w h i c h is p s e u d o s t r a t i f i e d c o l u m n a r i n t h e c a r -
Helix a n d a n t i h e l i x P o s t - a u r i c u l a r n o d e s , deep
tilaginous part, c o l u m n a r i n the b o n y part w i t h several
j u g u l a r a n d s p i n a l accessory
m u c o u s g l a n d s i n t h e s u b m u c o s a . T y m p a n i c c a v i t y is l i n e d
nodes
b y c i l i a t e d c o l u m n a r e p i t h e l i u m i n its a n t e r i o r a n d i n f e r i o r
M i d d l e ear a n d e u s t a c h i a n Retropharyngeal nodes -> i
part w h i c h changes to c u b o i d a l type i n the p o s t e r i o r part.
tube upper jugular chain
E p i t y m p a n u m a n d m a s t o i d a i r cells are l i n e d b y flat, n o n -
Inner ear No lymphatics I
ciliated e p i t h e l i u m .
 Round window

Opening of endolymphotic duct

cochlear aqueduct

Figure 1.13

( A ) Left b o n y l a b y r i n t h . ( B ) Left m e m b r a n o u s l a b y r i n t h . ( C ) C u t section o f b o n y l a b y r i n t h .

a c o u s t i c meatus a n d transmits vessels a n d nerves t o the c o c h l e a .

Bony Labyrinth (Fig. 1.13A)
A r o u n d t h e m o d i o l u s a n d w i n d i n g spirally l i k e the t h r e a d o f
a s c r e w , is a t h i n plate o f b o n e called osseous spiral lamina. It
I t consists o f t h r e e p a r t s : t h e v e s t i b u l e , t h e semicircular
divides t h e b o n y c o c h l e a i n c o m p l e t e l y , a n d gives a t t a c h m e n t
canals a n d t h e c o c h l e a .
t o t h e basilar m e m b r a n e . T h e b o n y b u l g e i n t h e m e d i a l w a l l
1. V e s t i b u l e is t h e c e n t r a l c h a m b e r o f the labyrinth. I n
o f m i d d l e e a r — t h e p r o m o n t o r y , is d u e t o the basal c o i l o f t h e
its l a t e r a l w a l l lies t h e o v a l w i n d o w . The i n s i d e o f its
cochlea. T h e b o n y cochlea contains three c o m p a r t m e n t s :
m e d i a l w a l l p r e s e n t s t w o recesses, a spherical recess, which
l o d g e s t h e s a c c u l e a n d a n elliptical recess w h i c h l o d g e s the (a) scala v e s t i b u l i ,

u t r i c l e . B e l o w t h e e l l i p t i c a l recess is t h e o p e n i n g o f a q u e - (b) scala t y m p a n i ,

d u c t o f v e s t i b u l e t h r o u g h w h i c h passes t h e e n d o l y m p h a t i c (c) scala m e d i a o r t h e m e m b r a n o u s c o c h l e a ( F i g . 1 . 1 4 ) .

d u c t . I n t h e p o s t e r o s u p e r i o r p a r t o f v e s t i b u l e are t h e f i v e
T h e scala v e s t i b u l i a n d scala t y m p a n i are f i l l e d w i t h p e r i l y m p h
o p e n i n g s o f s e m i c i r c u l a r canals ( F i g . 1 . 1 3 C ) .
a n d c o m m u n i c a t e w i t h each o t h e r at t h e a p e x o f c o c h l e a

2. Semicircular canals T h e y are t h r e e i n n u m b e r , the t h r o u g h a n o p e n i n g called helicotrema. Scala v e s t i b u l i is closed

l a t e r a l , p o s t e r i o r a n d s u p e r i o r , a n d l i e i n p l a n e s at right b y t h e f o o t p l a t e o f stapes w h i c h separates i t from the a i r - f i l l e d

angles t o o n e a n o t h e r . E a c h c a n a l has a n a m p u l l a t e d e n d m i d d l e ear. T h e scala t y m p a n i is closed b y secondary tym-

w h i c h opens i n d e p e n d e n t l y i n t o the vestibule and a n o n - p a n i c m e m b r a n e ; i t is also c o n n e c t e d w i t h t h e s u b a r a c h n o i d

ampullated end. T h e n o n - a m p u l l a t e d ends o f p o s t e r i o r space t h r o u g h t h e aqueduct of cochlea ( F i g . 1.15).

a n d s u p e r i o r canals u n i t e t o f o r m a c o m m o n c h a n n e l c a l l e d
t h e crus commune. T h u s , t h e t h r e e canals o p e n i n t o t h e v e s -
^ Membranous Labyrinth (Fig. 1.13B)
tibule by five openings.

3. C o c h l e a T h e b o n y c o c h l e a is a c o i l e d t u b e m a k i n g I t consists o f t h e c o c h l e a r d u c t , t h e u t r i c l e a n d s a c c u l e ,
2.5 t o 2 . 7 5 t u r n s r o u n d a c e n t r a l p y r a m i d o f b o n e c a l l e d t h e the three semicircular ducts, and the e n d o l y m p h a t i c d u c t
modiolus. T h e base o f m o d i o l u s is d i r e c t e d t o w a r d s i n t e r n a l a n d sac.
 Reissner's 2. U t r i c l e and saccule T h e u t r i c l e lies i n t h e p o s t e r i o r
membrane part o f b o n y vestibule. It receives the f i v e openings o f t h e
ocniear duct t h r e e s e m i c i r c u l a r d u c t s . I t is also c o n n e c t e d t o t h e s a c c u l e
scala media)
t h r o u g h u t r i c u l o s a c c u l a r d u c t . T h e sensory e p i t h e l i u m o f
Stria t h e u t r i c l e is c a l l e d t h e macula a n d is c o n c e r n e d w i t h l i n e a r
vascularis acceleration a n d d e c e l e r a t i o n . T h e s a c c u l e also lies i n t h e
b o n y v e s t i b u l e , a n t e r i o r t o t h e u t r i c l e a n d o p p o s i t e t h e stapes
f o o t p l a t e . Its s e n s o r y e p i t h e l i u m is also c a l l e d t h e m a c u l a .
Its e x a c t f u n c t i o n is n o t k n o w n . I t p r o b a b l y also r e s p o n d s
to linear acceleration and deceleration. In Meniere's dis-
Osseous ar ease, t h e d i s t e n d e d s a c c u l e lies against t h e stapes f o o t p l a t e
spiral lamina membrane
a n d can be surgically decompressed by perforating the

Scala tympani footplate.

3 . S e m i c i r c u l a r d u c t s T h e y are t h r e e i n n u m b e r a n d c o r -
Figure 1.14
r e s p o n d e x a c t i y t o t h e t h r e e b o n y canals. T h e y o p e n i n t h e
S e c t i o n t h r o u g h c o c h l e a t o s h o w scala m e d i a ( c o c h l e a r d u c t J u t r i c l e . T h e a m p u l l a t e d e n d o f each d u c t c o n t a i n s a t h i c k e n e d
scala v e s t i b u l i a n d scala t y m p a n i . r i d g e o f n e u r o e p i t h e l i u m called crista ampullaris.

4. E n d o l y m p h a t i c d u c t a n d sac Endolymphatic duct

is f o r m e d b y t h e u n i o n o f t w o d u c t s , o n e e a c h f r o m t h e
Stapes Helicotrema saccule a n d t h e u t r i c l e . I t passes t h r o u g h t h e vestibular
aqueduct. Its t e r m i n a l p a r t is d i l a t e d t o f o r m e n d o l y m -
Scaia vestibul p h a t i c sac w h i c h lies b e t w e e n t h e t w o layers o f d u r a o n
the p o s t e r i o r surface o f the p e t r o u s b o n e .

Scala tympani E n d o l y m p h a t i c sac is s u r g i c a l l y i m p o r t a n t . I t is e x p o s e d

f o r d r a i n a g e o r s h u n t o p e r a t i o n i n M e n i e r e ' s disease.
Scala media
R.W. — Aqueduct (endolymph)
membrane of cochlea
Subarachnoid space
C.S.F.
£ Inner E a r Fluids and their Circulation J

Figure 1.15 T h e r e are t w o m a i n fluids i n t h e i n n e r ear, p e r i l y m p h a n d

endolymph.
D i a g r a m m a t i c representation o f perilymphatic system. CSF
passes i n t o scala t y m p a n i t h r o u g h a q u e d u c t o f c o c h l e a . Perilymph resembles extracellular fluid a n d is r i c h in
N a i o n s . I t f i l l s t h e space b e t w e e n t h e b o n y a n d t h e m e m -
branous labyrinth. It communicates w i t h CSF t h r o u g h the
a q u e d u c t o f c o c h l e a w h i c h o p e n s i n t o t h e scala t y m p a n i
1. Cochlear duct (Fig. 1.14). A l s o called membranous
n e a r t h e r o u n d w i n d o w . I n fact t h i s d u c t is n o t a d i r e c t
c o c h l e a o r t h e scala m e d i a . I t is a b l i n d c o i l e d t u b e . I t
c o m m u n i c a t i o n b u t c o n t a i n s c o n n e c t i v e tissue r e s e m b l i n g
appears t r i a n g u l a r o n c r o s s - s e c t i o n a n d its t h r e e w a l l s are
a r a c h n o i d t h r o u g h w h i c h p e r i l y m p h p e r c o l a t e s . T h e r e are
formed by:
t w o v i e w s r e g a r d i n g t h e f o r m a t i o n o f p e r i l y m p h : (i) I t is a
(a) t h e basilar m e m b r a n e , w h i c h supports the o r g a n of f i l t e r a t e o f b l o o d s e r u m a n d is f o r m e d b y c a p i l l a r i e s o f t h e
corti, s p i r a l l i g a m e n t a n d ( i i ) i t is a d i r e c t c o n t i n u a t i o n o f CSF
(b) t h e R e i s s n e r ' s m e m b r a n e w h i c h separates i t f r o m t h e a n d reaches t h e l a b y r i n t h v i a a q u e d u c t o f c o c h l e a .
scala v e s t i b u l i ,
Endolymph fills t h e e n t i r e m e m b r a n o u s labyrinth and
(c) t h e stria vascularis, w h i c h c o n t a i n s v a s c u l a r e p i t h e l i u m
resembles intracellular fluid, being rich in K i o n s . I t is
a n d is c o n c e r n e d w i t h s e c r e t i o n o f e n d o l y m p h .
s e c r e t e d b y t h e s e c r e t o r y cells o f t h e stria vascularis o f t h e
C o c h l e a r d u c t is c o n n e c t e d t o t h e saccule b y ductus reuniens c o c h l e a a n d b y t h e d a r k cells (present i n t h e u t r i c l e a n d also
( F i g . 1 . 1 3 B ) . T h e l e n g t h o f basilar m e m b r a n e increases as n e a r t h e a m p u l l a t e d ends o f s e m i c i r c u l a r d u c t s ) . T h e r e are
w e p r o c e e d f r o m t h e basal c o i l t o t h e a p i c a l c o i l . I t is f o r t w o v i e w s r e g a r d i n g its flow: (i) L o n g i t u d i n a l , i . e . endo-
t h i s r e a s o n t h a t h i g h e r f r e q u e n c i e s o f s o u n d are h e a r d at t h e l y m p h f r o m t h e c o c h l e a reaches s a c c u l e , u t r i c l e a n d e n d o -
basal c o i l w h i l e l o w e r o n e s are h e a r d at t h e a p i c a l c o i l . l y m p h a t i c d u c t a n d gets a b s o r b e d t h r o u g h e n d o l y m p h a t i c
 A n a t o m y of Ear

sac w h i c h lies i n t h e s u b d u r a l space a n d ( i i ) r a d i a l , i . e . i n t e r n a l a u d i t o r y canal i t divides i n the m a n n e r s h o w n i n

endolymph is s e c r e t e d b y stria v a s c u l a r i s a n d also gets Figs 1.16 a n d 1.17.
a b s o r b e d b y t h e stria vascularis. T h i s v i e w p r e s u m e s t h a t V e n o u s d r a i n a g e is t h r o u g h t h r e e v e i n s , n a m e l y i n t e r n a l
e n d o l y m p h a t i c sac is a v e s t i g i a l s t r u c t u r e i n m a n a n d p l a y s auditory v e i n , v e i n o f cochlear aqueduct and vein o f vestibu-
n o part i n e n d o l y m p h absorption. C o m p o s i t i o n o f e n d o - lar a q u e d u c t w h i c h u l t i m a t e l y d r a i n i n t o i n f e r i o r p e t r o s a l
l y m p h , p e r i l y m p h a n d C S F is g i v e n i n T a b l e 1.2. sinus a n d l a t e r a l v e n o u s sinus.

Labyrinthine artery
Blood Supply of Labyrinth (from anterior-inferior
cerebellar artery)

The e n t i r e l a b y r i n t h r e c e i v e s its a r t e r i a l s u p p l y t h r o u g h
l a b y r i n t h i n e a r t e r y w h i c h is a b r a n c h o f a n t e r i o r - i n f e r i o r
c e r e b e l l a r a r t e r y b u t s o m e t i m e s f r o m t h e basilar. In the Common cochlear Anterior vestibular artery
(to utricle and lateral and
I superior canals)

I C o m p o s i t i o n o f i n n e r ear f l u i d s Vestibulocochlear Main cochlear artery

artery (to cochlea, 80%]
Endolymph Perilymph CSF

Na +
(mEq/L) 5 140 152

K* ( m E q / L ) 144 10 4
Cochlear branch Posterior vestibular artery
Protein (mg/dL) 126 200-400 20-50 (to cochlea, 20%) (to saccule and posterior canal

Glucose (mg/dL) 10-40 85 70

Figure 1.16
Values are average and may differ slightly according to the sice o f
collection o f endolymph (cochlea, utricle, sac) and perilymph Divisions o f the labyrinthine artery t o supply various parts o f
(scala tympani or scala vestibuli). labyrinth.

Anterior inferior
cerebellar artery Labyrinthine artery

Common cochlear artery

Anterior vestibular artery Main cochlear artery

(utricle, sup. and lateral canals % supply to cochlea)

Vestibulo cochlear artery

Cochlear branch
(20% supply to cochlea)
Posterior vestibular artery
(posterior canal, saccule

Figure 1.17

Blood supply o f labyrinth.

 I t is t o b e n o t e d t h a t : liferate f r o m the b o t t o m o f ectodermal cleft a n d f o r m a
meatal p l u g . Recanalisation o f this p l u g f o r m s t h e e p i t h e -
(a) B l o o d s u p p l y t o t h e i n n e r ear is i n d e p e n d e n t o f b l o o d
lial l i n i n g o f the b o n y meatus. Recanalisation begins from
s u p p l y t o m i d d l e ear a n d b o n y o t i c c a p s u l e , a n d t h e r e
the deeper part near the t y m p a n i c m e m b r a n e and pro-
is n o cross c i r c u l a t i o n b e t w e e n t h e t w o .
gresses o u t w a r d s , a n d t h a t e x p l a i n s w h y d e e p e r m e a t u s is
B l o o d s u p p l y t o c o c h l e a a n d v e s t i b u l a r l a b y r i n t h is
s o m e t i m e s d e v e l o p e d w h i l e t h e r e is atresia o f canal i n t h e
segmental, therefore, independent ischaemic damage
o u t e r p a r t . E x t e r n a l ear c a n a l is f u l l y f o r m e d b y t h e 2 8 t h
c a n o c c u r t o these o r g a n s c a u s i n g e i t h e r c o c h l e a r o r
w e e k o f gestation.
vestibular symptoms.
Tympanic membrane d e v e l o p s f r o m all t h e t h r e e ger-
m i n a l layers. O u t e r e p i t h e l i a l l a y e r is f o r m e d b y t h e e c t o -
DEVELOPMENT OF EAR derm, inner mucosal layer b y the endoderm and the
m i d d l e f i b r o u s layer b y the m e s o d e r m .

Auricle F i r s t b r a n c h i a l c l e f t is t h e p r e c u r s o r o f e x t e r n a l
Middle ear cleft T h e eustachian tube, t y m p a n i c cavity,
a u d i t o r y canal. A r o u n d t h e sixth w e e k o f e m b r y o n i c life, a
attic, a n t r u m a n d m a s t o i d air cells d e v e l o p from the e n d o d e m i
series o f six t u b e r c l e s appear a r o u n d t h e f i r s t b r a n c h i a l c l e f t .
o f t u b o t y m p a n i c recess w h i c h arises from the first a n d p a r t l y
T h e y p r o g r e s s i v e l y coalesce t o f o r m t h e a u r i c l e ( F i g . 1 . 1 8 ) .
from t h e s e c o n d p h a r y n g e a l p o u c h e s (Fig. 1.19).
T r a g u s d e v e l o p s f r o m t h e t u b e r c l e o f t h e first a r c h w h i l e
M a l l e u s a n d i n c u s are d e r i v e d f r o m m e s o d e r m o f t h e
t h e rest o f t h e p i n n a d e v e l o p s f r o m the r e m a i n i n g five
f i r s t a r c h w h i l e t h e stapes d e v e l o p f r o m t h e s e c o n d a r c h
tubercles o f the second a r c h . Faulty f u s i o n b e t w e e n the first
e x c e p t its f o o t p l a t e a n d a n n u l a r l i g a m e n t w h i c h are d e r i v e d
a n d t h e s e c o n d a r c h t u b e r c l e s causes p r e a u r i c u l a r sinus o r
f r o m the otic capsule.
cyst w h i c h is c o m m o n l y seen b e t w e e n t h e tragus a n d crus
o f h e l i x . B y t h e 2 0 t h w e e k , p i n n a a c h i e v e s a d u l t shape. Membranous inner ear D e v e l o p m e n t o f t h e i n n e r ear

I n i t i a l l y , t h e p i n n a is l o c a t e d l o w o n t h e side o f t h e n e c k starts i n t h e t h i r d w e e k o f f o e t a l l i f e a n d is c o m p l e t e b y t h e

a n d t h e n m o v e s o n t o a m o r e lateral a n d c r a n i a l p o s i t i o n .

External auditory meatus develops f r o m the first b r a n -

c h i a l c l e f t . B y a b o u t t h e 1 6 t h e m b r y o n i c w e e k , cells p r o -

Tubotymponic recess
Figure 1.18
Figure 1.19
D e v e l o p m e n t o f p i n n a . Six hillocks a r o u n d f i r s t b r a n c h i a l c l e f t
a n d the c o r r e s p o n d i n g parts o f pinna w h i c h develop f r o m t h e m . D e v e l o p m e n t o f external a u d i t o r y c a n a l a n d m i d d l e ear.

1 T i m i n g o f development o f the ear in the week o f g e s t a t i o n *

Development Pinna Meatus M i d d l e ear V e s t i b u l a r labyrinth Cochlea

Begins 6th 8th 3rd 3rd 3rd

Completes 20th 28th 30th 20th 20th

"Source: Gulya, A.J. Developmental Anatomy o f the Ear. In Glasscock and Shambaugh ed. Surgery o f the Ear. Philadelphia: W.B. Saunders
Company, 1990.
16th w e e k . E c t o d e r m i n the r e g i o n o f h i n d b r a i n thickens d e v e l o p m e n t o f t h e i n n e r ear. I t is t h e r e f o r e n o t u n u s u a l
t o f o r m a n auditory placode w h i c h is i n v a g i n a t e d t o f o r m t o see m a l f o r m e d a n d n o n - f u n c t i o n a l i n n e r ear i n t h e p r e s -
a u d i t o r y v e s i c l e o r t h e otocyst. T h e l a t t e r t h e n d i f f e r e n t i a t e s e n c e o f n o r m a l e x t e r n a l a n d m i d d l e ears, a n d v i c e versa.
i n t o t h e e n d o l y m p h a t i c d u c t a n d sac; t h e u t r i c l e , t h e s e m i - The c o c h l e a is d e v e l o p e d s u f f i c i e n t l y b y 2 0 w e e k s of
c i r c u l a r d u c t s ; a n d saccule a n d t h e c o c h l e a . D e v e l o p m e n t g e s t a t i o n ( T a b l e 1.3) a n d t h e f o e t u s c a n h e a r i n t h e w o m b
o f p h y l o genetically older part o f labyrinth—pars superior o f t h e m o t h e r . T h i s p r o b a b l y explains h o w A b h f m a n y u ,
( s e m i c i r c u l a r canals a n d u t r i c l e ) takes p l a c e e a r l i e r than pars while still u n b o r n , c o u l d have heard the conversation
inferior (saccule a n d c o c h l e a ) . between his m o t h e r a n d father (Arjuna) i n the legend
T h e e m b r y o l o g i c source and the t i m e o f d e v e l o p m e n t given i n the Great I n d i a n epic o f Mahabharata written
o f e x t e r n a l a n d m i d d l e ears is q u i t e i n d e p e n d e n t o f t h e t h o u s a n d s o f years a g o .
Peripheral Receptors a n d Physiology
o f A u d i t o r y a n d V e s t i b u l a r Systems

i n t h r e e o r f o u r r o w s . I n n e r h a i r cells are r i c h l y s u p p l i e d b y
AUDITORY SYSTEM a f f e r e n t c o c h l e a r f i b r e s a n d are p r o b a b l y m o r e i m p o r t a n t
i n t h e t r a n s m i s s i o n o f a u d i t o r y i m p u l s e s . O u t e r h a i r cells
m a i n l y receive efferent i n n e r v a t i o n f r o m the olivary c o m -
O r g a n o f C o r t i ( F i g . 2.1
p l e x a n d are c o n c e r n e d w i t h m o d u l a t i n g t h e f u n c t i o n o f
i n n e r h a i r cells. D i f f e r e n c e s b e t w e e n i n n e r a n d o u t e r h a i r
O r g a n o f c o r t i is t h e sense o r g a n o f h e a r i n g a n d is s i t u a t e d
cells are g i v e n i n T a b l e 2 . 1 .
o n t h e basilar m e m b r a n e . Important components o f the
o r g a n o f c o r t i are: 3. Supporting c e l l D e i t e r s ' cells are s i t u a t e d between

1. Tunnel of Corti w h i c h is f o r m e d b y t h e i n n e r a n d t h e o u t e r h a i r cells a n d p r o v i d e s u p p o r t t o t h e l a t t e r . C e l l s

outer rods. I t contains a fluid c a l l e d cortiiymph. The exact o f H e n s e n l i e o u t s i d e t h e D e i t e r s ' cells.

f u n c t i o n o f t h e r o d s a n d c o r t i i y m p h is n o t k n o w n .
4. Tectorial membrane I t consists o f g e l a t i n o u s m a t r i x
2. H a i r cells T h e y are i m p o r t a n t r e c e p t o r cells o f h e a r i n g w i t h delicate f i b r e s . I t overlies t h e o r g a n o f C o r t i . T h e shear-
and transduce s o u n d energy i n t o electrical energy. Inner i n g f o r c e b e t w e e n t h e h a i r cells a n d t e c t o r i a l membrane
h a i r cells f o r m a single r o w w h i l e o u t e r h a i r cells are a r r a n g e d p r o d u c e s t h e s t i m u l u s t o h a i r cells.

Stria vascularis

Spiral ligament

Cells of Claudius

Tunnel of Corti
Scarpa's ganglion
Nerve fibres [unmyelinated)

Cochlear nerve fibres (myelinated) B a s i | a r m e

Figure 2.1

Structure o f organ o f c o r t i .
 Peripheral Receptors

2000

+ 80 mV

4000

- 40 mV

20,000

8000

Figure 2.4

Frequency l o c a l i s a t i o n in t h e c o c h l e a . H i g h e r frequencies are Figure 2.5

localised in t h e basal t u r n a n d t h e n progressively decrease Davis' b a t t e r y m o d e l o f c o c h l e a r t r a n s d u c t i o n . Scala m e d i a

t o w a r d s t h e apex. has a D C p o t e n t i a l o f + 8 0 m V . S t i m u l a t i o n o f hair cells p r o -
duces i n t r a c e l l u l a r p o t e n t i a l o f — 4 0 m V . T h i s p r o v i d e s f l o w o f
c u r r e n t o f 1 2 0 m V t h r o u g h the t o p o f h a i r cells.
m e m b r a n e a n d s t i m u l a t e s t h a t s e g m e n t (travelling wave theory
of von Bekesy). H i g h e r frequencies are r e p r e s e n t e d i n t h e
t h r o u g h h a i r cells a n d p r o d u c e s v o l t a g e fluctuations called
basal t u r n o f t h e c o c h l e a a n d t h e p r o g r e s s i v e l y l o w e r ones
c o c h l e a r m i c r o p h o n i c . I t is an a l t e r n a t i n g c u r r e n t ( A C )
towards the apex (Fig. 2.4).
potential.

3. Neural Pathways
3. S u m m a t i n g potential (SP) I t is a D C p o t e n t i a l a n d

H a i r cells g e t i n n e r v a t i o n f r o m t h e b i p o l a r cells o f s p i r a l f o l l o w s " e n v e l o p e " o f s t i m u l a t i n g s o u n d . I t is p r o d u c e d b y

g a n g l i o n . C e n t r a l a x o n s o f these cells c o l l e c t t o f o r m c o c h l e a r h a i r cells. I t m a y b e n e g a t i v e o r p o s i t i v e . SP has b e e n u s e d

nerve w h i c h goes t o v e n t r a l a n d dorsal cochlear n u c l e i . i n diagnosis o f M e n i e r e ' s disease. I t is s u p e r i m p o s e d on

F r o m t h e r e , b o t h crossed a n d u n c r o s s e d f i b r e s t r a v e l t o t h e V I I I nerve action potential.

s u p e r i o r o l i v a r y nucleus, lateral lemniscus, i n f e r i o r c o l l i c u - B o t h C M a n d SP are r e c e p t o r p o t e n t i a l s as seen i n o t h e r

lus, m e d i a l g e n i c u l a t e b o d y a n d f i n a l l y r e a c h t h e a u d i t o r y sensory e n d - o r g a n s . T h e y differ from action potentials i n

cortex o f the t e m p o r a l lobe. that (a) t h e y are g r a d e d r a t h e r t h a n all o r n o n e p h e n o m e n o n ,

(b) h a v e n o l a t e n c y , (c) are n o t p r o p a g a t e d a n d (d) h a v e n o
post-response refractory p e r i o d .
Electrical Potentials o f C o c h l e a a n d C N VIII
4. Compound action potential I t is a n a l l o r none
response o f a u d i t o r y n e r v e fibres.
F o u r types o f potentials have been r e c o r d e d ; three from
t h e c o c h l e a a n d o n e f r o m C N V I I I f i b r e s . T h e y are:

1. Endocochlear potential
VESTIBULAR SYSTEM

2. Cochlear microphonic — f r o m cochlea

3. Summating potential
Peripheral Receptors
4. C o m p o u n d action potential ^ ) — f r o m nerve fibres

1. Endocochlear potential I t is a d i r e c t c u r r e n t (DC) T h e y are o f t w o t y p e s :

p o t e n t i a l r e c o r d e d f r o m scala m e d i a . I t is + 8 < ) m V a n d is
generated from t h e stria v a s c u l a r i s b y NaVK -ATPase
+
7. Cristae

p u m p a n d p r o v i d e s source o f energy for cochlear transduc- They are located i n the a m p u l l a t e d ends o f the three
t i o n (Fig. 2.5). I t is p r e s e n t at rest a n d d o e s n o t r e q u i r e semicircular ducts. These receptors respond to angular
s o u n d stimulus. T h i s p o t e n t i a l p r o v i d e s a sort o f " b a t t e r y " acceleration.
t o d r i v e t h e c u r r e n t t h r o u g h h a i r cells w h e n t h e y m o v e i n
response t o a s o u n d s t i m u l u s . 2. Maculae

2. C o c h l e a r microphonic (CM) W h e n basilar mem- T h e y are l o c a t e d i n o t o l i t h o r g a n s ( i . e . u t r i c l e a n d s a c c u l e ) .

b r a n e m o v e s i n r e s p o n s e t o s o u n d s t i m u l u s , e l e c t r i c a l resis- M a c u l a o f t h e u t r i c l e lies i n its floor i n a h o r i z o n t a l p l a n e .
t a n c e at t h e t i p s o f h a i r cells c h a n g e s a l l o w i n g flow o f K +
M a c u l a o f saccule lies i n its m e d i a l w a l l i n a v e r t i c a l p l a n e .
Diseases of Ear

Ampulla of Stereocilio Kinocilium

semicircular duct

Microvilli

Supporting cell

Nerve chalice

Figure 2.7

Crista ampullaris Sensory h a i r cells o f t h e v e s t i b u l a r o r g a n s . Type I ( l e f t ) a n d

Type II ( r i g h t ) .
Figure 2.6

S t r u c t u r e o f a m p u l l a r y end o f s e m i c i r c u l a r d u c t . Over the

crista lie sensory h a i r cells interspersed w i t h s u p p o r t i n g cells.
H a i r f r o m sensory cells p r o j e c t i n t o the g e l a t i n o u s s u b s t a n c e Vestibular Nerve
o f cupula.

V e s t i b u l a r o r Scarpa's g a n g l i o n is s i t u a t e d i n t h e l a t e r a l p a r t
o f t h e i n t e r n a l a c o u s t i c m e a t u s . I t c o n t a i n s b i p o l a r cells.
T h e y sense p o s i t i o n o f h e a d i n r e s p o n s e t o g r a v i t y a n d T h e d i s t a l processes o f b i p o l a r cells i n n e r v a t e t h e s e n s o r y
linear acceleration. epithelium o f the labyrinth w h i l e its c e n t r a l processes
Structure o f a crista ( F i g . 2 . 6 ) I t is a c r e s t - l i k e m o u n d aggregate t o f o r m t h e vestibular nerve,
o f connective tissues o n w h i c h l i e t h e s e n s o r y e p i t h e l i a l
cells. T h e c i l i a o f t h e sensory h a i r cells p r o j e c t i n t o t h e c u p -
Central Vestibular Connections J|
u l a w h i c h is a g e l a t i n o u s mass e x t e n d i n g f r o m t h e surface
o f crista t o t h e c e i l i n g o f the a m p u l l a a n d f o r m s a w a t e r
T h e fibres o f vestibular nerve e n d i n vestibular n u c l e i and
t i g h t p a r t i t i o n , o n l y t o be d i s p l a c e d t o o n e o r t h e o t h e r side
some go to the cerebellum directly.
like a swing door, w i t h movements of endolymph. The
Vestibular n u c l e i are four in number, the superior,
g e l a t i n o u s mass o f c u p u l a consists o f p o l y s a c c h a r i d e and
m e d i a l , lateral and descending. Afferents t o these n u c l e i
c o n t a i n s canals i n t o w h i c h p r o j e c t t h e c i l i a o f sensory cells.
come from:
H a i r cells are o f t w o t y p e s { F i g . 2 . 7 ) . Type I cells are
flask-shaped w i t h a single large c u p - l i k e nerve t e r m i n a l (i) Peripheral vestibular receptors (semicircular canals,
s u r r o u n d i n g t h e base. Type II cells are c y l i n d r i c a l w i t h u t r i c l e a n d saccule)
m u l t i p l e n e r v e t e r m i n a l s at t h e base. F r o m t h e u p p e r s u r - (ii) Cerebellum
face o f e a c h c e l l , p r o j e c t a s i n g l e h a i r , t h e k i n o c i l i u m a n d (iii) Reticular formation
a n u m b e r o f o t h e r c i l i a , t h e s t e r e o c i l i a . T h e k i n o c i l i u m is (iv) Spinal cord
t h i c k e r a n d is l o c a t e d o n t h e e d g e o f t h e c e l l . S e n s o r y cells (v) Contralateral vestibular nuclei.
are s u r r o u n d e d b y s u p p o r t i n g cells w h i c h s h o w m i c r o v i l l i
o n t h e i r u p p e r ends. T h u s , i n f o r m a t i o n received f r o m the labyrinthine recep-
t o r s is i n t e g r a t e d w i t h i n f o r m a t i o n f r o m o t h e r somatosen-
Structure of macula A m a c u l a consists m a i n l y o f t w o
sory systems.
p a r t s : (a) a s e n s o r y n e u r o e p i t h e i i u m , m a d e u p o f t y p e I a n d
Efferents f r o m vestibular nuclei go t o :
t y p e I I cells, s i m i l a r t o t h o s e i n t h e crista; (b) a n o t o l i t h i c
m e m b r a n e , w h i c h is m a d e u p o f a g e l a t i n o u s mass a n d o n (i) Nuclei of C N I I I , I V , V I via m e d i a l l o n g i t u d i n a l
t h e t o p , t h e crystals o f c a l c i u m c a r b o n a t e c a l l e d otoliths or b u n d l e . I t is t h e p a t h w a y f o r v e s t i b u l o - o c u l a r r e f l e x e s
otoconia ( F i g . 2 . 8 ) . T h e c i l i a o f h a i r cells p r o j e c t i n t o t h e a n d t h i s e x p l a i n s t h e genesis o f n y s t a g m u s .
gelatinous layer. T h e linear, gravitational a n d head tilt m o v e - (ii) M o t o r part o f spinal c o r d (vestibulospinal fibres). T h i s
m e n t s cause d i s p l a c e m e n t o f o t o l i t h i c m e m b r a n e a n d t h u s coordinates the m o v e m e n t s o f head, neck and b o d y
s t i m u l a t e t h e h a i r cells w h i c h l i e i n d i f f e r e n t planes. i n the maintenance o f balance.
 Peripheral Receptors

Otoliths

Gelatinous
substance
Subcupular
mesh work

Figure 2.8

S t r u c t u r e o f m a c u l a , t h e sensory e n d o r g a n o f t h e u t r i c l e a n d t h e saccule.

(iii) C e r e b e l l u m (vestibulocerebellar fibres). I t helps to

coordinate input information to maintain the b o d y
balance.
(iv) A u t o n o m i c nervous system. This explains nausea, Right SCC Left SCC
vomiting, p a l p i t a t i o n , s w e a t i n g a n d p a l l o r seen i n
v e s t i b u l a r d i s o r d e r s ( e . g . M e n i e r e ' s disease).
(v) V e s t i b u l a r n u c l e i o f t h e o p p o s i t e side.
(vi) C e r e b r a l c o r t e x ( t e m p o r a l l o b e ) . T h i s is r e s p o n s i b l e
Figure 2.9
f o r s u b j e c t i v e awareness o f m o t i o n .
R o t a t i o n test. A t the e n d o f r o t a t i o n t o the r i g h t , s e m i c i r c u l a r
canals s t o p b u t e n d o l y m p h c o n t i n u e s t o m o v e t o the r i g h t ,

PHYSIOLOGY OF VESTIBULAR SYSTEM i.e. t o w a r d s t h e left a m p u l l a b u t a w a y f r o m the r i g h t , c a u s i n g

n y s t a g m u s t o the left.

V e s t i b u l a r s y s t e m is c o n v e n i e n t l y d i v i d e d i n t o :

(a) Peripheral, w h i c h is m a d e u p o f m e m b r a n o u s l a b y r i n t h f r o m h o r i z o n t a l canal, r o t a t o r y f r o m the s u p e r i o r canal,

( s e m i c i r c u l a r d u c t s , u t r i c l e a n d saccule) a n d v e s t i b u l a r and v e r t i c a l f r o m t h e p o s t e r i o r canal.

nerve. T h e s t i m u l u s t o s e m i c i r c u l a r canal is f l o w o f e n d o l y m p h

(b) Central, w h i c h is m a d e u p o f n u c l e i a n d f i b r e tracts w h i c h displaces t h e c u p u l a . T h e flow m a y be towards the

i n the central nervous system t o integrate vestibular cupula (ampullopetal) o r away f r o m it (ampuHofugal), better

i m p u l s e s w i t h o t h e r systems t o m a i n t a i n b o d y balance. called u t r i c u l o p e t a l and utriculofugal. A m p u l l o p e t a l flow

Semicircular Canals
They r e s p o n d to angular acceleration and deceleration.
T h e t h r e e canals l i e at r i g h t angles t o e a c h o t h e r b u t t h e
o n e w h i c h lies at r i g h t angles t o t h e axis o f r o t a t i o n is
s t i m u l a t e d t h e most. T h u s h o r i z o n t a l canal w i l l respond
m a x i m u m t o r o t a t i o n o n t h e v e r t i c a l axis a n d so o n . D u e
t o t h i s a r r a n g e m e n t o f t h e t h r e e canals i n t h r e e d i f f e r e n t
planes, any c h a n g e i n p o s i t i o n o f head can be detected.
S t i m u l a t i o n o f s e m i c i r c u l a r canals p r o d u c e s n y s t a g m u s a n d
t h e d i r e c t i o n o f n y s t a g m u s is d e t e r m i n e d b y t h e p l a n e o f
t h e c a n a l b e i n g s t i m u l a t e d . T h u s , n y s t a g m u s is h o r i z o n t a l
is m o r e e f f e c t i v e t h a n a m p u l l o f u g a l f o r t h e h o r i z o n t a l c a n a l .
The q u i c k c o m p o n e n t o f n y s t a g m u s is a l w a y s o p p o s i t e
J t o t h e d i r e c t i o n o f flow o f e n d o l y m p h . T h u s , i f a p e r s o n is
rotated to the right f o r s o m e t i m e and t h e n abruptly stopped,
t h e e n d o l y m p h c o n t i n u e s t o m o v e t o t h e right d u e t o i n e r -
tia ( i . e . a m p u l l o p e t a l f o r l e f t c a n a l ) , t h e n y s t a g m u s w i l l b e
h o r i z o n t a l and d i r e c t e d to the left (Fig. 2.9).
Utricle a n d Saccule
U t r i c l e is s t i m u l a t e d b y l i n e a r a c c e l e r a t i o n a n d d e c e l e r a t i o n
or g r a v i t a t i o n a l p u l l d u r i n g the head tilts. T h e sensory hair
cells o f t h e m a c u l a l i e i n d i f f e r e n t planes a n d are s t i m u l a t e d
by displacement o f otolithic membrane d u r i n g the head and l i m b s (vestibulospinal reflex) to m a i n t a i n n e w p o s i t i o n
tilts. o f head a n d b o d y , b u t i f any c o m p o n e n t o f push a n d p u l l
T h e f u n c t i o n o f saccule is s i m i l a r t o t h a t o f u t r i c l e as s y s t e m o f o n e side is d i s t u r b e d f o r a l o n g e r t i m e d u e t o
t h e s t r u c t u r e o f m a c u l a e i n t h e t w o o r g a n s is s i m i l a r b u t disease, v e r t i g o a n d ataxia w i l l d e v e l o p .
e x p e r i m e n t a l l y , t h e s a c c u l e is also seen t o r e s p o n d t o s o u n d
vibrations.
T h e v e s t i b u l a r s y s t e m t h u s registers c h a n g e s i n t h e h e a d
| Vertigo and Dizziness J
position, linear or angular acceleration and deceleration
a n d g r a v i t a t i o n a l effects. T h i s i n f o r m a t i o n is sent t o the D i s o r i e n t a t i o n i n space causes v e r t i g o o r dizziness a n d can

central nervous system where information from other arise f r o m d i s o r d e r s o f a n y o f t h e t h r e e systems, v e s t i b u l a r ,

systems—visual, a u d i t o r y , somatosensory (muscles, j o i n t s , visual o r somatosensory. N o r m a l l y , the impulses reaching

tendons, s k i n ) — i s also r e c e i v e d . A l l t h i s i n f o m i a t i o n is t h e b r a i n f r o m t h e t h r e e systems are e q u a l a n d o p p o s i t e . I f

i n t e g r a t e d a n d used i n t h e r e g u l a t i o n o f e q u i l i b r i u m a n d a n y c o m p o n e n t o n o n e side is i n h i b i t e d o r s t i m u l a t e d , t h e

b o d y posture. i n f o r m a t i o n r e a c h i n g t h e c o r t e x is m i s m a t c h e d , r e s u l t i n g

C e r e b e l l u m , w h i c h is also c o n n e c t e d t o v e s t i b u l a r e n d in disorientation and vertigo. T h e vestibular inhibition

organs f u r t h e r coordinates m u s c l e m o v e m e n t s i n t h e i r rate, o n o n e side ( e . g . a c u t e v e s t i b u l a r f a i l u r e , l a b y r i n t h e c t o m y ,

r a n g e , f o r c e a n d d u r a t i o n a n d t h u s helps i n t h e maintenance Meniere's disease, V l l l t h nerve s e c t i o n ) causes v e r t i g o .

o f balance. Similarly, stimulation o f labyrinth by thermal or rotational

s t i m u l u s causes v e r t i g o . D i z z i n e s s can s i m i l a r l y r e s u l t f r o m
t h e o c u l a r causes, e.g. h i g h e r r o r s o f r e f r a c t i o n o r a c u t e
^ Maintenance of Body Equilibrium J e x t r a o c u l a r m u s c l e paralysis w i t h d i p l o p i a .

V e r t i g o a n d its causes are discussed i n d e t a i l i n C h a p t e r 7.

A useful clinical approach to understand the p h y s i o l o g y o f
e q u i l i b r i u m is t o i m a g i n e t h a t t h e b a l a n c e s y s t e m ( v e s t i b u -
lar, v i s u a l a n d s o m a t o s e n s o r y ) is a t w o - s i d e d p u s h a n d p u l l
system. I n static n e u t r a l p o s i t i o n , each side contributes
equal sensory i n f o r m a t i o n , i.e. p u s h and p u l l system o f o n e
side is e q u a l t o t h a t o f t h e o t h e r s i d e . I f o n e side p u l l s m o r e
t h a n t h e o t h e r , b a l a n c e o f t h e b o d y is d i s t u r b e d . D u r i n g
m o v e m e n t , i . e . t u r n i n g o r t i l t , t h e r e is a t e m p o r a r y c h a n g e
i n t h e p u s h a n d p u l l s y s t e m w h i c h is c o r r e c t e d b y a p p r o -
p r i a t e r e f l e x e s a n d m o t o r o u t p u t s t o t h e eyes ( v e s t i b u l o -
ocular reflex), neck (vestibulocervical reflex), and trunk
M o t i o n Sickness _ _ B
I t is c h a r a c t e r i s e d b y nausea, v o m i t i n g , p a l l o r a n d s w e a t i n g
d u r i n g sea, a i r , b u s o r car t r a v e l i n c e r t a i n s u s c e p t i b l e i n d i -
v i d u a l s . I t can b e i n d u c e d b y b o t h real a n d a p p a r e n t m o t i o n
a n d is t h o u g h t t o arise f r o m t h e m i s m a t c h o f i n f o m i a t i o n
reaching the vestibular nuclei and cerebellum from the
v i s u a l , l a b y r i n t h i n e a n d s o m a t o s e n s o r y systems. I t c a n be
c o n t r o l l e d b y t h e usual l a b y r i n t h i n e sedatives.
T h i s section aims t o i n t r o d u c e certain terms w h i c h
f r e q u e n d y used i n a u d i o l o g y a n d acoustics.
Sound I t is a f o r m o f e n e r g y p r o d u c e d b y a v i b r a t i n g
o b j e c t . A s o u n d w a v e consists o f c o m p r e s s i o n a n d r a r e f a c -
t i o n o f m o l e c u l e s o f t h e m e d i u m (air, l i q u i d o r s o l i d ) i n
are Decibel (dB) I t is 1 / 1 0 t h o f a b e l a n d is n a m e d a f t e r
A l e x a n d e r G r a h a m B e l l , t h e i n v e n t o r o f t e l e p h o n e . I t is n o t
an a b s o l u t e f i g u r e b u t represents a l o g a r i t h m i c r a t i o b e t w e e n
t w o sounds, n a m e l y the s o u n d b e i n g described and the
reference s o u n d , S o u n d c a n b e m e a s u r e d as p o w e r , i . e .
w a t t s / c m o r as pressure, i.e. d y n e s / c m . I n a u d i o l o g y , s o u n d is
2 2

w h i c h i t t r a v e l s . V e l o c i t y o f s o u n d is d i f f e r e n t i n d i f f e r e n t
m e a s u r e d as s o u n d pressure l e v e l ( S P L ) . I t is c o m p a r e d w i t h
m e d i a . I n t h e a i r , at 2 0 ° C , at sea l e v e l , s o u n d t r a v e l s 3 4 4
t h e r e f e r e n c e s o u n d w h i c h has a n S P L o f 0 . 0 0 0 2 d y n e s / c m 2

metres (1120 f e e t ) p e r s e c o n d , a n d is faster i n l i q u i d a n d

o r 2 0 p.Pa ( m i c r o p a s c a l s ) w h i c h r o u g h l y c o r r e s p o n d s t o t h e
s t i l l m o r e fast i n a s o l i d m e d i u m .
t h r e s h o l d o f h e a r i n g i n n o r m a l s u b j e c t s at 1 0 0 0 H z . D e c i b e l
Frequency I t is t h e n u m b e r o f c y c l e s p e r s e c o n d . The n o t a t i o n was i n t r o d u c e d i n a u d i o l o g y t o a v o i d dealing w i t h
u n i t o f f r e q u e n c y is H e r t z ( H z ) n a m e d a f t e r t h e G e r m a n large f i g u r e s o f s o u n d p r e s s u r e l e v e l ( 0 . 0 0 0 2 d y n e s / c m 2
at
scientist H e i n r i c h R u d o l f H e r t z . A s o u n d o f 1000 H z m e a n s normal threshold o f hearing to 200dynes/cm 2
w h i c h causes
1000 cycles p e r second. p a i n i n t h e ear. T h e l a t t e r is 1 , 0 0 0 , 0 0 0 t i m e s t h e f o r m e r ) .
F o r m u l a f o r d e c i b e l is:
P u r e t o n e A s i n g l e f r e q u e n c y s o u n d is c a l l e d a p u r e t o n e ,
e.g. a s o u n d o f 250, 500 o r 1000 H z . I n p u r e - t o n e a u d i - P o w e r o f S,
o m e t r y , w e measure the t h r e s h o l d o f h e a r i n g i n decibels Sound in dB = lOlog
P o w e r o f S,
f o r v a r i o u s p u r e t o n e s f r o m 125 t o 8 0 0 0 H z .

S = sound b e i n g described
(

Complex sound S o u n d w i t h m o r e t h a n o n e f r e q u e n c y is
S D— r e f e r e n c e s o u n d
c a l l e d a c o m p l e x s o u n d . H u m a n v o i c e is a c o m p l e x s o u n d . Q

Pitch I t is a s u b j e c t i v e s e n s a t i o n p r o d u c e d b y f r e q u e n c y (SPL o f S,) 2

o r 10 l o g
o f s o u n d . H i g h e r t h e f r e q u e n c y , g r e a t e r is t h e p i t c h . (SPL ofSJ 2

Overtones A c o m p l e x s o u n d has a f u n d a m e n t a l f r e q u e n c y , (because p o w e r o f s o u n d is p r o p o r t i o n a l t o square o f S P L )

i . e . t h e l o w e s t f r e q u e n c y at w h i c h a s o u r c e v i b r a t e s . A l l
S P L o f S.
f r e q u e n c i e s a b o v e t h a t t o n e are c a l l e d t h e o v e r t o n e s . The or 201o£ —
latter d e t e r m i n e the quality o r the t i m b r e o f sound.
5
S P L o f S„

Intensity I t is t h e s t r e n g t h o f s o u n d w h i c h d e t e m i i n e s its I f a s o u n d has an S P L o f 1 0 0 0 , i . e . (10*) t i m e s t h e r e f e r -

l o u d n e s s . I t is u s u a l l y m e a s u r e d i n d e c i b e l s . A t a d i s t a n c e e n c e s o u n d , i t is e x p r e s s e d as 2 0 X 3 = 6 0 d B . S i m i l a r l y ,

o f one metre, intensity o f a s o u n d o f 1 , 0 0 0 , 0 0 0 , i . e . {10'') t i m e s t h e r e f e r e n c e s o u n d

S P L is e x p r e s s e d s i m p l y as 1 2 0 d B a n d so o n .
Whisper = 30 d B
N o r m a l conversation — 60 d B Noise I t is d e f i n e d as a n a p e r i o d i c c o m p l e x s o u n d . T h e r e

Shout = 90dB are t h r e e t y p e s o f n o i s e :

D i s c o m f o r t o f t h e ear = 120dB
(a) White noise. I t c o n t a i n s all f r e q u e n c i e s i n a u d i b l e s p e c -
P a i n i n t h e ear = 130dB
t r u m a n d is c o m p a r a b l e t o t h e w h i t e l i g h t w h i c h c o n -
Loudness I t is t h e s u b j e c t i v e sensation p r o d u c e d b y i n t e n - tains a l l t h e c o l o u r s o f t h e v i s i b l e s p e c t r u m . I t is a
sity. M o r e t h e i n t e n s i t y o f s o u n d , g r e a t e r t h e l o u d n e s s . b r o a d - b a n d n o i s e a n d is u s e d f o r m a s k i n g .
(b) Narrow band noise. I t is w h i t e n o i s e w i t h c e r t a i n f r e - H e a r i n g level ( H L ) I t is t h e s o u n d pressure l e v e l p r o d u c e d
quencies, above and b e l o w the g i v e n noise, filtered b y a n a u d i o m e t e r at a s p e c i f i c f r e q u e n c y . I t is m e a s u r e d i n
out. T h u s , i t has a f r e q u e n c y r a n g e s m a l l e r t h a n t h e decibels w i t h r e f e r e n c e t o a u d i o m e t r i c z e r o . I f an a u d i o m e -
b r o a d - b a n d w h i t e n o i s e . I t is u s e d t o m a s k t h e test t e r d e l i v e r s a s o u n d at 7 0 d B , i t is r e p r e s e n t e d as 7 0 d B H L .
frequency i n pure tone audiometry.
Sensation level ( S L ) I t refers t o t h e l e v e l o f s o u n d a b o v e
(c) Speech noise. I t is a n o i s e h a v i n g f r e q u e n c i e s i n t h e
t h e t h r e s h o l d o f h e a r i n g f o r a n i n d i v i d u a l . I f s o m e o n e is
speech range (300-3000 Hz). A l l other frequencies
t e s t e d at 4 0 d B S L , i t m e a n s h e w a s t e s t e d at 4 0 d B a b o v e
are filtered out.
his t h r e s h o l d . F o r a n o r m a l p e r s o n , t h i s w o u l d b e a s o u n d
Masking I t is a p h e n o m e n o n to produce inaudibility of o f 0 + 4 0 , i . e . 4 0 d B H L , b u t f o r o n e w i t h a h e a r i n g loss
one s o u n d b y the presentation o f another. I n clinical audi- o f say 3 0 d B , i t w o u l d b e 3 0 + 4 0 , i . e . 7 0 d B H L . I n o t h e r
o m e t r y , o n e ear is k e p t b u s y b y a s o u n d w h i l e t h e other w o r d s , sensation level refers to the sound which will produce the
is b e i n g t e s t e d . M a s k i n g o f n o n - t e s t ear is essential i n a l l same sensation, as in normally hearing person. I n speech a u d i -
b o n e c o n d u c t i o n tests, b u t f o r a i r c o n d u c t i o n tests, i t is o m e t r y , d i s c r i m i n a t i o n scores are t e s t e d at 3 0 t o 4 0 d B ST.
required o n l y w h e n difference o f hearing between two S t a p e d i a l r e f l e x is e l i c i t e d w i t h a s o u n d o f 7 0 - 1 0 0 d B S L .
ears e x c e e d s 4 0 d B .
M o s t c o m f o r t a b l e level ( M C L ) I t is t h e i n t e n s i t y l e v e l
S o u n d pressure level ( S P L ) T h e SPL o f a sound i n deci- o f s o u n d t h a t is m o s t c o m f o r t a b l e f o r t h e p e r s o n .
bels is 2 0 t i m e s t h e l o g a r i t h m t o t h e base 10, o f t h e p r e s -
L o u d n e s s d i s c o m f o r t l e v e l I t is t h e l e v e l o f s o u n d w h i c h
sure o f a s o u n d t o t h e reference pressure. The reference
p r o d u c e s d i s c o m f o r t i n t h e ear. U s u a l l y , i t is 9 0 - 1 0 5 d B S L .
p r e s s u r e is t a k e n as 0 . 0 0 0 2 d y n e s / c m 2
o r 2 0 u,Pa ( m i c r o p a s -
I t is i m p o r t a n t t o find the loudness d i s c o m f o r t level o f a
cals) f o r a f r e q u e n c y o f 1 0 0 0 H z a n d r e p r e s e n t s t h e t h r e s h -
person w h e n prescribing a hearing aid.
o l d o f h e a r i n g i n n o r m a l l y h e a r i n g y o u n g adults.
Dynamic range I t is t h e d i f f e r e n c e b e t w e e n the most
Frequency range in n o r m a l hearing A n o r m a l person
c o m f o r t a b l e level a n d the loudness d i s c o m f o r t level. The
can hear frequencies o f 20 to 20,000 H z but i n routine
d y n a m i c r a n g e is r e d u c e d i n p a t i e n t s w i t h p o s i t i v e r e c r u i t -
a u d i o m e t r i c t e s t i n g o n l y 125 t o 8 0 0 0 H z are e v a l u a t e d .
m e n t p h e n o m e n o n , as is t h e case i n c o c h l e a r t y p e o f h e a r -
Speech frequencies Frequencies of 500, 1000 and i n g loss.
2 0 0 0 H z are c a l l e d speech frequencies as m o s t o f h u m a n v o i c e
S o u n d level m e t e r I t is an i n s t r u m e n t t o m e a s u r e l e v e l
falls w i t h i n this range. PTA {pure tone average) is the
o f noise a n d other sounds. S o u n d level meters have differ-
a v e r a g e t h r e s h o l d o f h e a r i n g i n these t h r e e speech f r e -
e n t w e i g h t i n g n e t w o r k s (e.g. A , B o r C ) f o r d i f f e r e n t s e n -
quencies. I t r o u g h l y corresponds t o t h e speech r e c e p t i o n
s i t i v i t i e s at d i f f e r e n t f r e q u e n c i e s . W h e n d e s c r i b i n g a s o u n d
threshold.
measured b y a s o u n d level meter, the w e i g h t i n g n e t w o r k
Audiometric zero T h r e s h o l d o f hearing, i.e. the f a i n t - must be i n d i c a t e d .
est i n t e n s i t y w h i c h a n o r m a l h e a l t h y p e r s o n c a n h e a r w i l l N o i s e levels are o f t e n e x p r e s s e d as d B ( A ) w h i c h refers
vary f r o m person to person. T h e I n t e r n a t i o n a l Standards to s o u n d pressure l e v e l m e a s u r e d w i t h " A " n e t w o r k w h e r e
Organisation (ISO) a d o p t e d a s t a n d a r d f o r t h i s , w h i c h is t h e l o w a n d e x t r e m e l y h i g h f r e q u e n c i e s are g i v e n m u c h
r e p r e s e n t e d as t h e z e r o l e v e l o n t h e a u d i o m e t e r . According less w e i g h t a g e c o m p a r e d t o those i n t h e m i d d l e r a n g e w h i c h
to ISO, audiometric zero is the mean value of minimal audible are m o r e i m p o r t a n t a n d are r e s p o n s i b l e f o r n o i s e - i n d u c e d
intensity in a group of normally hearing healthy young adults. h e a r i n g loss.
Assessment o f H e a r i n g

H e a r i n g loss c a n be o f t h r e e t y p e s :
ASSESSMENT OF HEARING
1 . C o n d u c t i v e h e a r i n g loss I t is c a u s e d b y a n y disease
process i n t e r f e r i n g w i t h t h e c o n d u c t i o n o f s o u n d f r o m t h e
e x t e r n a l ear t o t h e s t a p e d i o v e s t i b u l a r j o i n t . T h u s t h e cause H e a r i n g o f an i n d i v i d u a l c a n b e t e s t e d b y c l i n i c a l a n d a u d i -

m a y l i e i n t h e e x t e r n a l ear ( o b s t r u c t i o n s ) , t y m p a n i c m e m - o m e t r i c tests.

b r a n e ( p e r f o r a t i o n ) , m i d d l e ear ( f l u i d ) , ossicles ( f i x a t i o n o r
d i s r u p t i o n ) o r t h e eustachian t u b e ( o b s t r u c t i o n ) .
A . Clinical T e s t s o f Hearing
2 . S e n s o r i n e u r a l ( S N ) h e a r i n g l o s s I t results f r o m lesions
o f t h e c o c h l e a (sensory t y p e ) o r V H I t h n e r v e a n d its c e n - 1. F i n g e r f r i c t i o n test
t r a l c o n n e c t i o n s ( n e u r a l t y p e ) . T h e t e r m retrocochlearis used 2. W a t c h test
w h e n h e a r i n g loss is d u e t o lesions o f V H I t h n e r v e , a n d 3. S p e e c h tests
central deafness, w h e n i t is d u e t o l e s i o n s o f c e n t r a l a u d i t o r y 4. T u n i n g f o r k tests.
connections.
1. Finger Friction Test
3. M i x e d h e a r i n g loss I n this t y p e , e l e m e n t s o f b o t h c o n -
d u c t i v e a n d s e n s o r i n e u r a l deafness are p r e s e n t i n t h e same I t is a r o u g h b u t q u i c k m e t h o d o f s c r e e n i n g a n d consists o f

ear. T h e r e is a i r - b o n e gap i n d i c a t i n g c o n d u c t i v e e l e m e n t , rubbing or snapping the t h u m b a n d a f i n g e r close to

and i m p a i r m e n t o f bone c o n d u c t i o n indicating sensorineu- p a t i e n t ' s ear.

ral loss. M i x e d h e a r i n g loss is seen i n s o m e cases o f o t o s c l e -

rosis a n d c h r o n i c s u p p u r a t i v e o t i t i s m e d i a . 2. Watch Test

W h i l e assessing t h e a u d i t o r y f u n c t i o n i t is i m p o r t a n t t o A c l i c k i n g w a t c h is b r o u g h t close t o t h e ear a n d t h e d i s -

find out: t a n c e at w h i c h i t is h e a r d , is m e a s u r e d . I t h a d b e e n p o p u l a r
as a s c r e e n i n g test b e f o r e t h e a u d i o m e t r i c era b u t is p r a c t i -
(a) Type of hearing loss (conductive, sensorineural or
cally obsolete n o w .
mixed).
(b) Degree of hearing loss ( m i l d , m o d e r a t e , m o d e r a t e l y severe,
3. Speech (Voice) Tests
severe, p r o f o u n d o r total).
(c) Site of lesion. I f c o n d u c t i v e , t h e l e s i o n m a y b e at e x t e r - N o r m a l l y , a p e r s o n hears c o n v e r s a t i o n a l v o i c e at 12 m e t r e s
n a l ear, t y m p a n i c m e m b r a n e , m i d d l e ear, ossicles o r ( 4 0 feet) a n d w h i s p e r ( w i t h r e s i d u a l a i r a f t e r n o r m a l e x p i r a -
eustachian tube. Clinical examination and t y m p a - t i o n ) at 6 m e t r e s ( 2 0 feet) b u t f o r p u r p o s e s o f test, 6 m e t r e s
n o m e t r y c a n be h e l p f u l t o f i n d t h e site o f s u c h l e s i o n s . is t a k e n as n o r m a l f o r b o t h c o n v e r s a t i o n a n d w h i s p e r .
If sensorineural, find out whether the lesion is T h e test is c o n d u c t e d i n r e a s o n a b l y q u i e t s u r r o u n d i n g s .
cochlear, retrocochlear or central. Special tests of T h e p a t i e n t stands w i t h h i s test ear t o w a r d s t h e e x a m i n e r
h e a r i n g w i l l be r e q u i r e d t o d i f f e r e n t i a t e these t y p e s . at a d i s t a n c e o f 6 m e t r e s . H i s eyes are s h i e l d e d t o p r e v e n t
(d) Cause of hearing loss. T h e cause m a y b e congenital, h p r e a d i n g a n d t h e n o n - t e s t ear is b l o c k e d b y i n t e r m i t t e n t
traumatic, i n f e c t i v e , neoplastic, degenerative, meta- pressure o n t h e t r a g u s b y a n assistant. T h e e x a m i n e r uses
bolic, ototoxic, vascular or autoimmune process. spondee w o r d s (e.g. b l a c k - n i g h t , f o o t b a l l , daydream) o r
Detailed history and laboratory investigations are numbers w i t h letters ( X 3 B , 2 A Z , M 6 D ) and gradually
required. walks towards the patient.
 T h e distance at w h i c h c o n v e r s a t i o n a l v o i c e a n d t h e w h i s -
p e r e d v o i c e are h e a r d is m e a s u r e d . T h e disadvantage o f speech
tests is l a c k o f standardisation i n i n t e n s i t y a n d p i t c h o f v o i c e
used f o r t e s t i n g a n d t h e a m b i e n t noise o f t h e t e s t i n g place.
4. Tuning Fork Tests
T h e s e tests are p e r f o r m e d w i t h t u n i n g f o r k s o f d i f f e r e n t
f r e q u e n c i e s s u c h as 1 2 8 , 2 5 6 , 5 1 2 , 1 0 2 4 , 2 0 4 8 a n d 4 0 9 6 H z ,
b u t f o r r o u t i n e c l i n i c a l p r a c t i c e , t u n i n g f o r k o f 5 1 2 H z is
ideal. Forks o f l o w e r frequencies p r o d u c e sense o f b o n e
v i b r a t i o n w h i l e those o f h i g h e r f r e q u e n c y have a shorter
d e c a y t i m e a n d are t h u s n o t r o u t i n e l y p r e f e r r e d .
A t u n i n g f o r k is a c t i v a t e d b y s t r i k i n g i t g e n t l y against
the examiner's e l b o w , heel o f h a n d o r the r u b b e r heel of
the shoe.
To test air conduction (AC) ( F i g . 4.1), a v i b r a t i n g f o r k is
p l a c e d v e r t i c a l l y , a b o u t 2 c m a w a y from t h e o p e n i n g o f e x t e r -
nal a u d i t o r y m e a t u s . T h e s o u n d w a v e s are t r a n s m i t t e d t h r o u g h
t h e t y m p a n i c m e m b r a n e , m i d d l e ear a n d ossicles t o the
i n n e r ear. T h u s , b y t h e air c o n d u c t i o n test, t h e f u n c t i o n o f
b o t h t h e c o n d u c t i n g m e c h a n i s m a n d t h e c o c h l e a are tested.
N o r m a l l y , h e a r i n g t h r o u g h air c o n d u c t i o n is l o u d e r a n d
h e a r d t w i c e as l o n g as t h r o u g h t h e b o n e c o n d u c t i o n r o u t e .
To test bone conduction (BC), the footplate o f vibrating t u n -
i n g f o r k is p l a c e d f i r m l y o n the m a s t o i d b o n e . C o c h l e a is
stimulated d i r e c d y b y vibrations c o n d u c t e d t h r o u g h the skull
b o n e s . T h u s , B C is a measure o f t h e c o c h l e a r f u n c t i o n o n l y .
T h e c l i n i c a l l y u s e f u l t u n i n g f o r k tests i n c l u d e :
(a) R i n n e test I n t h i s test air c o n d u c t i o n o f t h e ear is
c o m p a r e d w i t h its b o n e c o n d u c t i o n . A v i b r a t i n g tuning
f o r k is p l a c e d o n t h e p a t i e n t ' s m a s t o i d a n d w h e n h e stops
F i g u r e 4.1
T u n i n g f o r k tests. ( A ) T e s t i n g f o r air c o n d u c t i o n . ( B ) T e s t i n g
f o r b o n e c o n d u c t i o n . ( C ) W e b e r test.
h e a r i n g , i t is b r o u g h t b e s i d e t h e m e a t u s . I f h e s t i l l hears,
A C is m o r e t h a n B C . A l t e r n a t i v e l y , t h e p a t i e n t is asked t o
c o m p a r e the loudness o f s o u n d h e a r d t h r o u g h air a n d b o n e
c o n d u c t i o n . R i n n e test is c a l l e d p o s i t i v e w h e n A C is l o n -
ger o r l o u d e r t h a n B C . I t is seen i n n o r m a l p e r s o n s or
those h a v i n g sensorineural deafness. A negative Rinne
{ B O AC) is seen i n c o n d u c t i v e deafness. A negative
R i n n e i n d i c a t e s a m i n i m u m a i r - b o n e g a p o f 15—20 d B .
A p r e d i c t i o n o f a i r - b o n e gap c a n be m a d e i f t u n i n g
f o r k s o f 2 5 6 , 5 1 2 a n d 1 0 2 4 H z are u s e d .
• A R i n n e test e q u a l o r n e g a t i v e f o r 2 5 6 H z b u t p o s i t i v e
f o r 5 1 2 H z i n d i c a t e s a i r - b o n e g a p o f 20—30 d B .
• A R i n n e test n e g a t i v e f o r 256 a n d 5 1 2 H z b u t p o s i t i v e
f o r 1024 H z indicates a i r - b o n e gap o f 3 0 - 4 5 d B .
e
A R i n n e negative f o r all t h e three t u n i n g forks o f 256,
5 1 2 a n d 1 0 2 4 H z , i n d i c a t e s a i r - b o n e gap o f 4 5 - 6 0 d B .
Remember that a negative Rinne for 256, 512 and
1 0 2 4 H z i n d i c a t e s a m i n i m u m A B gap o f 15, 3 0 , 4 5 d B
respectively.
False negative Rinne. I t is seen i n severe u n i l a t e r a l s e n -
s o r i n e u r a l h e a r i n g loss. P a t i e n t does n o t p e r c e i v e a n y s o u n d
o f t u n i n g f o r k b y air c o n d u c t i o n b u t responds t o b o n e c o n -
d u c t i o n t e s t i n g . T h i s r e s p o n s e t o b o n e c o n d u c t i o n is, i n
r e a l i t y , f r o m t h e o p p o s i t e ear b e c a u s e o f t r a n s c r a n i a l t r a n s -
m i s s i o n o f s o u n d . I n s u c h cases, c o r r e c t diagnosis c a n b e
m a d e b y m a s k i n g t h e n o n - t e s t ear w i t h B a r a n y ' s n o i s e b o x
w h i l e r e s t i n g f o r b o n e c o n d u c t i o n . W e b e r test w i l l f u r t h e r
h e l p as i t gets l a t e r a l i s e d t o t h e b e t t e r ear.
(b) W e b e r test I n t h i s test, a v i b r a t i n g t u n i n g f o r k is
placed i n the m i d d l e o f the forehead or the vertex and the
p a t i e n t is asked i n w h i c h ear t h e s o u n d is h e a r d . N o r m a l l y ,
i t is h e a r d e q u a l l y i n b o t h ears. I t is l a t e r a l i s e d t o t h e w o r s e
ear i n c o n d u c t i v e deafness a n d t o t h e b e t t e r ear i n s e n -
s o r i n e u r a l deafness. I n w e b e r test, s o u n d travels d i r e c t l y t o
t h e c o c h l e a v i a b o n e . L a t e r a l i s a t i o n o f s o u n d i n w e b e r test
w i t h a t u n i n g f o r k o f 5 1 2 H z i m p l i e s a c o n d u c t i v e loss o f
15—25 d B i n i p s i l a t e r a l ear o r a s e n s o r i n e u r a l loss i n t h e
c o n t r a l a t e r a l ear.
(c) A b s o l u t e b o n e c o n d u c t i o n ( A B C ) test B o n e c o n -
d u c t i o n is a m e a s u r e o f c o c h l e a r f u n c t i o n . I n A B C test,
p a t i e n t ' s b o n e c o n d u c t i o n is c o m p a r e d w i t h t h a t o f t h e
e x a m i n e r ( p r e s u m i n g t h a t t h e e x a m i n e r has n o r m a l h e a r -
ing). External a u d i t o r y meatus o f b o t h the patient a n d
e x a m i n e r s h o u l d b e occluded ( b y p r e s s i n g t h e tragus i n w a r d s ) ,
to p r e v e n t a m b i e n t noise e n t e r i n g t h r o u g h A C r o u t e . I n
c o n d u c t i v e deafness, t h e p a t i e n t a n d t h e e x a m i n e r h e a r t h e
f o r k f o r t h e s a m e d u r a t i o n o f time. I n s e n s o r i n e u r a l d e a f -
ness, t h e p a t i e n t hears t h e f o r k f o r a s h o r t e r d u r a t i o n .
(d) S c h w a b a c h ' s t e s t H e r e again B C o f p a t i e n t is c o m p a r e d
w i t h that o f the n o r m a l hearing person (examiner) b u t meatus
is not occluded. I t has t h e s a m e s i g n i f i c a n c e as a b s o l u t e b o n e
 Assessment o f Hearing

Table 4.1 T u n i n g f o r k tests a n d t h e i r i n t e r p r e t a t i o n

Test Normal Conductive deafness S N deafness

Rinne A O B C (Rinne positive) B O A C ( R i n n e negative) A O B C

Weber N o t lateralised Lateralised t o p o o r e r ear Lateralised t o b e t t e r ear

ABC Same as examiner's Same as examiner's Reduced

Schwabach Equal Lengthened Shortened

—

c o n d u c t i o n test. S c h w a b a c h is r e d u c e d i n sensorineural
deafness a n d l e n g t h e n e d i n c o n d u c t i v e deafness.
T a b l e 4.1 summarises the interpretation o f t u n i n g f o r k
tests.

(e) B i n g t e s t I t is a test o f b o n e c o n d u c t i o n a n d exam-

i n e s t h e e f f e c t o f occlusion of ear c a n a l o n t h e h e a r i n g . A
v i b r a t i n g t u n i n g f o r k is p l a c e d o n t h e m a s t o i d w h i l e t h e
examiner alternately closes a n d o p e n s t h e ear canal by
p r e s s i n g o n t h e tragus i n w a r d s . A n o r m a l p e r s o n o r one
w i t h s e n s o r i n e u r a l h e a r i n g loss hears l o u d e r w h e n ear c a n a l
is o c c l u d e d a n d s o f t e r w h e n t h e c a n a l is o p e n ( B i n g p o s i -
t i v e ) . A p a t i e n t w i t h c o n d u c t i v e h e a r i n g loss w i l l a p p r e c i -
ate n o c h a n g e ( B i n g n e g a t i v e ) .

(f) G e l l e ' s t e s t I t is also a test o f b o n e c o n d u c t i o n a n d

Figure 4.2
e x a m i n e s t h e e f f e c t o f increased air pressure i n ear c a n a l on
t h e h e a r i n g . N o r m a l l y , w h e n a i r pressure is i n c r e a s e d i n T w o - r o o m a u d i o m e t r y setup. A u d i o m e t r i c i a n w a t c h e s responses
t h e ear c a n a l b y Siegle's s p e c u l u m , i t pushes t h e t y m p a n i c o f t h e p a t i e n t s i t t i n g across a glass p a r t i t i o n .

m e m b r a n e a n d ossicles i n w a r d s , raises t h e i n t r a l a b y r i n t h i n e
pressure a n d causes i m m o b i l i t y o f basilar m e m b r a n e and
d e c r e a s e d h e a r i n g , b u t n o c h a n g e i n h e a r i n g is observed audiogram. T h e t h r e s h o l d o f b o n e c o n d u c t i o n is a m e a s u r e
w h e n o s s i c u l a r c h a i n is f i x e d o r d i s c o n n e c t e d . G e l l e ' s test o f cochlear f u n c t i o n . T h e difference i n the thresholds o f air
is p e r f o r m e d b y p l a c i n g a v i b r a t i n g f o r k o n t h e mastoid a n d b o n e c o n d u c t i o n ( A - B gap) is a m e a s u r e o f t h e d e g r e e
w h i l e c h a n g e s i n air p r e s s u r e i n t h e ear c a n a l are b r o u g h t o f c o n d u c t i v e deafness. I t m a y b e n o t e d t h a t a u d i o m e t e r is
a b o u t b y S i e g l e ' s s p e c u l u m . G e l l e ' s test is p o s i t i v e i n n o r - so c a l i b r a t e d t h a t t h e h e a r i n g o f a n o r m a l p e r s o n , b o t h f o r
m a l p e r s o n s a n d i n t h o s e w i t h s e n s o r i n e u r a l h e a r i n g loss. I t a i r a n d b o n e c o n d u c t i o n , is at z e r o d B a n d t h e r e is n o A - B
is n e g a t i v e w h e n o s s i c u l a r c h a i n is f i x e d o r disconnected. g a p , w h i l e t u r n i n g f o r k tests n o r m a l l y s h o w A O B C .
I t w a s a p o p u l a r test t o f i n d o u t stapes f i x a t i o n i n o t o s c l e -
W h e n d i f f e r e n c e b e t w e e n t h e t w o ears is 4 0 d B o r a b o v e
rosis b u t has n o w b e e n s u p e r c e d e d b y t y m p a n o m e t r y .
i n a i r c o n d u c t i o n t h r e s h o l d s , t h e b e t t e r ear is m a s k e d to
a v o i d g e t t i n g a s h a d o w c u r v e from t h e n o n - t e s t b e t t e r ear.
S i m i l a r l y , m a s k i n g is essential i n a l l b o n e c o n d u c t i o n s t u d -
B. Audiometric Tests
ies. M a s k i n g is d o n e b y e m p l o y i n g n a r r o w - b a n d n o i s e t o
the non-test ear.
1. Pure Tone Audiometry
Uses of pure tone audiogram
An audiometer is a n e l e c t r o n i c device which produces
p u r e tones, the i n t e n s i t y o f w h i c h can be increased or (i) I t is a m e a s u r e o f t h r e s h o l d o f h e a r i n g b y a i r a n d
d e c r e a s e d i n 5 d B steps ( F i g . 4 . 2 ) . U s u a l l y a i r c o n d u c t i o n b o n e c o n d u c t i o n and thus the degree a n d type of
t h r e s h o l d s are m e a s u r e d f o r t o n e s o f 1 2 5 , 2 5 0 , 5 0 0 , 1000, h e a r i n g loss.
2000 and 4000 and 8000 H z and bone conduction thresh- (ii) A r e c o r d can be k e p t f o r f u t u r e reference.
olds f o r 2 5 0 , 500, 1000 and 2000 and 4000Hz. The ( i i i ) A u d i o g r a m is essential f o r p r e s c r i p t i o n o f h e a r i n g a i d .
a m o u n t o f i n t e n s i t y t h a t has t o b e r a i s e d a b o v e t h e n o r m a l (iv) Helps to f i n d degree o f handicap for medicolegal
l e v e l is a m e a s u r e o f t h e d e g r e e o f h e a r i n g i m p a i r m e n t at purposes.
t h a t f r e q u e n c y . I t is c h a r t e d i n t h e f o r m o f a g r a p h c a l l e d (v) H e l p s to predict speech r e c e p t i o n threshold.
Diseases o f Ear

2. Speech Audiometry
100 -
I n t h i s test, t h e p a t i e n t ' s a b i l i t y to hear a n d understand
80 - A j B j i
s p e e c h is m e a s u r e d . T w o p a r a m e t e r s are s t u d i e d : (i) s p e e c h
r e c e p t i o n t h r e s h o l d a n d (ii) d i s c r i m i n a t i o n score. £ 60 -
P Normal / Conduclive loss
Speech reception threshold (SRT) I t is t h e m i n i m u m
£40
i n t e n s i t y at w h i c h 5 0 % o f t h e w o r d s are r e p e a t e d correctly
o
u
b y t h e p a t i e n t . A set o f s p o n d e e w o r d s ( t w o s y l l a b l e w o r d s 0 0
20
w i t h e q u a l stress o n e a c h s y l l a b l e , e.g. b a s e b a l l , s u n l i g h t ,
/ 1 1 Y I I I
d a y d r e a m , etc.) is d e l i v e r e d t o e a c h ear t h r o u g h t h e h e a d -
10 20 30 40 50 60 70 80 90 100
p h o n e o f an a u d i o m e t e r . T h e w o r d lists are d e l i v e r e d i n Amplification in dB
t h e f o r m o f r e c o r d e d tapes o r m o n i t o r e d v o i c e a n d t h e i r
i n t e n s i t y v a r i e d i n 5 d B steps t i l l h a l f o f t h e m are c o r r e c t l y 100

heard. N o r m a l l y , S R T is w i t h i n l O d B o f t h e a v e r a g e o f
80 -
p u r e t o n e t h r e s h o l d o f three speech frequencies (500, 1000 Sensorineura loss
and 2000 H z ) . A n S R T better t h a n p u r e t o n e average b y 60 -- c S — ° —
" °
m o r e t h a n l O d B suggests a f u n c t i o n a l h e a r i n g loss.
Z 40 —
Speech discrimination score A l s o c a l l e d speech recogni- o QJD
u
tion o r word recognition score. I t is a m e a s u r e o f p a t i e n t ' s a b i l - " 20
ity to understand speech. Here, a list o f phonetically 1 1 1 l / 1 1 1 1
balanced (PB) w o r d s (single syllable w o r d s , e.g. p i n , sin, 10 20 30 40 50 60 70 80 90 100

d a y , b u s , e t c . ) is d e l i v e r e d t o t h e p a t i e n t ' s e a c h ear s e p a - Amplification in dB

r a t e l y at 3 0 - 4 0 d B a b o v e his S R T and the percentage of

Figure 4.3
words correctly heard by the patient is recorded. In
n o r m a ! p e r s o n s a n d t h o s e w i t h c o n d u c t i v e h e a r i n g loss a Speech a u d i o g r a m .
h i g h score o f 9 0 - 1 0 0 % can be o b t a i n e d (Fig. 4 . 3 A , B and A—PB score in a n o r m a l p e r s o n 1 0 0 % a t 3 0 d B .
Table 4.2). B—PB score i n c o n d u c t i v e h e a r i n g loss 1 0 0 % at 70 d B . T h i s
curve r u n s p a r a l l e l t o t h a t o f a n o r m a l p e r s o n .

Performance intensity function for PB words C — C o c h l e a r S N H L . PB m a x is a t 70 d B a n d t h e n a t t a i n s a

plateau.
PB max. Instead o f u s i n g a single s u p r a t h r e s h o l d i n t e n s i t y D — R o l l over c u r v e : PB m a x at 8 0 d B . PB scores decline as
o f 3 0 - 4 0 d B above S R T as d e s c r i b e d a b o v e , i t is b e t t e r t o i n t e n s i t y increases f u r t h e r .
chart P B scores against s e v e r a l levels o f s p e e c h i n t e n s i t y
a n d f i n d the m a x i m u m score (PB m a x ) a p e r s o n can attain.
Also note the i n t e n s i t y o f s o u n d at w h i c h P B max is Table 4.2 A b i l i t y t o u n d e r s t a n d speech a n d its r e l a t i o n
a t t a i n e d . I t is a u s e f u l test c l i n i c a l l y t o set t h e v o l u m e of t o speech d i s c r i m i n a t i o n ( S D ) score

hearing aid (Fig. 4 . 3 C ) . M a x i m u m v o l u m e o f hearing aid

A list o f 5 0 PB w o r d s is presented a n d t h e n u m b e r c o r r e c t l y
s h o u l d n o t b e set a b o v e P B max.
heard is m u l t i p l i e d by 2.
Roll over phenomenon. I t is seen i n r e t r o c o c h l e a r hearing
S D score Ability to u n d e r s t a n d speech
loss. W i t h increase i n speech i n t e n s i t y a b o v e a p a r t i c u l a r
l e v e l , t h e P B w o r d score falls r a t h e r t h a n m a i n t a i n a plateau 90-100% Normal
as i n c o c h l e a r t y p e o f s e n s o r i n e u r a l h e a r i n g loss ( F i g . 4 . 3 D ) . 76-88% Slight d i f f i c u l t y
T h u s s p e e c h a u d i o m e t r y is u s e f u l i n s e v e r a l w a y s :
60-74% Moderate difficulty

(i) T o f i n d speech r e c e p t i o n t h r e s h o l d w h i c h correlates 40-58% Poor

w e l l w i t h average o f three speech frequencies o f p u r e <40% Very p o o r
tone audiogram.
(ii) To differentiate organic from non-organic (func-
3. Bekesy Audiometry
t i o n a l ) h e a r i n g loss.
(iit) T o f i n d t h e i n t e n s i t y at w h i c h d i s c r i m i n a t i o n s c o r e is I t is a s e l f - r e c o r d i n g a u d i o m e t r y w h e r e v a r i o u s p u r e t o n e
best. T h i s is h e l p f u l f o r f i t t i n g a h e a r i n g a i d a n d set- frequencies a u t o m a t i c a l l y m o v e from l o w t o h i g h w h i l e t h e
t i n g its v o l u m e f o r m a x i m u m d i s c r i m i n a t i o n , patient controls the intensity t h r o u g h a b u t t o n . T w o trac-
(iv) T o differentiate a cochlear f r o m a retrocochlear sen- ings, o n e w i t h c o n t i n u o u s a n d t h e o t h e r w i t h p u l s e d t o n e
s o r i n e u r a l h e a r i n g loss. are o b t a i n e d . T h e t r a c i n g s h e l p t o d i f f e r e n t i a t e a c o c h l e a r
 Assessment of Hearing

f r o m retrocochlear and an organic f r o m a f u n c t i o n a l hearing

loss.
V a r i o u s t y p e s o f t r a c i n g s o b t a i n e d are:

Type I C o n t i n u o u s a n d p u l s e d tracings o v e r l a p . Seen i n

n o r m a l h e a r i n g o r conductive hearing loss.
Type I I C o n t i n u o u s a n d pulsed tracings overlap u p t o
1 0 0 0 H z a n d t h e n c o n t i n u o u s t r a c i n g falls. Seen
BC
in cochlear loss.
T y p e I I I C o n t i n u o u s t r a c i n g falls b e l o w p u l s e d t r a c i n g at CE
100 to 500 H z even u p t o 4 0 - 5 0 d B . Seen i n
retrocochlear /neural lesion.
Type IV C o n t i n u o u s t r a c i n g falls b e l o w p u l s e d l e s i o n at
frequencies u p t o 1000 H z b y m o r e t h a n 25 d B .
S e e n i n retrocochlear/neural lesion.
Type V C o n t i n u o u s t r a c i n g is a b o v e p u l s e d o n e . S e e n i n
Figure 4.5
non-organic hearing loss.
Principle o f i m p e d a n c e a u d i o m e t r y . ( A ) O s c i l l a t o r t o p r o d u c e
B e k e s y a u d i o m e t r y is s e l d o m p e r f o r m e d t h e s e days. a tone o f 220 H z . ( B ) A i r p u m p t o increase o r decrease air
pressure in t h e air c a n a l . ( C ) M i c r o p h o n e t o p i c k u p a n d

4. Impedance Audiometry (Fig. 4.4) measure s o u n d pressure level reflected f r o m t h e t y m p a n i c

membrane.
I t is a n o b j e c t i v e test, w i d e l y u s e d i n c l i n i c a l p r a c t i c e a n d
is p a r t i c u l a r l y u s e f u l i n c h i l d r e n . I t consists o f :

(a) Tympanometry
(b) Acoustic reflex measurements o r stiffness o f t h e t y m p a n o - o s s i c u l a r s y s t e m a n d t h u s f i n d
t h e h e a l t h y o r diseased status o f t h e m i d d l e ear.
Tympanometry I t is b a s e d o n a s i m p l e p r i n c i p l e , i . e . Essentially, t h e e q u i p m e n t consists o f a p r o b e w h i c h s n u g l y
w h e n a s o u n d strikes t y m p a n i c m e m b r a n e , some o f the f i t s i n t o t h e e x t e r n a l a u d i t o r y canal a n d has t h r e e channels; (i)
sound energy is a b s o r b e d w h i l e t h e rest is r e f l e c t e d . A t o d e l i v e r a t o n e o f 2 2 0 H z , (ii) t o p i c k u p t h e r e f l e c t e d s o u n d
stiffer t y m p a n i c m e m b r a n e w o u l d reflect m o r e o f sound t h r o u g h a m i c r o p h o n e a n d (iii) t o b r i n g a b o u t changes i n air
e n e r g y t h a n a c o m p l i a n t o n e . B y c h a n g i n g t h e pressures i n pressure i n t h e ear canal from positive to n o r m a l and then
a sealed e x t e r n a l a u d i t o r y canal a n d t h e n m e a s u r i n g the negative (Fig. 4.5). B y charting the compliance o f t y m p a n o -
r e f l e c t e d s o u n d e n e r g y , i t is p o s s i b l e t o f i n d t h e c o m p l i a n c e ossicular system against v a r i o u s pressure changes, d i f f e r e n t

c
types o f graphs called tympanograms are o b t a i n e d w h i c h are to f i n d the patency o f the g r o m m e t placed i n the t y m p a n i c
d i a g n o s t i c o f c e r t a i n m i d d l e ear p a t h o l o g i e s . m e m b r a n e i n cases o f serous o t i t i s m e d i a .
A c o u s t i c r e f l e x I t is based o n t h e fact t h a t a l o u d s o u n d ,
Types of tympanograms (Fig. 4.6)
7 0 - 1 0 0 d B above the threshold o f hearing o f a particular
Type A Normal tympanogram. ear, causes b i l a t e r a l c o n t r a c t i o n o f t h e s t a p e d i a l m u s c l e s
T y p e As C o m p l i a n c e is l o w e r at o r n e a r a m b i e n t a i r p r e s - w h i c h can be detected b y t y m p a n o m e t r y . T o n e can be
s u r e . Seen i n f i x a t i o n o f ossicles, e.g. otosclerosis d e l i v e r e d t o o n e ear a n d t h e r e f l e x p i c k e d f r o m t h e same
or malleus fixation. o r t h e c o n t r a l a t e r a l ear. T h e r e f l e x arc i n v o l v e d is:
Type A H i g h c o m p l i a n c e at o r n e a r a m b i e n t pressure.
C N V I I I —» v e n t r a l c o c h l e a r n u c l e u s —> C N
D
Ipsilateral:
S e e n i n ossicular d i s c o n t i n u i t y o r t h i n a n d l a x
V I I n u c l e u s —> i p s i l a t e r a l stapedius m u s c l e .
tympanic membrane.
Contralateral: C N V I I I —> v e n t r a l cochlear n u c l e u s —»
Type B A flat o r dome-shaped graph. N o change i n
c o n t r a l a t e r a l m e d i a l s u p e r i o r o l i v a r y n u c l e u s —> c o n t r a l a t e r a l
c o m p l i a n c e w i t h pressure c h a n g e s . Seen i n m i d -
C N V I I n u c l e u s - » c o n t r a l a t e r a l stapedius m u s c l e ( F i g . 4 . 7 ) .
d l e ear fluid o r t h i c k t y m p a n i c m e m b r a n e .
T h i s test is u s e f u l i n several w a y s :
Type C M a x i m u m compliance occurs with negative
(i) To test the hearing in infants a n d y o u n g c h i l d r e n . I t is
pressure i n excess o f 1 0 0 m m o f H , 0 . S e e n i n
an o b j e c t i v e m e t h o d .
retracted tympanic m e m b r a n e and may show
(ii) To find malingerers. A p e r s o n w h o f e i g n s t o t a l deafness
s o m e fluid i n m i d d l e ear.
a n d does n o t g i v e a n y response o n p u r e t o n e a u d i o m -
Testing junction of eustachian tube. Tympanometry has e t r y b u t s h o w s a p o s i t i v e stapedial r e f l e x is a m a l i n g e r e r .
also b e e n u s e d t o f i n d f u n c t i o n o f e u s t a c h i a n t u b e i n cases (iii) To detect cochlear pathology. Presence o f stapedial reflex
o f intact or perforated t y m p a n i c m e m b r a n e . A negative or at l o w e r i n t e n s i t i e s , e.g. 4 0 t o 6 0 d B t h a n t h e u s u a l
a p o s i t i v e pressure ( — 2 0 0 o r + 2 0 0 m m o f H , 0 ) is c r e a t e d 70 d B indicates r e c r u i t m e n t a n d thus a cochlear type
i n t h e m i d d l e ear a n d t h e p e r s o n is a s k e d t o s w a l l o w 5 o f h e a r i n g loss.
t i m e s i n 2 0 s e c o n d s . T h e a b i l i t y t o e q u i l i b r a t e t h e pressure (iv) To detect VIHth nerve lesion. I f a sustained t o n e o f 500
i n d i c a t e s n o r m a l t u b a l f u n c t i o n . T h e test can also be u s e d or 1000Hz, delivered l O d B above acoustic reflex
t h r e s h o l d , f o r a p e r i o d o f 10 s e c o n d s , b r i n g s t h e r e f l e x

1
amplitude to 50%, it shows abnormal adaptation and
is i n d i c a t i v e o f V I H t h n e r v e l e s i o n ( s t a p e d i a l r e f l e x
decay).
IAD
(v) Lesions offacial nerve. A b s e n c e o f s t a p e d i a l r e f l e x w h e n
h e a r i n g is n o r m a l i n d i c a t e s l e s i o n o f t h e f a c i a l n e r v e ,
- A
C
p r o x i m a l t o the n e r v e t o stapedius. T h e r e f l e x can
also b e u s e d t o f m d p r o g n o s i s o f f a c i a l paralysis as t h e
appearance o f reflex, after i t was absent, indicates

-AS r e t u r n o f f u n c t i o n and a favourable prognosis.

B (vi) Lesion of brainstem. I f i p s i l a t e r a l r e f l e x is p r e s e n t b u t

t h e c o n t r a l a t e r a l r e f l e x is a b s e n t , l e s i o n is i n t h e area
o f crossed p a t h w a y s i n t h e b r a i n s t e m .

-200 -100 0 +100 +200

Figure 4.6

Types o f t y m p a n o g r a m s .
A—Normal.
As—Reduced c o m p l i a n c e at a m b i e n t pressure (otosclerosis).
AD—Increased compliance at ambient pressure (ossicular
discontinuity).
B—Flat o r d o m e - s h a p e d ( f l u i d in m i d d l e ear).
C — M a x i m u m c o m p l i a n c e a t pressures m o r e t h a n —100mm
Figure 4.7
H 0 (negative pressure in m i d d l e ear), e.g. e u s t a c h i a n
2 tube
o b s t r u c t i o n o r early stage o f o t i t i s m e d i a w i t h e f f u s i o n . A c o u s t i c reflex.

P h y s i c a l v o l u m e o f ear canal A c o u s t i c i m m i t t a n c e can
also m e a s u r e t h e p h y s i c a l v o l u m e o f a i r b e t w e e n t h e p r o b e
t i p a n d t y m p a n i c m e m b r a n e . N o r m a l l y i t is u p t o 1.0 m l i n
c h i l d r e n a n d 2 m l i n adults. A n y increase i n v o l u m e , > 2 m l
in c h i l d r e n and > 2 . 5 m l i n adults, indicates p e r f o r a t i o n o f
the t y m p a n i c m e m b r a n e (because m i d d l e ear v o l u m e is
a d d e d u p t o t h e v o l u m e o f e x t e r n a l ear c a n a l ) . T h i s has
also b e e n u s e d t o f i n d p a t e n c y o f t h e v e n t i l a t i o n t u b e .
^ ~ C . Special Tests o f Hearing ~ presented. Patient indicates the blips heard. I n c o n d u c t i v e
1. Recruitment
I t is a p h e n o m e n o n o f a b n o r m a l g r o w t h o f loudness. T h e ear
w h i c h does n o t hear l o w i n t e n s i t y s o u n d b e g i n s t o hear
g r e a t e r i n t e n s i t y sounds as l o u d o r e v e n l o u d e r t h a n n o r m a l
h e a r i n g ear. T h u s , a l o u d s o u n d w h i c h is t o l e r a b l e i n n o r m a l
ear m a y g r o w t o a b n o r m a l l e v e l s o f l o u d n e s s i n t h e r e c r u i t -
i n g ear a n d thus b e c o m e s i n t o l e r a b l e . T h e patients w i t h r e c r u i t -
m e n t are p o o r c a n d i d a t e s f o r h e a r i n g aids. R e c r u i t m e n t is
t y p i c a l l y seen i n lesions o f t h e c o c h l e a ( e . g . M e n i e r e ' s d i s -
ease, p r e s b y c u s i s ) a n d t h u s h e l p s t o d i f f e r e n t i a t e a c o c h l e a r
f r o m a r e t r o c o c h l e a r s e n s o r i n e u r a l h e a r i n g loss.
Alternate binaural loudness balance test is used t o detect
r e c r u i t m e n t i n u n i l a t e r a l cases. A t o n e , say o f 1 0 0 0 H z , is
p l a y e d a l t e r n a t e l y t o t h e n o r m a l a n d t h e a f f e c t e d ear a n d t h e
i n t e n s i t y i n t h e a f f e c t e d ear is a d j u s t e d t o m a t c h t h e l o u d n e s s
i n n o n n a l ear. T h e test is s t a r t e d at 2 0 d B a b o v e t h e t h r e s h -
o l d o f d e a f ear a n d t h e n r e p e a t e d at e v e r y 2 0 d B rise u n t i l
t h e l o u d n e s s is m a t c h e d o r t h e l i m i t s o f a u d i o m e t e r r e a c h e d .
I n c o n d u c t i v e a n d n e u r a l deafness, t h e i n i t i a l d i f f e r e n c e is
m a i n t a i n e d t h r o u g h o u t w h i l e i n c o c h l e a r lesions, partial,
c o m p l e t e o r o v e r - r e c r u i t m e n t m a y b e seen ( F i g . 4 . 8 ) .
Figure 4.8
A l t e r n a t e b i n a u r a l l o u d n e s s b a l a n c e test.
( A ) N o n - r e c r u i t i n g ear. T h e i n i t i a l d i f f e r e n c e o f 20 d B b e t w e e n
t h e r i g h t a n d l e f t ear is m a i n t a i n e d at all i n t e n s i t y levels.
( B ) R e c r u i t i n g ear r i g h t side. A t 8 0 d B l o u d n e s s perceived by
r i g h t ear is as g o o d as left ear t h o u g h t h e r e w a s d i f f e r e n c e o f
30 d B i n i t i a l l y .
Assessment of Hearing
2. Short Increment Sensitivity Index (SISI Test)
Patients w i t h c o c h l e a r lesions d i s t i n g u i s h smaller changes
i n i n t e n s i t y o f p u r e t o n e better t h a n n o r m a l persons a n d
those w i t h c o n d u c t i v e o r retrocochlear p a t h o l o g y . SISI
test is t h u s u s e d t o d i f f e r e n t i a t e a c o c h l e a r f r o m a r e t r o c o -
chlear lesion.
I n t h i s test, a c o n t i n u o u s t o n e is p r e s e n t e d 2 0 d B a b o v e
the t h r e s h o l d and sustained f o r a b o u t 2 m i n u t e s . E v e r y 5
s e c o n d s , t h e t o n e is i n c r e a s e d b y 1 d B a n d 2 0 s u c h b l i p s are
deafness, S I S I s c o r e is s e l d o m m o r e t h a n 1 5 % ; i t is 7 0 — 1 0 0 %
i n c o c h l e a r deafness; a n d 0—20% i n n e r v e deafness.
3. Threshold Tone Decay Test
I t is a m e a s u r e o f n e r v e f a t i g u e a n d is u s e d t o detect
r e t r o c o c h l e a r l e s i o n s . N o r m a l l y , a p e r s o n can h e a r a t o n e
c o n t i n u o u s l y f o r 60 seconds. I n n e r v e fatigue, he stops
h e a r i n g e a r l i e r . T h e t h r e s h o l d t o n e d e c a y test is s i m p l e a n d
is p e r f o r m e d i n t h e f o l l o w i n g m a n n e r :
A t o n e o f 4 0 0 0 H z is p r e s e n t e d at 5 d B a b o v e t h e p a t i e n t ' s
t h r e s h o l d o f h e a r i n g , c o n t i n u o u s l y f o r a p e r i o d o f 6 0 sec-
o n d s . I f p a t i e n t stops h e a r i n g earlier, i n t e n s i t y is i n c r e a s e d b y
a n o t h e r 5 d B . T h e p r o c e d u r e is c o n t i n u e d t i l l p a t i e n t can hear
t h e t o n e c o n t i n u o u s l y f o r 6 0 s e c o n d s , o r n o l e v e l exists
a b o v e t h e t h r e s h o l d w h e r e t o n e is a u d i b l e f o r f u l l 60 seconds.
T h e r e s u l t is e x p r e s s e d as n u m b e r o f d B o f d e c a y . A d e c a y
m o r e t h a n 2 5 d B is d i a g n o s t i c o f a r e t r o c o c h l e a r l e s i o n .
4. Evoked Response Audiometry
I t is a n o b j e c t i v e test w h i c h m e a s u r e s e l e c t r i c a l a c t i v i t y i n
t h e a u d i t o r y p a t h w a y s i n response t o a u d i t o r y s t i m u l i . I t
r e q u i r e s special e q u i p m e n t w i t h a n a v e r a g i n g c o m p u t e r .
T h e r e are several c o m p o n e n t s o f e v o k e d e l e c t r i c response
b u t o n l y t w o h a v e g a i n e d c l i n i c a l a c c e p t a n c e . T h e y are:
(a) Electrocochleography ( E c o G ) I t measures e l e c t r i -
cal potentials arising i n the cochlea a n d C N V I I I i n
response t o a u d i t o r y s t i m u l i w i t h i n first 5 m i l l i s e c -
o n d s . T h e response is i n t h e f o n n o f t h r e e p h e n o m -
ena: c o c h l e a r m i c r o p h o n i c s , s u m m a t i n g p o t e n t i a l s a n d
the action potential o f V I H t h nerve. T h e r e c o r d i n g
e l e c t r o d e is u s u a l l y a t h i n n e e d l e passed t h r o u g h t h e
t y m p a n i c m e m b r a n e o n t o the p r o m o n t o r y . I n adults,
i t c a n b e d o n e u n d e r l o c a l anaesthesia b u t i n c h i l d r e n
o r a n x i o u s p e r s o n s s e d a t i o n o r g e n e r a l anaesthesia is
r e q u i r e d . S e d a t i o n does n o t i n t e r f e r e i n these responses.
EcoG is u s e f u l (i) t o f i n d t h r e s h o l d o f h e a r i n g i n
y o u n g infants a n d c h i l d r e n t o w i t h i n 5 - 1 0 d B , (ii) t o
differentiate lesions o f cochlea from those of the
V I H t h nerve.
N o r m a l l y the ratio b e t w e e n the a m p l i t u d e o f s u m -
m a t i n g p o t e n t i a l t o t h e a c t i o n p o t e n t i a l is less t h a n
 Diseases of Ear

l-lll 2.0 ms
il-V 2.0 ms
l-V 4.0 ms

:> _

Milliseconds
~~I— —I— —r
1 1

3 4 5
(1.0 ms/div)

AP Figure 4.10
Stimulus
B r a i n s t e m a u d i t o r y evoked p o t e n t i a l s .
( a ) A m p l i t u d e o f a wave is measured in m i c r o v o l t s (u.V) f r o m
SP
peak o f a w a v e t o t h e peak o f next t r o u g h .
( b ) A b s o l u t e peak latency is t h e d u r a t i o n in m i l l i s e c o n d s ( m s )
f r o m t h e s t a r t o f click t o a p p e a r a n c e o f a w a v e .
Milliseconds
( c ) I n t e r p e a k latency o r interval is the d u r a t i o n in m i l l i s e c o n d s
b e t w e e n peaks o f t w o waves, e.g., waves l - l l l o r l - V o r III a n d
Figure 4.9
V, a n d i t is c o m p a r e d w i t h n o r m a t i v e d a t a ( l - l l l , 2.0 ms; l l l - V ,
E l e c t r o c o c h l e o g r a p h y . ( A ) N o r m a l ear. ( B ) Ear w i t h Meniere's 2.0 ms; l - V , 4 . 0 m s ) .
disease. V o l t a g e o f s u m m a t i n g p o t e n t i a l (SP) is c o m p a r e d (d) I n t e r a u r a l peak latency is the d i f f e r e n c e in m i l l i s e c o n d s
w i t h t h a t o f a c t i o n p o t e n t i a l ( A P ) . N o r m a l l y SP is 3 0 % o f A P . o f a p a r t i c u l a r wave between t w o ears. T h i s is useful in u n i l a t -
T h i s r a t i o is e n h a n c e d in M e n i e r e ' s disease. eral ear disease, e.g., a c o u s t i c n e u r o m a ( i n t e r a u r a l wave V
latencies).

3 0 % . A n i n c r e a s e i n t h i s r a t i o is i n d i c a t i v e o f M e n i e r e ' s Wave V Lateral lemniscus

disease ( F i g . 4 . 9 ) . Waves V I and V I I Inferior colliculus
(b) Auditory brainstem r e s p o n s e ( A B R ) Also called
As an aide m e m o r i e r e m e m b e r the p n e u m o n i c E E COLI
B A E R o r B A E P ( b r a i n s t e m a u d i t o r y e v o k e d response
(eight, eight, cochlear nucleus, olivary complex, lateral
o r potential) or B E R A ( b r a i n s t e m e v o k e d response
lemniscus, i n f e r i o r c o l l i c u l u s ) compare E COLI-MA in
a u d i o m e t r y ) is t o e l i c i t b r a i n s t e m responses t o a u d i t o r y
pathways o f hearing.
s t i m u l a t i o n b y c l i c k s o r t o n e b u r s t s . I t is a n o n - i n v a s i v e
A B R is u s e d :
technique to find the integrity o f central auditory
pathways t h r o u g h the V I H t h nerve, pons a n d m i d - (i) As a screening procedure for infants.

b r a i n . I n t h i s m e t h o d , e l e c t r i c a l p o t e n t i a l s are g e n e r a t e d (ii) T o d e t e r m i n e t h e t h r e s h o l d o f h e a r i n g i n i n f a n t s ; also

i n r e s p o n s e t o several c l i c k s t i m u l i o r t o n e - b u r s t s a n d i n c h i l d r e n a n d adults w h o d o n o t c o o p e r a t e a n d i n

p i c k e d u p f r o m t h e v e r t e x b y surface electrodes. I t m e a - malingerers.

sures h e a r i n g s e n s i t i v i t y i n t h e r a n g e o f 1 0 0 0 - 4 0 0 0 H z . (iii) To diagnose retrocochlear pathology particularly

I n a n o r m a l p e r s o n , 7 w a v e s are p r o d u c e d i n t h e f i r s t acoustic neuroma.

10 m i l l i s e c o n d s . T h e first, t h i r d a n d f i f t h w a v e s are m o s t (iv) T o diagnose b r a i n s t e m p a t h o l o g y , e.g. m u l t i p l e scle-

stable a n d are u s e d i n m e a s u r e m e n t s . T h e w a v e s are rosis o r p o n t i n e t u m o u r s .

s t u d i e d f o r a b s o l u t e latency, inter-wave latency (usually (vi) T o m o n i t o r C N V I I I intraoperatively i n surgery o f

b e t w e e n w a v e I a n d V ) a n d the amplitude (Fig. 4.10). acoustic neuromas to preserve the f u n c t i o n o f cochlear

nerve.
T h e e x a c t a n a t o m i c site o f n e u r a l g e n e r a t o r s f o r v a r i o u s
w a v e s is d i s p u t e d b u t t h e latest s t u d i e s i n d i c a t e t h e f o l l o w - 5. Otoacoustic Emissions (OAEs)
i n g sites:
T h e y are l o w i n t e n s i t y s o u n d s p r o d u c e d b y o u t e r h a i r cells
Wave I Distal part o f C N V I I I o f a n o r m a l cochlea a n d can be e l i c i t e d b y a v e r y sensitive
Wave II P r o x i m a l part o f C N V I I I near m i c r o p h o n e p l a c e d i n t h e e x t e r n a l ear c a n a l a n d a n a l y z e d
the brainstem b y a c o m p u t e r . S o u n d p r o d u c e d b y o u t e r h a i r cells t r a v e l s
Wave III Cochlear nucleus in a reverse d i r e c t i o n : o u t e r h a i r cells ~ * basdar mem-
Wave IV Superior olivary complex b r a n e - v p e r i l y m p h - » o v a l w i n d o w —• ossicles —• t y m p a n i c

1
©
 Assessment of Hearing

m e m b r a n e —> ear c a n a l . O A E s are p r e s e n t w h e n o u t e r h a i r 2. T h e y help to distinguish cochlear f r o m retrocochlear

cells are h e a l t h y a n d are a b s e n t w h e n t h e y are d a m a g e d h e a r i n g loss. O A E s are a b s e n t i n c o c h l e a r l e s i o n s , e . g .

a n d t h u s h e l p t o test t h e f u n c t i o n o f c o c h l e a . T h e y d o n o t o t o t o x i c s e n s o r i n e u r a l h e a r i n g loss. T h e y d e t e c t o t o -

d i s a p p e a r i n e i g h t h n e r v e p a t h o l o g y as c o c h l e a r h a i r cells t o x i c effects e a r l i e r t h a n p u r e - t o n e a u d i o m e t r y .

are n o r m a l . 3. O A E s are also u s e f u l t o d i a g n o s e r e t r o c o c h l e a r p a t h o l -

T y p e s o f O A E s : B r o a d l y O A E s are o f t w o t y p e s : s p o n - o g y , especially a u d i t o r y n e u r o p a t h y . A u d i t o r y n e u r o p -

taneous or evoked. T h e l a t t e r are elicited by a sound a t h y is a n e u r o l o g i c d i s o r d e r o f C N V I I I . A u d i o m e t r i c

stimulus. tests, e . g . S N H L f o r p u r e t o n e s , i m p a i r e d s p e e c h d i s -

Spontaneous OAEs: T h e y are p r e s e n t i n h e a l t h y n o r m a l c r i m i n a t i o n score, absent o r a b n o r m a l a u d i t o r y b r a i n -

h e a r i n g p e r s o n s w h e r e h e a r i n g loss does n o t e x c e e d 3 0 d B . stem response, s h o w a r e t r o c o c h l e a r t y p e o f lesion b u t

T h e y m a y be absent i n 5 0 % o f n o r m a l persons. O A E s are n o r m a l .

Evoked OAEs: T h e y are f u r t h e r d i v i d e d i n t o t w o t y p e s

O A E s are a b s e n t i n 5 0 % o f n o r m a l i n d i v i d u a l s , l e s i o n s
d e p e n d i n g o n the s o u n d stimulus used t o elicit t h e m .
o f cochlea, m i d d l e ear d i s o r d e r s (as s o u n d t r a v e l l i n g i n
(a) Transient evoked OAEs (TEOAEs). Evoked by reverse d i r e c t i o n c a n n o t b e p i c k e d u p ) a n d w h e n h e a r i n g
clicks. A series o f click stimuli are presented at loss e x c e e d s 3 0 d B .
8 0 - 8 5 d B S P L a n d response r e c o r d e d .
(b) D i s t o r t i o n p r o d u c t O A E s ( D P O A E s ) . T w o t o n e s are 6. Central Auditory Tests

simultaneously presented to the cochlea to produce

T h e s e tests are d e s i g n e d t o f i n d defects i n t h e c e n t r a l a u d i -
d i s t o r t i o n p r o d u c t s . T h e y h a v e b e e n u s e d t o test h e a r -
t o r y p a t h w a y s a n d t h e t e m p o r a l c o r t e x . S e v e r a l tests w i t h
i n g i n the range o f 1 0 0 0 - 8 0 0 0 H z .
test s i g n a l d e l i v e r e d t o o n e ear ( m o n o t i c ) o r b o t h ears
(dichotic) have been used, b u t c u r r e n t l y the "Staggered
Uses
s p o n d a i c w o r d s " test is w i d e l y e m p l o y e d . C e n t r a l a u d i t o r y
i. O A E s are u s e d as a s c r e e n i n g test o f h e a r i n g i n n e o - tests are n o t u s e d r o u t i n e l y .
nates a n d t o test h e a r i n g i n u n c o o p e r a t i v e o r m e n t a l l y
c h a l l e n g e d i n d i v i d u a l s after s e d a t i o n . S e d a t i o n does 7. Hearing Assessment in Infants and Children
not interfere w i t h O A E s . (seepage 131)
H e a r i n g Loss

A v e r a g e H e a r i n g L o s s S e e n in D i f f e r e n t L e s i o n s
CLASSIFICATION
of Conductive Apparatus
I
Hearing Loss
C o m p l e t e o b s t r u c t i o n o f ear c a n a l : 30 dB

Organic Non-organic 2. Perforation o f tympanic membrane

( I t v a r i e s a n d is d i r e c t l y p r o p o r t i o n a l
t o t h e size o f p e r f o r a t i o n ) : 10-40dB
Conductive Sensorineural
Ossicular i n t e r r u p t i o n w i t h intact d r u m : 54 d B
4. Ossicular i n t e r r u p t i o n w i t h p e r f o r a t i o n : 38 d B
Sensory Neural
Malleus fixation: 10-25dB
cochlear)
6. Closure o f oval w i n d o w : 60 dB

Central
N o t e h e r e t h a t ossicular i n t e r r u p t i o n w i t h i n t a c t d r u m
(Vlllih nerve) (Central auditory
pathways) causes m o r e loss t h a n ossicular i n t e r r u p t i o n w i t h p e r f o r a t e d
drum.

CONDUCTIVE HEARING LOSS AND ITS

MANAGEMENT

A n y disease p r o c e s s w h i c h i n t e r f e r e s w i t h t h e c o n d u c t i o n Frequency in Hertz

o f s o u n d t o r e a c h c o c h l e a causes c o n d u c t i v e h e a r i n g loss. 125 250 500 1000 2000 4000 8000
T h e l e s i o n m a y l i e i n t h e e x t e r n a l ear a n d t y m p a n i c m e m - 0
~ <• e — t <
b r a n e , m i d d l e ear o r ossicles u p t o s t a p e d i o v e s t i b u l a r j o i n t . 10
T h e c h a r a c t e r i s t i c s o f c o n d u c t i v e h e a r i n g loss are: cn 20
~° 30
cv
L N e g a t i v e R i n n e test, i . e . B O AC. t 40 x.
S 50 i i
\
2. W e b e r l a t e r a l i s e d t o p o o r e r ear. *. B
f 60
N o r m a l absolute b o n e c o n d u c t i o n . Ear
8 7 0
Modality
L o w frequencies affected m o r e . Right Left
I 80
90 AC unmasked
A u d i o m e t r y shows b o n e c o n d u c t i o n b e t t e r t h a n air X
100 AC masked A
c o n d u c t i o n w i t h air-bone gap. Greater the air-bone
110
•
g a p , m o r e is t h e c o n d u c t i v e loss ( F i g . 5 . 1 ) . BC unmasked < >
6. Loss is n o t m o r e t h a n 6 0 d B . BC masked C •
7. S p e e c h d i s c r i m i n a t i o n is g o o d .
No response

[ Aetiology J F i g u r e 5.1

( A ) A u d i o g r a m o f r i g h t ear s h o w i n g c o n d u c t i v e h e a r i n g loss
The cause m a y b e congenital (Table 5.1) or acquired
w i t h A - B g a p . ( B ) S y m b o l s used in a u d i o g r a m c h a r t i n g .
(Table 5.2).
 Hearing Loss

w i t h m a s t o i d e c t o m y i f disease process so d e m a n d s . T y p e o f
Table 5.1 C o n g e n i t a l causes o f c o n d u c t i v e h e a r i n g loss
m i d d l e ear r e c o n s t r u c t i o n d e p e n d s o n t h e d a m a g e p r e s e n t
M e a t a l atresia i n t h e ear. T h e p r o c e d u r e m a y b e l i m i t e d o n l y t o r e p a i r o f
Fixation o f stapes f o o t p l a t e t y m p a n i c m e m b r a n e (myringoplasty), or to reconstruction o f
F i x a t i o n o f m a l l e u s head ossicular chain (ossiculoplasty), or both (tympanoplasty).

Ossicular d i s c o n t i n u i t y R e c o n s t r u c t i v e s u r g e r y o f t h e ear has b e e n g r e a d y f a c i l i t a t e d

by development o f operating microscope, microsurgical
Congenital cholesteatoma
instruments a n d b i o c o m p a t i b l e i m p l a n t materials.
F r o m the physiology o f hearing mechanism, the f o l l o w -
i n g principles can be d e d u c e d t o restore h e a r i n g surgically:
Table 5.2 A c q u i r e d causes o f c o n d u c t i v e h e a r i n g loss

External ear A n y o b s t r u c t i o n in t h e ear c a n a l , e.g. w a x , (i) An intact tympanic membrane, t o p r o v i d e large h y d r a u -

foreign body, furuncle, acute i n f l a m m a t o r y l i c r a t i o b e t w e e n t h e t y m p a n i c m e m b r a n e a n d stapes
swelling, benign o r malignant t u m o u r or
footplate.
atresia o f c a n a l .
(ii) Ossicular chain, to conduct sound from tympanic
M i d d l e ear (a) Perforation o f tympanic membrane, m e m b r a n e to the oval w i n d o w .
t r a u m a t i c o r infective
(iii) Two functioning windows, o n e o n t h e scala v e s t i b u l i ( t o
(b) F l u i d in t h e m i d d l e ear, e.g. a c u t e o t i t i s
r e c e i v e s o u n d v i b r a t i o n s ) a n d t h e o t h e r o n t h e scala
m e d i a , serous o t i t i s m e d i a o r
t y m p a n i ( t o act as a r e l i e f w i n d o w ) . I f i t is o n l y o n e
haemotympanum
w i n d o w , as i n stapes f i x a t i o n o r c l o s u r e o f r o u n d w i n -
(c) M a s s in m i d d l e ear, e.g. b e n i g n o r
d o w , there w i l l be n o m o v e m e n t o f cochlear fluids
malignant t u m o u r
r e s u l t i n g i n c o n d u c t i v e h e a r i n g loss.
(d) D i s r u p t i o n o f ossicles, e.g. t r a u m a r o
ossicular c h a i n , c h r o n i c s u p p u r a t i v e (iv) Acoustic separation of two windows, so t h a t s o u n d does

otitis media, cholesteatoma n o t r e a c h b o t h t h e w i n d o w s s i m u l t a n e o u s l y . I t c a n be

(e) F i x a t i o n o f ossicles, e.g. o t o s c l e r o s i s , achieved b y p r o v i d i n g an intact t y m p a n i c m e m b r a n e ,
t y m p a n o s c l e r o s i s , adhesive o t i t i s m e d i a preferential p a t h w a y t o o n e w i n d o w (usually the oval)
(f) Eustachian t u b e blockage, e.g. retracted b y p r o v i d i n g ossicular c h a i n a n d b y the presence o f
t y m p a n i c m e m b r a n e , serous o t i t i s m e d i a . air i n t h e m i d d l e ear.
(v) Functioning eustachian tube, t o p r o v i d e a e r a t i o n t o t h e
m i d d l e ear.
Management
(vi) A functioning sensorineural apparatus, i.e. the cochlea and
V H I t h nerve.
M o s t cases o f c o n d u c t i v e h e a r i n g loss c a n b e m a n a g e d b y
m e d i c a l o r s u r g i c a l m e a n s . T r e a t m e n t o f these c o n d i t i o n s Types of tympanoplasty W u l l s t e i n classified t y m p a n o -
is d i s c u s s e d i n r e s p e c t i v e s e c t i o n s . B r i e f l y , i t consists o f : plasty i n t o f i v e types ( F i g . 5.2).

1. R e m o v a l o f c a n a l o b s t r u c t i o n s , e.g. i m p a c t e d w a x ,
Type I D e f e c t is p e r f o r a t i o n o f t y m p a n i c membrane
f o r e i g n b o d y , o s t e o m a o r exostosis, k e r a t o t i c mass,
w h i c h is r e p a i r e d w i t h a g r a f t . I t is also c a l l e d
b e n i g n o r m a l i g n a n t t u m o u r s , m e a t a l atresia.
myringoplasty.
2. Removal o f fluid M y r i n g o t o m y w i t h or without
Type II D e f e c t is p e r f o r a t i o n o f t y m p a n i c membrane
g r o m m e t insertion.
w i t h e r o s i o n o f m a l l e u s . G r a f t is p l a c e d o n t h e
3. R e m o v a l o f m a s s f r o m m i d d l e ear Tympanotomy
incus o r r e m n a n t o f malleus.
a n d r e m o v a l o f s m a l l m i d d l e ear t u m o u r s o r c h o l e s t e -
Type III Malleus a n d incus are absent. G r a f t is placed
atoma b e h i n d intact tympanic membrane.
d i r e c t l y o n t h e stapes h e a d . I t is also c a l l e d myrin-
4. S t a p e d e c t o m y , as i n o t o s c l e r o t i c f i x a t i o n o f stapes
gostapediopexy or columella tympanoplasty.
footplate.
Type I V O n l y the f o o t p l a t e o f stapes is p r e s e n t . I t is
Tympanoplasty R e p a i r o f p e r f o r a t i o n , ossicular c h a i n
e x p o s e d t o t h e e x t e r n a l ear, a n d g r a f t is p l a c e d
or both.
b e t w e e n the oval and r o u n d w i n d o w s . A nar-
6. Hearing aid I n cases, w h e r e s u r g e r y is n o t p o s s i b l e ,
r o w m i d d l e ear ( c a v u m m i n o r ) is t h u s created,
r e f u s e d o r has f a i l e d .
t o have an air p o c k e t a r o u n d the r o u n d w i n d o w .
A m u c o s a - l i n e d space e x t e n d s f r o m t h e eusta-
Tympanoplasty
c h i a n t u b e t o t h e r o u n d w i n d o w . S o u n d waves
I t is a n o p e r a t i o n t o (i) eradicate disease i n t h e m i d d l e ear a n d i n t h i s case act d i r e c t l y o n t h e f o o t p l a t e w h i l e
(ii) t o r e c o n s t r u c t h e a r i n g m e c h a n i s m . I t m a y b e combined t h e r o u n d w i n d o w has b e e n s h i e l d e d .
 Type III (Myringostapediopexy) Type IV Type V (Fenestration)

Figure 5.2

Types o f t y m p a n o p l a s t y . T h e g r a f t is progressively in c o n t a c t w i t h malleus (type I ) , incus (type I I ) , stapes (type I I I ) , stapes f o o t p l a t e

(type IV), o r fenestra in h o r i z o n t a l semicircular canal ( t y p e V ) . In classical type IV, the g r a f t w a s a t t a c h e d t o p r o m o n t o r y , this provides
s o u n d p r o t e c t i o n f o r r o u n d w i n d o w w h i l e f o o t p l a t e w a s directly exposed.

TypeV Stapes f o o t p l a t e is f i x e d b u t r o u n d w i n d o w is
f u n c t i o n i n g . I n s u c h cases, a n o t h e r w i n d o w is
created o n horizontal semicircular canal and
covered w i t h a graft. A l s o called fenestration
operation.

S e v e r a l m o d i f i c a t i o n s h a v e a p p e a r e d i n t h e a b o v e clas-
s i f i c a t i o n a n d t h e y m a i n l y p e r t a i n t o t h e types o f ossicular
reconstruction.
Figure 5.3
Myringoplasty I t is r e p a i r o f t y m p a n i c m e m b r a n e . Graft
m a t e r i a l s o f c h o i c e are t e m p o r a l i s fascia o r t h e p e r i c h o n - M y r i n g o p l a s t y . ( A ) U n d e r l a y technique—fascia g r a f t is u n d e r
d r i u m t a k e n f r o m the patient. S o m e t i m e s , h o m o g r a f t s such the a n t e r i o r a n n u l u s . It is s u p p o r t e d by g e l f o a m in the m i d d l e
as d u r a , v e i n , fascia o r c a d a v e r t y m p a n i c m e m b r a n e are also ear t o prevent m e d i a l d i s p l a c e m e n t . (B) Overlay t e c h n i q u e -

used. R e p a i r can be d o n e b y t w o t e c h n i q u e s — t h e underlay fascia g r a f t lies lateral t o a n t e r i o r a n n u l u s o n t o t h e a n t e r i o r

b o n y canal w a l l . It is placed m e d i a l t o malleus h a n d l e t o pre-
o r t h e o v e r l a y . I n t h e underlay technique, margins o f perfo-
vent l a t e r a l i z a t i o n .
r a t i o n are f r e s h e n e d a n d t h e g r a f t p l a c e d m e d i a l t o p e r f o -
r a t i o n o r t y m p a n i c a n n u l u s , i f l a r g e , a n d is s u p p o r t e d b y
g e l f o a m i n t h e m i d d l e ear ( F i g . 5 . 3 A ) . I n t h e overlay tech-
nique, t h e g r a f t is p l a c e d l a t e r a l t o f i b r o u s l a y e r o f t h e t y m -
panic membrane after c a r e f u l l y r e m o v i n g all squamous prosthetic implants made o f ceramic (hydroxyapatite) or
e p i t h e l i u m f r o m t h e l a t e r a l surface o f t y m p a n i c membrane teflon. T h e techniques c o m m o n l y e m p l o y e d i n ossicular
r e m n a n t ( F i g . 5.313 a n d C h a p t e r SO). r e c o n s t r u c t i o n i n s u c h cases are i n c u s t r a n s p o s i t i o n o r a
s c u l p t u r e d ossicle ( F i g . 5 . 4 ) .
Ossicular reconstruction I t is r e q u i r e d w h e n t h e r e is
Most common o s s i c u l a r f i x a t i o n s are t h e a n k y l o s i s of
d e s t r u c t i o n o r f i x a t i o n o f ossicular c h a i n . M o s t common
stapes f o o t p l a t e as i n o t o s c l e r o s i s , a n d t h e c o n g e n i t a l or
d e f e c t is n e c r o s i s o f t h e l o n g p r o c e s s o f i n c u s , t h e m a l l e u s
acquired f i x a t i o n o f the head o f malleus i n the attic.
a n d t h e stapes b e i n g n o r m a l . I n o t h e r s , t h e r e is a d d i t i o n a l
A n k y l o s i s o f stapes c a n b e c o r r e c t e d b y r e m o v a l o f t h e
loss o f stapes s u p e r s t r u c t u r e , l e a v i n g o n l y a m o b i l e f o o t -
f i x e d stapes a n d its r e p l a c e m e n t b y a prosthesis w h i l e t h e
p l a t e a n d m a l l e u s . Y e t i n o t h e r s , o n l y t h e f o o t p l a t e is l e f t ,
a t t i c f i x a t i o n o f m a l l e u s h e a d entails r e m o v a l o f t h e h e a d
all o t h e r ossicles, t h e m a l l e u s , i n c u s a n d t h e stapes s u p e r -
o f malleus and entire incus and t h e n establishing contact
s t r u c t u r e are d e s t r o y e d .
b e t w e e n h a n d l e o f m a l l e u s a n d t h e stapes.
Repair o f ossicular chain can be achieved b y the use Prosthetic implants i n c l u d e a T O R P o r a P O R P (total o r
o f a u t o g r a f t i n c u s o r c a r t i l a g e , h o m o g r a f t ossicles, o r t h e p a r t i a l o s s i c u l a r r e p l a c e m e n t p r o s t h e s i s ) . T h e y are m a d e o f
 Hearing Loss

t e f l o n o r c e r a m i c ( F i g . 5 . 5 ) . A T O R P is u s e d t o b r i d g e t h e
SENSORINEURAL HEARING LOSS AND
gap b e t w e e n tympanic membrane a n d stapes f o o t p l a t e
ITS MANAGEMENT
w h i l e a P O R P is u s e d t o p r o v i d e a d i r e c t c o n t a c t b e t w e e n
t y m p a n i c m e m b r a n e a n d stapes h e a d .

S e n s o r i n e u r a l h e a r i n g l o s s ( S N H L ) results f r o m lesions
o f the cochlea, V I H t h nerve o r central a u d i t o r y pathways.
I n m a y b e p r e s e n t at b i r t h ( c o n g e n i t a l ) o r start l a t e r i n l i f e
(acquired).
T h e c h a r a c t e r i s t i c s o f s e n s o r i n e u r a l h e a r i n g loss are:

. A p o s i t i v e R i n n e test, i . e . a i r A C > BC.

2. W e b e r l a t e r a l i s e d t o b e t t e r ear.
B o n e c o n d u c t i o n r e d u c e d o n Schwabach a n d absolute
b o n e c o n d u c t i o n tests.
:
M o r e often i n v o l v i n g h i g h frequencies.
5. N o gap b e t w e e n a i r a n d b o n e c o n d u c t i o n c u r v e o n
a u d i o m e t r y (Fig. 5.6).
6. Loss m a y e x c e e d 6 0 d B .
7. S p e e c h d i s c r i m i n a t i o n is p o o r .
S. T h e r e is d i f f i c u l t y i n h e a r i n g i n t h e p r e s e n c e o f n o i s e .

| Aetiology of S N H L |

Figure 5.4 Congenital

Ossicular reconstruction. Sculptured autograft or h o m o g r a f t I t is p r e s e n t at b i r t h a n d is t h e r e s u l t o f a n o m a l i e s o f t h e

ossicles have been used. (A) Malleus—Stapes assembly. i n n e r ear o r d a m a g e t o t h e h e a r i n g a p p a r a t u s b y p r e n a t a l
M o d i f i e d incus g r a f t c o n n e c t i n g m a l l e u s h a n d l e w i t h stapes o r p e r i n a t a l f a c t o r s (see p a g e 127).
head. (B) M a l l e u s — F o o t p l a t e assembly. Modified malleus
c o n n e c t i n g m a l l e u s h a n d l e w i t h stapes f o o t p l a t e . ( C ) M o d i f i e d
Acquired
incus c o n n e c t i n g T M t o stapes h e a d . M a l l e u s is m i s s i n g . ( D )
M o d i f i e d incus c o n n e c t i n g T M t o stapes f o o t p l a t e . I t appears l a t e r i n l i f e . T h e cause m a y b e g e n e t i c o r n o n -
genetic. The genetic cause m a y m a n i f e s t l a t e (delayed
onset) a n d affect o n l y t h e h e a r i n g , o r b e a p a r t o f a l a r g e r
I I
Frequency in Hertz
125 25C 500 1000 2000 4000 8000

0
10
20
LT
30 ^ r
40 "1 rr
VJ LA
50
J c
60
70
X
80
90
100
110

Figure 5.6
Figure 5.5
A u d i o g r a m o f r i g h t ear s h o w i n g s e n s o r i n e u r a l loss w i t h n o
H y d r o x y a p a t i t e T O R P and PORP centered ( A ) and offset (B) types. A - B gap.
syndrome affecting other systems o f t h e b o d y as well. c o r r e c t e d surgically b y sealing the fistula i n the oval o r
C o m m o n causes o f a c q u i r e d S N H L i n c l u d e : r o u n d w i n d o w w i t h fat.
Ototoxic drugs s h o u l d b e u s e d w i t h c a r e a n d d i s c o n t i n -
1. Infections o f l a b y r i n t h - v i r a l , bacterial o r spirochaetal,
u e d i f c a u s i n g h e a r i n g loss. I n m a n y s u c h cases, i t m a y b e
2. Trauma to labyrinth or V I H t h n e r v e , e.g. fractures
p o s s i b l e t o r e g a i n h e a r i n g , t o t a l o r p a r t i a l , i f t h e d r u g is
o f t e m p o r a l bone or concussion of labyrinth or ear
s t o p p e d . Noise induced hearing loss c a n b e p r e v e n t e d f r o m
surgery,
f u r t h e r d e t e r i o r a t i o n i f t h e p e r s o n is r e m o v e d f r o m the
3. N o i s e - i n d u c e d h e a r i n g loss,
noisy surroundings.
4. O t o t o x i c drugs,
Rehabilitation of hearing-impaired w i t h hearing aids
5. Presbycusis,
a n d o t h e r d e v i c e s is discussed i n C h a p t e r 20.
6. M e n i e r e ' s disease,
7. Acoustic neuroma,
8. S u d d e n h e a r i n g loss,
9. Familial progressive S N H L ,
SPECIFIC FORMS OF HEARING LOSS

10. S y s t e m i c d i s o r d e r s , e.g. diabetes, h y p o t h y r o i d i s m , k i d -

n e y disease, a u t o i m m u n e d i s o r d e r s , m u l t i p l e sclerosis,
A. Inflammations of Labyrinth
b l o o d dyscrasias.

I t m a y be viral, bacterial or syphilitic.

Diagnosis 1 . V i r a l labyrinthitis V i m s e s u s u a l l y r e a c h t h e i n n e r ear b y

b l o o d stream a f f e c t i n g stria vascularis a n d t h e n t h e e n d o l y m p h
a n d o r g a n o f C o r t i . Measles, m u m p s a n d c y t o m e g a l o v i r u s e s
1. H i s t o r y i t is i m p o r t a n t t o k n o w w h e t h e r disease is
are w e l l d o c u m e n t e d t o cause l a b y r i n t h i t i s . Several other
congenital o r a c q u i r e d , stationary or progressive, associ-
v i m s e s , e.g. r u b e l l a , herpes zoster, herpes s i m p l e x , i n f l u e n z a
ated w i t h o t h e r syndromes o r n o t , i n v o l v e m e n t o f o t h e r
a n d E p s t e i n - B a r r are c l i n i c a l l y k n o w n t o cause deafness b u t
m e m b e r s o f the f a m i l y a n d possible aetiologic factors.
d i r e c t p r o o f o f t h e i r i n v a s i o n o f l a b y r i n t h is l a c k i n g .
2. Severity of deafness (mild, moderate, moderately
2. B a c t e r i a l Bacterial infections reach l a b y r i n t h t h r o u g h
severe, severe, p r o f o u n d o r total) T h i s can b e f o u n d o u t
t h e m i d d l e ear ( t y m p a n o g e n i c ) o r t h r o u g h C S F (meningo-
on audiometry.
g e n i c ) . L a b y r i n t h i t i s as a c o m p l i c a t i o n o f m i d d l e ear i n f e c t i o n
3. T y p e o f a u d i o g r a m w h e t h e r loss is h i g h frequency, is discussed o n p a g e 5 2 . S e n s o r i n e u r a l deafness f o l l o w i n g
l o w f r e q u e n c y , m i d - f r e q u e n c y o r flat t y p e . m e n i n g i t i s is a w e l l - k n o w n c l i n i c a l e n t i t y . B a c t e r i a can
i n v a d e t h e l a b y r i n t h a l o n g n e r v e s , vessels, c o c h l e a r a q u e -
4. Site o f l e s i o n , i.e. cochlear, retrocochlear o r central.
d u c t o r t h e e n d o l y m p h a t i c sac. M e m b r a n o u s l a b y r i n t h is
5. Laboratory tests T h e y depend on the aetiology totally destroyed.
suspected, e.g. X - r a y s o r C T scan o f t e m p o r a l b o n e f o r
3. S y p h i l i t i c Sensorineural h e a r i n g loss is c a u s e d b o t h
evidence o f bone destruction (congenital cholesteatoma,
b y c o n g e n i t a l a n d a c q u i r e d s y p h i l i s . C o n g e n i t a l s y p h i l i s is
g l o m u s t u m o u r , m i d d l e ear m a l i g n a n c y o r a c o u s t i c n e u -
o f t w o t y p e s : t h e early form, m a n i f e s t i n g at t h e age o f 2 o r
r o m a ) , b l o o d c o u n t s ( l e u k a e m i a ) , b l o o d sugar (diabetes),
t h e late form, m a n i f e s t i n g at t h e age o f 8 - 2 0 years. S y p h i l i t i c
serology for syphilis, t h y r o i d functions ( h y p o t h y r o i d i s m ) ,
i n v o l v e m e n t o f t h e i n n e r ear c a n cause:
k i d n e y f u n c t i o n tests, etc.

(i) S u d d e n s e n s o r i n e u r a l h e a r i n g loss w h i c h m a y b e u n i -
l a t e r a l o r b i l a t e r a l . T h e l a t t e r is u s u a l l y s y m m e t r i c a l i n
Management
h i g h f r e q u e n c i e s o r is a flat t y p e .
(ii) M e n i e r e ' s s y n d r o m e w i t h episodic v e r t i g o , fluctuating
E a r l y d e t e c t i o n o f S N H L is i m p o r t a n t as m e a s u r e s c a n b e
h e a r i n g loss, t i n n i t u s a n d a u r a l fullness—-a picture
t a k e n t o s t o p its progress, reverse i t o r t o start a n e a r l y r e h a -
s i m u l a t i n g M e n i e r e ' s disease.
b i l i t a t i o n p r o g r a m m e , so essential f o r c o m m u n i c a t i o n .
(iii) H e n n e b e r t ' s s i g n . A p o s i t i v e f i s t u l a s i g n i n t h e absence
Syphilis o f t h e i n n e r ear is t r e a t a b l e w i t h h i g h doses o f
o f a f i s t u l a . T h i s is d u e t o f i b r o u s a d h e s i o n s b e t w e e n
penicillin and steroids with improvement in hearing.
t h e stapes f o o t p l a t e a n d t h e m e m b r a n o u s l a b y r i n t h .
Hearing loss of hypothyroidism can be reversed with
(iv) T u l l i o p h e n o m e n o n i n w h i c h l o u d sounds produce
replacement t h e r a p y . Serous labyrinthitis can be reversed
vertigo.
b y a t t e n t i o n t o m i d d l e ear i n f e c t i o n . E a r l y management
of Meniere's disease can p r e v e n t f u r t h e r e p i s o d e s o f v e r t i g o Diagnosis o f otosyphilis can be m a d e b y o t h e r clinical
a n d h e a r i n g loss. S N H L d u e t o perilymph fistula can be e v i d e n c e o f late a c q u i r e d o r c o n g e n i t a l s y p h i l i s ( i n t e r s t i t i a l
k e r a t i t i s , H u t c h i n s o n ' s t e e t h , saddle n o s e , nasal septal p e r -
1 Ototoxic drugs
f o r a t i o n a n d f r o n t a l b o s s i n g ) a n d t h e l a b o r a t o r y tests. F T A -
A. Aminoglycoside antibiotics Analgesics
ABS ( f l u o r e s c e n t t r e p o n e m a - a b s o r p t i o n test) a n d V D R L
• Streptomycin • Salicylates
or R P R ( r a p i d p l a s m a r e a g i n ) tests f r o m C S F are u s e f u l t o
• Gentamicin • Indomethacin
establish t h e d i a g n o s i s .
• Tobramycin • Phenyl b u t a z o n e
Treatment o f otosyphilis includes i.v. penicillin and
• Neomycin • Ibuprofen
steroids.
• Kanamycin F. Chemicals

I 1
• Amikacin • Alcohol
• Sisomycin • Tobacco
B. Familial Progressive Sensorineural
B. Diuretics • Marijuana
Hearing Loss
• Furosemid • Carbon monoxide
* Ethacrynic acid poisoning
I t is a g e n e t i c d i s o r d e r i n w h i c h t h e r e is p r o g r e s s i v e d e g e n -
C Antimalarials C. Miscellaneous
e r a t i o n o f t h e c o c h l e a starting i n late c h i l d h o o d o r early • Quinine Erythromycin
•
a d u l t l i f e . H e a r i n g loss is b i l a t e r a l w i t h f l a t o r b a s i n - s h a p e d • Chloroquin Ampicillin
•
a u d i o g r a m b u t an excellent speech d i s c r i m i n a t i o n . D. Cytotoxic drugs Propranolol
•
• Nitrogen mustard • Propyl t h i o u r a c i l
• Cisplatin • Deferoxamine
• Carboplatin
H C . Ototoxicity j|

V a r i o u s d r u g s a n d c h e m i c a l s c a n d a m a g e t h e i n n e r ear a n d
cause s e n s o r i n e u r a l h e a r i n g loss a n d t i n n i t u s ( T a b l e
1 . A m i n o g l y c o s i d e antibiotics Streptomycin, gentamicin
a n d t o b r a m y c i n are p r i m a r i l y v e s t i b u l o t o x i c . T h e y selec-
t i v e l y d e s t r o y t y p e I h a i r cells o f t h e crista a m p u l l a r i s b u t ,
have f a i l e d t o s h o w any m o r p h o l o g i c changes i n the h a i r
5.3).
cells. P o s s i b l y t h e y i n t e r f e r e at e n z y m a t i c l e v e l . H e a r i n g loss
d u e t o salicylates is reversible after t h e d r u g is d i s c o n t i n u e d .
4 . Q u i n i n e O t o t o x i c s y m p t o m s d u e t o q u i n i n e are t i n n i t u s

a d m i n i s t e r e d i n l a r g e doses, c a n also d a m a g e t h e c o c h l e a . a n d s e n s o r i n e u r a l h e a r i n g loss, b o t h o f w h i c h are reversible.

N e o m y c i n , k a n a m y c i n , amikacin, sisomycin and d i h y - T h e s y m p t o m s g e n e r a l l y appear w i t h p r o l o n g e d m e d i c a -

d r o s t r e p t o m y c i n are c o c h l e o t o x i c . They cause selective t i o n b u t m a y o c c u r w i t h s m a l l e r doses i n t h o s e w h o are

d e s t r u c t i o n o f o u t e r h a i r cells, s t a r t i n g at t h e basal c o i l a n d s u s c e p t i b l e . C o n g e n i t a l deafness a n d h y p o p l a s i a o f c o c h l e a

progressing o n t o the apex o f cochlea. have been reported i n children w h o s e mothers received

P a t i e n t s p a r t i c u l a r l y at r i s k are t h o s e this d r u g d u r i n g t h e first trimester o f p r e g n a n c y . O t o t o x i c

effects o f q u i n i n e are d u e t o v a s o c o n s t r i c t i o n i n t h e s m a l l
(i) h a v i n g i m p a i r e d renal f u n c t i o n ,
vessels o f t h e c o c h l e a a n d stria v a s c u l a r i s .
(ii) e l d e r l y p e o p l e a b o v e t h e age o f 6 5 ,
(iii) c o n c o m i t a n t l y r e c e i v i n g other o t o t o x i c drugs, 5. C h l o r o q u i n E f f e c t is s i m i l a r t o t h a t o f q u i n i n e a n d
(iv) w h o h a v e already r e c e i v e d a m i n o g l y c o s i d e a n t i b i o t i c s , p e r m a n e n t deafness c a n r e s u l t .
(v) w h o have genetic susceptibility to aminoglycosides.
6. C y t o t o x i c drugs N i t r o g e n mustard, cisplatin a n d car-
H e r e the antibiotic binds to the ribosome and inter-
b o p l a t i n c a n cause c o c h l e a r d a m a g e . T h e y a f f e c t t h e o u t e r
feres w i t h p r o t e i n synthesis, t h u s c a u s i n g d e a t h o f t h e
h a i r cells o f c o c h l e a .
c o c h l e a r cells.
7. Deferoxamine (Desferrioxamine) I t is an lron-
S y m p t o m s o f o t o t o x i c i t y — h e a r i n g loss, t i n n i t u s a n d / o r
c h e l a t i n g substance used i n the t r e a t m e n t o f thalassaemic
g i d d i n e s s — m a y manifest d u r i n g t r e a t m e n t o r after c o m -
patients w h o receive repeated b l o o d transfusions a n d i n
p l e t i o n o f the treatment (delayed t o x i c i t y ) .
t u r n have h i g h i r o n - l o a d . L i k e cisplatin and a m i n o g l y c o -
2. D i u r e t i c s F u r o s e m i d e a n d e t h a c r y n i c a c i d are called sides, d e f e r o x a m i n e also causes h i g h f r e q u e n c y s e n s o r i n e u -
loop diuretics as t h e y b l o c k t r a n s p o r t o f s o d i u m a n d c h l o r i d e ral h e a r i n g loss. O n s e t o f h e a r i n g loss is s u d d e n o r d e l a y e d .
i o n s i n t h e a s c e n d i n g l o o p o f H e n l e . T h e y are k n o w n t o I t is p e r m a n e n t b u t i n s o m e cases i t m a y b e r e v e r s i b l e w h e n
cause o e d e m a a n d c y s t i c c h a n g e s i n t h e stria vascularis of t h e d r u g is d i s c o n t i n u e d .
t h e c o c h l e a r d u c t . I n m o s t cases, t h e e f f e c t is reversible but
8. M i s c e l l a n e o u s I s o l a t e d cases o f deafness h a v e been
permanent damage m a y occur.
reported w i t h erythromycin, ampicillin and chloramphen-
3. Salicylates Symptoms of salicylate ototoxicity are icol, indomethacin, phenylbutazone, ibuprofen, tetanus
t i n n i t u s a n d b i l a t e r a l s e n s o r i n e u r a l h e a r i n g loss p a r t i c u l a r l y antitoxin, propranolol and propylthiouracil.
a f f e c t i n g h i g h e r frequencies. Site o f l e s i o n testing indicates A l c o h o l , t o b a c c o a n d m a r i j u a n a also cause d a m a g e to
cochlear i n v o l v e m e n t , b u t light and electron microscopy t h e i n n e r ear.
9 . T o p i c a l e a r d r o p s T o p i c a l use o f d r u g s i n t h e m i d d l e
Table 5.4 Permissible exposure in cases o f c o n t i n u o u s
ear c a n also cause d a m a g e t o t h e c o c h l e a b y absorption
noise or a n u m b e r o f s h o r t term exposures.
t h r o u g h o v a l a n d r o u n d w i n d o w s . D e a f n e s s has occurred [ G o v e r n m e n t o f India, Ministry o f Labour,
w i t h t h e use o f c h l o r h e x i d i n e w h i c h was used i n t h e p r e p a - Model Rules under Factories Act 1948
r a t i o n o f ear canal b e f o r e s u r g e r y o r use o f ear d r o p s c o n t a i n - (corrected up to 3 1 . 3 . 8 7 ) ]
i n g a m i n o - g l y c o s i d e a n t i b i o t i c s , e.g. n e o m y c i n , f r a m y c e t i n
N o i s e level* ( d B A ) Permitted daily e x p o s u r e ( h o u r s )
and gentamicin.
90 8.0

92 6.0

95 4.0
| D. Noise T r a u m a J
97 3,0
H e a r i n g loss associated w i t h e x p o s u r e t o n o i s e has b e e n
100 2.0
w e l l - k n o w n i n boiler makers, i r o n - a n d coppersmiths and
102 11/2
a r t i l l e r y m e n . L a t e l y , n o i s e t r a u m a has a s s u m e d g r e a t e r s i g -
105 1.0
n i f i c a n c e b e c a u s e o f its b e i n g a n o c c u p a t i o n a l h a z a r d ; t h e
compensations asked f o r a n d the responsibilities thrust 110 1/2

u p o n the e m p l o y e r and the employee to conserve hearing. 115 1/4

H e a r i n g loss c a u s e d b y e x c e s s i v e n o i s e c a n b e d i v i d e d i n t o *5 dB rule o f time-intensity states that "any rise o f 5 dB noise level

t w o groups: will reduce the permitted noise exposure time to half".

1. A c o u s t i c trauma Permanent damage to hearing can

b e c a u s e d b y a single brief exposure to very intense sound,
Frequency in Hertz
e.g. an explosion, g u n f i r e o r a p o w e r f u l cracker. Noise
125 250 500 1000 2000 4000 8000
level i n rifle or a g u n fire m a y reach 1 4 0 - 1 7 0 d B SPL.
S u d d e n l o u d s o u n d m a y d a m a g e o u t e r h a i r cells, d i s r u p t 0
the organ o f C o r t i and r u p t u r e the Reissner's membrane. 10
A severe blast m a y c o n c o m i t a n t l y r u p t u r e t y m p a n i c m e m - 20 K
b r a n e a n d d i s r u p t ossicular c h a i n . 30 V <

2. N o i s e - i n d u c e d hearing loss ( N I H L ) H e a r i n g loss,

40 \>
50
i n t h i s case, f o l l o w s chronic exposure t o less i n t e n s e sounds
60
t h a n seen i n a c o u s t i c t r a u m a a n d is m a i n l y a h a z a r d o f n o i s y
70
occupations.
80

(a) T e m p o r a r y t h r e s h o l d s h i f t T h e h e a r i n g is i m p a i r e d 90

i m m e d i a t e l y a f t e r e x p o s u r e t o n o i s e b u t r e c o v e r s after 100

an interval o f a f e w m i n u t e s to a f e w hours. 110

(b) Permanent threshold shift The hearing impair-

m e n t is p e r m a n e n t a n d d o e s n o t r e c o v e r at a l l . Figure 5.7

Early case o f n o i s e - i n d u c e d hearing loss. N o t e d i p a t 4 0 0 0 Hz.

T h e d a m a g e c a u s e d b y n o i s e t r a u m a d e p e n d s o n several
factors:

1. F r e q u e n c y o f noise A frequency o f 2 0 0 0 to 3000 H z

o f L a b o u r , G o v t , o f I n d i a - M o d e l R u l e s u n d e r Factories
causes m o r e d a m a g e t h a n l o w e r o r h i g h e r frequencies;
A c t . ( T a b l e 5 . 4 ) . N o e x p o s u r e i n excess o f 1 1 5 d B ( A ) is t o
2. Intensity and duration o f n o i s e As the intensity
be p e r m i t t e d . N o i m p u l s e noise o f intensity greater than
increases, p e r m i s s i b l e t i m e f o r exposure is reduced.
1 4 0 d B ( A ) is p e r m i t t e d .
T a b l e 5.4 gives the permissible l i m i t s o f t i m e f o r v a r i -
T h e a u d i o g r a m i n N I H L s h o w s a t y p i c a l n o t c h , at 4 k H z ,
o u s i n t e n s i t y levels f o r t h e safety o f ear;
b o t h f o r a i r a n d b o n e c o n d u c t i o n ( F i g . 5 . 7 ) . I t is u s u a l l y
3. Continuous vs interrupted noise Continuous
s y m m e t r i c a l o n b o t h sides. A t t h i s stage, p a t i e n t c o m p l a i n s
n o i s e is m o r e h a r m f u l ;
o f high pitched tinnitus and difficulty i n hearing i n noisy
4. Susceptibility o f the individual
s u r r o u n d i n g s b u t n o d i f f i c u l t y i n day t o d a y h e a r i n g . A s t h e
5. P r e - e x i s t i n g ear disease.
d u r a t i o n o f noise exposure increases, t h e n o t c h deepens
A n o i s e o f 9 0 d B ( A ) S P L , 8 h o u r s a d a y f o r 5 days p e r a n d also w i d e n s t o i n v o l v e l o w e r a n d h i g h e r frequencies.
w e e k is t h e m a x i m u m safe l i m i t as r e c o m m e n d e d b y M i n i s t r y H e a r i n g i m p a i r m e n t becomes clinically apparent to the
patient w h e n the frequencies o f 500, 1000 and 2000 H z s y p h i l i s , diabetes, h y p o t h y r o i d i s m , b l o o d disorders a n d l i p i d
( t h e s p e e c h f r e q u e n c i e s ) are also a f f e c t e d . p r o f i l e s . S o m e cases m a y r e q u i r e e x p l o r a t o r y tympano-
N I H L causes d a m a g e t o h a i r c e l l s , s t a r t i n g i n t h e basal t o m y w h e r e p e r i l y m p h f i s t u l a is s t r o n g l y s u s p e c t e d . W h e r e
t u r n o f c o c h l e a . O u t e r h a i r cells are a f f e c t e d b e f o r e the t h e cause s t i l l r e m a i n s o b s c u r e , t r e a t m e n t is e m p i r i c a l a n d
i n n e r h a i r cells. consists o f :
N o i s e - i n d u c e d h e a r i n g loss is p r e v e n t a b l e . P e r s o n s w h o
1. Bed rest.
h a v e t o w o r k at places w h e r e n o i s e is a b o v e 8 5 d B (A)
2. Steroid therapy Prednisolone 4 0 - 6 0 m g i n a single
should have p r e - e m p l o y m e n t and then annual audiograms
m o r n i n g dose f o r o n e w e e k a n d t h e n tailed o f f i n a
f o r e a r l y d e t e c t i o n . E a r p r o t e c t o r s (ear p l u g s o r ear m u f f s )
p e r i o d o f 3 w e e k s . S t e r o i d s are a n t i - i n f l a m m a t o r y a n d
s h o u l d b e u s e d w h e r e n o i s e l e v e l s e x c e e d 85 d B ( A ) . T h e y
relieve oedema. T h e y have b e e n f o u n d useful i n i d i o -
p r o v i d e p r o t e c t i o n u p t o 3 5 d B . I f h e a r i n g i m p a i r m e n t has
p a t h i c s u d d e n h e a r i n g loss o f m o d e r a t e degree.
a l r e a d y o c c u r r e d , r e h a b i l i t a t i o n is s i m i l a r t o t h a t e m p l o y e d
3. Inhalation of carbogen (5% C O , + 95% 0 )
2

f o r o t h e r s e n s o r i n e u r a l h e a r i n g losses.
It increases cochlear blood flow and improves
oxygenation.
4. Vasodilator drugs.
J E . Sudden Hearing Loss 5. L o w m o l e c u l a r w e i g h t d e x t r a n I t decreases b l o o d
v i s c o s i t y . I t is c o n t r a i n d i c a t e d i n c a r d i a c f a i l u r e a n d
I t is d e f i n e d as s e n s o r i n e u r a l h e a r i n g loss t h a t has d e v e l o p e d
b l e e d i n g disorders.
o v e r a p e r i o d o f h o u r s o r a f e w days. Loss m a y be p a r t i a l o r
6. Hyperbaric oxygen therapy Given i n the first
c o m p l e t e . M o s d y i t is u n i l a t e r a l . I t m a y b e accompanied
m o n t h o f o n s e t o f h e a r i n g loss, s o m e b e n e f i t s have
b y t i n n i t u s o r t e m p o r a r y spell o f v e r t i g o .
been claimed.
A e t i o l o g y M o s t o f t e n t h e cause o f s u d d e n deafness r e m a i n s
o b s c u r e , i n w h i c h case i t is c a l l e d t h e i d i o p a t h i c v a r i e t y . I n P r o g n o s i s F o r t u n a t e l y , a b o u t h a l f the patients o f i d i o -
s u c h cases, t h r e e a e t i o l o g i c a l f a c t o r s are considered—viral, pathic sensorineural h e a r i n g loss r e c o v e r spontaneously
vascular o r t h e rupture of cochlear membranes. Spontaneous w i t h i n 15 days. C h a n c e s o f r e c o v e r y are p o o r after 1 m o n t h .
p e r i l y m p h fistulae m a y f o r m i n the oval o r r o u n d w i n d o w . S e v e r e h e a r i n g loss a n d t h a t associated w i t h v e r t i g o h a v e
Other aetiological factors which cause s u d d e n deafness p o o r prognosis. Y o u n g e r patients b e l o w 40 a n d those w i t h
a n d m u s t b e e x c l u d e d are l i s t e d b e l o w . R e m e m b e r the m o d e r a t e losses h a v e b e t t e r prognosis.
m n e m o n i c " I n T h e V e r y Ear T o o N o M a j o r Pathology".

1. Infections Mumps, herpes zoster, meningitis,

£ F. Presbycusis
encephalitis, syphilis, otitis m e d i a .
2. Trauma H e a d i n j u r y , ear o p e r a t i o n s , n o i s e t r a u m a ,
Sensorineural h e a r i n g loss associated w i t h physiological
barotrauma, spontaneous rupture of cochlear
a g i n g p r o c e s s i n t h e ear is c a l l e d p r e s b y c u s i s . I t usually
membranes.
m a n i f e s t s at t h e age o f 6 5 years b u t m a y d o so e a r l y i f t h e r e
3. Vascular Haemorrhage (leukaemia), embolism or
is h e r e d i t a r y p r e d i s p o s i t i o n , c h r o n i c n o i s e e x p o s u r e o r g e n -
thrombosis o f labyrinthine or cochlear artery or their
e r a l i s e d v a s c u l a r disease.
vasospasm. T h e y m a y be associated w i t h diabetes,
Four pathological types of presbycusis have been
hypertension, polycythaemia, macroglobfnaemia or
identified.
sickle cell trait.
1. Sensory T h i s is c h a r a c t e r i s e d b y d e g e n e r a t i o n o f t h e
4. E a r ( o t o l o g i c ) M e n i e r e ' s disease, C o g a n ' s s y n d r o m e ,
o r g a n o f c o r t i , s t a r t i n g at t h e basal c o i l a n d progressing
large vestibular a q u e d u c t .
g r a d u a l l y t o t h e a p e x . H i g h e r f r e q u e n c i e s are a f f e c t e d b u t
5. T o x i c O t o t o x i c drugs, insecticides.
speech d i s c r i m i n a t i o n remains g o o d .
6. N e o p l a s t i c A c o u s t i c n e u r o m a . Metastases i n c e r e b e l -
l o p o n t i n e angle, c a r c i n o m a t o u s neuropathy. 2. N e u r a l T h i s is c h a r a c t e r i s e d b y d e g e n e r a t i o n o f the
7 Miscellaneous Multiple sclerosis, h y p o t h y r o i d i s m , cells o f s p i r a l g a n g l i o n , s t a r t i n g at t h e basal c o i l a n d p r o -
sarcoidosis. gressing t o the apex. N e u r o n s o f h i g h e r a u d i t o r y p a t h w a y s
8. Psychogenic. m a y also b e a f f e c t e d . T h i s m a n i f e s t s w i t h h i g h t o n e loss
b u t s p e e c h d i s c r i m i n a t i o n is p o o r a n d o u t o f p r o p o r t i o n t o
Management A s far as p o s s i b l e , t h e a e t i o l o g y o f s u d d e n
t h e p u r e t o n e loss.
h e a r i n g loss s h o u l d b e d i s c o v e r e d b y d e t a i l e d h i s t o r y , p h y s -
ical e x a m i n a t i o n and laboratory investigations. T h e inves- 3 . S t r i a l o r m e t a b o l i c T h i s is c h a r a c t e r i s e d b y a t r o p h y o f
t i g a t i o n s m a y i n c l u d e a u d i o m e t r y , v e s t i b u l a r tests, i m a g i n g stria vascularis i n all t u r n s o f cochlea. I n this, the p h y s i c a l
studies o f t e m p o r a l bones, sedimentation rate, tests f o r a n d c h e m i c a l processes o f e n e r g y p r o d u c t i o n are a f f e c t e d .
I t r u n s i n f a m i l i e s . A u d i o g r a m is flat b u t s p e e c h d i s c r i m i - i n v o l v e d is t h a t , i f a t o n e o f t w o i n t e n s i t i e s , o n e greater
n a t i o n is g o o d . t h a n t h e o t h e r , is d e l i v e r e d t o t w o ears s i m u l t a n e o u s l y ,
o n l y t h e ear w h i c h r e c e i v e s t o n e o f g r e a t e r i n t e n s i t y w i l l
4. C o c h l e a r conductive T h i s is d u e t o s t i f f e n i n g o f t h e
hear i t . T o d o t h i s test, t a k e t w o t u n i n g f o r k s o f e q u a l
basilar m e m b r a n e t h u s a f f e c t i n g its m o v e m e n t s . A u d i o g r a m
f r e q u e n c y , s t r i k e a n d k e e p t h e m say 2 5 c m f r o m e a c h ear.
is s l o p i n g t y p e .
P a t i e n t w i l l c l a i m t o h e a r i t i n t h e n o r m a l ear. N o w b r i n g
P a t i e n t s o f presbycusis h a v e g r e a t d i f f i c u l t y i n h e a r i n g i n
t h e t u n i n g f o r k o n t h e side o f f e i g n e d deafness t o w i t h i n
the presence o f b a c k g r o u n d noise t h o u g h t h e y m a y hear
8 c m , k e e p i n g t h e t u n i n g f o r k o n t h e n o r m a l side at t h e
w e l l i n q u i e t s u r r o u n d i n g s . T h e y m a y c o m p l a i n o f speech
same d i s t a n c e . The patient w i l l deny hearing anything
being heard b u t not understood. R e c r u i t m e n t phenomenon
e v e n t h o u g h t u n i n g f o r k o n n o r m a l side is w h e r e i t c o u l d
is p o s i t i v e a n d all t h e s o u n d s s u d d e n l y b e c o m e i n t o l e r a b l e
b e h e a r d e a r l i e r . A p e r s o n w i t h t r u e deafness s h o u l d c o n -
w h e n v o l u m e is r a i s e d . T i n n i t u s is a n o t h e r bothersome
t i n u e t o h e a r o n t h e n o r m a l side. P a t i e n t s h o u l d b e b l i n d -
p r o b l e m a n d i n s o m e i t is t h e o n l y c o m p l a i n t .
f o l d e d d u r i n g t h i s test.
Patients o f presbycusis can be h e l p e d b y a h e a r i n g aid.
T h i s same test c a n b e p e r f o r m e d w i t h a t w o - c h a n n e l
T h e y s h o u l d also h a v e lessons i n s p e e c h r e a d i n g t h r o u g h
a u d i o m e t e r u s i n g p u r e t o n e o r s p e e c h signals.
v i s u a l cues. C u r t a i l m e n t o f s m o k i n g a n d s t i m u l a n t s l i k e tea
a n d c o f f e e m a y h e l p t o decrease t i n n i t u s . 6. A c o u s t i c reflex threshold N o r m a l l y , stapedial r e f l e x
is e l i c i t e d at 70— l O O d B S L . I f p a t i e n t c l a i m s t o t a l deafness
but the reflex can be elicited, it indicates NOHL.
NON-ORGANIC HEARING LOSS (NOHL)
7. E l e c t r i c r e s p o n s e a u d i o m e t r y ( E R A ) I t is v e r y u s e -
f u l i n N O H L a n d c a n establish h e a r i n g a c u i t y o f t h e p e r s o n
I n t h i s t y p e o f h e a r i n g loss, t h e r e is n o o r g a n i c l e s i o n . I t is
to w i t h i n 5 - 1 O d B o f a c t u a l t h r e s h o l d s .
e i t h e r d u e t o m a l i n g e r i n g o r is p s y c h o g e n i c . I n t h e f o r m e r ,
u s u a l l y t h e r e is a m o t i v e t o c l a i m s o m e c o m p e n s a t i o n for
b e i n g e x p o s e d t o i n d u s t r i a l noises, h e a d i n j u r y o r o t o t o x i c
SOCIAL AND LEGAL ASPECTS OF
medication. Patient m a y present with any o f the three
HEARING LOSS
clinical situations:
(a) T o t a l h e a r i n g loss i n b o t h ears, (b) t o t a l loss i n o n l y
o n e ear o r (c) e x a g g e r a t e d loss i n o n e o r b o t h ears. T h e
J Hearing Loss and Deafness __J|
r e s p o n s i b i l i t y o f t h e p h y s i c i a n is t o f i n d o u t : Is t h e p a t i e n t
m a l i n g e r i n g ? I f so, w h a t is h i s a c t u a l t h r e s h o l d o f h e a r i n g ?
Hearing loss is i m p a i r m e n t o f h e a r i n g a n d its s e v e r i t y
T h i s is a c c o m p l i s h e d b y :
m a y v a r y f r o m m i l d t o severe o r p r o f o u n d , w h i l e t h e t e r m
1. H i g h index of suspicion S u s p i c i o n f u r t h e r rises w h e n deafness is u s e d , w h e n t h e r e is l i t t l e o r n o h e a r i n g at a l l . I n
the patient makes exaggerated efforts t o hear, f r e q u e n t l y s o m e c o u n t r i e s , t h i s r i g i d d i f f e r e n t i a t i o n is n o t m a d e . T h e y
m a k i n g r e q u e s t s t o repeat t h e q u e s t i o n o r p l a c i n g a c u p p e d use t h e t e r m deafness t o d e n o t e a n y d e g r e e o f h e a r i n g loss
h a n d t o t h e ear. i r r e s p e c t i v e o f its s e v e r i t y . I n 1 9 8 0 , W H O recommended
that the t e r m " d e a f s h o u l d be applied o n l y to those i n d i -
2. I n c o n s i s t e n t results o n r e p e a t p u r e t o n e a n d speech
v i d u a l s w h o s e h e a r i n g i m p a i r m e n t is so severe t h a t t h e y
a u d i o m e t r y t e s t s N o r m a l l y , t h e r e s u l t o f r e p e a t tests are
are u n a b l e t o b e n e f i t f r o m a n y t y p e o f a m p l i f i c a t i o n . A
w i t h i n ± 5 d B . A v a r i a t i o n g r e a t e r t h a n 15 d B is d i a g n o s t i c
s i m i l a r d e f i n i t i o n is u s e d i n o u r c o u n t r y w h i l e e x t e n d i n g
of N O H L .
benefits to the hearing handicapped.
3. A b s e n c e of shadow c u r v e N o m i a l l y , a shadow curve
can b e o b t a i n e d w h i l e t e s t i n g b o n e c o n d u c t i o n , i f t h e h e a l t h y
ear is n o t m a s k e d . T h i s is d u e t o transcranial t r a n s m i s s i o n o f Definition of D e a f
s o u n d t o t h e h e a l t h y ear. A b s e n c e o f this c u r v e i n a p a t i e n t
c o m p l a i n i n g o f u n i l a t e r a l deafness is diagnostic o f N O H L . (Ministry of Social Welfare, Government of India—
S c h e m e o f Assistance t o H e a r i n g H a n d i c a p ) .
4. Inconsistency in PTA and SRT Normally, pure
"The d e a f are t h o s e i n w h o m t h e sense o f h e a r i n g is
t o n e average ( P T A ) o f three speech frequencies (500, 1000
n o n - f u n c t i o n a l f o r o r d i n a r y purposes o f l i f e " . T h e y d o n o t
a n d 2 0 0 0 H z ) is w i t h i n 10 d B o f S R T . A n S R T better than
h e a r / u n d e r s t a n d s o u n d s at a l l e v e n w i t h a m p l i f i e d s p e e c h .
P T A b y m o r e than l O d B points to NOHL.
T h e cases i n c l u d e d i n t h e c a t e g o r y w i l l b e t h o s e h a v i n g
5. S t e n g e r test I t can be d o n e w i t h a pair o f identical h e a r i n g loss m o r e t h a n 9 0 d B i n t h e b e t t e r ear ( p r o f o u n d
t u n i n g forks or a double-channel audiometer. Principle i m p a i r m e n t ) o r t o t a l loss o f h e a r i n g i n b o t h ears.
T h e partially hearing are d e f i n e d as t h o s e f a l l i n g u n d e r T o e x e m p l i f y , i n j u r y (disease) t o t h e ear m a y result i n h e a r -

any o n e o f the f o l l o w i n g categories: i n g i m p a i m i e n t w h i c h , d e p e n d i n g o n its severity, w i l l affect

t h e i n d i v i d u a l ' s a b i l i t y t o hear a n d p e r f o r m c e r t a i n activities
Category Hearing acuity
(disability) a n d w i l l be t e m i e d as h a n d i c a p b y t h e society:
M i l d impairment M o r e than 30 b u t n o t m o r e than
Disease -» Impairment -> Disability - * Handicap.
45 d B i n better ear
Serious i m p a i r m e n t M o r e t h a n 45 b u t n o t m o r e t h a n
60 d B i n better ear Degree of Handicap [
Severe i m p a i r m e n t M o r e t h a n 60 b u t n o t m o r e t h a n
90 d B i n better ear. S o m e t i m e s i t is desired t o express t h e i m p a i r m e n t a n d h a n d i -
cap i n t e r m s o f p e r c e n t a g e f o r t h e purposes o f c o m p e n s a t i o n .
D i f f e r e n t c o u n t r i e s a n d professional b o d i e s h a v e a d o p t e d t h e i r
Degree of Hearing Loss ( W H O classification)
o w n system t o calculate this p e r c e n t a g e .

W H O (1980) r e c o m m e n d e d the f o l l o w i n g classification Frequency in Hertz (Hz)

o n t h e basis o f p u r e t o n e a u d i o g r a m t a k i n g t h e a v e r a g e o f 125 250 500 1000 2500 4000 8000

the thresholds o f hearing for frequencies o f 500, 1000 and 750 1500 3000 6000
-10
2 0 0 0 H z w i t h reference to I S O : R. 389-1970 (interna-
0
tional calibration o f audiometers).
10

I
Degree of hearing loss ( F i g . 5.8) 20
30
1. Mild 26-40 dB
-% 40
2. Moderate 41-55 dB
3. M o d e r a t e l y severe 56-70 dB '% 50
4. Severe 71-91 dB
(a

I
5. Profound M o r e than 91 dB
I 70
6. Total 80

F r o m t h i s i t is i m p l i e d t h a t t h e r e is n o apparent impair- | 90
m e n t o f h e a r i n g f r o m 0 t o 25 d B . 100
T h e d i s a b i l i t y t o u n d e r s t a n d s p e e c h w i t h d i f f e r e n t degrees
no
o f h e a r i n g loss is g i v e n i n T a b l e 5.5.
120

130
Impairment, Disability and H a n d i c a p s J
Minimal loss (1 5-25 dB) Mild loss (26-40 dB)
Moderate loss (41-55 dB) Moderately severe loss
W h e n a disease process strikes an o r g a n o r a system i t causes an (56-70 dB)
impairment e i t h e r i n s t r u c t u r e o r f u n c t i o n , b u t this i m p a i r m e n t Severe loss (71-91 dB) Profound loss (>91 dB]
m a y o r m a y n o t b e c o m e clinically manifested. W h e n i m p a i r -
m e n t affects t h e a b i l i t y t o p e r f o r m c e r t a i n f u n c t i o n s i n t h e Figure 5.8
range c o n s i d e r e d n o r m a l f o r that i n d i v i d u a l i t is called disabil-
Classification o f hearing loss. N i n e t y five percent o f p o p u l a t i o n
ity. T h e d i s a b i l i t y f u r t h e r restricts the duties a n d roles e x p e c t e d
has t h r e s h o l d s between - 1 0 and + 1 0 dB HL.
from an i n d i v i d u a l b y society a n d is called a handicap.

1 H e a r i n g loss a n d difficulty in h e a r i n g speech

H e a r i n g t h r e s h o l d in better ear Degree of impairment Ability to u n d e r s t a n d s p e e c h

(average o f 5 0 0 , 1000, 2000 Hz) (WHO classification)

0-25 N o t significant N o s i g n i f i c a n t d i f f i c u l t y w i t h f a i n t speech

26-40 Mild Difficulty w i t h f a i n t speech.

41-55 Moderate F r e q u e n t d i f f i c u l t y w i t h n o r m a l speech.

56-70 M o d e r a t e l y severe F r e q u e n t d i f f i c u l t y even w i t h l o u d speech.

71-91 Severe C a n u n d e r s t a n d o n l y s h o u t e d o r a m p l i f i e d speech.

A b o v e 91 Profound Usually c a n n o t u n d e r s t a n d even a m p l i f i e d speech.

Recommended categorisation and percentage of hearing impairment (Dept. o f Personnel, Govt, of India)

R e c o m m e n d a t i o n s a b o u t the categories a n d the tests required

1. R e c o m m e n d e d classification

S. n o . Category Type of impairment d B level a n d / o r Speech Percentage o f

discrimination impairment

1. |. M i l d hearing i m p a i r m e n t d B 26 t o 4 0 d B 80 t o 1 0 0 % in Less t h a n 4 0 %
in b e t t e r ear b e t t e r ear

2. II. M o d e r a t e hearing i m p a i r m e n t 4 1 t o 55 d B 5 0 t o 8 0 % in 40 to 50%

in b e t t e r ear b e t t e r ear

3. III. Severe h e a r i n g i m p a i r m e n t 56 t o 7 0 d B 40 t o 50% 50 to 75%

hearing i m p a i r m e n t
in b e t t e r ear

4. IV. ( a ) T o t a l deafness No hearing No discrimination 100%

( b ) N e a r t o t a l deafness 91 d B a n d above in 100%
-do-
b e t t e r ear
Less t h a n 4 0 %
(c) P r o f o u n d hearing 71 t o 90 d B 75 t o 1 0 0 %
Impairment in b e t t e r ear

(Pure t o n e average o f h e a r i n g in 5 0 0 , 1 0 0 0 a n d 2 0 0 0 H z by air c o n d u c t i o n s h o u l d be t a k e n as basis f o r c o n s i d e r a t i o n as per

t h e test r e c o m m e n d a t i o n s ) .
F u r t h e r i t s h o u l d be n o t e d t h a t :
( a ) W h e n t h e r e is o n l y an island o f h e a r i n g present in o n e o r t w o frequencies in b e t t e r ear, i t s h o u l d be c o n s i d e r e d as t o t a l
loss o f h e a r i n g .
( b ) W h e r e v e r there is n o response ( N R ) at any o f t h e 3 f r e q u e n c i e s ( 5 0 0 , 1 0 0 , 2 0 0 0 H z ) i t s h o u l d be c o n s i d e r e d as e q u i v a l e n t
t o 130 d B loss f o r t h e p u r p o s e s o f c l a s s i f i c a t i o n o f d i s a b i l i t y a n d in a r r i v i n g at t h e average. T h i s is based o n t h e f a c t t h a t
m a x i m u m i n t e n s i t y l i m i t s in m o s t o f t h e a u d i o m e t e r s is 110 d B a n d s o m e a u d i o m e t e r s have a d d i t i o n a l facilities f o r
2 0 d B for testing.
II. R e c o m m e n d a t i o n s a b o u t the categories o f disability ( H e a r i n g i m p a i r m e n t - P h y s i c a l a s p e c t o n l y - T e s t recommended).
(a) Pure t o n e a u d i o m e t r y ( I S O R 3 8 9 - 1 9 7 0 at present, is b e i n g used as A u d i o m e t r i c S t a n d a r d in m o s t o f t h e a u d i o m e t e r s .
H e n c e t h e a u d i o m e t e r s used in t e s t i n g s h o u l d be a c c o r d i n g l y c a l i b r a t e d ) . T h r e e f r e q u e n c y average at 5 0 0 , 1 0 0 0 and
2 0 0 0 H z b y A i r C o n d u c t i o n ( A . C . ) , w i l l be used f o r c a t e g o r i s a t i o n .
( b ) W h e r e v e r possible t h e p u r e t o n e a u d i o m e t r i c results s h o u l d be s u p p l e m e n t e d by t h e speech d i s c r i m i n a t i o n score-tested
at s e n s a t i o n level ( S . L . ) , i.e. t h e speech d i s c r i m i n a t i o n s test is c o n d u c t e d at 3 0 - 4 0 d B * t h e p a t i e n t ' s h e a r i n g t h r e s h o l d .
T h e s t i m u l i used be either p h o n e t i c a l l y b a l a n c e w o r d s (PB) o f t h e p a r t i c u l a r language o r its e q u i v a l e n t m a t e r i a l . A t
present o n l y a f e w I n d i a n languages have s t a n d a r d speech m a t e r i a l f o r t e s t i n g . H e n c e wherever t h e s t a n d a r d i s e d test
m a t e r i a l is n o t a v a i l a b l e , e i t h e r s t a n d a r d i s e d I n d i a n English Test c o u l d be m a d e use o f w i t h English k n o w i n g p o p u l a t i o n
o r e q u i v a l e n t m a t e r i a l t o PB, be used.
( c ) W h e r e v e r c h i l d r e n are tested a n d p u r e t o n e a u d i o m e t r y is n o t possible, free field t e s t i n g s h o u l d be e m p l o y e d .
S u g g e s t i o n s o f the facilities to be offered to the d i s a b l e d f o r rehabilitation.
Category I N o special benefits.
C a t e g o r y II C o n s i d e r e d f o r H e a r i n g A i d s at free o r c o n c e s s i o n a l costs o n l y .
C a t e g o r y III H e a r i n g aids, free o f c o s t o r at c o n c e s s i o n a l rates. J o b r e s e r v a t i o n - b e n e f i t o f special E m p l o y m e n t Exchange.
S c h o l a r s h i p s at S c h o o l . Single language f o r m u l a .
C a t e g o r y IV H e a r i n g Aids-facilities o f reservation-special e m p l o y m e n t exchange. Special facilities in schools like scholarships.
H e a r i n g a i d s - e x e m p t i o n f r o m 3 language f o r m u l a ( t o s t u d y in r e c o m m e n d e d single l a n g u a g e ) .
It is felt t h a t f o r c o n s i d e r a t i o n o f a d m i s s i o n u n d e r special c a t e g o r y f o r courses c o n d u c t e d by i n s t i t u t i o n s like I n d i a n I n s t i t u t e
o f T e c h n o l o g y ( I I T ) , I n d u s t r i a l T r a i n i n g I n s t i t u t e ( I T l ) a n d o t h e r s , categories I a n d II o n l y s h o u l d be c o n s i d e r e d f o r reservation
o f seats, p r o v i d e d they f u l f i l l the o t h e r e d u c a t i o n a l s t i p u l a t i o n s f o r t h e c o u r s e .
W e have c o n s i d e r e d t h e d i f f e r e n t types o f h e a r i n g a f f e c t i o n , i.e. c o n d u c t i v e versus s e n s o r i n e u r a l , a n d agree t h a t the d i s a b i l i t y
w i l l be j u d g e d by the c o n d i t i o n s prevalent in t h e p a t i e n t at t h e t i m e o f referral a n d e x a m i n a t i o n . In case o f f a i l u r e o f surgery o r
o t h e r t h e r a p e u t i c i n t e r v e n t i o n s , t h e p a t i e n t w i l l be c o n s i d e r e d a n d categorised o n the basis o f t h e r e c o m m e n d e d tests.

*Left blank is the original recommendations; has been added by the author.
 Hearing Loss

O n e o f t h e m e t h o d s t o f i n d h e a r i n g h a n d i c a p is g i v e n f e l t t h a t f r e q u e n c y o f 3 0 0 0 H z is i m p o r t a n t f o r h e a r i n g i n
below: t h e p r e s e n c e o f n o i s e a n d s h o u l d also b e t a k e n i n t o a c c o u n t .
A m e r i c a n A c a d e m y o f O p h t h a l m o l o g y and O t o l a r y n g o l o g y
(i) Take an audiogram and calculate the average of
recommends a n d takes i n t o a c c o u n t the average o f f o u r
thresholds o f h e a r i n g f o r frequencies o f 500, 1000
frequencies 500, 1000, 2 0 0 0 a n d 3 0 0 0 H z w h e n c a l c u l a t i n g
a n d 2 0 0 0 H z say = A .
the handicap.
(ii) D e d u c t f r o m i t 2 5 d B (as t h e r e is n o i m p a i r m e n t u p
Government o f India reserved certain percentage of
t o 25 d B ) , i.e. A - 2 5 .
vacancies i n G r o u p C a n d D i n f a v o u r o f t h e physically
(iii) M u l t i p l y i t b y 1.5, i . e . ( A - 2 5 ) X 1.5.
h a n d i c a p p e d a n d has e x t e n d e d c e r t a i n o t h e r b e n e f i t s . It
T h i s is t h e p e r c e n t a g e o f h e a r i n g i m p a i r m e n t f o r t h a t ear. has also r e c o m m e n d e d t h e c l a s s i f i c a t i o n based o n p e r c e n t -
S i m i l a r l y calculate t h e percentage o f h e a r i n g i m p a i r m e n t age o f i m p a i r m e n t a n d t h e test r e q u i r e d t o b e p e r f o r m e d
f o r t h e o t h e r ear. (see Table 5.6). (Brochure o n Reservations and conces-
T o t a l percentage handicap o f an i n d i v i d u a l sions f o r p h y s i c a l l y h a n d i c a p p e d i n c e n t r a l G o v t . S e r v i c e s
p u b l i s h e d b y M i n i s t r y o f Personnel, P u b l i c grievances and
( b e t t e r ear % X 5) + w o r s e ear%
pensions, D e p t . o f Personnel and T r a i n i n g ) .

Example: Unilateral Hearing Loss

500 H z 1000 H z 2000 H z Average

U n i l a t e r a l loss o f h e a r i n g , e v e n t h o u g h t o t a l , does n o t p r o -
R i g h t ear 60 75 90 75 d B
d u c e a serious h a n d i c a p o r affect s p e e c h b u t i t i m p a i r s l o c a l i -
L e f t ear 30 45 60 45 d B
sation o f the s o u n d source, d i f f i c u l t y i n d i s c r i m i n a t i o n o f
I m p a i r m e n t R t . ear: 7 5 — 2 5 = 5 0 ; 5 0 X 1.5 = 75%
speech i n the presence o f b a c k g r o u n d noise a n d some d i f -
I m p a i r m e n t L t . ear: 4 5 - 2 5 = 2 0 ; 2 0 X 1.5 = 30%
f i c u l t y at a m e e t i n g o r i n c l a s s r o o m w h e n t h e s p e a k e r is o n
(30X5)+75 223 t h e side o f a f f e c t e d ear. I t s h o u l d also a l e r t t h e i n d i v i d u a l
T o t a l handicap —
6 t h a t he does n o t h a v e a "spare o r r e s e r v e e a r " a n d has t o take

= 37.5% all p r e c a u t i o n s f o r t h e safety o f t h e o n l y h e a r i n g ear; also

= 3 8 % ( r o u n d e d off) t h e s u r g e o n s h o u l d b e c a r e f u l w h e n h e is c a l l e d u p o n t o
o p e r a t e o n t h i s o n l y h e a r i n g ear. B o n e - a n c h o r e d hearing

I n the a b o v e c a l c u l a t i o n o n l y three speech frequencies aids are t h e t r e a t m e n t o f c h o i c e f o r m a n a g e m e n t o f s i n g l e -

(500, 1000 a n d 2 0 0 0 H z ) are t a k e n i n t o a c c o u n t b u t i t is s i d e d deafness (see page 137).

ef
Assessment o f V e s t i b u l a r Functions

A s s e s s m e n t o f v e s t i b u l a r f u n c t i o n s c a n be d i v i d e d i n t o t w o l e s i o n is i n t h e c e n t r a l n e u r a l p a t h w a y s ( v e s t i b u l a r n u c l e i ,

groups: brainstem, cerebellum).

I r r i t a t i v e lesions o f t h e l a b y r i n t h (serous labyrinthitis)
A. C l i n i c a l tests
cause n y s t a g m u s t o t h e side o f l e s i o n . P a r e t i c l e s i o n s ( p u r u -
B. L a b o r a t o r y tests
lent labyrinthitis, trauma to labyrinth, section o f V I H t h
n e r v e ) cause n y s t a g m u s t o t h e h e a l t h y side. N y s t a g m u s o f
p e r i p h e r a l o r i g i n can b e suppressed b y o p t i c f i x a t i o n b y
A. Clinical Tests
l o o k i n g at a f i x e d p o i n t , a n d e n h a n c e d i n darkness o r b y
t h e use o f F r e n z e l glasses ( + 2 0 d i o p t r e glasses) b o t h of
1. Spontaneous Nystagmus
w h i c h abolish optic f i x a t i o n .
N y s t a g m u s is a n i m p o r t a n t s i g n i n t h e e v a l u a t i o n o f v e s t i -
Nystagmus o f central o r i g i n cannot be suppressed by
b u l a r s y s t e m . I t is d e f i n e d as i n v o l u n t a r y , r h y t h m i c a l , o s c i l -
o p t i c f i x a t i o n . P u r e l y torsional nystagmus indicates lesion o f
l a t o r y m o v e m e n t o f eyes. I t m a y b e h o r i z o n t a l , v e r t i c a l o r
t h e b r a i n s t e m / v e s t i b u l a r n u c l e i a n d is seen i n s y r i n g o m y -
r o t a t o r y . V e s t i b u l a r n y s t a g m u s has a s l o w a n d a fast c o m p o -
elia. Vertical downbeat n y s t a g m u s i n d i c a t e s l e s i o n at c r a n i o -
n e n t , a n d b y c o n v e n t i o n , t h e d i r e c t i o n o f n y s t a g m u s is
cervical r e g i o n such as A r n o l d - C h i a r i malformation or
i n d i c a t e d b y t h e d i r e c t i o n o f t h e fast c o m p o n e n t . I n t e n s i t y
d e g e n e r a t i v e l e s i o n o f t h e c e r e b e l l u m . Vertical upbeat n y s t a g -
o f n y s t a g m u s is i n d i c a t e d b y its d e g r e e ( T a b l e 6.1).
m u s is seen i n lesions at t h e j u n c t i o n o f p o n s a n d m e d u l l a o r
T o e l i c i t n y s t a g m u s , p a t i e n t is seated i n f r o n t o f t h e e x a m - p o n s a n d m i d - b r a i n . Pendular nystagmus is e i t h e r c o n g e n i t a l
i n e r o r lies s u p i n e o n t h e b e d . T h e e x a m i n e r keeps his f i n g e r o r a c q u i r e d . T h e l a t t e r is seen i n m u l t i p l e sclerosis. P e n d u l a r
about 30 c m from t h e p a t i e n t ' s eye i n t h e c e n t r a l p o s i t i o n n y s t a g m u s m a y also b e d i s c o n j u g a t e , i . e . v e r t i c a l i n o n e eye
a n d m o v e s i t t o t h e right o r left, u p o r d o w n , b u t n o t m o v - a n d h o r i z o n t a l i n the o t h e r . T a b l e 6.2 shows differences i n
i n g at a n y t i m e , m o r e t h a n 3 0 ° f r o m t h e c e n t r a l p o s i t i o n t o t h e n y s t a g m u s o f p e r i p h e r a l a n d c e n t r a l lesions.
a v o i d gaze n y s t a g m u s . Presence o f s p o n t a n e o u s nystagmus
always indicates an organic lesion.
V e s t i b u l a r n y s t a g m u s is c a l l e d peripheral, w h e n i t is d u e
t o l e s i o n o f l a b y r i n t h o r V I H t h n e r v e a n d central, when T a b l e 6.2 P o s i t i o n a l n y s t a g m u s in p e r i p h e r a l a n d cen-
t r a l lesions o f v e s t i b u l a r s y s t e m . P o s i t i o n a l
n y s t a g m u s is e l i c i t e d b y H a l l p i k e m a n o e u v r e
r
jSM Degree o f n y s t a g m u s *
(vide infra)
1 st degree It is weak nystagmus a n d is present w h e n
Peripheral Central
patient looks in the direction o f fast c o m p o n e n t .
Latency 2 - 2 0 seconds N o latency
2 n d degree It is s t r o n g e r t h a n the 1 st degree n y s t a g m u s
a n d is present w h e n p a t i e n t l o o k s s t r a i g h t Duration Less t h a n 1 m i n u t e More than 1 minute
ahead. Direction o f D i r e c t i o n fixed, Direction changing
3 r d degree I t is s t r o n g e r t h a n 2 n d degree n y s t a g m u s a n d nystagmus t o w a r d s the
is present even w h e n p a t i e n t l o o k s in t h e u n d e r m o s t ear
d i r e c t i o n o f the s l o w c o m p o n e n t . Fatiguability Fatiguable Non-fatiguable

*These degrees are according to Alexander's law and may not Accompanying Severe v e r t i g o N o n e o r slight
hold true in case o f nystagmus o f central origin. symptoms
 Assessment of Vestibular Functions

2. Fistula Test 6, Hallpike Manoeuvre (Positional Test)

T h e basis o f t h i s test is t o i n d u c e n y s t a g m u s b y p r o d u c i n g T h i s test is p a r t i c u l a r l y u s e f u l w h e n p a t i e n t c o m p l a i n s of

pressure c h a n g e s i n t h e e x t e r n a l canal w h i c h are t h e n t r a n s - v e r t i g o i n c e r t a i n h e a d p o s i t i o n s . I t also h e l p s t o d i f f e r e n t i -
m i t t e d t o t h e l a b y r i n t h . S t i m u l a t i o n o f l a b y r i n t h results i n ate a p e r i p h e r a l f r o m a c e n t r a l l e s i o n .
n y s t a g m u s a n d v e r t i g o . T h e test is p e r f o r m e d b y a p p l y i n g
Method Patient sits o n a couch. Examiner holds the
i n t e r m i t t e n t pressure o n t h e tragus o r b y u s i n g Siegle's
p a t i e n t ' s h e a d , t u r n s i t 4 5 ° t o t h e right a n d t h e n places t h e
s p e c u l u m . N o r m a l l y , t h e test is n e g a t i v e because t h e p r e s -
p a t i e n t i n a s u p i n e p o s i t i o n so t h a t his h e a d h a n g s 3 0 ° b e l o w
sure c h a n g e s i n t h e e x t e r n a l a u d i t o r y canal c a n n o t be t r a n s -
the h o r i z o n t a l (Fig. 6.1). P a t i e n t ' s eyes are o b s e r v e d for
m i t t e d t o t h e l a b y r i n t h . I t is p o s i t i v e w h e n t h e r e is e r o s i o n
n y s t a g m u s . T h e test is r e p e a t e d w i t h h e a d t u r n e d t o l e f t a n d
o f h o r i z o n t a l s e m i c i r c u l a r canal as i n c h o l e s t e a t o m a o r a
t h e n again i n straight h e a d - h a n g i n g p o s i t i o n . F o u r p a r a m -
surgically-created w i n d o w i n t h e h o r i z o n t a l canal (fenes-
eters o f n y s t a g m u s are o b s e r v e d : latency, duration, direction
tration operation), abnormal o p e n i n g i n the oval w i n d o w
a n d fatiguability (sec T a b l e 6 . 2 ) . I n b e n i g n p a r o x y s m a l p o s i -
(post-stapedectomy fistula) o r t h e r o u n d w i n d o w ( r u p t u r e
tional vertigo, nystagmus appears after a l a t e n t p e r i o d of
o f r o u n d w i n d o w m e m b r a n e ) . A p o s i t i v e f i s t u l a also i m p l i e s
2—20 seconds, lasts f o r less t h a n a m i n u t e a n d is a l w a y s i n
t h a t t h e l a b y r i n t h is s t i l l f u n c t i o n i n g ; i t is absent w h e n l a b y -
o n e d i r e c t i o n , i.e. t o w a r d s t h e ear t h a t is u n d e r m o s t . On
rinth is d e a d . A false negative fistula test is also seen w h e n
r e p e t i t i o n o f t h e test, n y s t a g m u s m a y still b e e l i c i t e d b u t
c h o l e s t e a t o m a c o v e r s t h e site o f f i s t u l a a n d does n o t a l l o w
lasts f o r a s h o r t e r p e r i o d . O n s u b s e q u e n t r e p e t i t i o n s i t d i s -
pressure c h a n g e s t o b e t r a n s m i t t e d t o t h e l a b y r i n t h .
appears a l t o g e t h e r , i.e. n y s t a g m u s is f a t i g u a b l e . P a t i e n t also
A false positive fistula test ( i . e . p o s i t i v e f i s t u l a test w i t h o u t c o m p l a i n s o f v e r t i g o w h e n t h e h e a d is i n c r i t i c a l p o s i t i o n .
t h e p r e s e n c e o f a f i s t u l a ) is seen i n c o n g e n i t a l s y p h i l i s a n d I n c e n t r a l lesions ( t u m o u r s o f I V t h v e n t r i c l e , cerebel-
i n a b o u t 2 5 % cases o f M e n i e r e ' s disease (Hcnncbert's sign). lum, temporal lobe, m u l t i p l e sclerosis, vertebrobasilar
I n c o n g e n i t a l s y p h i l i s , stapes f o o t p l a t e is h y p e r m o b i l e w h i l e i n s u f f i c i e n c y o r raised i n t r a c r a n i a l t e n s i o n ) nystagmus is
i n M e n i e r e ' s disease i t is d u e t o t h e f i b r o u s b a n d s c o n n e c t - p r o d u c e d i m m e d i a t e l y , as s o o n as t h e h e a d is i n c r i t i c a l
i n g u t r i c u l a r m a c u l a t o t h e stapes f o o t p l a t e . I n b o t h these
c o n d i t i o n s , m o v e m e n t s o f stapes r e s u l t i n s t i m u l a t i o n o f t h e
utricular macula.

3. Romberg Test

T h e p a t i e n t is a s k e d t o s t a n d w i t h f e e t t o g e t h e r , a n d a m i s
b y t h e side w i t h eyes f i r s t o p e n a n d t h e n c l o s e d . W i t h t h e
eyes o p e n , p a t i e n t c a n s t i l l c o m p e n s a t e t h e i m b a l a n c e but
w i t h eyes c l o s e d , v e s t i b u l a r s y s t e m is at m o r e disadvantage.
I n p e r i p h e r a l v e s t i b u l a r lesions, t h e p a t i e n t sways t o the
side o f l e s i o n . I n c e n t r a l v e s t i b u l a r d i s o r d e r , p a t i e n t s h o w s
i n s t a b i l i t y . I f p a t i e n t c a n p e r f o r m t h i s test w i t h o u t sway,
"sharpened Romberg test", is p e r f o r m e d . In this the
p a t i e n t stands w i t h one heel i n front o f toes a n d arms
f o l d e d across t h e c h e s t . I n a b i l i t y t o p e r f o r m t h e sharpened
R o m b e r g test i n d i c a t e s v e s t i b u l a r i m p a i r m e n t .

4. Gait

T h e p a t i e n t is a s k e d t o w a l k a l o n g a s t r a i g h t l i n e t o a f i x e d
p o i n t , first w i t h eyes o p e n a n d t h e n c l o s e d . I n case of
uncompensated lesion o f peripheral vestibular system,
w i t h eyes c l o s e d , t h e p a t i e n t d e v i a t e s t o t h e a f f e c t e d side.

5. Past-pointing and Falling

T h e past-pointing, falling and slow c o m p o n e n t o f nystag-

m u s are a l l i n t h e s a m e d i r e c t i o n . I f t h e r e is a c u t e v e s t i b u -
lar f a i l u r e , say o n t h e right side, n y s t a g m u s is t o t h e l e f t b u t Figure 6.1
the p a s t - p o i n t i n g a n d f a l l i n g w i l l be t o w a r d s the r i g h t , i.e.
Hallpike manoeuvre.
t o w a r d s side o f t h e s l o w component.
Diseases of Ear

p o s i t i o n w i t h o u t a n y l a t e n c y a n d lasts as l o n g as h e a d is i n
t h a t c r i t i c a l p o s i t i o n . D i r e c t i o n o f n y s t a g m u s also v a r i e s i n
d i f f e r e n t test p o s i t i o n s ( d i r e c t i o n c h a n g i n g ) a n d is n o n -
f a t i g u a b l e o n r e p e t i t i o n o f test ( T a b l e 6.2).

Test of Cerebellar Dysfunction

A l l cases o f g i d d i n e s s s h o u l d b e t e s t e d f o r c e r e b e l l a r d i s o r -
ders. Disease o f t h e c e r e b e l l a r h e m i s p h e r e causes:

(i) A s y n e r g i a ( a b n o r m a l f m g e r - n o s e test)
(n) D y s m e t r i a (inability to c o n t r o l range o f m o t i o n )
(iii) A d i a d o c h o k i n e s i a (inability t o p e r f o r m rapid alter-
nating movements)
(iv) R e b o u n d p h e n o m e n o n (inability to control m o v e -
m e n t o f e x t r e m i t y w h e n o p p o s i n g f o r c e f u l r e s t r a i n t is
s u d d e n l y released)
Utricle
M i d l i n e disease o f c e r e b e l l u m causes: 30°C

(i) W i d e base g a i t
(ii) Falling i n any d i r e c t i o n Horizontal SCC
(iii) Inability to make sudden turns w h i l e w a l k i n g
(iv) T r u n c a l ataxia

N y s t a g m u s observed i n m i d l i n e or hemispheral disorders

F i g u r e 6.2
o f c e r e b e l l u m i n c l u d e s gaze e v o k e d n y s t a g m u s , r e b o u n d
nystagmus and a b n o r m a l o p t o k i n e t i c nystagmus. F i t z g e r a l d - H a l l p i k e test. ( A ) Patient is in s u p i n e p o s i t i o n
and head raised by 3 0 ° t o m a k e h o r i z o n t a l c a n a l v e r t i c a l .
( B ) P o s i t i o n o f canal a n d the d i r e c t i o n o f f l o w o f e n d o l y m p h .
B. Laboratory Tests of Vestibular Function

1. Caloric Test
p o i n t o f n y s t a g m u s is r e c o r d e d a n d c h a r t e d o n a calorigram
T h e basis o f this test is t o i n d u c e n y s t a g m u s b y t h e m i a l s t i m -
(Fig. 6 . 3 ) . I f n o n y s t a g m u s is e l i c i t e d f r o m a n y ear, test is
u l a t i o n o f t h e v e s t i b u l a r s y s t e m . A d v a n t a g e o f t h e test is t h a t
r e p e a t e d w i t h w a t e r at 2 0 ° C f o r 4 m i n u t e s b e f o r e l a b e l l i n g
e a c h l a b y r i n t h c a n b e tested separately. P a t i e n t is also asked
t h e l a b y r i n t h d e a d . A gap o f 5 m i n u t e s s h o u l d b e a l l o w e d
w h e t h e r v e r t i g o i n d u c e d b y t h e c a l o r i c test is q u a l i t a t i v e l y
b e t w e e n t w o ears. C o l d w a t e r i n d u c e s n y s t a g m u s t o o p p o -
similar t o the type experienced b y h i m d u r i n g the episode o f
site side a n d w a r m w a t e r t o t h e same side ( r e m e m b e r m n e -
v e r t i g o . I f yes, i t p r o v e s l a b y r i n t h i n e o r i g i n o f v e r t i g o .
monic C O W S : Cold-Opposite, Warm-Same). Depending
( a ) M o d i f i e d K o b r a k t e s t I t is a q u i c k o f f i c e p r o c e d u r e . o n response t o t h e c a l o r i c test, w e c a n f i n d c a n a l paresis o r
P a t i e n t is seated w i t h h e a d t i l t e d 6 0 ° b a c k w a r d s t o p l a c e d e a d l a b y r i n t h , d i r e c t i o n a l p r e p o n d e r a n c e , i . e . n y s t a g m u s is
h o r i z o n t a l canal i n v e r t i c a l p o s i t i o n . E a r is i r r i g a t e d w i t h ice m o r e i n one particular direction than i n the other, or b o t h
w a t e r f o r 60 seconds, first with 5 m l a n d i f t h e r e is n o canal paresis a n d d i r e c t i o n a l p r e p o n d e r a n c e .
response, 10 m l , 2 0 m l a n d 4 0 m l . N o r m a l l y , nystagmus
Canal paresis. I t i n d i c a t e s t h a t response ( m e a s u r e d as d u r a -
b e a t i n g t o w a r d s t h e o p p o s i t e ear, w i l l b e seen w i t h 5 m l o f
t i o n o f n y s t a g m u s ) e l i c i t e d from a p a r t i c u l a r canal ( l a b y r i n t h ) ,
i c e w a t e r . I f response is seen w i t h increased q u a n t i t i e s o f
r i g h t o r l e f t , after s t i m u l a t i o n w i t h c o l d a n d w a r m w a t e r is
w a t e r b e t w e e n 5 a n d 4 0 m l , l a b y r i n t h is c o n s i d e r e d h y p o a c -
less t h a n t h a t from t h e o p p o s i t e side. I t can also b e expressed
t i v e . N o response t o 4 0 m l w a t e r i n d i c a t e s d e a d l a b y r i n t h .
as p e r c e n t a g e o f t h e t o t a l response f r o m b o t h ears.

(b) F i t z g e r a l d - H a l l p i k e test ( b i t h e r m a l c a l o r i c test)

I n t h i s test, p a t i e n t lies s u p i n e w i t h h e a d t i l t e d 3 0 ° f o r w a r d L„+L .X100 4

R e s p o n s e f r o m t h e l e f t ear =
so t h a t h o r i z o n t a l c a n a l is v e r t i c a l ( F i g . 6 . 2 ) . Ears are i r r i -
g a t e d f o r 4 0 s e c o n d s a l t e r n a t e l y w i t h w a t e r at 3 0 ° C a n d at
4 4 ° C (i.e. 7 ° b e l o w a n d above n o r m a l b o d y temperature)
a n d eyes o b s e r v e d f o r a p p e a r a n c e o f n y s t a g m u s t i l l its e n d R e s p o n s e from t h e r i g h t ear =
p o i n t . T i m e t a k e n f r o m t h e start o f i r r i g a t i o n t o t h e e n d
 Assessment of Vestibular Functions

X(120 sec] B X (70 sec)

L L I i • I ll i I i i I
R
30 + L
44
J i 1 I L Left beating nystagmus = X100
30°C' X (120 sec) 30°C( X (120 sec) L
30 + L
4 + R
3n + R
44
I I
4
X
RI i i I i i I i i N
RI i i i i l i I
X (110 sec) X (60 sec)
. i l l ' I l_i i I I ' I i i I I f t h e n y s t a g m u s is 2 5 - 3 0 % o r m o r e o n o n e side t h a n t h e
X (120 sec)
44°c; X (110 sec) 44°C o t h e r , i t is c a l l e d d i r e c t i o n a l p r e p o n d e r a n c e t o t h a t side.
R I L R I—L I I I i I
It is b e l i e v e d that directional preponderance occurs
Normal Left conal paresis
t o w a r d s t h e side o f a c e n t r a l l e s i o n , a w a y f r o m t h e side i n
a p e r i p h e r a l l e s i o n ; h o w e v e r i t does n o t h e l p t o l o c a l i s e t h e
lesion i n central vestibular pathways.
30°c: X (12C )sec)
C a n a l paresis a n d d i r e c t i o n a l p r e p o n d e r a n c e c a n also b e
, 1 i i 1
X(1H D sec) seen t o g e t h e r .
1 1 1 1 1 1 1 i I 1
C a n a l paresis o n o n e side w i t h d i r e c t i o n a l p r e p o n d e r -
44°C;
X (50 sec}
1 i i Ii i i 1 i i 1
a n c e t o t h e o p p o s i t e side is seen i n u n i l a t e r a l Meniere's

Left directional preponderance disease w h i l e c a n a l paresis w i t h d i r e c t i o n a l p r e p o n d e r a n c e

t o i p s i l a t e r a l side is seen i n a c o u s t i c n e u r o m a .
Figure 6.3 ( c ) C o l d - a i r c a l o r i c t e s t T h i s test is d o n e w h e n t h e r e is

Calorigram. p e r f o r a t i o n o f t y m p a n i c m e m b r a n e because i r r i g a t i o n w i t h

A. N o r m a l : Responses f r o m b o t h l a b y r i n t h s are a l m o s t same w a t e r i n s u c h a case w i t h p e r f o r a t i o n is c o n t r a i n d i c a t e d .

w i t h b o t h c o l d a n d w a r m w a t e r . C o l d w a t e r is usually a
s t r o n g e r s t i m u l u s t h a n the w a r m o n e .
B. Left c a n a l paresis. Responses f r o m left l a b y r i n t h b o t h w i t h
c o l d a n d w a r m w a t e r are m u c h less c o m p a r e d t o t h o s e
f r o m right.
The test e m p l o y s D u n d a s G r a n t t u b e w h i c h is a c o i l e d
c o p p e r t u b e w r a p p e d i n c l o t h . T h e a i r i n t h e t u b e is c o o l e d
b y p o u r i n g e t h y l c h l o r i d e , a n d t h e n b l o w n i n t o t h e ear. I t
is o n l y a r o u g h q u a l i t a t i v e test.

7 0 + 60 130 2. Electronystagmography
(L) Left canal paresis
70 + 120 + 60 + 120 370
I t is a m e t h o d o f d e t e c t i n g a n d r e c o r d i n g o f n y s t a g m u s

1 2 0 + 120 240 w h i c h is s p o n t a n e o u s or i n d u c e d b y caloric, positional,

(R) rotational or optokinetic stimulus. T h e test d e p e n d s on
70 + 120 + 60 + 120 370
t h e p r e s e n c e o f c o r n e o r e t i n a l p o t e n t i a l s w h i c h are r e c o r d e d
C. Left d i r e c t i o n a l p r e p o n d e r a n c e . Nystagmus to left is
b y p l a c i n g e l e c t r o d e s at s u i t a b l e places r o u n d t h e eyes. T h e
2 3 0 sec c o m p a r e d t o t h e o n e d i r e c t e d t o r i g h t at 1 4 0 .
test is also u s e f u l t o d e t e c t n y s t a g m u s w h i c h is n o t seen
120-110 230 Left d i r e c t i o n a l w i t h t h e n a k e d e y e . I t also p e r m i t s t o k e e p a p e r m a n e n t
( )
L
9 0 + 1 2 0 + 110 + 50 370 preponderance record o f nystagmus.

9 0 + 50 140
(R) 90 + 120 + 110 + 50 370
3. Optokinetic Test

P a t i e n t is asked t o f o l l o w a series o f v e r t i c a l stripes o n a

d r u m m o v i n g first f r o m r i g h t to left a n d t h e n f r o m left to
where L is t h e r e s p o n s e f r o m l e f t side w i t h w a t e r at 3 0 ° C
right. N o r m a l l y it produces nystagmus w i t h s l o w c o m p o -
and L 4 4 is r e s p o n s e f r o m l e f t ear a f t e r s t i m u l a t i o n w i t h
n e n t i n t h e d i r e c t i o n o f m o v i n g stripes a n d fast c o m p o n e n t
w a r m w a t e r at 4 4 ° C . Less o r n o r e s p o n s e from a p a r t i c u l a r
in the opposite direction. O p t o k i n e t i c abnormalities are
side is i n d i c a t i v e o f d e p r e s s e d f u n c t i o n o f t h e i p s i l a t e r a l
seen i n b r a i n s t e m a n d c e r e b r a l h e m i s p h e r e lesions. Thus
l a b y r i n t h , v e s t i b u l a r n e r v e o r v e s t i b u l a r n u c l e i a n d is seen i n
t h i s test is u s e f u l t o d i a g n o s e a c e n t r a l l e s i o n .
M e n i e r e ' s disease, a c o u s t i c n e u r o m a , p o s t - l a b y r i n t h e c t o m y
or vestibular nerve section.
4. Rotation Test
Directional preponderance. I t takes i n t o c o n s i d e r a t i o n the
duration o f nystagmus to the right or left i r r e s p e c t i v e of P a t i e n t is seated i n B a r a n y ' s r e v o l v i n g c h a i r w i t h his h e a d
w h e t h e r i t is e l i c i t e d f r o m t h e r i g h t o r l e f t l a b y r i n t h . We t i l t e d 3 0 ° f o r w a r d a n d t h e n r o t a t e d 10 t u r n s i n 2 0 seconds.
k n o w that: The c h a i r is s t o p p e d a b r u p t l y a n d n y s t a g m u s observed.
R i g h t b e a t i n g n y s t a g m u s is c a u s e d b y L „ a n d R 4 4 and N o r m a l l y t h e r e is n y s t a g m u s f o r 2 5 - 4 0 seconds. T h e test is
l e f t b e a t i n g n y s t a g m u s is caused b y R and L . Therefore: u s e f u l as i t c a n be p e r f o r m e d i n cases o f c o n g e n i t a l abnor-
m a l i t i e s w h e r e ear canal has f a i l e d t o d e v e l o p a n d i t is n o t

R i g h t beating nystagmus = X 100 possible t o p e r f o r m t h e c a l o r i c test. D i s a d v a n t a g e o f t h e test

is t h a t b o t h t h e l a b y r i n t h s are s i m u l t a n e o u s l y s t i m u l a t e d
d u r i n g t h e r o t a t i o n process a n d c a n n o t b e tested i n d i v i d u - N o r m a l l y , p e r s o n sways t o w a r d s t h e side o f a n o d a l c u r r e n t .
a l l y . T h e test has n o w b e e n m a d e m o r e s o p h i s t i c a t e d b y t h e B o d y s w a y c a n b e s t u d i e d b y a special p l a t f o r m .
use o f t o r s i o n s w i n g s , e l e c t r o n y s t a g m o g r a p h y a n d c o m p u t e r
analysis o f t h e results. 6. Posturography

I t is a m e t h o d t o e v a l u a t e v e s t i b u l a r f u n c t i o n b y m e a s u r i n g
5. Galvanic Test
p o s t u r a l s t a b i l i t y a n d is based o n t h e fact t h a t m a i n t e n a n c e of
I t is t h e o n l y v e s t i b u l a r test w h i c h h e l p s i n d i f f e r e n t i a t i n g p o s t u r e d e p e n d s o n t h r e e sensory i n p u t s — v i s u a l , v e s t i b u l a r
an e n d o r g a n lesion f r o m that o f vestibular nerve. Patient and somatosensory. I t uses e i t h e r a f i x e d o r a m o v i n g p l a t -
stands w i t h h i s feet t o g e t h e r , eyes c l o s e d a n d a r m s out- f o r m . V i s u a l cues c a n also b e v a r i e d . T h e c l i n i c a l a p p l i c a t i o n
s t r e t c h e d a n d t h e n a c u r r e n t o f 1 m A is passed t o o n e ear. o f p o s t u r o g r a p h y is s t i l l u n d e r i n v e s t i g a t i o n .
Disorders o f V e s t i b u l a r System

D i s o r d e r s o f v e s t i b u l a r s y s t e m cause v e r t i g o a n d are d i v i d e d c e r t a i n c r i t i c a l p o s i t i o n . T h e r e is n o h e a r i n g loss o r o t h e r

into: neurologic symptoms. Positional testing establishes the
diagnosis a n d helps t o d i f f e r e n t i a t e i t f r o m p o s i t i o n a l v e r -
A . Peripheral w h i c h i n v o l v e vestibular e n d organs a n d
t i g o o f central o r i g i n (Table 7.1). Disease is c a u s e d b y a
t h e i r first o r d e r neurons (i.e. t h e v e s t i b u l a r n e r v e ) . The
disorder of posterior semicircular canal though many
cause lies i n t h e i n t e r n a l ear o r t h e V I H t h n e r v e . T h e y are
p a t i e n t s h a v e h i s t o r y o f h e a d t r a u m a a n d ear i n f e c t i o n .
r e s p o n s i b l e f o r 8 5 % o f a l l cases o f v e r t i g o .
I t has b e e n d e m o n s t r a t e d t h a t o t o c o n i a l d e b r i s , c o n s i s t -
B. Central w h i c h i n v o l v e central n e r v o u s system after
i n g o f crystals o f c a l c i u m c a r b o n a t e , is released f r o m the
the entrance o f vestibular nerve i n the brainstem and
d e g e n e r a t i n g m a c u l a o f t h e u t r i c l e a n d floats f r e e l y i n t h e
involve vestibulo-ocular, vestibulospinal and other cen-
endolymph. When i t settles o n t h e c u p u l a o f p o s t e r i o r
tral n e r v o u s system pathways.
s e m i c i r c u l a r canal i n a c r i t i c a l h e a d p o s i t i o n , i t causes d i s -
T a b l e 7 . 1 lists t h e c o m m o n causes o f v e r t i g o o f p e r i p h - p l a c e m e n t o f t h e c u p u l a a n d v e r t i g o . T h e v e r t i g o is f a t i g u -
eral a n d c e n t r a l o r i g i n . able o n assuming the same p o s i t i o n r e p e a t e d l y due to
dispersal o f t h e o t o c o n i a b u t c a n b e i n d u c e d a g a i n a f t e r a
p e r i o d o f rest. T h u s , t y p i c a l h i s t o r y a n d H a l l p i k e m a n o e u v r e
A. PERIPHERAL VESTIBULAR DISORDERS
establishes t h e d i a g n o s i s .
The c o n d i t i o n can be treated b y p e r f o r m i n g E p l e y ' s
1. M e n i e r e ' s disease ( e n d o l y m p h a t i c hydrops) I t is m a n o e u v r e . T h e p r i n c i p l e o f t h i s m a n o e u v r e is t o r e p o -
c h a r a c t e r i s e d b y v e r t i g o , f l u c t u a t i n g h e a r i n g loss, t i n n i t u s sition the o t o c o n i a l debris f r o m the posterior semicircular
a n d sense o f p r e s s u r e i n t h e i n v o l v e d ear. V e r t i g o is o f s u d - canal b a c k i n t o t h e u t r i c l e . T h e d o c t o r stands b e h i n d t h e
d e n o n s e t , lasts f o r a f e w m i n u t e s t o 2 4 h o u r s o r so. (The p a t i e n t a n d t h e assistant o n t h e s i d e . T h e p a t i e n t is m a d e t o
disease has b e e n discussed o n p a g e 111). sit o n t h e table so that w h e n he is m a d e t o l i e d o w n , his head
is b e y o n d t h e e d g e o f t h e t a b l e as is d o n e i n D i x - H a l l p i k e
2. B e n i g n paroxysmal positional vertigo ( B P P V ) It
m a n o e u v r e . H i s face is t u r n e d 4 5 ° t o t h e a f f e c t e d side.
is c h a r a c t e r i s e d b y v e r t i g o w h e n t h e h e a d is p l a c e d i n a
T h e m a n o e u v r e consists o f f i v e p o s i t i o n s .

Position 1. W i t h t h e h e a d t u r n e d 4 5 ° , t h e p a t i e n t is m a d e
Table 7.1 Vestibular disorders
to lie d o w n i n h e a d - h a n g i n g p o s i t i o n ( D i x -
Peripheral ( L e s i o n s o f end Central (Lesions of brainstem H a l l p i k e m a n o e u v r e ) . I t w i l l cause v e r t i g o a n d
o r g a n s vestibular nerve) and central connections) nystagmus. W a i t till vertigo and nystagmus

• M e n i e r e ' s disease V e r t e b r o b a s i l a r insufficiency subside.

• Benign p a r o x y s m a l Posterior i n f e r i o r cerebellar P o s i t i o n 2. H e a d is n o w t u r n e d so t h a t a f f e c t e d ear is u p .

positional vertigo artery syndrome Position 3. The w h o l e b o d y a n d h e a d are n o w r o t a t e d

• Vestibular neuronitis Basilar m i g r a i n e a w a y f r o m t h e a f f e c t e d ear t o a lateral r e c u m -
• Labyrinthitis C e r e b e l l a r disease bent position i n a face-down position.
• Vestibulotoxic drugs M u l t i p l e sclerosis Position 4. P a t i e n t is n o w b r o u g h t t o a s i t t i n g p o s i t i o n
• Head t r a u m a Tumours o f brainstem and
w i t h head still t u r n e d t o the unaffected side
• Perilymph fistula f o u r t h ventricle
by 45°.
• Syphilis Epilepsy
Position 5. The head is n o w t u r n e d f o r w a r d a n d chin
• Acoustic neuroma Cervical v e r t i g o
brought d o w n 20°.
 T h e r e s h o u l d b e a pause at e a c h p o s i t i o n t i l l t h e r e is n o causes i n t e r m i t t e n t v e r t i g o a n d f l u c t u a t i n g sensorineural
n y s t a g m u s o r t h e r e is s l o w i n g o f n y s t a g m u s , b e f o r e chang- h e a r i n g loss, s o m e t i m e s w i t h t i n n i t u s a n d sense o f fullness
i n g to the n e x t position. A f t e r m a n o e u v r e is complete, i n t h e ear (compare M e n i e r e ' s disease).
p a t i e n t s h o u l d m a i n t a i n an u p r i g h t p o s t u r e f o r 4 8 hours.
8 . S y p h i l i s S y p h i l i s o f i n n e r ear, b o t h a c q u i r e d a n d c o n -
Eighty percent o f t h e p a t i e n t s w i l l b e c u r e d b y a single
g e n i t a l , causes dizziness i n a d d i t i o n t o s e n s o r i n e u r a l h e a r i n g
manoeuvre. If the patient remains symptomatic, the
loss. L a t e c o n g e n i t a l s y p h i l i s u s u a l l y m a n i f e s t i n g between
manoeuvre can be repeated. A b o n e vibrator placed on
8 a n d 2 0 years, m i m i c s M e n i e r e ' s disease w i t h episodes o f
t h e m a s t o i d b o n e helps t o loosen t h e debris.
acute vertigo, sensorineural hearing loss and tinnitus.
3. Vestibular neuronitis I t is c h a r a c t e r i s e d b y severe v e r - H e n n e b e r t ' s s i g n , i . e . a p o s i t i v e f i s t u l a test i n t h e p r e s e n c e
t i g o o f sudden onset w i t h n o cochlear s y m p t o m s . Attacks o f a n i n t a c t t y m p a n i c m e m b r a n e , is p r e s e n t i n c o n g e n i t a l
m a y last f r o m a f e w days t o 2 o r 3 w e e k s . I t is t h o u g h t t o s y p h i l i s . N e u r o s y p h i l i s ( t e r t i a r y a c q u i r e d ) can cause c e n t r a l
occur due to a virus that attacks v e s t i b u l a r ganglion. type o f vestibular dysfunction.
M a n a g e m e n t o f a c u t e a t t a c k is s i m i l a r t o t h a t i n M e n i e r e ' s
9. A c o u s t i c neuroma I t has b e e n classified i n p e r i p h e r a l
disease. T h e disease is u s u a l l y s e l f - l i m i t i n g .
v e s t i b u l a r d i s o r d e r s as i t arises f r o m C N V I I I w i t h i n i n t e r -
4. L a b y r i n t h i t i s It has b e e n discussed i n d e t a i l o n page 9 0 . n a l a c o u s t i c m e a t u s . I t causes o n l y unsteadiness o r v a g u e
Circumscribed labyrinthitis is seen i n cases o f unsafe t y p e o f s e n s a t i o n o f m o t i o n . S e v e r e e p i s o d i c v e r t i g o , as seen i n t h e
C S O M , a n d f i s t u l a test is p o s i t i v e . end organ disease, is u s u a l l y m i s s i n g . (For details refer
Serous labyrinthitis is c a u s e d b y t r a u m a o r i n f e c t i o n ( v i r a l Chapter 18).
o r b a c t e r i a l ) a d j a c e n t t o i n n e r ear b u t w i t h o u t a c t u a l i n v a - O t h e r t u m o u r s o f t e m p o r a l b o n e (e.g. g l o m u s t u m o u r ,
s i o n . T h e r e is severe v e r t i g o a n d s e n s o r i n e u r a l hearing carcinoma o f external or m i d d l e ear and secondaries),
loss. A p a r t i a l o r f u l l r e c o v e r y o f i n n e r ear f u n c t i o n s is p o s - d e s t r o y t h e l a b y r i n t h d i r e c t l y a n d cause v e r t i g o .
sible i f t r e a t e d e a r l y .
Purulent labyrinthitis is a c o m p l i c a t i o n o f C S O M . There
is a c t u a l b a c t e r i a l i n v a s i o n o f i n n e r ear w i t h t o t a l loss o f B. CENTRAL VESTIBULAR DISORDERS
c o c h l e a r a n d vestibular f u n c t i o n s . V e r t i g o i n this c o n d i -
t i o n is d u e t o a c u t e v e s t i b u l a r f a i l u r e . T h e r e is severe n a u -
1. Vertebrobasilar insufficiency I t is a c o m m o n cause o f
sea a n d v o m i t i n g . N y s t a g m u s is seen t o t h e o p p o s i t e side
c e n t r a l v e r t i g o i n p a t i e n t s o v e r t h e age o f 5 0 years. T h e r e
due to d e s t r u c t i o n o f the affected l a b y r i n t h .
is t r a n s i e n t decrease i n c e r e b r a l b l o o d f l o w . C o m m o n cause
5. V e s t i b u l o t o x i c drugs S e v e r a l d r u g s cause o t o t o x i c i t y is a t h e r o s c l e r o s i s . I s c h a e m i a i n these p a t i e n t s m a y also b e
b y d a m a g i n g t h e h a i r cells o f t h e i n n e r ear. S o m e p r i m a r i l y precipitated by hypotension or neck movements when
affect the c o c h l e a r w h i l e others affect the v e s t i b u l a r l a b y - c e r v i c a l o s t e o p h y t e s press o n t h e v e r t e b r a l arteries during
r i n t h . A m i n o g l y c o s i d e antibiotics particularly streptomy- rotation and extension o f head.
cin, gentamicin, kanamycin have been s h o w n to affect V e r t i g o is a b r u p t i n o n s e t , lasts s e v e r a l m i n u t e s a n d is
h a i r cells o f t h e crista a m p u l l a r i s a n d t o s o m e e x t e n t t h o s e associated w i t h nausea a n d v o m i t i n g . O t h e r neurological
o f t h e m a c u l a e . C e r t a i n o t h e r d r u g s w h i c h cause dizziness s y m p t o m s l i k e visual disturbances, d r o p attacks, d i p l o p i a ,
o r u n s t e a d i n e s s are a n t i h y p e r t e n s i v e s , l a b y r i n t h i n e seda- h e m i a n o p i a , dysphagia, hemiparesis resulting f r o m ischae-
tives, oestrogen preparations, diuretics, antimicrobials m i a t o o t h e r areas o f b r a i n m a y also a c c o m p a n y vertigo.
(nalidixic acid, metronidazole) and antimalarials. H o w e v e r , S o m e p a t i e n t s o n l y c o m p l a i n o f i n t e r m i t t e n t attacks o f
t h e i r m o d e o f a c t i o n m a y be d i f f e r e n t . dizziness o r v e r t i g o o n lateral r o t a t i o n a n d e x t e n s i o n o f h e a d .

6. H e a d trauma H e a d i n j u r y m a y cause c o n c u s s i o n of 2. Posterior inferior cerebellar artery syndrome

l a b y r i n t h , c o m p l e t e l y disrupt the b o n y l a b y r i n t h o r V I H t h (Wallenberg's s y n d r o m e ) T h r o m b o s i s o f the posterior
n e r v e , o r cause a p e r i l y m p h f i s t u l a . S e v e r e a c o u s t i c t r a u m a , i n f e r i o r cerebellar artery cuts o f f b l o o d s u p p l y t o lateral
s u c h as t h a t c a u s e d b y an e x p l o s i o n c a n also d i s t u r b t h e m e d u l l a r y area. T h e r e is v i o l e n t v e r t i g o a l o n g w i t h d i p l o -
vestibular e n d organ (otoliths) a n d result i n v e r t i g o . p i a , d y s p h a g i a , hoarseness o f v o i c e , Horner's syndrome,
s e n s o r y loss o n i p s i l a t e r a l side o f face a n d c o n t r a l a t e r a l side
7. P e r i l y m p h fistula I n t h i s c o n d i t i o n , p e r i l y m p h leaks
o f t h e b o d y , a n d a t a x i a . T h e r e m a y be h o r i z o n t a l o r r o t a -
i n t o t h e m i d d l e ear t h r o u g h t h e o v a l o r r o u n d w i n d o w . I t
t o r y n y s t a g m u s t o t h e side o f t h e l e s i o n .
c a n f o l l o w as a c o m p l i c a t i o n o f s t a p e d e c t o m y , o r ear s u r g e r y
w h e n stapes is a c c i d e n t a l l y d i s l o c a t e d . I t can also result f r o m 3. Basilar migraine M i g r a i n e is a vascular syndrome,
s u d d e n p r e s s u r e c h a n g e s i n t h e m i d d l e ear ( e . g . b a r o t r a u m a , p r o d u c i n g r e c u r r e n t headaches w i t h s y m p t o m - f r e e i n t e r -
diving, f o r c e f u l Valsalva) o r r a i s e d i n t r a c r a n i a l pressure vals. H e a d a c h e is u s u a l l y u n i l a t e r a l a n d o f t h e t h r o b b i n g
( w e i g h t l i f t i n g o r v i g o r o u s c o u g h i n g ) . A p e r i l y m p h fistula t y p e . Basilar artery m i g r a i n e p r o d u c e s o c c i p i t a l headache,
 Disorders of Vestibular System

visual disturbances, d i p l o p i a a n d severe v e r t i g o w h i c h is f o l l o w i n g t h e aura m a y h e l p i n t h e d i a g n o s i s . S o m e t i m e s ,

a b r u p t a n d m a y last f o r 5—60 m i n u t e s . Basilar m i g r a i n e is v e r t i g o is t h e o n l y s y m p t o m o f e p i l e p s y a n d t h a t m a y p o s e
c o m m o n i n adolescent girls w i t h s t r o n g m e n s t r u a l rela- a difficult diagnostic p r o b l e m . E . E . G . m a y show abnor-
tionship and positive family history. malities d u r i n g the attack.

4. Cerebellar disease C e r e b e l l u m m a y be affected by 8. C e r v i c a l v e r t i g o V e r t i g o m a y f o l l o w injuries o f neck

haemorrhage (hypertension), infarction (occlusion of 7—10 days a f t e r t h e a c c i d e n t . I t is u s u a l l y p r o v o k e d w i t h
arterial supply), i n f e c t i o n (otogenic c e r e b e l l a r abscess) o r m o v e m e n t s o f n e c k t o t h e side o f i n j u r y . E x a m i n a t i o n s h o w s
t u m o u r s (glioma, teratoma or haemangioma). A c u t e cere- t e n d e r n e s s o f n e c k , spasms o f c e r v i c a l m u s c l e s a n d l i m i t a -
bellar disease m a y cause severe v e r t i g o , v o m i t i n g and t i o n o f n e c k m o v e m e n t s . X - r a y s s h o w loss o f c e r v i c a l l o r -
ataxia s i m u l a t i n g an a c u t e p e r i p h e r a l l a b y r i n t h i n e d i s o r d e r . dosis. E x a c t m e c h a n i s m o f c e r v i c a l v e r t i g o is n o t k n o w n .
T u m o u r s are s l o w g r o w i n g a n d p r o d u c e classical features It m a y be due to disturbed vertebrobasilar circulation,
o f c e r e b e l l a r disease, i . e . incoordination, past-pointing, i n v o l v e m e n t o f sympathetic vertebral plexus or alteration
a d i a d o k o k i n e s i a , r e b o u n d p h e n o m e n o n , w i d e - b a s e d gait. o f tonic n e c k reflexes.

5. M u l t i p l e sclerosis I t is a d e m y e l i n a t i n g disease a f f e c t i n g
y o u n g adults. V e r t i g o a n d dizziness are c o m m o n c o m p l a i n t s .
O t h e r C a u s e s of Vertigo
T h e r e are o t h e r m u l t i p l e n e u r o l o g i c a l signs a n d s y m p t o m s ,
e.g. b l u r r i n g o r loss o f v i s i o n , d i p l o p i a , d y s a r t h r i a , p a r a e s t h e -
Ocular vertigo N o n n a l l y , b a l a n c e is m a i n t a i n e d b y i n t e -
sia a n d ataxia. S p o n t a n e o u s n y s t a g m u s m a y b e seen. A c q u i r e d
g r a t e d i n f o r m a t i o n r e c e i v e d f r o m t h e eyes, l a b y r i n t h s a n d
pendular nystagmus, dissociated nystagmus and vertical
somatosensory system. A m i s m a t c h o f i n f o r m a t i o n f r o m
u p b e a t n y s t a g m u s are i m p o r t a n t features i n d i a g n o s i s .
a n y o f these o r g a n s causes v e r t i g o a n d i n t h i s case f r o m t h e
6. T u m o u r s o f b r a i n s t e m and floor of IVth ventricle eyes. O c u l a r v e r t i g o m a y o c c u r i n case o f a c u t e e x t r a o c u -
G l i o m a s , a s t r o c y t o m a s m a y arise f r o m p o n s a n d m i d b r a i n ; l a r m u s c l e paresis o r h i g h e r r o r s o f r e f r a c t i o n .
m e d u l l o b l a s t o m a , e p i d y m o m a s , e p i d e r m o i d cysts o r t e r a -
Psychogenic vertigo This diagnosis is suspected in
t o m a s m a y arise f r o m f l o o r o f I V t h v e n t r i c l e . T h e s e t u m o u r s
patients suffering f r o m emotional tension and anxiety.
cause o t h e r n e u r o l o g i c a l signs a n d s y m p t o m s i n a d d i t i o n
O f t e n o t h e r s y m p t o m s o f neurosis, e.g. p a l p i t a t i o n , b r e a t h -
t o v e r t i g o a n d dizziness. P o s i t i o n a l v e r t i g o a n d n y s t a g m u s
lessness, f a t i g u e , i n s o m n i a , p r o f u s e s w e a t i n g a n d t r e m o r s
m a y also b e t h e p r e s e n t i n g f e a t u r e s . C T scan a n d m a g n e t i c
are also p r e s e n t . S y m p t o m o f v e r t i g o is o f t e n v a g u e i n t h e
r e s o n a n c e i m a g i n g are u s e f u l i n t h e i r d i a g n o s i s .
f o r m o f f l o a t i n g o r s w i m m i n g sensation o r l i g h t - h e a d e d -
7 . E p i l e p s y V e r t i g o m a y o c c u r as a n aura i n t e m p o r a l ness. T h e r e is n o n y s t a g m u s o r h e a r i n g loss. C a l o r i c test
l o b e epilepsy. T h e h i s t o r y o f seizure a n d / o r u n c o n s c i o u s n e s s shows an exaggerated response.
Diseases o f External Ear

3. P r e a u r i c u l a r pit or s i n u s T h i s is c o m m o n l y seen at
I. DISEASES OF THE PINNA t h e r o o t o f h e l i x a n d is d u e t o i n c o m p l e t e f u s i o n o f t u b e r -
cles. I t m a y g e t r e p e a t e d l y i n f e c t e d c a u s i n g p u r u l e n t d i s -

The pinna may be afflicted b y congenital, traumatic, c h a r g e . Abscess m a y also f o r m . T r e a t m e n t is surgical e x c i s i o n

i n f l a m m a t o r y or neoplastic disorders. o f t h e t r a c k i f t h e sinus gets r e p e a t e d l y i n f e c t e d ( F i g . 8 . 2 ) .

4. A n o t i a I t is c o m p l e t e absence o f p i n n a , a n d u s u a l l y
f o r m s part o f t h e first arch s y n d r o m e (Fig. 8.3).
A. Congenital Disorders

5. M a c r o t i a I t is e x c e s s i v e l y l a r g e p i n n a .
T h e d e v e l o p m e n t a l a b n o r m a l i t i e s o f t h e p i n n a m a y be j u s t
6. M i c r o t i a ( F i g . 8.4) I t is a m a j o r d e v e l o p m e n t a l a n o m -
m i n o r variations f r o m the n o r m a l or m a j o r abnormalities.
aly. D e g r e e o f m i c r o t i a m a y v a r y . I t is f r e q u e n t l y a s s o c i -
1. Bat ear ( L o p ear) T h i s is an a b n o r m a l l y p r o t r u d i n g
ated w i t h anomalies o f e x t e r n a l a u d i t o r y canal, m i d d l e a n d
ear. T h e c o n c h a is l a r g e w i t h p o o r l y d e v e l o p e d a n t i h e l i x
i n t e r n a l ear. T h e c o n d i t i o n m a y be u n i l a t e r a l o r b i l a t e r a l .
a n d scapha. T h e d e f o r m i t y can b e c o r r e c t e d s u r g i c a l l y a n y
H e a r i n g loss is f r e q u e n t .
t i m e after t h e age o f 6 years, i f c o s m e t i c a p p e a r a n c e so
demands.

2. P r e a u r i c u l a r appendages T h e y are s k i n - c o v e r e d tags

J B . T r a u m a to the Auricle |
t h a t a p p e a r o n a l i n e d r a w n f r o m t h e tragus t o t h e angle
of mouth. They may c o n t a i n s m a l l pieces o f cartilage 1 . H a e m a t o m a o f the a u r i c l e I t is c o l l e c t i o n o f b l o o d
(Fig. 8.1). between the a u r i c u l a r cartilage a n d its p e r i c h o n d r i u m .

Figure 8.2
Figure 8.1
Infected preauricular sinus with pus exuding from the

Preauricular appendages. opening.

 Figure 8.6

Figure 8.4
Laceration left pinna.

Microtia right ear.

s u t u r e s . S p e c i a l care is t a k e n t o p r e v e n t s t r i p p i n g o f p e r -

O f t e n i t is t h e r e s u l t o f b l u n t t r a u m a seen i n b o x e r s , w r e s - i c h o n d r i u m f r o m c a r t i l a g e f o r fear o f avascular necrosis.

tlers a n d r u g b y p l a y e r s . E x t r a v a s a t e d b l o o d m a y c l o t a n d S k i n is c l o s e d with fine non-absorbable sutures. Broad

then organise, resulting i n a typical d e f o r m i t y called s p e c t r u m a n t i b i o t i c s are g i v e n f o r o n e w e e k .

Cauliflower eax (Fig. 8.5). I f haematoma gets infected, 3. A v u l s i o n o f p i n n a W h e n p i n n a is still a t t a c h e d t o t h e

s e v e r e p e r i c h o n d r i t i s m a y set i n . head b y a small pedicle o f skin, primary reattachment
T r e a t m e n t is a s p i r a t i o n o f t h e h a e m a t o m a u n d e r strict s h o u l d b e c o n s i d e r e d a n d i t is u s u a l l y successful. C o m p l e t e l y
aseptic p r e c a u t i o n s a n d a pressure d r e s s i n g , c a r e f u l l y p a c k - a v u l s e d p i n n a c a n b e r e i m p l a n t e d i n s e l e c t e d cases b y t h e
ing all concavities o f the auricle t o prevent reaccumula- microvascular techniques; i n others, t h e skin o f the avulsed
t i o n . A s p i r a t i o n m a y need t o be repeated. W h e n aspiration s e g m e n t o f p i n n a is r e m o v e d a n d t h e c a r t i l a g e i m p l a n t e d
fails, i n c i s i o n a n d d r a i n a g e s h o u l d b e d o n e a n d pressure u n d e r t h e postauricular skin f o r later r e c o n s t r u c t i o n .
applied b y dental rolls t i e d w i t h through and through
4. F r o s t b i t e I n j u r y d u e t o f r o s t b i t e varies b e t w e e n ery-
s u t u r e s . A l l cases s h o u l d r e c e i v e p r o p h y l a c t i c a n t i b i o t i c s .
t h e m a a n d oedema, bullae f o r m a t i o n , necrosis o f s k i n a n d
2. L a c e r a t i o n s ( F i g . 8.6) T h e y are r e p a i r e d as e a r l y as s u b c u t a n e o u s tissue, a n d c o m p l e t e n e c r o s i s w i t h loss o f t h e
p o s s i b l e . T h e p e r i c h o n d r i u m is s t i t c h e d w i t h absorbable affected part.
 T r e a t m e n t o f a f r o s t - b i t t e n ear consists o f :

(a) r e w a r m i n g w i t h m o i s t c o t t o n p l e d g e t s at a t e m p e r a -
ture o f 3 8 - 4 2 ° C ,
(b) a p p l i c a t i o n o f 0 . 5 % s i l v e r n i t r a t e soaks f o r s u p e r f i c i a l
infection,
(c) analgesics f o r p a i n ; r a p i d r e w a r m i n g o f f r o s t b i t t e n ear
causes c o n s i d e r a b l e p a i n ,
(d) p r o t e c t i o n o f bullae f r o m rupture,
(e) systemic antibiotics f o r deep i n f e c t i o n ,
(0 s u r g i c a l d e b r i d e m e n t s h o u l d w a i t several m o n t h s as
the true demarcation between the dead and l i v i n g tis-
sues appears q u i t e l a t e .

5. K e l o i d o f auricle It may follow trauma or piercing o f

F i g u r e 8.7
t h e ear f o r o r n a m e n t s . U s u a l sites are t h e l o b u l e o r h e l i x
Keloid following piercing o f pinna for ornaments.
( F i g . 8 . 7 ) . S u r g i c a l e x c i s i o n o f t h e k e l o i d u s u a l l y results i n
r e c u r r e n c e . R e c u r r e n c e o f k e l o i d can b e a v o i d e d b y p r e -
a n d p o s t - o p e r a t i v e r a d i a t i o n w i t h a t o t a l dose o f 6 0 0 - 8 0 0
rads d e l i v e r e d i n f o u r d i v i d e d doses. S o m e p r e f e r l o c a l
i n j e c t i o n o f s t e r o i d after e x c i s i o n .

J C . Inflammatory Disorders

1. Perichondritis (Fig. 8.8) I t results f r o m infection

secondary t o lacerations, h a e m a t o m a o r surgical incisions.
I t c a n also r e s u l t f r o m e x t e n s i o n o f i n f e c t i o n f r o m d i f f u s e
otitis externa o r a f u r u n c l e o f the meatus. Pseudomonas
a n d m i x e d f l o r a are t h e c o m m o n pathogens.
I n i t i a l s y m p t o m s are r e d , h o t a n d p a i n f u l p i n n a w h i c h
feels stiff. L a t e r abscess m a y f o m i b e t w e e n the cartilage
a n d p e r i c h o n d r i u m w i t h n e c r o s i s o f c a r t i l a g e as t h e c a r t i -
lage s u r v i v e s o n l y o n t h e b l o o d s u p p l y f r o m its p e r i c h o n -
drium. Treatment in early stages consists of systemic Figure 8.8
a n t i b i o t i c s a n d l o c a l a p p l i c a t i o n o f 4 % a l u m i n i u m acetate
Perichondritis.
c o m p r e s s e s . W h e n abscess has f o m i e d , i t m u s t b e d r a i n e d
p r o m p t l y a n d c u l t u r e a n d s e n s i t i v i t y o t t h e pus o b t a i n e d .
I n c i s i o n is m a d e i n t h e n a t u r a l f o l d a n d d e v i t a l i s e d c a r t i -
lage removed. S o m e p r e f e r t o place a catheter in the D. Tumours

abscess a n d a d m i n i s t e r a c o n t i n u o u s d r i p o f a n t i b i o t i c s ,
s e l e c t e d b y c u l t u r e a n d s e n s i t i v i t y , f o r 7—10 days. See page 117.

2. R e l a p s i n g p o l y c h o n d r i t i s I t is a r a r e a u t o i m m u n e
d i s o r d e r i n v o l v i n g cartilage o f t h e ear. O t h e r cartilages, s e p -
II. DISEASES OF EXTERNAL
t a l , l a r y n g e a l , t r a c h e a l , costal m a y also b e i n v o l v e d . The
AUDITORY CANAL
e n t i r e a u r i c l e e x c e p t its l o b u l e b e c o m e s i n f l a m e d a n d t e n -
d e r . E x t e r n a l ear canal b e c o m e s s t e n o t i c . T r e a t m e n t consists
o f h i g h doses o f s y s t e m i c s t e r o i d s . T h e diseases o f e x t e r n a l a u d i t o r y c a n a l are g r o u p e d as:

3. Chondrodermatitis nodularis chronica helicis A. C o n g e n i t a l disorders

Small p a i n f u l n o d u l e s appear near the free b o r d e r o f h e l i x B. Trauma
i n m e n a b o u t t h e age o f 5 0 years. N o d u l e s are t e n d e r a n d C. Inflammation
t h e p a t i e n t is u n a b l e t o sleep o n t h e a f f e c t e d s i d e . T r e a t m e n t D. Tumours
is e x c i s i o n o f t h e n o d u l e w i t h its s k i n a n d c a r t i l a g e . E. Miscellaneous conditions.
 Diseases of External Ear

m e a t u s , f u r u n c l e is seen o n l y i n t h i s p a r t o f m e a t u s . U s u a l l y
A. Congenital Disorders
single, the furuncles m a y be m u l t i p l e .
P a t i e n t usually presents w i t h severe p a i n a n d tenderness
1. Atresia of external canal C o n g e n i t a l atresia o f t h e
w h i c h are o u t o f p r o p o r t i o n t o t h e size o f t h e f u r u n c l e .
meatus m a y o c c u r alone or i n association with microtia.
M o v e m e n t s o f t h e p i n n a are p a i n f u l . J a w m o v e m e n t s , as i n
W h e n i t o c c u r s a l o n e , i t is d u e t o f a i l u r e o f c a n a l i s a t i o n of
c h e w i n g , also cause p a i n i n t h e ear. A f u r u n c l e o f p o s t e r i o r
t h e e c t o d e r m a l c o r e t h a t fills t h e d o r s a l p a r t o f t h e f i r s t
m e a t a l w a l l causes o e d e m a o v e r t h e m a s t o i d w i t h o b l i t e r a t i o n
b r a n c h i a l c l e f t . T h e o u t e r m e a t u s , i n these cases, is o b l i t e r -
o f the retroauricular g r o o v e . Periauricular l y m p h nodes (ante-
a t e d w i t h f i b r o u s tissue o r b o n e w h i l e t h e d e e p m e a t u s a n d
r i o r , p o s t e r i o r a n d i n f e r i o r ) m a y also be e n l a r g e d a n d t e n d e r .
t h e t y m p a n i c m e m b r a n e are n o r m a l . A t r e s i a w i t h m i c r o t i a
Treatment i n early cases, w i t h o u t abscess f o r m a t i o n ,
is m o r e c o m m o n . I t m a y b e associated w i t h a b n o r m a l i t i e s
consists o f s y s t e m i c a n t i b i o t i c s , analgesics a n d l o c a l h e a t .
o f t h e m i d d l e ear, i n t e r n a l ear a n d o t h e r s t r u c t u r e s .
A n ear p a c k o f 1 0 % i c h t h a m m o l g l y c e r i n e p r o v i d e s s p l i n t -
2. C o l l a u r a l fistula T h i s is an a b n o r m a l i t y o f t h e f i r s t age and reduces p a i n . H y g r o s c o p i c action of glycerine
b r a n c h i a l c l e f t . T h e f i s t u l a has t w o o p e n i n g s ; o n e , s i t u a t e d r e d u c e s o e d e m a , w h i l e i c h t h a m m o l is m i l d l y a n t i s e p t i c . I f
i n the n e c k j u s t b e l o w and b e h i n d the angle o f m a n d i b l e , abscess has f o r m e d , i n c i s i o n a n d d r a i n a g e s h o u l d b e d o n e .
a n d t h e o t h e r i n t h e e x t e r n a l c a n a l o r t h e m i d d l e ear. The In case of recurrent furunculosis, diabetes should be
t r a c k o f t h e f i s t u l a traverses t h r o u g h t h e p a r o t i d i n close e x c l u d e d , a n d a t t e n t i o n p a i d t o t h e p a t i e n t ' s nasal v e s t i -
r e l a t i o n t o the facial n e r v e . bules w h i c h m a y h a r b o u r s t a p h y l o c o c c i a n d t h e i n f e c t i o n
transferred b y patient's fingers. Staphylococcal infections
o f t h e s k i n as a p o s s i b l e s o u r c e s h o u l d also b e e x c l u d e d a n d

J B. T r a u m a to E a r C a n a l ^ suitably treated.

Minor lacerations o f canal s k i n result f r o m Q-tip injury 2. D i f f u s e otitis e x t e r n a I t is d i f f u s e i n f l a m m a t i o n o f

( s c r a t c h i n g t h e ear w i t h h a i r p i n s , n e e d l e s o r m a t c h s t i c k ) meatal s k i n w h i c h m a y spread t o i n v o l v e t h e p i n n a and

or unskilled i n s t r u m e n t a t i o n b y the physician. T h e y u s u - e p i d e r m a l layer o f t y m p a n i c membrane.

a l l y h e a l w i t h o u t sequelae. Aetiology Disease is c o m m o n l y seen i n h o t a n d h u m i d

Major lacerations result f r o m g u n shot w o u n d s , a u t o m o - c l i m a t e a n d i n s w i m m e r s . Excessive s w e a t i n g changes the
bile accidents o r fights. T h e condyle o f mandible may pH o f meatal skin f r o m that o f acid to alkaline which
f o r c e t h r o u g h t h e a n t e r i o r canal w a l l . T h e s e cases r e q u i r e favours growth o f pathogens. Two factors commonly
c a r e f u l t r e a t m e n t . A i m is t o a t t a i n a s k i n - l i n e d m e a t u s of r e s p o n s i b l e f o r t h i s c o n d i t i o n are:
a d e q u a t e d i a m e t e r . Stenosis o f t h e ear c a n a l is a c o m m o n
(a) t r a u m a to the meatal s k i n , a n d
complication.
(b) invasion by pathogenic organisms.

Trauma can r e s u l t f r o m s c r a t c h i n g t h e ear canal w i t h h a i r

C. Inflammations of Ear Canal
p i n s o r m a t c h sticks, u n s k i l l e d i n s t r u m e n t a t i o n t o r e m o v e
f o r e i g n b o d i e s , v i g o r o u s c l e a n i n g o f ear c a n a l a f t e r a s w i m
O t i t i s e x t e r n a m a y b e d i v i d e d , o n a e t i o l o g i c a l basis, i n t o :
w h e n m e a t a l s k i n is a l r e a d y m a c e r a t e d . B r e a k i n c o n t i n u i t y
o f m e a t a l l i n i n g sets t h e g r o u n d f o r o r g a n i s m s t o i n v a d e .
(i) Infective group
Common organisms responsible for otitis externa are
Localised otitis externa (Furuncle)
Staph, aureus, Pseud, pyocyaneus, B. protcus a n d Esch. coli b u t
Bacterial Diffuse otitis e x t e r n o
m o r e o f t e n t h e i n f e c t i o n is m i x e d .
M a l i g n a n t otitis externa
S o m e cases o f o t i t i s e x t e r n a are s e c o n d a r y to infection
Otomycosis
o f t h e m i d d l e ear, o r a l l e r g i c s e n s i t i s a t i o n t o t h e t o p i c a l ear
Herpes zoster oticus
drops used for chronic suppurative otitis media.
Otitis externa haemorrhagica

C l i n i c a l f e a t u r e s D i f f u s e otitis externa m a y be acute or

(H) Reactive group c h r o n i c w i t h v a r y i n g degrees o f s e v e r i t y .
Acute phase is c h a r a c t e r i s e d b y h o t b u r n i n g s e n s a t i o n i n
• Eczematous otitis externa
t h e ear, f o l l o w e d b y p a i n w h i c h is a g g r a v a t e d b y move-
• Seborrhoeic otitis externa
m e n t s o f j a w . E a r starts o o z i n g t h i n serous d i s c h a r g e w h i c h
• Neurodermatitis
later b e c o m e s t h i c k a n d p u r u l e n t . M e a t a l l i n i n g b e c o m e s
1. Furuncle (localised acute otitis externa) A f u r u n - i n f l a m e d and s w o l l e n . C o l l e c t i o n o f debris a n d discharge
cle is a s t a p h y l o c o c c a l i n f e c t i o n o f t h e h a i r f o l l i c l e . A s t h e a c c o m p a n i e d w i t h m e a t a l s w e l l i n g g i v e s rise t o c o n d u c t i v e
h a i r are c o n f i n e d o n l y to the cartilaginous part o f the h e a r i n g loss. I n severe cases, r e g i o n a l l y m p h n o d e s b e c o m e
enlarged and tender with cellulitis o f the s u r r o u n d i n g m u s t y o d o u r , a n d ear b l o c k a g e . The f u n g a l mass may
tissues. a p p e a r w h i t e , b r o w n o r b l a c k a n d has b e e n l i k e n e d t o a
Chronic phase is c h a r a c t e r i s e d b y i r r i t a t i o n a n d s t r o n g desire w e t piece o f filter paper.
t o i t c h . T h i s is responsible f o r acute e x a c e r b a t i o n s a n d r e i n - E x a m i n e d w i t h a n o t o s c o p e , A. niger appears as b l a c k -
f e c t i o n . D i s c h a r g e is scanty a n d m a y d r y u p t o f o r m crusts. headed filamentous g r o w t h , A. fumigatus, pale b l u e or
M e a t a l s k i n w h i c h is t h i c k a n d s w o l l e n m a y also s h o w scal- g r e e n ; a n d C a n d i d a as w h i t e o r c r e a m y deposit. Meatal
i n g and fissuring. Rarely, the skin becomes h y p e r t r o p h i c s k i n appears s o d d e n , r e d a n d oedematous.
l e a d i n g t o m e a t a l stenosis (chronic stenotic otitis externa). Treatment consists o f t h o r o u g h ear t o i l e t t o r e m o v e all
T r e a t m e n t Acute phase is t r e a t e d as f o l l o w s : d i s c h a r g e a n d e p i t h e l i a l d e b r i s w h i c h are c o n d u c i v e t o t h e
g r o w t h o f fungus. I t can be d o n e b y s y r i n g i n g , s u c t i o n or
(a) Ear t o i l e t : I t is t h e m o s t i m p o r t a n t s i n g l e f a c t o r i n
m o p p i n g . S p e c i f i c a n t i f u n g a l agents c a n b e a p p l i e d . N y s t a t i n
the treatment o f diffuse otitis externa. A l l exudate and
( 1 0 0 , 0 0 0 u n i t s / m l o f p r o p y l e n e g l y c o l ) is e f f e c t i v e against
debris s h o u l d be m e t i c u l o u s l y a n d gently removed.
C a n d i d a . O t h e r b r o a d s p e c t r u m a n t i f u n g a l agents i n c l u d e
Special a t t e n t i o n should be paid to anteroinferior
clotrimazole and povidone iodine. 2 % salicylic acid i n
m e a t a l recess w h i c h f o r m s a b l i n d p o c k e t w h e r e d i s -
a l c o h o l is also e f f e c t i v e . I t is a k e r a t o l y t i c a g e n t w h i c h
c h a r g e is a c c u m u l a t e d . E a r t o i l e t c a n b e d o n e b y d r y
r e m o v e s s u p e r f i c i a l layers o f e p i d e r m i s , a n d a l o n g w i t h t h a t ,
mopping, suction clearance o r i r r i g a t i n g the canal
the fungal mycelia g r o w i n g i n t o t h e m . A n t i f u n g a l treat-
w i t h w a r m , sterile n o r m a l saline.
m e n t s h o u l d b e c o n t i n u e d f o r a w e e k e v e n after a p p a r e n t
(b) Medicated wicks: A f t e r t h o r o u g h toilet, a gauze
cure to a v o i d recurrences. Ear m u s t be k e p t d r y . Bacterial
w i c k s o a k e d i n a n t i b i o t i c s t e r o i d p r e p a r a t i o n is i n s e r t e d
i n f e c t i o n s are o f t e n associated w i t h o t o m y c o s i s , a n d t r e a t -
i n t h e ear canal a n d p a t i e n t a d v i s e d t o k e e p i t m o i s t b y
m e n t w i t h an a n t i b i o t i c / s t e r o i d p r e p a r a t i o n h e l p s t o r e d u c e
i n s t i l l i n g t h e same d r o p s t w i c e o r t h r i c e a d a y . W i c k is
i n f l a m m a t i o n and oedema a n d thus p e r m i t t i n g better p e n -
changed daily f o r 2 - 3 days w h e n i t c a n b e s u b s t i t u t e d
e t r a t i o n o f a n t i f u n g a l agents.
by ear drops. Local steroid drops help to relieve
oedema and erythema, and prevent itching. A l u m i n i u m 4. Otitis externa h a e m o r r h a g i c a I t is c h a r a c t e r i s e d b y
acetate (8%) o r s i l v e r n i t r a t e (3%) are m i l d astringents f o r m a t i o n o f haemorrhagic bullae o n the t y m p a n i c m e m -
a n d can be used i n the f o r m o f a w i c k to f o r m a p r o - b r a n e a n d d e e p m e a t u s . I t is p r o b a b l y v i r a l i n o r i g i n a n d
tective c o a g u l u m to d r y - u p an o o z i n g meatus. m a y b e seen i n i n f l u e n z a e p i d e m i c s . T h e c o n d i t i o n causes

(c) A n t i b i o t i c s : B r o a d s p e c t r u m s y s t e m i c a n t i b i o t i c s are severe p a i n i n t h e ear a n d b l o o d - s t a i n e d d i s c h a r g e when

used when there is cellulitis and acute tender t h e b u l l a e r u p t u r e . T r e a t m e n t w i t h analgesics is d i r e c t e d

lymphadenitis. t o g i v e r e l i e f f r o m p a i n . A n t i b i o t i c s are g i v e n f o r s e c o n d -

(d) Analgesics: For relief o f pain. a r y i n f e c t i o n o f t h e ear c a n a l , o r m i d d l e ear i f t h e b u l l a has

r u p t u r e d i n t o t h e m i d d l e ear.
Chronic phase. T r e a t m e n t a i m s at (a) r e d u c t i o n o f m e a t a l
s w e l l i n g so t h a t ear t o i l e t c a n b e effectively done, and 5. H e r p e s zoster oticus I t is c h a r a c t e r i s e d b y f o r m a t i o n
(b) a l l e v i a t i o n o f i t c h i n g so t h a t s c r a t c h i n g is s t o p p e d a n d o f vesicles o n t h e t y m p a n i c m e m b r a n e , m e a t a l s k i n , c o n -

further recurrences controlled. cha a n d p o s t a u r i c u l a r g r o o v e . T h e seventh a n d e i g h t h cra-

A gauze w i c k soaked i n 1 0 % i c h t h a m m o l g l y c e r i n e a n d nial nerves m a y be i n v o l v e d .

i n s e r t e d i n t o t h e c a n a l h e l p s t o r e d u c e s w e l l i n g . T h i s is
6. Malignant (necrotising) otitis e x t e r n a I t is an
f o l l o w e d b y ear t o i l e t w i t h p a r t i c u l a r a t t e n t i o n t o a n t e r o -
i n f l a m m a t o r y c o n d i t i o n caused b y pseudomonas infection
i n f e r i o r m e a t a l recess. I t c h i n g c a n b e c o n t r o l l e d b y t o p i c a l
usually i n t h e elderly diabetics, o r i n those o n i m m u n o -
application o f antibiotic steroid cream.
s u p p r e s s i v e d r u g s . Its e a r l y m a n i f e s t a t i o n s r e s e m b l e d i f f u s e
When the meatal s k i n is t h i c k e n e d to the point of
o t i t i s e x t e r n a b u t t h e r e is e x c r u c i a t i n g p a i n a n d a p p e a r a n c e
o b s t r u c t i o n a n d resists a l l f o r m s o f m e d i c a l t r e a t m e n t , i.e.
o f g r a n u l a t i o n s i n t h e m e a t u s . F a c i a l paralysis is c o m m o n .
c h r o n i c s t e n o t i c o t i t i s e x t e r n a , i t is s u r g i c a l l y e x c i s e d , b o n y
I n f e c t i o n m a y spread t o t h e s k u l l base a n d j u g u l a r f o r a m e n
m e a t u s is w i d e n e d w i t h a d r i l l a n d l i n e d b y s p l i t - s k i n g r a f t .
c a u s i n g m u l t i p l e c r a n i a l n e r v e palsies. A n t e r i o r l y , i n f e c t i o n
3. O t o m y c o s i s Otomycosis is a f u n g a l i n f e c t i o n o f t h e spreads t o temporomandibular fossa, p o s t e r i o r l y t o the
ear c a n a l t h a t o f t e n o c c u r s d u e t o Aspergillus niger, A. furnig- mastoid and medially i n t o the m i d d l e ear and petrous
atus o r Candida albicans. I t is s e e n i n h o t a n d h u m i d c l i m a t e b o n e . C T scan is u s e f u l , t o k n o w t h e e x t e n t o f disease.
o f tropical and subtropical countries. Secondary fungal Treatment consists of high doses o f i.v. antibiotics
g r o w t h is also seen i n p a t i e n t s u s i n g t o p i c a l a n t i b i o t i c s f o r d i r e c t e d against p s e u d o m o n a s (tobramycin, ticarcillin or
t r e a t m e n t o f o t i t i s e x t e r n a o r m i d d l e ear s u p p u r a t i o n . t h i r d g e n e r a t i o n c e p h a l o s p o r i n s ) . A n t i b i o t i c s are g i v e n f o r
T h e clinical features o f otomycosis i n c l u d e : intense i t c h - 6-8 weeks or longer. Diabetes should be controlled.
i n g , d i s c o m f o r t o r p a i n i n t h e ear, w a t e r y d i s c h a r g e w i t h a S u r g i c a l d e b r i d e m e n t o f d e v i t a l i s e d tissue a n d b o n e s h o u l d
 Diseases of External Ear

be d o n e j u d i c i o u s l y . R a d i c a l resections have b e e n aban-

D. Tumours
d o n e d i n favour o f p r o l o n g e d intensive medical therapy.

7. E c z e m a t o u s otitis e x t e r n a I t is t h e r e s u l t o f h y p e r - See p a g e 118.

s e n s i t i v i t y t o i n f e c t i v e o r g a n i s m s o r t o p i c a l ear d r o p s s u c h
as C h l o r o m y c e t i n o r n e o m y c i n , etc. I t is m a r k e d b y i n t e n s e
i r r i t a t i o n , vesicle formation, oozing and crusting i n the E. Miscellaneous Conditions

c a n a l . T r e a t m e n t is w i t h d r a w a l o f t o p i c a l a n t i b i o t i c c a u s -
i n g sensitivity, and application o f steroid cream. 1. Impacted wax or cerumen Wax is c o m p o s e d of
secretion o f s e b a c e o u s glands, ceruminous glands, hair,
8. S e b o r r h o e i c otitis e x t e r n a I t is associated w i t h seb-
desquamated epithelial debris, k e r a t i n a n d dirt.
o r r h o e i c d e r m a t i t i s o f t h e scalp. I t c h i n g is t h e m a i n c o m -
Sebaceous and ceruminous ( m o d i f i e d sweat glands)
p l a i n t . G r e a s y y e l l o w scales are seen i n t h e e x t e r n a l c a n a l ,
o p e n i n t o t h e space o f t h e h a i r f o l l i c l e ( F i g . 8 . 9 ) . S e b a c e o u s
o v e r the l o b u l e a n d p o s t a u r i c u l a r sulcus. T r e a t m e n t con-
g l a n d s p r o v i d e f l u i d r i c h i n f a t t y acids w h i l e s e c r e t i o n of
sists o f ear t o i l e t , a p p l i c a t i o n o f a c r e a m c o n t a i n i n g s a l i c y l i c
c e r u m i n o u s g l a n d is r i c h i n l i p i d s a n d p i g m e n t granules.
acid and sulphur, and attention to the scalp for
S e c r e t i o n o f b o t h these g l a n d s m i x e s w i t h t h e d e s q u a m a t e d
seborrhoea.
e p i t h e l i a l cells a n d k e r a t i n s h e d f r o m t h e t y m p a n i c m e m -
9. N e u r o d e r m a t i t i s I t is c a u s e d b y c o m p u l s i v e s c r a t c h -
brane a n d deep b o n y meatus t o f o r m w a x .
i n g due t o p s y c h o l o g i c a l factors. Patient's m a i n c o m p l a i n t
W a x has a p r o t e c t i v e f u n c t i o n as i t l u b r i c a t e s t h e ear
is i n t e n s e i t c h i n g . O t i t i s e x t e r n a o f b a c t e r i a l type m a y f o l -
canal a n d entraps any f o r e i g n material that happens to
l o w i n f e c t i o n o f r a w area l e f t b y s c r a t c h i n g . T r e a t m e n t is
e n t e r t h e c a n a l . N o r m a l l y , o n l y a s m a l l a m o u n t o f w a x is
sympathetic p s y c h o t h e r a p y and m e a n t f o r any secondary
s e c r e t e d , w h i c h dries u p a n d is l a t e r e x p e l l e d f r o m the
i n f e c t i o n . E a r p a c k a n d b a n d a g e t o t h e ear are h e l p f u l t o
meatus b y m o v e m e n t s o f the j a w . As some people sweat
prevent compulsive scratching.
m o r e t h a n o t h e r s , t h e a c t i v i t y o f c e r u m i n o u s g l a n d s also
10. Primary cholesteatoma of external auditory v a r i e s ; excessive w a x m a y b e s e c r e t e d a n d d e p o s i t e d as a
canal I n c o n t r a s t t o m i d d l e ear c h o l e s t e a t o m a , squamous p l u g i n the meatus. C e r t a i n o t h e r factors l i k e n a r r o w a n d
e p i t h e l i u m o f t h e e x t e r n a l canal i n v a d e s its b o n e . U s u a l l y t o r t u o u s ear c a n a l , s t i f f h a i r o r o b s t r u c t i v e l e s i o n o f t h e
t h e r e is s o m e a b n o r m a l i t y o f b o n e o f e x t e r n a l canal w h i c h canal, e.g. exostosis, m a y f a v o u r r e t e n t i o n o f w a x . I t m a y
is c o n d u c i v e f o r e p i t h e l i u m t o i n v a d e i t . I t m a y b e p o s t - d r y u p a n d f o r m a h a r d i m p a c t e d mass.
t r a u m a t i c o r p o s t s u r g i c a l . C l i n i c a l features i n c l u d e p u r u l e n t P a t i e n t u s u a l l y presents w i t h i m p a i r m e n t o f h e a r i n g o r
otorrhoea and pain; tympanic membrane being normal. sense o f b l o c k e d ear. T i n n i t u s a n d giddiness m a y r e s u l t from
G r a n u l a t i o n s associated w i t h s e q u e s t r a t e d b o n e n e e d h i s t o - i m p a c t i o n o f w a x against t h e t y m p a n i c m e m b r a n e . Reflex
logical examination to differentiate it f r o m carcinoma, c o u g h d u e t o s t i m u l a t i o n o f auricular b r a n c h o f vagus m a y
n e c r o t i z i n g otitis externa and a b e n i g n sequestrum. sometimes o c c u r . T h e o n s e t o f these s y m p t o m s m a y be
Treatment consists o f r e m o v a l o f n e c r o t i c bone and s u d d e n w h e n w a t e r e n t e r s t h e ear c a n a l d u r i n g b a t h i n g o r
cholesteatoma, a n d l i n i n g t h e d e f e c t w i t h fascia. s w i m m i n g a n d t h e w a x swells u p . L o n g s t a n d i n g i m p a c t e d

Figure 8.9

Structure o f skin o f cartilaginous meatus.

w a x m a y ulcerate the meatal skin a n d result i n g r a n u l o m a Instrumental manipulation. It s h o u l d always be d o n e by
f o r m a t i o n (wax granuloma). skilled hands and under direct vision. C e r u m e n hook,
T r e a t m e n t o f w a x consists i n its r e m o v a l b y s y r i n g i n g o r s c o o p o r J o b s o n - H o m e p r o b e are o f t e n u s e d . F i r s t , a space
instrumental manipulation. Hard impacted mass may is c r e a t e d b e t w e e n t h e w a x a n d m e a t a l w a l l , t h e i n s t r u -
sometimes r e q u i r e p r i o r s o f t e n i n g w i t h w a x solvents. m e n t is passed b e y o n d t h e w a x , a n d w h o l e p l u g then
Technique of syringing the ear. P a t i e n t is seated w i t h ear t o dragged o u t i n a single piece. I f it breaks, s y r i n g i n g m a y be
b e s y r i n g e d t o w a r d s t h e e x a m i n e r . A t o w e l is p l a c e d r o u n d used t o r e m o v e the fragments.
h i s n e c k . A k i d n e y t r a y is p l a c e d o v e r t h e s h o u l d e r a n d O c c a s i o n a l l y , i f t h e w a x is t o o h a r d a n d i m p a c t e d , t o be
h e l d s n u g l y b y t h e p a t i e n t . P a t i e n t ' s h e a d is s l i g h t l y t i l t e d r e m o v e d b y s y r i n g i n g o r instruments, i t s h o u l d be soft-
over the tray t o collect the r e t u r n f l u i d . e n e d b y d r o p s o f 5 % soda b i c a r b i n e q u a l parts o f g l y c e r i n e
P i n n a is p u l l e d u p w a r d s a n d b a c k w a r d s a n d a s t r e a m of a n d w a t e r i n s t i l l e d t w o o r t h r e e t i m e s a d a y f o r a f e w days.
w a t e r f r o m t h e ear s y r i n g e is d i r e c t e d a l o n g t h e p o s t e r o s u - H y d r o g e n p e r o x i d e , l i q u i d p a r a f f i n o r o l i v e o i l m a y also
perior wall o f the meatus. Pressure o f w a t e r , b u i l t up a c h i e v e t h e same result. C o m m e r c i a l drops containing
deeper t o the w a x , expels the w a x o u t (Fig. 8.10). I f w a x c e r u m o l y t i c agents l i k e p a r a d i c h l o r o b e n z e n e 2 % c a n also
is t i g h t l y i m p a c t e d , i t is necessary t o c r e a t e a space b e t w e e n be used and above m e t h o d s t r i e d again.
i t a n d t h e m e a t a l w a l l f o r t h e j e t o f w a t e r t o pass, o t h e r w i s e
2. F o r e i g n bodies o f ear (a) Non-living. Children may
s y r i n g i n g w i l l be ineffective o r m a y even push the wax
i n s e r t a v a r i e t y o f f o r e i g n b o d i e s i n t h e ear; t h e common
d e e p e r . E a r c a n a l s h o u l d be i n s p e c t e d f r o m t i m e t o t i m e t o
o n e s o f t e n seen are: a p i e c e o f p a p e r o r s p o n g e , g r a i n seeds
see i f a l l w a x has b e e n r e m o v e d . U n n e c e s s a r y s y r i n g i n g
( r i c e , w h e a t , m a i z e ) , slate p e n c i l , p i e c e o f c h a l k o r m e t a l l i c
should be avoided.
ball bearings. A n a d u l t m a y present w i t h a b r o k e n e n d o f
A t t h e e n d o f t h e p r o c e d u r e , ear c a n a l a n d t y m p a n i c m a t c h s t i c k u s e d f o r s c r a t c h i n g t h e ear o r a n o v e r l o o k e d
m e m b r a n e must be inspected and d r i e d w i t h a pledget o f c o t t o n swab. Vegetable f o r e i g n bodies t e n d to swell u p
c o t t o n . A n y u l c e r a t i o n seen i n m e a t a l w a l l as a r e s u l t o f w i t h t i m e a n d g e t t i g h t l y i m p a c t e d i n t h e ear c a n a l o r m a y
impacted wax is protected by application o f suitable even suppurate.
a n t i b i o t i c o i n t m e n t . N o r m a l l y , b o i l e d tap w a t e r c o o l e d t o
Methods o f removing a foreign body include:
b o d y t e m p e r a t u r e is u s e d . I f i t is t o o c o l d o r t o o h o t i t
(i) Forceps r e m o v a l
w o u l d s t i m u l a t e t h e l a b y r i n t h , as i n c a l o r i c t e s t i n g , a n d
(ii) Syringing
cause v e r t i g o . T o o m u c h f o r c e u s e d i n s y r i n g i n g m a y r u p -
(iii) Suction
t u r e t h e t y m p a n i c m e m b r a n e e s p e c i a l l y w h e n i t has a l r e a d y
(iv) M i c r o s c o p i c r e m o v a l w i t h special i n s t r u m e n t s
b e e n w e a k e n e d b y p r e v i o u s disease. P a t i e n t c o m p l a i n s of
(v) Postaural approach.
i n t e n s e p a i n a n d m a y b e c o m e g i d d y a n d e v e n f a i n t . I t is
necessary b e f o r e s y r i n g i n g t o ask t h e p a t i e n t f o r a n y past Soft a n d irregular f o r e i g n bodies l i k e a piece o f paper,
h i s t o r y o f ear d i s c h a r g e o r an e x i s t i n g p e r f o r a t i o n . A q u i - swab o r a piece o f sponge can be r e m o v e d w i t h f i n e c r o c -
escent o t i t i s m e d i a m a y be r e a c t i v a t e d b y s y r i n g i n g . odile forceps.

Figure 8.10

( A ) S y r i n g i n g o f ear. (B) Illustration to s h o w h o w jet o f w a t e r expels the wax or a foreign body.

 Diseases of External Ear

Most o f t h e seed g r a i n s a n d s m o o t h o b j e c t s can be

removed w i t h syringing. Smooth a n d h a r d objects like
steel b a l l b e a r i n g s h o u l d n o t b e g r a s p e d w i t h f o r c e p s as
t h e y t e n d to m o v e inwards and m a y injure the t y m p a n i c
m e m b r a n e . In all impacted foreign bodies or in those where ear-
lier attempts at extraction have been made, it is preferable to use
general anaesthetic and an operating microscope. Occasionally,
postaural approach is used to remove foreign bodies
i m p a c t e d i n deep meatus, m e d i a l t o the i s t h m u s or those
w h i c h h a v e b e e n p u s h e d i n t o t h e m i d d l e ear.
U n s k i l l e d a t t e m p t s at r e m o v a l o f f o r e i g n b o d i e s may
lacerate t h e meatal l i n i n g , damage the tympanic mem-
b r a n e o r t h e ear ossicles.
(b) Living. F l y i n g o r c r a w l i n g insects l i k e mosquitoes, Figure 8.11
beatles, c o c k r o a c h o r a n a n t m a y e n t e r t h e ear c a n a l a n d
Meatal stenosis f o l l o w i n g c h r o n i c otitis externa.
cause i n t e n s e i r r i t a t i o n a n d p a i n . N o a t t e m p t s h o u l d b e
m a d e t o catch t h e m alive. First, t h e insect s h o u l d be k i l l e d
b y i n s t i l l i n g o i l (a h o u s e h o l d r e m e d y ) , s p i r i t o r c h l o r o f o r m
c a n b e c h e c k e d t o s o m e e x t e n t b y t h e use o f k e r a t o l y t i c
water. O n c e k i l l e d , the insect can be r e m o v e d b y any o f
a g e n t s u c h as 2 % s a l i c y l i c a c i d i n a l c o h o l .
the m e t h o d s described above.
Maggots in the ear. Flies m a y b e a t t r a c t e d t o t h e f o u l - 4. A c q u i r e d atresia and stenosis of meatus It can

s m e l l i n g ear d i s c h a r g e a n d l a y eggs w h i c h h a t c h o u t i n t o result f r o m :

l a r v a e c a l l e d m a g g o t s . T h e y are c o m m o n l y seen i n t h e
(a) Infections, e.g. chronic otitis externa-an i m p o r t a n t
m o n t h o f A u g u s t , S e p t e m b e r , a n d O c t o b e r . T h e r e is severe
cause ( F i g . 8 . 1 1 ) .
p a i n w i t h s w e l l i n g r o u n d t h e ear a n d b l o o d - s t a i n e d w a t e r y
(b) T r a u m a , e.g. lacerations, fracture o f t y m p a n i c plate,
d i s c h a r g e . M a g g o t s m a y b e s e e n f i l l i n g t h e ear c a n a l .
s u r g e r y o n ear c a n a l o r m a s t o i d .
T r e a t m e n t consists o f i n s t i l l i n g c h l o r o f o r m w a t e r t o k i l l (c) B u r n s — t h e r m a l or chemical.
t h e m a g g o t s w h i c h can l a t e r b e r e m o v e d b y f o r c e p s . U s u a l l y ,
s u c h p a t i e n t s h a v e d i s c h a r g i n g ears w i t h p e r f o r a t i o n o f t h e T r e a t m e n t is m e a t o p l a s t y . U s i n g a p o s t a u r a l i n c i s i o n ,

t y m p a n i c m e m b r a n e , a n d s y r i n g i n g m a y n o t be advisable. scar tissue a n d t h i c k e n e d m e a t a l s k i n are e x c i s e d , bony

m e a t u s is e n l a r g e d a n d t h e r a w m e a t a l b o n e is covered
3. Keratosis obturans C o l l e c t i o n o f a p e a r l y w h i t e mass
w i t h p e d i c l e d flaps f r o m m e a t u s o r s p l i t s k i n g r a f t s .
o f d e s q u a m a t e d e p i t h e l i a l cells i n t h e d e e p m e a t u s is c a l l e d
keratosis obturans. This, by its p r e s s u r e effect, causes
a b s o r p t i o n o f b o n e l e a d i n g t o w i d e n i n g o f t h e m e a t u s so
III. DISEASES O F TYMPANIC MEMBRANE
m u c h so t h a t f a c i a l n e r v e m a y b e e x p o s e d a n d p a r a l y s e d .
Aetiology. I t is c o m m o n l y s e e n b e t w e e n 5 a n d 2 0 years
Diseases o f t y m p a n i c m e m b r a n e m a y b e p r i m a r y o r sec-
a n d m a y a f f e c t o n e o r b o t h ears. I t m a y s o m e t i m e s b e asso-
o n d a r y t o c o n d i t i o n s a f f e c t i n g e x t e r n a l ear, m i d d l e ear o r
ciated w i t h bronchiectasis a n d c h r o n i c sinusitis. N o r m a l l y ,
eustachian t u b e .
e p i t h e l i u m f r o m surface o f t y m p a n i c m e m b r a n e migrates
o n t o t h e posterior meatal w a l l . Failure o f this m i g r a t i o n or Normal tympanic membrane. I t is s h i n y a n d p e a r l y - g r e y i n

o b s t r u c t i o n t o m i g r a t i o n caused b y w a x m a y lead t o a c c u - c o l o u r w i t h a c o n c a v i t y o n its l a t e r a l surface, m o r e m a r k e d

m u l a t i o n o f the epithelial p l u g i n the deep meatus. at t h e t i p o f m a l l e u s , t h e u m b o . A b r i g h t c o n e o f l i g h t c a n

be seen i n t h e a n t e r o - i n f e r i o r q u a d r a n t . A t t i c area lies
Clinical features. Presenting s y m p t o m s m a y be pain i n the
a b o v e t h e l a t e r a l process o f m a l l e u s a n d is s l i g h t l y p i n k i s h .
ear, h e a r i n g loss, t i n n i t u s a n d s o m e t i m e s ear d i s c h a r g e .
Transparency v a r i e s . S o m e m i d d l e ear s t r u c t u r e s c a n be
O n e x a m i n a t i o n , ear c a n a l m a y b e f u l l o f p e a r l y w h i t e
seen t h r o u g h a t r a n s p a r e n t m e m b r a n e . A n o r m a l t y m p a n i c
mass o f k e r a t i n m a t e r i a l d i s p o s e d i n several l a y e r s . R e m o v a l
membrane is m o b i l e w h e n t e s t e d w i t h p n e u m a t i c oto-
o f t h i s mass m a y s h o w w i d e n i n g o f b o n y m e a t u s with
scope o r Siegle's s p e c u l u m .
ulceration and even granuloma formation.
Treatment. K e r a t o t i c mass is r e m o v e d e i t h e r b y s y r i n g - 1. Retracted tympanic membrane I t appears d u l l a n d
i n g or instrumentation, similar to the techniques e m p l o y e d lustreless. C o n e o f l i g h t is absent o r i n t e r r u p t e d . H a n d l e o f
f o r i m p a c t e d w a x . Secondary otitis externa m a y be present m a l l e u s appears f o r e s h o r t e n e d . L a t e r a l p r o c e s s o f m a l l e u s
and should be treated. Patient s h o u l d be periodically becomes m o r e p r o m i n e n t . A n t e r i o r and posterior malleal
checked a n d any reaccumulations r e m o v e d . R e c u r r e n c e folds become sickle-shaped (Fig. 8.12). A retracted
 (c) P r e s s u r e b y a f l u i d c o l u m n , e.g. d i v i n g , w a t e r sports
or forceful syringing.
(d) Fracture o f t e m p o r a l bone.

Treatment. I n a m a j o r i t y o f cases, edges o f p e r f o r a t i o n

g e t i n v e r t e d t o w a r d s t h e m i d d l e ear. I n s u c h cases, t h e ear
Foreshortened
hondle of malleus
s h o u l d be e x a m i n e d u n d e r o p e r a t i n g m i c r o s c o p e and the
edges o f p e r f o r a t i o n r e p o s i t i o n e d a n d s p l i n t e d (see page
417).
I n j u r i e s o f t y m p a n i c m e m b r a n e m a y b e associated w i t h
f a c i a l paralysis o r s u b l u x a t i o n o f stapes ( v e r t i g o a n d n y s t a g -
m u s ) a n d s e n s o r i n e u r a l h e a r i n g loss. I n s u c h cases, u r g e n t
Figure 8.12 e x p l o r a t i o n m a y be r e q u i r e d .

Retracted tympanic m e m b r a n e . 6. A t r o p h i c tympanic membrane A normal tympanic

membrane consists o f o u t e r e p i t h e l i a l , m i d d l e f i b r o u s a n d
i n n e r m u c o s a l layer. I n serous o t i t i s m e d i a , t h e m i d d l e f i b r o u s
t y m p a n i c m e m b r a n e is t h e r e s u l t o f n e g a t i v e i n t r a t y m p a n i c
l a y e r gets a b s o r b e d l e a v i n g a t h i n d r u m h e a d w h i c h easily gets
pressure w h e n t h e e u s t a c h i a n t u b e is b l o c k e d .
collapsed w i t h eustachian t u b e i n s u f f i c i e n c y . A p e r f o r a t i o n
2. Myringitis bullosa I t is a p a i n f u l c o n d i t i o n c h a r a c t e r - of tympanic membrane also heals o n l y b y e p i t h e l i a l a n d
ised b y f o r m a t i o n o f h a e m o r r h a g i c blebs o n the t y m p a n i c m u c o s a l layers w i t h o u t t h e i n t e r v e n i n g f i b r o u s layer.
membrane a n d deep meatus. I t is p r o b a b l y c a u s e d b y a
7. R e t r a c t i o n p o c k e t s a n d a t e l e c t a s i s W h e n the t y m -
virus or mycoplasma pneumoniae.
panic m e m b r a n e is t h i n a n d a t r o p h i c , a s e g m e n t o f i t o r
3. H e r p e s zoster oticus I t is a v i r a l i n f e c t i o n i n v o l v i n g
the entire m e m b r a n e m a y collapse i n w a r d s d u e t o eusta-
geniculate g a n g l i o n o f f a c i a l n e r v e . I t is c h a r a c t e r i s e d b y
chian tube insufficiency. It may form a retraction pocket
a p p e a r a n c e o f vesicles o n t h e t y m p a n i c m e m b r a n e , deep
o r g e t p l a s t e r e d o n t o p r o m o n t o r y a n d also w r a p r o u n d t h e
m e a t u s , c o n c h a a n d r e t r o a u r i c u l a r sulcus. I t m a y i n v o l v e
ossicles. A d e e p r e t r a c t i o n p o c k e t m a y a c c u m u l a t e k e r a t i n
seventh ( m o r e often) a n d t h e e i g h t h cranial nerves.
debris a n d f o r m a cholesteatoma.

4. Myringitis granulosa N o n - s p e c i f i c granulations f o r m

8. T y m p a n o s c l e r o s i s I t is h y a l i n i s a t i o n a n d l a t e r c a l c i f i -
o n the o u t e r surface o f t y m p a n i c m e m b r a n e . It may be
c a t i o n i n t h e f i b r o u s l a y e r o f t y m p a n i c m e m b r a n e . I t appears
associated w i t h i m p a c t e d w a x , l o n g - s t a n d i n g f o r e i g n b o d y
as c h a l k y w h i t e p l a q u e . M o s t l y , i t r e m a i n s asymptomatic.
o r e x t e r n a l ear i n f e c t i o n .
I t is frequently seen i n cases o f serous o t i t i s m e d i a as a
5. T r a u m a t i c rupture Tympanic membrane may be complication o f ventilation tube. Tympanosclerosis mostly
ruptured by: affects t y m p a n i c m e m b r a n e b u t m a y b e seen involving
l i g a m e n t s , j o i n t s o f ossicles, m u s c l e t e n d o n s a n d s u b m u -
(a) T r a u m a due t o a hair p i n , m a t c h stick or unskilled
cosal l a y e r o f m i d d l e ear c l e f t , a n d i n t e r f e r e s i n t h e con-
attempts to r e m o v e a foreign b o d y .
duction o f sound.
(b) S u d d e n c h a n g e i n a i r p r e s s u r e , e.g. a slap o r a kiss o n
t h e ear o r a s u d d e n blast. F o r c e f u l V a l s a l v a m a y r u p - 9 . P e r f o r a t i o n s T h e y m a y b e c e n t r a l , attic o r m a r g i n a l
ture a t h i n atrophic membrane. a n d are associated w i t h c h r o n i c o t i t i s m e d i a , (see page 8 9 ) .
 Eustachian T u b e and Its D i s o r d e r s

a b o v e t h e l e v e l o f f l o o r . T h e pharyngeal end o f t h e t u b e is
Anatomy
s l i t - l i k e , v e r t i c a l l y . T h e c a r t i l a g e at t h i s e n d raises a n e l e v a -
tion c a l l e d t o r u s t u b a r i u s w h i c h is s i t u a t e d i n t h e l a t e r a l
E u s t a c h i a n t u b e , also called t h e auditory or the pharyngotym-
w a l l o f t h e n a s o p h a r y n x , 1—1.25 c m b e h i n d t h e p o s t e r i o r
panic tube, c o n n e c t s n a s o p h a r y n x w i t h t h e t y m p a n i c c a v i t y . I n
end o f inferior turbinate.
an a d u l t , i t is a b o u t 3 6 m m l o n g a n d r u n s d o w n w a r d s , for-
w a r d s a n d m e d i a l l y from its t y m p a n i c e n d , f o m i i n g a n angle
o f 4 5 ° w i t h t h e h o r i z o n t a l . I t is d i v i d e d i n t o t w o parts: T h e
bony, w h i c h is posterolateral, f o n n s o n e t h i r d ( 1 2 m m ) o f t h e Structure

t o t a l l e n g t h a n d fibrocartilaginous, w h i c h is a n t e r o m e d i a l , f o r m s
t w o - t h i r d s (24 m m ) . T h e t w o parts m e e t at i s t h m u s w h i c h is
t h e n a r r o w e s t p a r t o f t h e t u b e ( F i g . 9.1). T h e f i b r o c a r t i l a g i -
n o u s p a r t o f t h e t u b e is m a d e o f a single p i e c e o f cartilage
f o l d e d u p o n itself i n such a w a y that i t forms the w h o l e o f
m e d i a l l a m i n a , r o o f a n d a p a r t o f t h e lateral l a m i n a ; t h e rest o f
its lateral l a m i n a is m a d e o f f i b r o u s m e m b r a n e .
T h e tympanic end o f t h e t u b e is b o n y , measures 5 X 2 m m
a n d is s i t u a t e d i n t h e a n t e r i o r w a l l o f m i d d l e ear, a l i t t l e
r—Tympanic end
Muscles Related to Eustachian Tube ( F i g . 9 . 2 )
T h r e e m u s c l e s are r e l a t e d t o t h e t u b e : T e n s o r v e l i p a l a t i n i ,
Levator veli palatini and the Salpingopharyngeus. The
m e d i a l f i b r e s o f t h e t e n s o r v e l i p a l a t i n i are a t t a c h e d t o t h e
lateral l a m i n a o f the tube, a n d w h e n they contract help to
o p e n t h e t u b a l l u m e n . T h e s e f i b r e s h a v e also b e e n c a l l e d
t h e dilator tubae m u s c l e . T h e e x a c t r o l e o f t h e l e v a t o r v e l i
palatini a n d the Salpingopharyngeus muscles to o p e n the
t u b e is u n c e r t a i n . I t is b e l i e v e d t h a t l e v a t o r v e l i p a l a t i n i
muscle w h i c h runs i n f e r i o r and parallel to the cartilaginous
part o f the tube forms a b u l k under the medial lamina, and
d u r i n g c o n t r a c t i o n pushes i t u p w a r d a n d m e d i a l l y thus
assisting i n o p e n i n g t h e t u b e .
The elastin hinge. T h e c a r t i l a g e , at t h e j u n c t i o n o f m e d i a l ,
a n d l a t e r a l l a m i n a at t h e r o o f , is rich i n e l a s t i n f i b r e s w h i c h
f o r m a h i n g e . B y its r e c o i l i t h e l p s t o k e e p t h e t u b e c l o s e d

Isthmus w h e n n o l o n g e r acted u p o n b y d i l a t o r tubae muscle.

Ostmann's pad of fat. I t is a mass o f f a t t y tissues r e l a t e d
laterally to the m e m b r a n o u s part o f the cartilaginous tube.
I t also h e l p s t o k e e p t h e t u b e c l o s e d a n d t h u s p r o t e c t i t
Cartilaginous part
f r o m the r e f l u x o f nasopharyngeal secretions.

Pharyngeal end
Lining of the Eustachian Tube

Histologically, the mucosa shows pseudostratified ciliated

c o l u m n a r e p i t h e l i u m interspersed w i t h m u c o u s secreting g o b -

Figure 9.1 let cells. S u b m u c o s a , p a r t i c u l a r l y i n the cartilaginous p a r t o f

the t u b e , is rich i n s e r o m u c i n o u s glands. T h e cilia beat i n t h e
Horizontal section through the eustachian tube showing bony
d i r e c t i o n o f n a s o p h a r y n x a n d thus helps t o d r a i n secretions
and cartilaginous parts, isthmus, tympanic and pharyngeal ends.
a n d f l u i d from t h e m i d d l e ear i n t o t h e n a s o p h a r y n x .
 Figure 9.2

Vertical section through eustachian tube. Note: Cartilage o f the tube forms medial wall, r o o f and part o f lateral wall. Elastin is

situated in the r o o f at the junction o f medial and lateral laminae and helps the medial laminae to regain its o r i g i n a l position o f

c l o s u r e . ( A ) E u s t a c h i a n t u b e is c l o s e d i n r e s t i n g p o s i t i o n . ( B ) T u b e is o p e n w h e n t e n s o r veli p a l a t i n i ( d i l a t o r t u b a e ) m u s c l e contracts.

Nerve Supply N o r m a l l y , the eustachian t u b e remains closed and opens

i n t e r m i t t e n t l y d u r i n g s w a l l o w i n g , y a w n i n g and sneezing.
T y m p a n i c b r a n c h o f C N I X s u p p l i e s s e n s o r y as w e l l as
P o s t u r e also affects t h e f u n c t i o n ; t u b a l o p e n i n g is less e f f i -
parasympathetic s e c r e t o m o t o r fibres to t h e t u b a l mucosa.
cient i n recumbent position and during sleep d u e to
T e n s o r v e l i p a l a t i n i is s u p p l i e d b y m a n d i b u l a r b r a n c h of
v e n o u s e n g o r g e m e n t . T u b a l f u n c t i o n is also p o o r i n i n f a n t s
t r i g e m i n a l (V^) n e r v e . L e v a t o r v e l i p a l a t i n i a n d s a l p i n g o -
and y o u n g c h i l d r e n a n d thus responsible for more ear
pharyngeus receive m o t o r nerve supply t h r o u g h p h a r y n -
p r o b l e m s i n t h a t age g r o u p . I t u s u a l l y n o r m a l i z e s b y t h e
geal p l e x u s ( C r a n i a l p a r t o f C N X I t h r o u g h v a g u s ) .
age o f 7 - 1 0 years.

Differences Between the Infant and Adult Eustachian Tube 2. Protective functions A b n o r m a l l y , h i g h s o u n d pres-
sures f r o m t h e n a s o p h a r y n x c a n b e t r a n s m i t t e d t o t h e m i d -
T h e e u s t a c h i a n t u b e o f i n f a n t s is w i d e r , s h o r t e r a n d m o r e
d l e ear i f t h e t u b e is o p e n t h u s i n t e r f e r i n g w i t h n o r m a l
horizontal; thus infections from t h e n a s o p h a r y n x c a n eas-
hearing. N o r m a l l y , the eustachian t u b e remains closed a n d
i l y r e a c h t h e m i d d l e ear. E v e n t h e m i l k m a y r e g u r g i t a t e
p r o t e c t s t h e m i d d l e ear against these s o u n d s .
i n t o t h e m i d d l e ear i f t h e i n f a n t s are n o t f e d i n h e a d - u p
A n o r m a l e u s t a c h i a n t u b e also p r o t e c t s t h e m i d d l e ear
p o s i t i o n (see T a b l e 9.1).
f r o m r e f l u x o f nasopharyngeal secretions i n t o the m i d d l e
ear. T h i s r e f l u x o c c u r s m o r e r e a d i l y i f t h e t u b e is w i d e i n

Functions d i a m e t e r ( p a t u l o u s t u b e ) , s h o r t i n l e n g t h , (as i n b a b i e s ) , o r
the t y m p a n i c m e m b r a n e is p e r f o r a t e d (cause f o r p e r s i s -

Physiologically, eustachian tube performs three main t e n c e o f m i d d l e ear i n f e c t i o n s i n cases o f t y m p a n i c m e m -

functions; brane perforations).

I V e n t i l a t i o n a n d t h u s r e g u l a t i o n o f m i d d l e ear pressure.
2- P r o t e c t i o n against (a) N a s o p h a r y n g e a l s o u n d pressure
a n d (b) R e f l u x o f n a s o p h a r y n g e a l secretions.
3. M i d d l e ear c l e a r a n c e o f s e c r e t i o n s .
1. V e n t i l a t i o n a n d r e g u l a t i o n o f m i d d l e ear
F o r n o r m a l h e a r i n g , i t is essential t h a t pressure
sides o f t h e t y m p a n i c m e m b r a n e s h o u l d b e e q u a l . N e g a t i v e
o r p o s i t i v e pressure i n t h e m i d d l e ear affects h e a r i n g . T h u s ,
eustachian tube s h o u l d o p e n p e r i o d i c a l l y to equilibrate the
a i r p r e s s u r e i n t h e m i d d l e ear w i t h t h e a m b i e n t
H i g h pressures i n t h e n a s o p h a r y n x c a n also f o r c e n a s o -
p h a r y n g e a l s e c r e t i o n s i n t o t h e m i d d l e ear, e.g. forceful
nose b l o w i n g , c l o s e d - n o s e s w a l l o w i n g as i n t h e p r e s e n c e
o f a d e n o i d s o r b i l a t e r a l nasal o b s t r u c t i o n .
3. C l e a r a n c e o f m i d d l e ear secretions Mucous m e m -
pressure brane o f the eustachian tube a n d anterior part o f the m i d -
on two d l e ear is l i n e d b y c i l i a t e d c o l u m n a r cells. T h e c i l i a b e a t i n
t h e d i r e c t i o n o f n a s o p h a r y n x . T h i s helps t o clear the secre-
t i o n s a n d d e b r i s i n t h e m i d d l e ear t o w a r d s t h e nasophar-
y n x . T h e c l e a r a n c e f u n c t i o n is f u r t h e r a u g m e n t e d b y a c t i v e
pressure. o p e n i n g and closing o f the tube.
 E u s t a c h i a n T u b e a n d Its D i s o r d e r s

Differences between infant and adult eustachian t u b e

Infant A d u l t

Length 1 3 - 1 8 m m at b i r t h ( a b o u t h a l f as 36 m m ( 3 1 - 3 8 m m )
l o n g as in a d u l t )

Direction M o r e h o r i z o n t a l . A t birth it f o r m s F o r m s an angle o f 4 5 ° w i t h t h e h o r i z o n t a l

an angle o f 1 0 ° w i t h t h e h o r i z o n t a l
A t age 7 a n d l a t e r i t is 4 5 °

A n g u l a t i o n at i s t h m u s No angulation A n g u l a t i o n present

B o n y versus c a r t i l a g i n o u s p a r t Bony p a r t is s l i g h t l y longer t h a n B o n y p a r t 1/3; c a r t i l a g i n o u s p a r t 2/3

1/3 o f t h e t o t a l l e n g t h o f t h e
t u b e a n d is relatively w i d e r

T u b a l cartilage F l a c c i d . R e t r o g r a d e reflux o f Comparatively rigid. Remains closed and protects

n a s o p h a r y n g e a l secretions c a n the m i d d l e ear from the reflux

occur

D e n s i t y o f elastin a t t h e hinge Less dense; t u b e does n o t e f f i c i e n t l y Density o f elastin m o r e and helps to keep the

close by r e c o i l tube closed by recoil o f cartilage

Ostmann's pad o f fat Less in v o l u m e Large and helps to keep the tube closed

| Eustachian Tube Function Tests
1. Valsalva test T h e p r i n c i p l e o f t h i s test, as also
p o l i t z e r i s a t i o n , is t o b u i l d p o s i t i v e pressure i n t h e n a s o -
p h a r y n x so t h a t a i r e n t e r s t h e e u s t a c h i a n t u b e . T o d o t h i s
test, p a t i e n t p i n c h e s h i s n o s e b e t w e e n t h e t h u m b a n d i n d e x
finger, takes a d e e p b r e a t h , closes h i s m o u t h a n d tries t o
b l o w a i r i n t o t h e ears. I f air e n t e r s t h e m i d d l e ear, t h e t y m -
panic m e m b r a n e w i l l m o v e o u t w a r d s w h i c h can be v e r i -
fied by otoscope o r the m i c r o s c o p e . I n the presence o f a
t y m p a n i c m e m b r a n e p e r f o r a t i o n , a h i s s i n g s o u n d is p r o -
d u c e d o r i f discharge is also p r e s e n t i n t h e m i d d l e car,
c r a c k i n g s o u n d w i l l b e h e a r d . F a i l u r e o f t h i s test does n o t
p r o v e b l o c k a g e o f t h e t u b e because o n l y a b o u t 6 5 % o f p e r -
sons c a n s u c c e s s f u l l y p e r f o r m t h i s test. T h i s test s h o u l d b e
a v o i d e d (i) i n t h e presence o f a t r o p h i c scar o f t y m p a n i c m e m -
brane w h i c h can r u p t u r e , a n d (ii) i n the presence o f i n f e c -
t i o n o f nose a n d n a s o p h a r y n x w h e r e i n f e c t e d s e c r e t i o n s are
l i k e l y t o be p u s h e d i n t o t h e m i d d l e ear c a u s i n g o t i t i s m e d i a .
2 . P o l i t z e r t e s t T h i s test is d o n e i n c h i l d r e n w h o are u n a b l e
t o p e r f o m i V a l s a l v a test. I n t h i s test, o l i v e - s h a p e d t i p o f t h e
P o l i t z e r ' s b a g is i n t r o d u c e d i n t o t h e p a t i e n t ' s n o s t r i l o n t h e
side o f w h i c h t h e t u b a l f u n c t i o n is d e s i r e d t o b e tested.
O t h e r n o s t r i l is c l o s e d , a n d t h e b a g c o m p r e s s e d w h i l e at
t h e s a m e t i m e t h e p a t i e n t s w a l l o w s (he c a n b e g i v e n sips o f
w a t e r ) o r says " i k , i k , i k " . B y m e a n s o f an a u s c u l t a t i o n t u b e ,
c o n n e c t i n g t h e p a t i e n t ' s ear u n d e r test t o t h a t o f t h e e x a m -
i n e r , a h i s s i n g s o u n d is h e a r d i f t u b e is p a t i e n t . C o m p r e s s e d
air c a n also b e u s e d i n s t e a d o f P o l i t z e r ' s b a g . T h e test is also
u s e d t h e r a p e u t i c a l l y t o v e n t i l a t e t h e m i d d l e ear.
3. C a t h e t e r i s a t i o n I n t h i s test, n o s e is f i r s t anaesthetised
by t o p i c a l spray o f l i g n o c a i n e a n d t h e n a e u s t a c h i a n tube
J
c a t h e t e r , t h e t i p o f w h i c h is b e n t , is passed a l o n g t h e floor
of o f n o s e t i l l i t reaches t h e n a s o p h a r y n x . H e r e i t is r o t a t e d
9 0 ° m e d i a l l y a n d g r a d u a l l y p u l l e d b a c k t i l l i t engages o n
t h e p o s t e r i o r b o r d e r o f nasal s e p t u m ( F i g . 9 . 3 A ) . I t is t h e n
r o t a t e d 1 8 0 ° l a t e r a l l y so t h a t t h e t i p lies against t h e t u b a l
o p e n i n g ( F i g . 9 . 3 B ) . A P o l i t z e r ' s b a g is n o w c o n n e c t e d t o
t h e c a t h e t e r a n d a i r i n s u f f l a t e d . E n t r y o f air i n t o t h e m i d d l e
ear is v e r i f i e d b y a n a u s c u l t a t i o n t u b e . T h e p r o c e d u r e of
c a t h e t e r i z a t i o n s h o u l d be g e n t l e as i t is k n o w n t o cause
c o m p l i c a t i o n s s u c h as:
(a) I n j u r y t o e u s t a c h i a n t u b e o p e n i n g w h i c h causes scar-
ring later.
(b) B l e e d i n g f r o m the nose.
ic) T r a n s m i s s i o n o f nasal a n d n a s o p h a r y n g e a l infection
i n t o t h e m i d d l e ear c a u s i n g o t i t i s m e d i a .
(d) R u p t u r e o f a t r o p h i c area o f t y m p a n i c m e m b r a n e if
t o o m u c h pressure is u s e d .
4 . T o y n b e e ' s t e s t W h i l e t h e a b o v e t h r e e tests use a p o s i t i v e
pressure, T o y n b e e ' s m a n o e u v r e causes n e g a t i v e pressure. I t
is a m o r e p h y s i o l o g i c a l test. I t is p e r f o r m e d b y a s k i n g the
p a t i e n t t o s w a l l o w w h i l e nose has b e e n p i n c h e d . T h i s d r a w s
air from t h e m i d d l e ear i n t o t h e n a s o p h a r y n x a n d causes
i n w a r d m o v e m e n t o f t y m p a n i c m e m b r a n e w h i c h is v e r i f i e d
by the examiner otoscopically o r w i t h a microscope.
5. T y m p a n o m e t r y ( A l s o c a l l e d i n f l a t i o n - d e f l a t i o n test)
I n this test, p o s i t i v e a n d n e g a t i v e pressures are c r e a t e d i n
t h e e x t e r n a l ear canal a n d t h e p a t i e n t s w a l l o w s r e p e a t e d l y .
T h e ability o f the tube to equilibrate p o s i t i v e a n d negative
Diseases of Ear

pressures t o t h e a m b i e n t pressure indicates n o r m a l t u b a l through the active contraction o f Tensor veli palatini
f u n c t i o n . T h e test c a n b e d o n e b o t h i n p a t i e n t s w i t h p e r - muscle. A i r , composed o f o x y g e n , carbon d i o x i d e , nitrogen
f o r a t e d o r i n t a c t t y m p a n i c m e m b r a n e s (sec page 2 9 ) . a n d w a t e r v a p o u r , n o r m a l l y fills t h e m i d d l e ear a n d m a s -

6. R a d i o l o g i c a l test A r a d i o - o p a q u e d y e , e.g. h y p a q u e t o i d . W h e n t u b e is b l o c k e d , f i r s t o x y g e n is a b s o r b e d , b u t

o r l i p o i d a l i n s t i l l e d i n t o t h e m i d d l e ear t h r o u g h a p r e - l a t e r o t h e r gases, C O a n d n i t r o g e n also d i f f u s e o u t i n t o

existing p e r f o r a t i o n , and X - r a y s taken s h o u l d delineate the t h e b l o o d . T h i s results i n n e g a t i v e pressure i n t h e m i d d l e

tube and any obstruction. T h e t i m e taken b y the dye t o ear and retraction o f tympanic membrane. I f negative

r e a c h t h e n a s o p h a r y n x also i n d i c a t e s its c l e a r a n c e f u n c t i o n . pressure is s t i l l f u r t h e r i n c r e a s e d , i t causes " l o c k i n g " o f t h e

T h i s test is n o l o n g e r p o p u l a r n o w . t u b e w i t h c o l l e c t i o n o f transudate a n d later exudate and

e v e n h a e m o r r h a g e . Effects o f acute a n d l o n g - t e r m tubal
7. S a c c h a r i n e or methylene b l u e test Saccharine s o l u -
b l o c k a g e are s h o w n i n T a b l e 9.2.
t i o n is p l a c e d i n t o t h e m i d d l e ear t h r o u g h a p r e - e x i s t i n g
E u s t a c h i a n t u b e o b s t r u c t i o n c a n be m e c h a n i c a l , f u n c -
p e r f o r a t i o n . T h e t i m e t a k e n b y i t t o reach the p h a r y n x a n d
t i o n a l o r b o t h . Mechanical obstruction can result f r o m (a)
i m p a r t a s w e e t taste is also a m e a s u r e o f clearance f u n c t i o n .
i n t r i n s i c causes s u c h as i n f l a m m a t i o n o r a l l e r g y o r (b) e x t r i n -
S i m i l a r l y , m e t h y l e n e b l u e d y e c a n be i n s t i l l e d i n t o t h e
sic causes s u c h as t u m o u r i n t h e n a s o p h a r y n x o r a d e n o i d s .
m i d d l e ear a n d t h e t i m e t a k e n b y i t t o s t a i n t h e p h a r y n g e a l
Functional obstruction is c a u s e d b y c o l l a p s e o f t h e t u b e d u e
s e c r e t i o n s can b e n o t e d .
t o i n c r e a s e d c a r t i l a g e c o m p l i a n c e w h i c h resists o p e n i n g o f
I n d i r e c t e v i d e n c e o f d r a i n a g e / c l e a r a n c e f u n c t i o n is estab-
the tube or failure o f active t u b a l - o p e n i n g m e c h a n i s m due
l i s h e d w h e n ear d r o p s i n s t i l l e d i n t o t h e ear w i t h t y m p a n i c
to p o o r f u n c t i o n o f tensor veli palatini. T h e c o m m o n c l i n -
m e m b r a n e p e r f o r a t i o n cause b a d taste i n t h r o a t .
i c a l c o n d i t i o n s w h i c h c a n cause t u b a l o b s t r u c t i o n are l i s t e d
8. S o n o t u b o m e t r y A t o n e is p r e s e n t e d t o t h e n o s e a n d its
in Table 9.3.
r e c o r d i n g t a k e n f r o m t h e e x t e r n a l c a n a l . T h e t o n e is h e a r d
S y m p t o m s o f tubal occlusion i n c l u d e otalgia, which
l o u d e r w h e n t h e t u b e is p a t e n t ( c o m p a r e p a t u l o u s e u s t a -
m a y b e m i l d t o s e v e r e , h e a r i n g loss, p o p p i n g sensation,
c h i a n t u b e ) . I t also tells t h e d u r a t i o n f o r w h i c h t h e t u b e
tinnitus and disturbances o f e q u i l i b r i u m o r - e v e n v e r t i g o .
r e m a i n s o p e n . I t is a n o n - i n v a s i v e t e c h n i q u e a n d p r o v i d e s
Signs o f t u b a l o c c l u s i o n w i l l v a r y a n d d e p e n d u p o n the
information o n active tubal o p e n i n g . Accessory sounds
acuteness o f t h e c o n d i t i o n and severity. T h e y include,
p r o d u c e d i n the nasopharynx, d u r i n g s w a l l o w i n g , may i n t e r -
retracted t y m p a n i c m e m b r a n e , congestion along the handle
f e r e w i t h t h e test results. T h e test is u n d e r d e v e l o p m e n t .
o f m a l l e u s a n d t h e pars tensa, t r a n s u d a t e b e h i n d t h e t y m -
panic m e m b r a n e , i m p a r t i n g it an amber c o l o u r and some-
Disorders of Eustachian Tube ( E T ) t i m e s a fluid l e v e l w i t h c o n d u c t i v e h e a r i n g loss. I n severe
cases, as i n b a r o t r a u m a , t y m p a n i c m e m b r a n e is m a r k e d l y
Tubal blockage N o r m a l l y , E T is c l o s e d . I t o p e n s i n t e r - retracted w i t h haemorrhages i n subepithelial layer, h a e m o -
mittently during swallowing, yawning and sneezing t y m p a n u m or sometimes a perforation.
 E u s t a c h i a n T u b e a n d Its D i s o r d e r s

O t i t i s m e d i a w i t h e f f u s i o n is c o m m o n i n these p a t i e n t s .
Table 9.2 Effects o f acute and prolonged tubal blockage
E v e n after r e p a i r o f t h e c l e f t palate d e f o n n i t y , m a n y o f t h e m
Acute tubal blockage
r e q u i r e i n s e r t i o n o f g r o m m e t s t o v e n t i l a t e t h e m i d d l e ear.
I
Absorption o f M E gases
Down's syndrome and tubal function Function of

I eustachian t u b e is d e f e c t i v e p o s s i b l y d u e t o p o o r t o n e of

Negative p r e s s u r e in M E tensor v e l i p a l a t i n i m u s c l e a n d a b n o r m a l shape o f nasophar-

\ y n x . C h i l d r e n w i t h this s y n d r o m e are p r o n e t o f r e q u e n t
otitis media o r otitis media w i t h effusion.
Retraction o f T M

I Barotrauma See p a g e 7 4 .
T r a n s u d a t e in M E / h a e m o r r h a g e (acute O M E )

Prolonged tubal blockage/dysfunction

1 Retraction Pockets and Eustachian Tube

O M E (thin watery or m u c o i d discharge)

I I n v e n t i l a t i o n o f t h e m i d d l e ear c l e f t , a i r passes f r o m e u s t a -
Atelectatic ear/perforation
chian tube to m e s o t y m p a n u m , f r o m there to attic, aditus,
I
a n t r u m a n d m a s t o i d air cell system. M e s o t y m p a n u m c o m -
Retraction pocket/cholesteatoma
m u n i c a t e s w i t h the attic v i a a n t e r i o r a n d p o s t e r i o r i s t h m i .
I
Erosion o f incudostapedial joint situated i n m e m b r a n o u s diaphragm between the meso-
t y m p a n u m a n d t h e a t t i c . Anterior isthmus is s i t u a t e d b e t w e e n
ME—middle ear, TM—tympanic membrane, OME—otitis media

with effusion t e n d o n o f t e n s o r t y m p a n i a n d t h e stapes. Posterior isthmus is

s i t u a t e d b e t w e e n t e n d o n o f stapedius m u s c l e a n d p y r a m i d ,
a n d t h e s h o r t p r o c e s s o f i n c u s . I n s o m e cases, m i d d l e ear
Table 9.3 Causes o f eustachian tube obstruction c a n also c o m m u n i c a t e d i r e c t l y w i t h t h e m a s t o i d a i r cells
t h r o u g h t h e r e t r o f a c i a l cells. A n y o b s t r u c t i o n i n t h e p a t h -
U p p e r respiratory infection (viral or bacterial)

Allergy
w a y s o f v e n t i l a t i o n c a n cause r e t r a c t i o n p o c k e t s o r a t e l e c t a -

Sinusitis sis o f t y m p a n i c m e m b r a n e , e.g,

Nasal polypi
(i) O b s t r u c t i o n o f e u s t a c h i a n t u b e —> T o t a l atelectasis o f
D N S
tympanic membrane.
Hypertrophic adenoids
(ii) O b s t r u c t i o n i n m i d d l e car - » R e t r a c t i o n pocket in
Nasopharyngeal t u m o u r / m a s s

Cleft palate
p o s t e r i o r p a r t o f m i d d l e ear w h i l e a n t e r i o r p a r t is

S u b m u c o u s cleft palate
ventilated.

D o w n ' s syndrome (iii) O b s t r u c t i o n o f i s t h m i —> A t t i c r e t r a c t i o n p o c k e t .

Functional (iv) O b s t r u c t i o n at a d i t u s —> C h o l e s t e r o l g r a n u l o m a a n d
c o l l e c t i o n o f m u c o i d d i s c h a r g e i n m a s t o i d air cells,
w h i l e m i d d l e ear a n d a t t i c a p p e a r n o r m a l .
Adenoids and eustachian tube function Adenoids
cause t u b a l d y s f u n c t i o n b y : D e p e n d i n g o n t h e l o c a t i o n o f p a t h o l o g i c process, o t h e r
c h a n g e s s u c h as t h i n a t r o p h i c t y m p a n i c m e m b r a n e , p a r t i a l
Mechanical obstruction o f the tubal opening,
or total, (due to absorption o f m i d d l e fibrous layer), c h o -
i. A c t i n g as r e s e r v o i r f o r p a t h o g e n i c organisms,
lesteatoma, ossicular necrosis, and tympanosclerotic
i i. I n cases o f a l l e r g y , mast cells o f t h e a d e n o i d tissue release
c h a n g e s m a y also b e f o u n d .
i n f l a m m a t o r y m e d i a t o r s w h i c h cause t u b a l b l o c k a g e .
Principles of management o f retraction pockets and
T h u s , a d e n o i d s c a n cause o t i t i s m e d i a w i t h e f f u s i o n o r atelectasis o f m i d d l e ear w o u l d e n t a i l c o r r e c t i o n / r e p a i r of
recurrent acute otitis media. Adenoidectorny can help t h e i r r e v e r s i b l e p a t h o l o g i c processes a n d e s t a b l i s h m e n t of
b o t h these c o n d i t i o n s . the v e n t i l a t i o n .

Cleft palate a n d tubal function T u b a l f u n c t i o n is d i s -

t u r b e d i n c l e f t palate p a t i e n t s d u e t o :
(i) A b n o r m a l i t i e s o f torus tubarius, w h i c h shows high
elastin d e n s i t y m a k i n g t u b e d i f f i c u l t t o o p e n .
(ii) T e n s o r v e l i p a l a t i n i m u s c l e does n o t i n s e r t i n t o t h e
t o r u s t u b a r i u s i n 4 0 % cases o f c l e f t palate a n d w h e r e
i t does i n s e r t , its f u n c t i o n is p o o r .
Patulous Eustachian Tube
I n this c o n d i t i o n , t h e e u s t a c h i a n t u b e is a b n o r m a l l y p a t e n t .
M o s t o f t h e t i m e i t is i d i o p a t h i c b u t r a p i d w e i g h t loss,
p r e g n a n c y e s p e c i a l l y t h i r d t r i m e s t e r , o r m u l t i p l e sclerosis
can also cause i t .
 P a t i e n t ' s c h i e f c o m p l a i n t s are h e a r i n g his o w n v o i c e ( a u t o - nasopharyngoscope. T h e e x t r i n s i c causes w h i c h obstruct
p h o n y ) , e v e n his o w n b r e a t h s o u n d s , w h i c h is v e r y d i s t u r b - this e n d can be e x c l u d e d .
ing. Due t o a b n o r m a l p o t e n c y , pressure changes i n t h e Tympanic end o f t h e t u b e c a n b e e x a m i n e d b y m i c r o -
n a s o p h a r y n x are easily t r a n s m i t t e d t o t h e m i d d l e ear so m u c h scope o r endoscope, i f t h e r e is a p r e e x i s t i n g p e r f o r a t i o n .
so t h a t t h e m o v e m e n t s o f t y m p a n i c can be seen w i t h i n s p i r a - E u s t a c h i a n t u b e e n d o s c o p y o r m i d d l e ear e n d o s c o p y can
t i o n a n d e x p i r a t i o n ; these m o v e m e n t s are farther exagger- be d o n e w i t h v e r y fine flexible endoscopes. Simple e x a m i -
a t e d i f p a t i e n t breathes after c l o s i n g t h e o p p o s i t e n o s t r i l . nation o f tympanic m e m b r a n e w i t h otoscope or m i c r o -
A c u t e c o n d i t i o n o f p a t u l o u s t u b e is s e l f - l i m i t i n g a n d scope m a y reveal r e t r a c t i o n pockets o r f l u i d i n t h e m i d d l e
does n o t r e q u i r e t r e a t m e n t . I n others, w e i g h t gain, oral ear. S i m i l a r l y , m o v e m e n t s o f t y m p a n i c m e m b r a n e with
administration o f p o t a s s i u m i o d i d e is h e l p f u l b u t some respiration p o i n t to patulous eustachian tube.
l o n g - s t a n d i n g cases m a y r e q u i r e c a u t e r i s a t i o n o f t h e t u b e s F u r t h e r assessment o f f u n c t i o n o f t h e t u b e c a n b e m a d e
or insertion o f a g r o m m e t . b y V a l s a l v a , p o l i t z e r i s a t i o n , T o y n b e e a n d o t h e r tests a l r e a d y
described.
Aetiologic causes o f e u s t a c h i a n t u b e d y s f u n c t i o n c a n be
Examination of Eustachian Tube assessed b y t h o r o u g h nasal e x a m i n a t i o n i n c l u d i n g endos-
c o p y , tests o f a l l e r g y , C T scan o f t e m p o r a l b o n e s a n d o f
Pharyngeal end o f t h e e u s t a c h i a n t u b e c a n b e e x a m i n e d b y paranasal sinuses. M R 1 m a y b e r e q u i r e d t o e x c l u d e m u l t i p l e
posterior rhinoscopy, rigid nasal endoscope or flexible sclerosis i n p a t u l o u s e u s t a c h i a n t u b e .
D i s o r d e r s o f M i d d l e Ear

Infections o f tonsils a n d adenoids.

ACUTE SUPPURATIVE OTITIS MEDIA
3. C h r o n i c r h i n i t i s a n d sinusitis.
4. Nasal allergy.
I t is a n a c u t e i n f l a m m a t i o n o f m i d d l e ear b y p y o g e n i c o r g a n - T u m o u r s o f nasopharynx, p a c k i n g o f nose o r nasophar-
isms. H e r e , m i d d l e ear i m p l i e s m i d d l e ear cleft, i.e. eustachian y n x f o r epistaxis.
t u b e , m i d d l e ear, a t t i c , a d i t u s , a n t r u m a n d m a s t o i d air cells. ('. C l e f t palate.

Bacteriology Most common organisms i n infants and

Aetiology y o u n g c h i l d r e n are Streptococcus pneumoniae (30%), Haemophilus
influenzae (20%) a n d Moraxella catairhalis ( 1 2 % ) . O t h e r o r g a n -
I t is m o r e c o m m o n e s p e c i a l l y i n i n f a n t s a n d c h i l d r e n o f isms i n c l u d e Streptococcus pyogenes, Staphylococcus aureus and
l o w e r s o c i o - e c o n o m i c g r o u p . T y p i c a l l y , t h e disease f o l - sometimes Pseudomonas aeruginosa. I n about 18—20%, no
l o w s viral i n f e c t i o n o f u p p e r respiratory tract b u t soon the g r o w t h is seen. M a n y o f t h e strains o f H. influenzae and
p y o g e n i c o r g a n i s m s i n v a d e t h e m i d d l e ear. Moraxella catarrhalis are B - l a c t a m a s e p r o d u c i n g .

Routes of Infection
3 M Pathology and Clinical Features

1. V i a eustachian tube I t is t h e m o s t c o m m o n route. T h e disease r u n s t h r o u g h t h e f o l l o w i n g stages:

I n f e c t i o n travels v i a the l u m e n o f t h e t u b e o r a l o n g s u b e p i -
1 . Stage o f tubal occlusion O e d e m a and hyperaemia o f
thelial p e r i t u b a l lymphatics. Eustachian tube i n infants and
nasopharyngeal e n d o f eustachian tube blocks the tube,
y o u n g c h i l d r e n is s h o r t e r , w i d e r a n d m o r e h o r i z o n t a l a n d
l e a d i n g t o a b s o r p t i o n o f air a n d n e g a t i v e intratympanic
thus m a y a c c o u n t f o r h i g h e r i n c i d e n c e o f infections i n this
p r e s s u r e . T h e r e is r e t r a c t i o n o f t y m p a n i c m e m b r a n e with
age g r o u p . B r e a s t o r b o t d e f e e d i n g i n a y o u n g i n f a n t i n
s o m e d e g r e e o f e f f u s i o n i n t h e m i d d l e ear b u t fluid may
horizontal position m a y force fluids t h r o u g h the tube into
n o t be clinically appreciable.
m e ' m i d d l e ear a n d h e n c e t h e n e e d to keep the infant
Symptoms. D e a f n e s s a n d e a r a c h e are t h e t w o s y m p t o m s
p r o p p e d u p w i t h head a little higher. S w i m m i n g and d i v i n g
b u t t h e y are n o t m a r k e d . T h e r e is g e n e r a l l y n o f e v e r .
c a n also f o r c e w a t e r t h r o u g h t h e t u b e i n t o t h e m i d d l e ear.
Signs. T y m p a n i c m e m b r a n e is r e t r a c t e d w i t h h a n d l e o f
2. V i a external ear Traumatic perforations o f tympanic
malleus assuming a m o r e h o r i z o n t a l p o s i t i o n , p r o m i n e n c e
membrane d u e t o a n y cause o p e n a r o u t e t o m i d d l e ear
o f l a t e r a l p r o c e s s o f m a l l e u s a n d loss o f l i g h t r e f l e x . T u n i n g
infection.
f o r k tests s h o w c o n d u c t i v e deafness.
3. B l o o d - b o r n e T h i s is an u n c o m m o n r o u t e .
2. Stage of pre-suppuration I f tubal occlusion is
prolonged, pyogenic organisms invade tympanic cavity
Predisposing Factors causing hyperaemia o f its l i n i n g . I n f l a m m a t o r y exudate
appears i n t h e m i d d l e ear. T y m p a n i c m e m b r a n e becomes
A n y t h i n g that interferes w i t h n o r m a l f u n c t i o n i n g o f eusta- congested.
c h i a n t u b e predisposes t o m i d d l e ear i n f e c t i o n . I t c o u l d b e : Symptoms. T h e r e is m a r k e d earache w h i c h m a y d i s t u r b
R e c u r r e n t attacks o f c o m m o n c o l d , u p p e r r e s p i r a t o r y sleep a n d is o f t h r o b b i n g n a t u r e . D e a f n e s s a n d t i n n i t u s are
t r a c t i n f e c t i o n s , a n d e x a n t h e m a t o u s fevers l i k e measles, also p r e s e n t , b u t c o m p l a i n e d o n l y b y a d u l t s . U s u a l l y , c h i l d
diphtheria, w h o o p i n g cough. r u n s h i g h d e g r e e o f f e v e r a n d is restless.
 Signs. T o b e g i n w i t h , t h e r e is c o n g e s t i o n o f pars tensa. tensa. H y p e r a e m i a o f t y m p a n i c m e m b r a n e b e g i n s t o s u b -
L e a s h o f b l o o d vessels a p p e a r a l o n g t h e h a n d l e o f m a l l e u s side w i t h r e t u r n t o n o r m a l c o l o u r a n d l a n d m a r k s .
a n d at t h e p e r i p h e r y o f t y m p a n i c m e m b r a n e i m p a r t i n g i t a
5. Stage of complication I f v i r u l e n c e o f o r g a n i s m is
c a r t - w h e e l appearance. Later, w h o l e o f t y m p a n i c mem-
h i g h o r resistance o f p a t i e n t p o o r , r e s o l u t i o n m a y n o t take
b r a n e i n c l u d i n g pars flaccida becomes u n i f o r m l y red.
p l a c e a n d disease spreads b e y o n d t h e c o n f i n e s of middle
T u n i n g f o r k tests w i l l a g a i n s h o w c o n d u c t i v e t y p e of ear. I t m a y l e a d t o a c u t e m a s t o i d i t i s , s u b p e r i o s t e a l abscess,
h e a r i n g loss. f a c i a l paralysis, l a b y r i n t h i t i s , p e t r o s i t i s , e x t r a d u r a l abscess,
3. Stage o f suppuration T h i s is m a r k e d b y f o m i a t i o n o f m e n i n g i t i s , b r a i n abscess o r lateral sinus t h r o m b o p h l e b i t i s .
pus i n t h e m i d d l e ear a n d t o s o m e e x t e n t i n m a s t o i d air cells.
T y m p a n i c m e m b r a n e starts b u l g i n g t o t h e p o i n t o f r u p t u r e .
Symptoms. Earache becomes excruciating. Deafness Treatment
increases, c h i l d m a y r u n f e v e r o f 1 0 2 — 1 0 3 ° F . T h i s m a y b e
accompanied by v o m i t i n g and even convulsions. 1. Antibacterial therapy (Table 10.1) I t is i n d i c a t e d
Signs. Tympanic membrane appears r e d a n d b u l g i n g i n all cases w i t h f e v e r a n d severe earache. A s t h e m o s t c o m -
w i t h loss o f l a n d m a r k s . H a n d l e o f m a l l e u s m a y b e e n g u l f e d mon o r g a n i s m s are S t r e p t . p n e u m o n i a e a n d H. influenzae,
by the swollen and p r o t r u d i n g tympanic membrane and the drugs w h i c h are e f f e c t i v e i n a c u t e o t i t i s m e d i a are
m a y n o t b e d i s c e r n i b l e . A y e l l o w s p o t m a y be seen o n t h e a m p i c i l l i n ( 5 0 m g / k g / d a y i n 4 d i v i d e d doses), a m o x i c i l l i n
t y m p a n i c m e m b r a n e w h e r e r u p t u r e is i m m i n e n t . I n p r e - ( 4 0 m g / k g / d a y i n 3 d i v i d e d doses). T h o s e a l l e r g i c t o these
a n t i b i o t i c era, o n e c o u l d see a n i p p l e - l i k e p r o t r u s i o n o f p e n i c i l l i n s can be g i v e n cefaclor, c o - t r i m o x a z o l e o r e r y t h r o -
tympanic membrane w i t h a y e l l o w s p o t o n its s u m m i t . m y c i n . I n cases w h e r e ( 3 - l a c t a m a s e - p r o d u c i n g H. influenzae
Tenderness m a y be elicited over the m a s t o i d a n t r u m . o r Moraxella catarrhalis are isolated, a n t i b i o t i c s l i k e a m o x i c i l l i n -
X - r a y s o f m a s t o i d w i l l s h o w c l o u d i n g o f air cells because clavulanate, a u g m e n t i n , c e f u r o x i m e axetil o r c e f i x i m e m a y
o f exudate. be used. A n t i b a c t e r i a l therapy must be c o n t i n u e d f o r a
minimum o f 10 days, till tympanic membrane regains
4. Stage of resolution The tympanic membrane rup-
n o r m a l appearance a n d hearing returns t o n o r m a l . Early
tures w i t h release o f p u s a n d s u b s i d e n c e o f s y m p t o m s .
d i s c o n t i n u a n c e o f t h e r a p y w i t h r e l i e f o f earache a n d f e v e r ,
I n f l a m m a t o r y process begins to resolve. I f proper treat-
o r t h e r a p y g i v e n i n i n a d e q u a t e doses m a y l e a d t o s e c r e t o r y
m e n t is s t a r t e d e a r l y o f i f t h e i n f e c t i o n w a s m i l d , r e s o l u t i o n
o t i t i s m e d i a a n d r e s i d u a l h e a r i n g loss.
m a y start e v e n w i t h o u t r u p t u r e o f t y m p a n i c membrane.
Symptoms. W i t h e v a c u a t i o n o f p u s , e a r a c h e is r e l i e v e d , 2. Decongestant nasal drops Ephedrine nose drops
f e v e r c o m e s d o w n a n d c h i l d feels b e t t e r . (1% i n adults and 0.5% i n children) or oxymetazoline
Signs. E x t e r n a l a u d i t o r y canal m a y c o n t a i n b l o o d - t i n g e d ( N a s i v i o n ) o r x y l o m e t a z o l i n e ( O t r i v i n ) s h o u l d b e used t o
discharge w h i c h later b e c o m e s m u c o p u r u l e n t . U s u a l l y , a relieve eustachian tube oedema and p r o m o t e ventilation
s m a l l p e r f o r a t i o n is seen i n a n t e r o - i n f e r i o r q u a d r a n t o f pars o f m i d d l e ear.

1 A n t i b a c t e r i a l a g e n t s a n d t h e i r d o s a g e in a c u t e o t i t i s m e d i a

Drug Trade names T o t a l daily d o s e Divided dose

Amoxicillin Novamox, Biomox 40 mg/kg 3

Ampicillin Biocillin 5 0 - 1 00 mg/kg 4

Co-amoxiclav A u g m e n t i n , Enhancin 40 mg/kg 2-3

Erythromycin Emycin, Althrocin 3 0 - 5 0 mg/kg 4

C e f a c l o r (II g e n e r a t i o n ) Keflor, D i s t a c l o r 20 m g / k g - 2-3

Cefixime (III g e n e r a t i o n ) Taxim-0, Biotax-0 8 mg/kg 1 or 2

Cefpodoxime proxetil Cepodem, Cefoprox 10 m g / k g ( m a x . 4 0 0 m g / d a y ) 2

C e f t i b u t e n (III g e n e r a t i o n ) Procadax 9 mg/kg 1

Co-trimoxazol (Trimethoprim + Ciplin, Septran 8mg(TMP) + 40mg(SMZ)/kg 2

Sulphamethoxazole)

•Follow the dosage and instructions o f the manufacturer.

 Disorders of Middle Ear

3. O r a l nasal decongestants Pseudoephedrine (Sudafed)

3 0 m g t w i c e daily or a c o m b i n a t i o n o f decongestant and
ACUTE NECROTISING OTITIS MEDIA

antihistamine ( T r i o m i n i c ) m a y a c h i e v e t h e same result

w i t h o u t r e s o r t t o nasal d r o p s w h i c h are d i f f i c u l t t o a d m i n - I t is a v a r i e t y o f a c u t e s u p p u r a t i v e o t i t i s m e d i a , o f t e n seen
ister i n c h i l d r e n . i n c h i l d r e n s u f f e r i n g f r o m measles, scarlet f e v e r o r i n f l u -

4. Analgesics and antipyretics Paracetamol helps to e n z a . C a u s a t i v e o r g a n i s m is [ 3 - h a e m o l y t i c streptococcus.

relieve pain and b r i n g d o w n temperature. There is r a p i d d e s t r u c t i o n o f w h o l e o f t y m p a n i c mem-

b r a n e w i t h its a n n u l u s , m u c o s a o f p r o m o n t o r y , ossicular
5. E a r toilet I f t h e r e is d i s c h a r g e i n t h e ear, i t is d r y -
c h a i n a n d e v e n m a s t o i d a i r cells. T h e r e is p r o f u s e o t o r r h o e a .
m o p p e d w i t h sterile c o t t o n b u d s a n d a w i c k moistened
I n these cases, h e a l i n g is f o l l o w e d b y f i b r o s i s o r i n g r o w t h
w i t h a n t i b i o t i c m a y be inserted.
o f s q u a m o u s e p i t h e l i u m f r o m t h e m e a t u s (secondary acquired
6. D r y l o c a l h e a t It helps t o relieve p a i n .
cholesteatoma).
7. M y r i n g o t o m y I t is i n c i s i n g t h e d r u m t o e v a c u a t e p u s T r e a t m e n t is e a r l y i n s t i t u t i o n o f a n t i b a c t e r i a l t h e r a p y . I t
a n d is i n d i c a t e d w h e n (a) d r u m is b u l g i n g a n d t h e r e is a c u t e is c o n t i n u e d f o r at least 7—10 days, e v e n i f r e s p o n s e is seen
p a i n , (b) t h e r e is an i n c o m p l e t e r e s o l u t i o n d e s p i t e anti- early. C o r t i c a l m a s t o i d e c t o m y m a y be i n d i c a t e d i f m e d i c a l
biotics w h e n d r u m remains f u l l w i t h persistent c o n d u c t i v e t r e a t m e n t fails t o c o n t r o l o r t h e c o n d i t i o n gets c o m p l i c a t e d
deafness, (c) t h e r e is p e r s i s t e n t e f f u s i o n b e y o n d 12 w e e k s . b y acute mastoiditis.

A l l cases o f a c u t e s u p p u r a t i v e o t i t i s m e d i a s h o u l d be c a r e -
fully f o l l o w e d till d r u m membrane r e t u r n s t o its n o r m a l
a p p e a r a n c e a n d c o n d u c t i v e deafness disappears ( F i g . 1 0 . 1 ) . OTITIS MEDIA WITH EFFUSION

Syn. Serous Otitis Media, Secretory Otitis

A c u l e otitis medio Media, Mucoid Otitis Media, " G l u e E a r "
1
T h i s is an i n s i d i o u s c o n d i t i o n c h a r a c t e r i s e d b y accumula-

Antibacterial therapy t i o n o f n o n - p u r u l e n t e f f u s i o n i n t h e m i d d l e ear c l e f t . O f t e n

t h e e f f u s i o n is t h i c k a n d v i s c i d b u t s o m e t i m e s it may be
Review ofter 4 8 - 7 2 hours
t h i n a n d s e r o u s . T h e f l u i d is n e a r l y s t e r i l e . T h e c o n d i t i o n
is c o m m o n l y seen i n s c h o o l - g o i n g c h i l d r e n .

Earache and fever Good response

persist or increose

Another antibacterial
therapy far 10 days or J Pathogenesis J
Continue same
myringotomy and
for 10 days
culture and specific T w o m a i n m e c h a n i s m s are t h o u g h t t o b e responsible:
antimicrobial for
10 days 1. Malfunctioning o f eustachian tube Eustachian tube
fails t o aerate t h e m i d d l e ear a n d is also u n a b l e t o d r a i n t h e
fluid.

C o m p l e t e resolution Persistent fluid but Complete

2. I n c r e a s e d s e c r e t o r y activity o f m i d d l e ear m u c o s a
earache anc fever a b a t e resolution B i o p s i e s o f m i d d l e ear m u c o s a i n these cases h a v e con-

Periodic checks f i r m e d increase i n n u m b e r o f m u c u s o r serous-secreting

for 12 weeks cells.
r

Complete resolution Persistent

(no effusion)
Aetiology
effusion

1. Malfunctioning of eustachian t u b e T h e causes are:

T r e a t as otitis media
(i) A d e n o i d hyperplasia.
with effusion
(ii) C h r o n i c r h i n i t i s a n d sinusitis.

Figure 10.1 (iii) Chronic tonsillitis. Enlarged tonsils mechanically

obstruct the m o v e m e n t s o f soft palate a n d i n t e r f e r e
T r e a t m e n t o f acute otitis media.
w i t h the p h y s i o l o g i c a l o p e n i n g o f eustachian tube.
(iv) Benign and malignant t u m o u r s o f nasopharynx. This Otoscopic findings T y m p a n i c m e m b r a n e is o f t e n d u l l
cause s h o u l d a l w a y s b e e x c l u d e d i n u n i l a t e r a l serous a n d o p a q u e w i t h loss o f l i g h t r e f l e x . I t m a y a p p e a r y e l l o w ,
otitis m e d i a i n an adult. grey o r b l u i s h i n c o l o u r .
•. - ) Palatal defects, e . g . c l e f t p a l a t e , p a l a t a l paralysis. T h i n leash o f b l o o d vessels m a y be seen a l o n g the h a n d l e o f
malleus o r at t h e p e r i p h e r y o f t y m p a n i c m e m b r a n e a n d differs
2. Allergy Seasonal o r p e r e n n i a l a l l e r g y t o i n h a l a n t s o r
from m a r k e d c o n g e s t i o n o f acute s u p p u r a t i v e otitis m e d i a .
f o o d s t u f f is c o m m o n i n c h i l d r e n . T h i s n o t o n l y o b s t r u c t s
T y m p a n i c m e m b r a n e m a y s h o w v a r y i n g degree o f retrac-
e u s t a c h i a n t u b e b y o e d e m a b u t m a y also l e a d t o i n c r e a s e d
t i o n . S o m e t i m e s , i t m a y appear f u l l o r s l i g h t l y b u l g i n g i n its
secretory a c t i v i t y as m i d d l e ear m u c o s a acts as a shock
posterior part due to effusion.
o r g a n i n s u c h cases.
F l u i d l e v e l a n d a i r b u b b l e s m a y b e seen w h e n fluid is
3. U n r e s o l v e d otitis m e d i a Inadequate antibiotic ther-
t h i n a n d t y m p a n i c m e m b r a n e transparent (Fig. 10.2).
apy i n acute suppurative otitis m e d i a m a y inactivate i n f e c -
M o b i l i t y o f t h e t y m p a n i c m e m b r a n e is r e s t r i c t e d .
t i o n b u t fail t o resolve i t c o m p l e t e l y . L o w grade i n f e c t i o n
l i n g e r s o n . T h i s acts as s t i m u l u s f o r m u c o s a t o secrete m o r e
f l u i d . T h e n u m b e r o f g o b l e t cells a n d m u c o u s g l a n d s also | Hearing Tests |
i n c r e a s e . R e c e n t i n c r e a s e i n t h e i n c i d e n c e o f t h i s disease
seems t o b e d u e t o t h i s f a c t o r . (i) Tuning fork tests s h o w c o n d u c t i v e h e a r i n g loss.

4. V i r a l infections Various adeno- and rhino-viruses o f (ii) Audiometry. T h e r e is c o n d u c t i v e h e a r i n g loss of20—40 d B .

u p p e r r e s p i r a t o r y t r a c t m a y i n v a d e m i d d l e ear m u c o s a a n d Sometimes, t h e r e is associated s e n s o r i n e u r a l h e a r i n g
stimulate i t t o increased secretory activity. loss d u e t o fluid p r e s s i n g o n t h e r o u n d w i n d o w m e m -
b r a n e . T h i s disappears w i t h e v a c u a t i o n o f fluid.
(m) Impedance audiometry. I t is a n o b j e c t i v e test u s e f u l i n
Clinical Features i n f a n t s a n d c h i l d r e n . P r e s e n c e o f fluid is i n d i c a t e d b y
r e d u c e d c o m p l i a n c e a n d flat c u r v e w i t h a s h i f t t o n e g -
Symptoms T h e disease affects c h i l d r e n o f 5—8 years o f ative side.
age. T h e s y m p t o m s i n c l u d e : (iv) X-ray mastoids. T h e r e is c l o u d i n g o f air cells d u e t o fluid.

(i) Hearing loss. T h i s is t h e p r e s e n t i n g a n d s o m e t i m e s t h e

o n l y s y m p t o m . I t is i n s i d i o u s i n onset a n d r a r e l y exceeds
4 0 d B . Deafness m a y pass u n n o t i c e d b y t h e parents a n d
m a y be accidentally discovered d u r i n g a u d i o m e t r i c
s c r e e n i n g tests. 11 Treatment ^
(ii) Delayed and defective speech. B e c a u s e o f h e a r i n g loss,
d e v e l o p m e n t o f s p e e c h is d e l a y e d o r d e f e c t i v e . T h e a i m o f t r e a t m e n t is r e m o v a l o f fluid a n d p r e v e n t i o n o f
(iii) Mild earaches. T h e r e m a y b e h i s t o r y o f u p p e r r e s p i r a - its r e c u r r e n c e .
A. Medical
t o r y t r a c t i n f e c t i o n s w i t h m i l d earaches.
1. Decongestants T o p i c a l decongestants i n the f o r m of
nasal d r o p s , sprays o r s y s t e m i c d e c o n g e s t a n t s h e l p t o r e l i e v e
oedema o f eustachian tube.
2. A n t i a l l e r g i c m e a s u r e s Antihistaminics or sometimes
s t e r o i d s m a y b e u s e d i n cases o f a l l e r g y . I f p o s s i b l e , a l l e r g e n
s h o u l d be f o u n d a n d desensitisation d o n e .
3. Antibiotics T h e y are u s e f u l i n cases o f u p p e r r e s p i r a t o r y
tract i n f e c t i o n s o r u n r e s o l v e d acute s u p p u r a t i v e o t i t i s m e d i a .
4. M i d d l e ear a e r a t i o n Patient s h o u l d repeatedly per-
f o r m Valsalva m a n o e u v r e . Sometimes, politzerisation or
e u s t a c h i a n t u b e c a t h e t e r i s a t i o n has t o b e d o n e . T h i s h e l p s
t o v e n t i l a t e m i d d l e ear a n d p r o m o t e d r a i n a g e o f fluid.
C h i l d r e n can be g i v e n c h e w i n g g u m to encourage repeated
s w a l l o w i n g w h i c h opens the tube.

Figure 10.2
B. Surgical
Otitis media with effusion. Note appearance o f bubbles on
W h e n f l u i d is t h i c k a n d m e d i c a l t r e a t m e n t a l o n e does n o t
Valsalva.
h e l p , fluid m u s t b e s u r g i c a l l y r e m o v e d .
 Disorders of Middle Ear

Figure 10.3
Figure 10.4
To aspirate thick mucus, t w o incisions may be required in the
G r o m m e t in the t y m p a n i c m e m b r a n e (A & B), the g r o m m e t
t y m p a n i c m e m b r a n e .
(Q-

1. Myringotomy and aspiration o f fluid A n i n c i s i o n is

m a d e i n t y m p a n i c m e m b r a n e a n d fluid aspirated w i t h s u c - pockets or cholesteatoma. S i m i l a r p o c k e t s m a y b e seen i n
tion. T h i c k m u c u s m a y r e q u i r e i n s t a l l a t i o n o f saline o r a m u c - t h e attic r e g i o n .
olytic agent l i k e c h y m o t r y p s i n s o l u t i o n to l i q u e f y m u c u s 5 . C h o l e s t e r o l g r a n u l o m a T h i s is d u e t o stasis o f s e c r e -
b e f o r e i t can be aspirated. S o m e t i m e s , t w o i n c i s i o n s are m a d e t i o n s i n m i d d l e ear a n d m a s t o i d .
i n the t y m p a n i c m e m b r a n e , one i n the a n t e r o - i n f e r i o r a n d
t h e o t h e r i n a n t e r o - s u p e r i o r q u a d r a n t , t o aspirate thick,
g l u e - l i k e s e c r e t i o n s ( F i g . 10.3) o n " b e e r - c a n " p r i n c i p l e . Recurrent Acute Otitis Media

2. G r o m m e t insertion I f m y r i n g o t o m y and aspiration

I n f a n t s a n d c h i l d r e n b e t w e e n t h e age o f 6 m o n t h s a n d 6 years
c o m b i n e d w i t h m e d i c a l m e a s u r e s has n o t h e l p e d a n d fluid
m a y get r e c u r r e n t episodes o f acute o t i t i s m e d i a . S u c h e p i -
r e c u r s , a g r o m m e t is i n s e r t e d t o p r o v i d e c o n t i n u e d a e r a -
sodes m a y o c c u r 4—5 t i m e s i n a y e a r . U s u a l l y , t h e y o c c u r
t i o n o f m i d d l e ear ( F i g . 1 0 . 4 ) . I t is l e f t i n p l a c e f o r w e e k s
after a c u t e u p p e r r e s p i r a t o r y i n f e c t i o n , t h e c h i l d b e i n g f r e e
o r m o n t h s o r t i l l i t is s p o n t a n e o u s l y e x t r u d e d .
o f symptoms between the episodes; R e c u r r e n t middle
3. T y m p a n o t o m y or cortical mastoidectomy I t is
infections m a y sometimes be s u p e r i m p o s e d u p o n an exist-
sometimes required for removal o f loculated thick fluid or
i n g m i d d l e ear e f f u s i o n . S o m e t i m e s , t h e u n d e r l y i n g cause
o t h e r associated p a t h o l o g y s u c h as c h o l e s t e r o l g r a n u l o m a .
is r e c u r r e n t s i n u s i t i s , v e l o p h a r y n g e a l i n s u f f i c i e n c y , h y p e r -
4. Surgical treatment of causative factor Adenoi-
t r o p h y o f adenoids, i n f e c t e d tonsils, allergy and i m m u n e
dectomy, tonsillectomy and/or wash-out o f maxillary
d e f i c i e n c y . F e e d i n g the babies i n supine p o s i t i o n w i t h o u t
a n t r a , m a y b e r e q u i r e d . T h i s is u s u a l l y d o n e at t h e t i m e o f
p r o p p i n g u p t h e h e a d m a y also cause t h e m i l k t o e n t e r t h e
myringotomy.
m i d d l e ear d i r e c t l y t h a t c a n l e a d t o m i d d l e ear i n f e c t i o n .
M a n a g e m e n t o f such c h i l d r e n involves:
Sequelae of Chronic Secretory Otitis Media
F i n d i n g t h e cause a n d e l i m i n a t i n g i t , i f p o s s i b l e .
1. Atrophic tympanic m e m b r a n e a n d atelectasis of
2. Antimicrobial prophylaxis. Amoxicillin (20mg/kg for
the m i d d l e ear I n p r o l o n g e d e f f u s i o n s , t h e r e is d i s s o l u -
3 t o 6 m o n t h s ) o r sulphasoxazole have been used b u t
t i o n o f fibrous layer o f t y m p a n i c m e m b r a n e . It becomes
t h e y prevent o n l y 1-2 bouts o f otitis m e d i a i n a year
t h i n a n d a t r o p h i c a n d r e t r a c t s i n t o t h e m i d d l e ear.
and have the disadvantage o f creating antimicrobial
2. Ossicular necrosis M o s t c o m m o n l y , l o n g process o f
resistance o r h y p e r s e n s i t i v i t y r e a c t i o n a n d thus not
i n c u s gets n e c r o s e d . S o m e t i m e s , stapes s u p e r s t r u c t u r e also
p r e f e r r e d b y m a n y i n f a v o u r o f early i n s e r t i o n o f t y m -
gets n e c r o s e d . T h i s increases t h e c o n d u c t i v e h e a r i n g loss
panostomy tubes.
to m o r e than 50 d B .
3. Myringotomy and insertion of tympanostomy tube. I f the
3. Tympanosclerosis Hyalinised collagen with chalky c h i l d has 4 b o u t s o f a c u t e o t i t i s m e d i a i n 6 m o n t h s o r
deposits m a y be seen i n t y m p a n i c m e m b r a n e , a r o u n d t h e 6 b o u t s i n 1 y e a r , i n s e r t i o n o f a t y m p a n o s t o m y t u b e is
ossicles o r t h e i r j o i n t s , l e a d i n g t o t h e i r f i x a t i o n . recommended.

4. R e t r a c t i o n pockets a n d cholesteatoma T h i n atro- A d e n o i d e c t o m y w i t h or w i t h o u t tonsillectomy.

p h i c p a r t o f pars tensa m a y g e t i n v a g i n a t e d t o f o r m r e t r a c t i o n 5. M a n a g e m e n t o f inhalant o r f o o d allergy.

 M i d d l e ear m a y s h o w a i r b u b b l e s o r h a e m o r r h a g i c e f f u -
AERO-OTITIS MEDIA (OTITIC BAROTRAUMA) s i o n . H e a r i n g loss is u s u a l l y c o n d u c t i v e b u t s e n s o r i n e u r a l
t y p e o f loss m a y also be seen.

I t is a n o n - s u p p u r a t i v e c o n d i t i o n r e s u l t i n g f r o m f a i l u r e o f
e u s t a c h i a n t u b e t o m a i n t a i n m i d d l e ear p r e s s u r e at a m b i e n t
a t m o s p h e r i c l e v e l . T h e u s u a l cause is r a p i d d e s c e n t d u r i n g Treatment
air flight, u n d e r w a t e r d i v i n g o r c o m p r e s s i o n i n pressure
chamber. T h e a i m is t o r e s t o r e m i d d l e ear a e r a t i o n . T h i s is d o n e b y
c a t h e t e r i s a t i o n o r p o l i t z e r i s a t i o n . I n m i l d cases, d e c o n g e s -
t a n t nasal d r o p s o r o r a l nasal d e c o n g e s t a n t w i t h a n t i h i s t a -
J Mechanism
m i n i c s are h e l p f u l . I n t h e p r e s e n c e o f fluid o r f a i l u r e o f t h e
above methods, myringotomy may be performed to
E u s t a c h i a n t u b e a l l o w s easy a n d passive egress o f a i r f r o m
" u n l o c k " t h e t u b e a n d aspirate t h e fluid.
m i d d l e ear t o t h e p h a r y n x i f m i d d l e ear p r e s s u r e is h i g h . I n
t h e r e v e r s e s i t u a t i o n , w h e r e n a s o p h a r y n g e a l a i r p r e s s u r e is
h i g h , a i r c a n n o t e n t e r t h e m i d d l e ear unless t u b e is a c t i v e l y
o p e n e d b y t h e c o n t r a c t i o n o f m u s c l e s as i n s w a l l o w i n g , Prevention

y a w n i n g o r Valsalva m a n o e u v r e . W h e n a t m o s p h e r i c pressure
is h i g h e r t h a n t h a t o f m i d d l e ear b y c r i t i c a l l e v e l o f 9 0 m m A e r o - o t i t i s can be p r e v e n t e d b y the f o l l o w i n g measures:

o f H g , e u s t a c h i a n t u b e gets " l o c k e d " , i . e . s o f t tissues o f

1. A v o i d air travel i n the presence o f u p p e r respiratory
p h a r y n g e a l e n d o f t h e t u b e are f o r c e d i n t o its l u m e n . I n t h e
i n f e c t i o n or allergy.
presence o f eustachian t u b e o e d e m a , e v e n smaller pressure
2. S w a l l o w repeatedly d u r i n g descent. S u c k i n g sweets
d i f f e r e n t i a l s cause " l o c k i n g " o f t h e t u b e . S u d d e n n e g a t i v e
o r c h e w i n g g u m is u s e f u l .
pressure i n t h e m i d d l e ear causes r e t r a c t i o n o f t y m p a n i c
Do n o t p e r m i t sleep d u r i n g d e s c e n t as n u m b e r of
m e m b r a n e , h y p e r a e m i a a n d e n g o r g e m e n t o f vessels, t r a n -
s w a l l o w s n o r m a l l y decrease d u r i n g sleep.
sudation and haemorrhages.
A u t o i n f l a t i o n o f the t u b e b y Valsalva s h o u l d be per-
S o m e t i m e s , t h o u g h r a r e l y , t h e r e is r u p t u r e o f l a b y r i n t h i n e
formed intermittently during descent.
m e m b r a n e s w i t h v e r t i g o a n d sensorineural h e a r i n g loss.
5. U s e v a s o c o n s t r i c t o r nasal spray a n d a t a b l e t o f a n t i -
h i s t a m i n i c and systemic decongestant, h a l f an h o u r
[ Clinical Features J b e f o r e d e s c e n t i n p e r s o n s w i t h p r e v i o u s h i s t o r y o f this
episode.
S e v e r e e a r a c h e , h e a r i n g loss a n d t i n n i t u s are c o m m o n c o m - 6. I n recurrent barotrauma, a t t e n t i o n s h o u l d be paid to
p l a i n t s . V e r t i g o is u n c o m m o n . T y m p a n i c m e m b r a n e appears nasal p o l y p s , septal d e v i a t i o n , nasal a l l e r g y a n d c h r o n i c
r e t r a c t e d a n d congested. I t m a y get r u p t u r e d . sinus i n f e c t i o n s .
Cholesteatoma and Chronic
Otitis Media

Origin of Cholesteatoma
CHOLESTEATOMA

G e n e s i s o f c h o l e s t e a t o m a is a m a t t e r o f d e b a t e . A n y t h e o r y
N o r m a l l y , m i d d l e ear c l e f t is l i n e d b y d i f f e r e n t types o f e p i -
o f its genesis m u s t explain h o w squamous epithelium
t h e l i u m i n different regions: ciliated c o l u m n a r i n the anterior
a p p e a r e d i n t h e m i d d l e ear c l e f t . T h e v a r i o u s v i e w s expressed
a n d i n f e r i o r part, c u b o i d a l i n the m i d d l e part a n d p a v e m e n t -
are:
l i k e i n t h e a t t i c . T h e m i d d l e ear is n o w h e r e l i n e d b y k e r a -
t i n i s i n g s q u a m o u s e p i t h e l i u m . I t is t h e p r e s e n c e o f l a t t e r 1. P r e s e n c e o f c o n g e n i t a l c e l l rests.

t y p e o f e p i t h e l i u m i n t h e m i d d l e ear o r m a s t o i d t h a t c o n - 2. I n v a g i n a t i o n o f t y m p a n i c m e m b r a n e f r o m the attic o r

stitutes a cholesteatoma. I n o t h e r w o r d s , c h o l e s t e a t o m a is posterosuperior p a r t o f pars tensa i n t h e form of

a "skin in the wrong place". The t e r m c h o l e s t e a t o m a is a r e t r a c t i o n p o c k e t s ( F i g . 11.2) ( W i t t m a a c k ' s theory). The

m i s n o m e r , because i t n e i t h e r c o n t a i n s c h o l e s t e r o l crystals o u t e r s u r f a c e o f t y m p a n i c m e m b r a n e is l i n e d b y s t r a t i -

n o r is i t a t u m o u r t o m e r i t t h e s u f f i x " o m a " . H o w e v e r , t h e fied squamous epithelium which after i n v a g i n a t i o n

t e r m has b e e n r e t a i n e d because o f its w i d e r usage. f o r m s t h e m a t r i x o f c h o l e s t e a t o m a a n d lays d o w n k e r -

E s s e n t i a l l y , c h o l e s t e a t o m a consists o f t w o parts, (i) t h e atin i n the pocket.

matrix, w h i c h is m a d e u p o f k e r a t i n i s i n g s q u a m o u s epithe- 3. Basal c e l l h y p e r p l a s i a (Ruedi's theory). T h e basal cells

l i u m r e s t i n g o n a t h i n s t r o m a o f f i b r o u s tissues a n d ( i i ) a o f g e r m i n a l layer o f skin proliferate u n d e r the i n f l u -

c e n t r a l w h i t e mass, c o n s i s t i n g o f keratin debris p r o d u c e d b y ence o f i n f e c t i o n , a n d lay d o w n k e r a t i n i s i n g squamous

t h e m a t r i x (Fig. 11.1). F o r this reason, i t has also b e e n epithelium.

n a m e d epidennosis or keratoma. 4. E p i t h e l i a l i n v a s i o n (Habermann's theory). T h e e p i t h e l i u m

f r o m the meatus o r o u t e r d r u m surface g r o w s i n t o the
m i d d l e ear t h r o u g h a p r e - e x i s t i n g p e r f o r a t i o n e s p e -
cially o f the m a r g i n a l type w h e r e part o f annulus t y m -
p a n i c u s has a l r e a d y b e e n d e s t r o y e d .
a. Metaplasia (Sade's theory). Middle ear m u c o s a , like
respiratory mucosa elsewhere, undergoes metaplasia
due t o repeated infections and transfonris i n t o squamous
epithelium.
Matrix
(stratified)
sq. epi.
Classification o f C h o l e s t e a t o m a (Fig. 11.3)

T h e c h o l e s t e a t o m a is classified i n t o :

!. Congenital
Acquired, primary
Acquired, secondary

Figure 11.1 1. Congenital c h o l e s t e a t o m a I t arises f r o m t h e e m b r y -

o n i c e p i d e r m a l c e l l rests i n t h e m i d d l e ear c l e f t o r t e m p o r a l
Schematic structure o f cholesteatoma.
b o n e . C o n g e n i t a l c h o l e s t e a t o m a o c c u r s at t h r e e i m p o r t a n t
 sites: m i d d l e ear, p e t r o u s a p e x a n d t h e cerebellopontine
angle, and produces s y m p t o m a t o l o g y d e p e n d i n g o n its
location.
A m i d d l e ear c o n g e n i t a l cholesteatoma presents as a
white mass b e h i n d an intact tympanic m e m b r a n e and
causes c o n d u c t i v e h e a r i n g loss. I t m a y s o m e t i m e s b e d i s -
Retraction pocket c o v e r e d o n r o u t i n e e x a m i n a t i o n o f c h i l d r e n o r at t h e t i m e
of myringotomy.
I t m a y also s p o n t a n e o u s l y r u p t u r e t h r o u g h t h e t y m p a n i c
membrane a n d present w i t h a d i s c h a r g i n g ear indistin-
g u i s h a b l e f r o m a case o f c h r o n i c s u p p u r a t i v e o t i t i s m e d i a
(CSOM).

2. P r i m a r y a c q u i r e d c h o l e s t e a t o m a I t is c a l l e d p r i m a r y
as t h e r e is n o h i s t o r y o f p r e v i o u s o t i t i s m e d i a o r a p r e -
Basal cell hyperplasia
e x i s t i n g p e r f o r a t i o n . T h e o r i e s o n its genesis are:

(a) Invagination of pars flaccida. P e r s i s t e n t n e g a t i v e pressure

i n t h e a t t i c causes a r e t r a c t i o n p o c k e t w h i c h accumu-
lates k e r a t i n d e b r i s . W h e n i n f e c t e d , t h e k e r a t i n mass
e x p a n d s t o w a r d s t h e m i d d l e ear. T h u s , attic p e r f o r a t i o n
is i n f a c t t h e p r o x i m a l e n d o f an e x p a n d i n g i n v a g i -
n a t e d sac.
Epithelial invasion through posterosuperior perforation
(b) Basal cell hyperplasia. T h e r e is p r o l i f e r a t i o n o f t h e basal
l a y e r o f pars f l a c c i d a i n d u c e d b y s u b c l i n i c a l c h i l d h o o d
Figure 11.2
infections. Expanding cholesteatoma then breaks
Genesis o f cholesteatoma.
t h r o u g h pars f l a c c i d a f o r m i n g a n a t t i c p e r f o r a t i o n .
(c) Squamous metaplasia. Normal pavement epithelium o f
attic undergoes metaplasia, k e r a t i n i s i n g squamous e p i -
Eustachian tube obstruction t h e l i u m d u e t o s u b c l i n i c a l i n f e c t i o n s . S u c h a c h a n g e has

I also b e e n d e m o n s t r a t e d i n cases o f o t i t i s m e d i a w i t h
Persistent n e g a t i v e p r e s s u r e in m i d d l e ear effusion.

I 3. S e c o n d a r y acquired cholesteatoma I n these cases,

Attic or p o s t e r o s u p e r i o r retraction pocket
t h e r e is a l r e a d y a p r e - e x i s t i n g p e r f o r a t i o n i n pars tensa.
T h i s is o f t e n associated w i t h p o s t e r o s u p e r i o r m a r g i n a l p e r -
Metaplasia of Primary acquired Proliferation of
m i d d l e ear mucosa cholesteatoma basol layer f o r a t i o n o r s o m e t i m e s large c e n t r a l p e r f o r a t i o n . T h e o r i e s
o n its genesis i n c l u d e :

Subclinical infections
(a) Migration of squamous epithelium. Keratinising squamous
of m i d d l e ear
e p i t h e l i u m o f e x t e r n a l a u d i t o r y c a n a l o r o u t e r surface
Repeated infection Acute necrotising o f t y m p a n i c m e m b r a n e migrates t h r o u g h the perfora-
through perforation otitis media
t i o n i n t o t h e m i d d l e ear. P e r f o r a t i o n s , i n v o l v i n g t y m -
i p a n i c a n n u l u s as i n a c u t e n e c r o t i s i n g o t i t i s m e d i a , are
Large central or
m o r e likely t o a l l o w i n - g r o w t h o f squamous e p i t h e l i u m .
marginal perforation
(b) Metaplasia. M i d d l e ear m u c o s a u n d e r g o e s metaplasia
I d u e t o r e p e a t e d i n f e c t i o n s o f m i d d l e ear t h r o u g h t h e
Metaplasia of Epithelial migration
pre-existing perforation.
m i d d l e ear mucosa through perforation

Figure 11.3
Secondary
cholesteatoma
acquired

I Expansion of Cholesteatoma
Destruction of Bone
and

Genesis o f primary and
O n c e c h o l e s t e a t o m a e n t e r s t h e m i d d l e ear c l e f t , i t i n v a d e s
1
the s u r r o u n d i n g structures, first b y f o l l o w i n g t h e p a t h o f
secondary cholesteatoma.
least resistance, a n d t h e n b y e n z y m a t i c b o n e d e s t r u c t i o n .
 Cholesteatoma and Chronic Otitis Media

An attic cholesteatoma m a y e x t e n d b a c k w a r d s into the

Table 11.1 Differences between atticoantral and
aditus, a n t r u m a n d m a s t o i d ; d o w n w a r d s i n t o the m e s o t y m -
t u b o t y m p a n i c type o f C S O M
p a n u m ; medially, it m a y s u r r o u n d the incus and/or head o f
malleus. Tubotympanic or Atticoantral or
safe type unsafe t y p e
C h o l e s t e a t o m a has t h e p r o p e r t y t o d e s t r o y b o n e . I t m a y
cause d e s t r u c t i o n o f ear ossicles, e r o s i o n o f b o n y l a b y r i n t h , Discharge Profuse, m u c o i d , Scanty, purulent,

canal o f f a c i a l n e r v e , sinus p l a t e o r t e g m e n t y m p a n i a n d odourless foul-smelling

t h u s cause s e v e r a l c o m p l i c a t i o n s . B o n e d e s t r u c t i o n b y c h o - Perforation Central Attic or marginal

l e s t e a t o m a has b e e n a t t r i b u t e d t o v a r i o u s e n z y m e s s u c h as Granulations U n c o m m o n C o m m o n

collagenase, acid phosphatase and p r o t e o l y t i c enzymes,

Polyp Pale Red and fleshy
l i b e r a t e d b y osteoclasts a n d m o n o n u c l e a r i n f l a m m a t o r y cells,
Cholesteatoma Absent Present
seen i n a s s o c i a t i o n w i t h c h o l e s t e a t o m a . T h e e a r l i e r t h e o r y
Complications Rare C o m m o n
t h a t c h o l e s t e a t o m a causes d e s t r u c t i o n o f b o n e b y p r e s s u r e
n e c r o s i s is n o t a c c e p t e d t h e s e days. A u d i o g r a m M i l d to moderate Conductive or

conductive deafness mixed deafness

CHRONIC SUPPURATIVE OTITIS MEDIA

A. Tubotympanic Type

C h r o n i c s u p p u r a t i v e o t i t i s m e d i a ( C S O M ) is a l o n g - s t a n d -
Aetiology
i n g i n f e c t i o n o f a p a r t o r w h o l e o f t h e m i d d l e ear cleft
c h a r a c t e r i s e d b y ear d i s c h a r g e and a permanent perfora- T h e disease starts i n c h i l d h o o d a n d is t h e r e f o r e common

t i o n . A p e r f o r a t i o n b e c o m e s p e r m a n e n t w h e n its edges are i n t h a t age g r o u p .

covered b y squamous e p i t h e l i u m a n d i t does n o t heal

1. I t is t h e s e q u e l a of acute otitis media u s u a l l y f o l l o w i n g
spontaneously. A p e r m a n e n t p e r f o r a t i o n can be l i k e n e d to
exanthematous fever and l e a v i n g b e h i n d a large c e n -
an e p i t h e l i u m - l i n e d fistulous track.
tral p e r f o r a t i o n .
The perforation becomes permanent and permits

Epidemiology M repeated infection f r o m the external ear. Also the

m i d d l e ear m u c o s a is e x p o s e d t o t h e e n v i r o n m e n t a n d

Incidence of C S O M is h i g h e r i n d e v e l o p i n g countries gets sensitised t o d u s t , p o l l e n a n d o t h e r a e r o a l l e r g e n s

because o f p o o r s o c i o - e c o n o m i c standards, p o o r n u t r i t i o n causing persistent otorrhoea.

a n d l a c k o f h e a l t h e d u c a t i o n . I t affects b o t h sexes a n d a l l 2. A s c e n d i n g infections via the eustachian tube. Infec-

age g r o u p s . I n I n d i a , t h e o v e r a l l p r e v a l e n c e r a t e is 4 6 a n d t i o n f r o m t o n s i l s , a d e n o i d s a n d i n f e c t e d sinuses m a y

16 p e r s o n s p e r t h o u s a n d i n r u r a l a n d u r b a n p o p u l a t i o n be responsible f o r persistent or recurring otorrhoea.

respectively. I t is also t h e s i n g l e m o s t i m p o r t a n t cause of A s c e n d i n g i n f e c t i o n t o m i d d l e ear o c c u r m o r e easily

hearing i m p a i r m e n t i n rural p o p u l a t i o n . i n the presence o f i n f e c t i o n .

3. P e r s i s t e n t m u c o i d o t o r r h o e a is s o m e t i m e s t h e result
o f a l l e r g y t o i n g e s t a n t s s u c h as m i l k , eggs, f i s h , etc.
[ Types of C S O M [
Pathology

C l i n i c a l l y , i t is d i v i d e d i n t o t w o t y p e s : T h e t u b o t y m p a n i c disease r e m a i n l o c a l i s e d t o t h e m u c o s a
1, Tubotympanic A l s o c a l l e d t h e safe o r benign type; it and, that t o o , m o s t l y to anteroinferior part o f the m i d d l e
i n v o l v e s a n t e r o i n f e r i o r p a r t o f m i d d l e ear c l e f t , i . e . e u s t a - ear c l e f t . L i k e a n y o t h e r c h r o n i c i n f e c t i o n , t h e processes o f
c h i a n t u b e a n d m e s o t y m p a n u m a n d is associated w i t h a c e n - healing and destruction go hand i n hand and either of
t r a l p e r f o r a t i o n . T h e r e is n o r i s k o f s e r i o u s c o m p l i c a t i o n s . t h e m m a y take advantage over the other, d e p e n d i n g o n
t h e v i r u l e n c e o f o r g a n i s m a n d resistance o f t h e patient.
2 . A t t i c o a n t r a l A l s o c a l l e d unsafe o r dangerous type; it
T h u s , a c u t e e x a c e r b a t i o n s are n o t u n c o m m o n . T h e p a t h -
i n v o l v e s posterosuperior part o f the cleft (i.e. attic, a n t r u m
o l o g i c a l changes seen i n this t y p e o f C S O M are:
a n d m a s t o i d ) a n d is associated w i t h an a t t i c o r a m a r g i n a l
perforation. The disease is o f t e n associated w i t h a b o n e - 1. Perforation o f pars tensa I t is a c e n t r a l p e r f o r a t i o n
e r o d i n g process such as c h o l e s t e a t o m a , granulations or a n d its size a n d p o s i t i o n v a r i e s .
o s t e i t i s . R i s k o f c o m p l i c a t i o n s is h i g h i n t h i s v a r i e t y . 2. M i d d l e ear m u c o s a I t m a y b e n o r m a l w h e n disease is
T a b l e 11.1 shows differences b e t w e e n t h e t w o types o f q u i e s c e n t o r i n a c t i v e . I t is o e d e m a t o u s a n d v e l v e t y w h e n
CSOM. disease is a c t i v e .
3 . P o l y p A p o l y p is a s m o o t h mass o f o e d e m a t o u s a n d p r o m o n t o r y , ossicles, j o i n t s , t e n d o n s a n d o v a l a n d r o u n d
i n f l a m e d m u c o s a w h i c h has p r o t r u d e d t h r o u g h a p e r f o r a - windows. Tympanosclerotic masses m a y i n t e r f e r e with
t i o n a n d p r e s e n t s i n t h e e x t e r n a l c a n a l . I t is u s u a l l y p a l e i n the mobility o f these structures a n d cause conductive
c o n t r a s t t o p i n k , f l e s h y p o l y p seen i n a t t i c o a n t r a l disease deafness.
(Fig. 11.4).
6 . F i b r o s i s a n d a d h e s i o n s T h e y are t h e r e s u l t o f h e a l i n g

4. Ossicular chain I t is u s u a l l y i n t a c t a n d m o b i l e b u t process a n d m a y f u r t h e r i m p a i r m o b i l i t y o f ossicular c h a i n

m a y s h o w s o m e degree o f necrosis, particularly o f t h e l o n g or b l o c k the eustachian tube.

process o f i n c u s .
Bacteriology
5. T y m p a n o s c l e r o s i s I t is h y a l i n i s a t i o n a n d s u b s e q u e n t
c a l c i f i c a t i o n o f s u b e p i t h e l i a l c o n n e c t i v e tissue. I t is seen Pus c u l t u r e i n b o t h t y p e s o f a e r o b i c a n d a n a e r o b i c C S O M
in remnants o f tympanic membrane or under the mucosa m a y s h o w m u l t i p l e organisms. C o m m o n aerobic o r g a n -
o f m i d d l e ear. I t is seen as w h i t e c h a l k y d e p o s i t o n t h e isms are Ps aeruginosa, Proteus, Esch. coli a n d Staph, aureus,

F i g u r e 11.4

(A) Polyp in the ear canal. (B) Schematic illustration o f a polyp arising f r o m the p r o m o n t o r y passing through the perforation and

presenting in the ear canal.

Perforation of tympanic membrane

Pars tensa Pars flaccida

Attic perforation

Central perforation Marginal perforation

Anterior Anterior to h a n d l e of malleus Perforation destroys even the

annulus and reaches sulcus
Posterior Posterior to h a n d l e of malleus
tympanicus. It m a y be
Inferior to h a n d l e of malleus
Inferior
Very large perforation of pors • Posterosuperior
Subtotal
tensa where parts of pars tensa • Anterior

a n d / o r a n n u l u s o f T M is s t i l l • Inferior
preserved
• Total
(posterosuperior marginal
perforation is t h e m o s t common)

F i g u r e 11.5

Perforation o f tympanic m e m b r a n e .

Note: Attic and posterosuperior marginal perforation are seen in d a n g e r o u s type o f C S O M and are often associated with cholestea-

toma. Stratified s q u a m o u s epithelium from the external auditory canal can g r o w into the m i d d l e ear in any type o f m a r g i n a l perfora-

tion by immigration and form a cholesteatoma. Therefore, all m a r g i n a l perforations are considered dangerous. Central perforations

are considered safe as c h o l e s t e a t o m a is u s u a l l y n o t a s s o c i a t e d w i t h them.

 Cholesteatoma and Chronic Otitis Media

w h i l e a n a e r o b e s i n c l u d e Bacteroides fragiUs and anaerobic 2 . H e a r i n g l o s s I t is c o n d u c t i v e t y p e ; s e v e r i t y v a r i e s b u t

Streptococci. rarely exceeds 50 d B . S o m e t i m e s , t h e p a t i e n t reports o f a p a r a -
d o x i c a l e f f e c t , i . e . hears b e t t e r i n t h e p r e s e n c e o f d i s c h a r g e
Alternative Classification of Chronic Otitis Media t h a n w h e n t h e ear is d r y . T h i s is d u e t o "round window shielding
effect" p r o d u c e d b y d i s c h a r g e w h i c h helps t o m a i n t a i n phase
T u b o t y m p a n i c disease o f m i d d l e ear is a m u c o s a l disease
d i f f e r e n t i a l . I n t h e d r y ear w i t h p e r f o r a t i o n , s o u n d w a v e s
w i t h n o e v i d e n c e o f i n v a s i o n o f s q u a m o u s e p i t h e l i u m . I t is
strike b o t h t h e o v a l a n d r o u n d w i n d o w s s i m u l t a n e o u s l y , thus
c a l l e d "active" w h e n t h e r e is a p e r f o r a t i o n o f pars tensa
c a n c e l l i n g e a c h o t h e r ' s e f f e c t (see P h y s i o l o g y o f h e a r i n g ) .
w i t h i n f l a m m a t i o n o f mucosa and m u c o p u r u l e n t discharge.
I n l o n g s t a n d i n g cases, c o c h l e a m a y s u f f e r d a m a g e d u e
I t is c a l l e d "inactive" w h e n t h e r e is a p e r m a n e n t p e r f o r a t i o n
to absorption o f toxins f r o m the oval and r o u n d w i n d o w s
o f pars tensa b u t m i d d l e ear m u c o s a is n o t i n f l a m e d a n d
a n d h e a r i n g loss b e c o m e s m i x e d t y p e .
t h e r e is n o discharge. Permanent perforation implies that
s q u a m o u s e p i t h e l i u m o n t h e e x t e r n a l s u r f a c e o f pars tensa 3. Perforation Always central, it m a y lie anterior, poste-

a n d m u c o s a l i n i n g its i n n e r s ur f ace h a v e f u s e d across its rior o r inferior t o the handle o f malleus. I t m a y be small,

e d g e . Healed chronic otitis media is t h e c o n d i t i o n w h e n t y m - m e d i u m o r large o r e x t e n d i n g u p t o the annulus, i.e. s u b -

p a n i c m e m b r a n e has h e a l e d ( u s u a l l y b y t w o l a y e r s ) , is a t r o - total (Fig. 11.7).

p h i c a n d easily r e t r a c t e d i f t h e r e is n e g a t i v e p r e s s u r e i n t h e 4. M i d d l e ear m u c o s a I t is s e e n w h e n t h e p e r f o r a t i o n is
m i d d l e ear. H e a l e d o t i t i s m e d i a m a y also h a v e p a t c h e s of l a r g e . N o r m a l l y , i t is p a l e p i n k a n d m o i s t ; w h e n i n f l a m e d i t
t y m p a n o s c l e r o s i s i n t y m p a n i c m e m b r a n e , o r i n m i d d l e ear looks red, oedematous and swollen. Occasionally, a polyp
i n v o l v i n g p r o m o n t o r y , ossicles, t e n d o n s o f s t a p e d i u s a n d m a y b e seen.
t e n s o r t y m p a n i c . F i b r o t i c tissue m a y a p p e a r i n m i d d l e ear.
I t is a l w a y s associated w i t h some degree o f c o n d u c t i v e Investigations
h e a r i n g loss.
A t t i c o a n t r a l disease has b e e n c a l l e d s q u a m o s a l disease o f 1. Examination under microscope is essential i n e v e r y

m i d d l e ear. I t m a y b e "inactive" w h e n t h e r e are r e t r a c t i o n case a n d p r o v i d e s u s e f u l i n f o m i a t i o n r e g a r d i n g p r e s e n c e o f

p o c k e t s i n pars tensa ( u s u a l l y t h e p o s t e r o s u p e r i o r r e g i o n ) granulations, i n - g r o w t h o f squamous e p i t h e l i u m f r o m the

o r pars flaccida. T h e r e is n o d i s c h a r g e b u t t h e r e is a p o s s i - edges o f p e r f o r a t i o n , status o f o s s i c u l a r c h a i n , t y m p a n o -

b i l i t y o f squamous debris i n r e t r a c t i o n pockets to become sclerosis a n d a d h e s i o n s . A n ear w h i c h appears d r y m a y

i n f e c t e d a n d start d i s c h a r g i n g . S o m e r e t r a c t i o n p o c k e t s are show hidden discharge u n d e r the microscope. Rarely,

s h a l l o w a n d s e l f c l e a n s i n g . "Active" s q u a m o s a l disease o f cholesteatoma m a y co-exist w i t h a central perforation and

m i d d l e ear i m p l i e s p r e s e n c e o f c h o l e s t e a t o m a o f p o s t e r o - c a n be seen u n d e r a m i c r o s c o p e .

s u p e r i o r r e g i o n o f pars tensa o r i n t h e pars flaccida. It 2. A u d i o g r a m I t g i v e s a n assessment o f d e g r e e o f h e a r i n g

erodes b o n e , f o r m s g r a n u l a t i o n tissue a n d has purulent loss a n d its t y p e . U s u a l l y , t h e loss is c o n d u c t i v e b u t a s e n -
offensive discharge (Fig. 11.6). sorineural e l e m e n t m a y be present.

3. C u l t u r e a n d sensitivity o f ear discharge I t helps t o

Clinical Features select p r o p e r a n t i b i o t i c ear d r o p s .

l . E a r discharge I t is n o n - o f f e n s i v e , m u c o i d o r m u c o p u - 4. Mastoid X - r a y s / C T scan temporal bone Mastoid

rulent, constant or intermittent. The discharge appears is u s u a l l y s c l e r o t i c b u t m a y b e p n e u m a t i s e d w i t h c l o u d i n g o f
m o s t l y at t i m e o f u p p e r r e s p i r a t o r y t r a c t i n f e c t i o n o r o n air cells. T h e r e is n o e v i d e n c e o f b o n e d e s t r u c t i o n . P r e s e n c e
a c c i d e n t a l e n t r y o f w a t e r i n t o t h e ear. o f b o n e d e s t r u c t i o n is a f e a t u r e o f a t t i c o a n t r a l disease.

C h r o n i c otitis media

Mucosal disease Squamosal disease

Active Inactive Healed Refraction p o c k e t s (in p a r s Active

(chronic suppurative (permanent (adhesive otitis tensa or pars flaccida or (cholesteatoma
otitis media) perforation) media) also called atelectatic ear) with discharge)

Figure 11.6

Classification o f chronic otitis media.

 Centra! perforation Central perforation Subtotal perforation
(anterior) (medium sized)

Total perforation with Attic perforation Posterosuperior marginal

destruction of even perforation
the f i b r o u s annulus

Figure 11.7

Types o f perforations in the tympanic m e m b r a n e seen in C S O M .

Treatment R u b b e r inserts c a n b e u s e d . H a r d n o s e - b l o w i n g c a n also

push the infection f r o m nasopharynx t o m i d d l e ear and
T h e a i m is t o c o n t r o l i n f e c t i o n a n d e l i m i n a t e ear discharge a n d
s h o u l d be a v o i d e d .
at a later stage, t o c o r r e c t t h e h e a r i n g loss b y s u r g i c a l m e a n s .
5. T r e a t m e n t o f c o n t r i b u t o r y causes Attention should
1 . A u r a l t o i l e t R e m o v e all discharge a n d debris f r o m the
be p a i d t o treat c o n c o m i t a n t l y i n f e c t e d tonsils, adenoids,
ear. I t c a n b e d o n e b y d r y m o p p i n g w i t h a b s o r b e n t c o t t o n
m a x i l l a r y a n t r a , a n d nasal a l l e r g y .
buds, suction clearance u n d e r m i c r o s c o p e or irrigation
( n o t f o r c e f u l s y r i n g i n g ) w i t h sterile n o r m a l saline. E a r m u s t 6. Surgical t r e a t m e n t A u r a l p o l y p or granulations, if

be d r i e d a f t e r i r r i g a t i o n . present, s h o u l d be r e m o v e d before local treatment with

a n t i b i o t i c s . I t w i l l f a c i l i t a t e ear t o i l e t a n d p e r m i t ear d r o p s
2. E a r d r o p s A n t i b i o t i c ear d r o p s c o n t a i n i n g n e o m y c i n ,
t o b e u s e d e f f e c t i v e l y . An aural polyp should never be avulsed
p o l y m y x i n , C h l o r o m y c e t i n o r g e n t a m i c i n are used. T h e y are
as i t m a y b e a r i s i n g f r o m t h e stapes, f a c i a l n e r v e o r h o r i -
c o m b i n e d w i t h steroids w h i c h h a v e l o c a l a n t i - i n f l a m m a t o r y
zontal canal and thus lead to facial paralysis or
e f f e c t . T o use ear d r o p s , p a t i e n t lies d o w n w i t h t h e diseased
labyrinthitis.
ear u p , a n t i b i o t i c d r o p s are i n s t i l l e d a n d t h e n i n t e r m i t t e n t
pressure a p p l i e d o n t h e tragus f o r a n t i b i o t i c s o l u t i o n t o 7. R e c o n s t r u c t i v e s u r g e r y O n c e ear is d r y , m y r i n g o -

r e a c h t h e m i d d l e ear. T h i s s h o u l d be d o n e t h r e e o r f o u r plasty w i t h o r w i t h o u t ossicular r e c o n s t r u c t i o n can be

times a day. A c i d p H helps to eliminate pseudomonas d o n e t o r e s t o r e h e a r i n g . C l o s u r e o f p e r f o r a t i o n w i l l also

i n f e c t i o n , a n d i r r i g a t i o n s w i t h 1 . 5 % a c e t i c a c i d are u s e f u l . c h e c k repeated i n f e c t i o n f r o m the e x t e r n a l canal.

C a r e s h o u l d be t a k e n as ear d r o p s are l i k e l y t o cause

m a c e r a t i o n o f canal s k i n , l o c a l a l l e r g y , g r o w t h o f f u n g u s o r
resistance o f o r g a n i s m s . S o m e ear d r o p s are potentially
ototoxic.

3. S y s t e m i c antibiotics T h e y are u s e f u l i n a c u t e e x a c e r - J B. Atticoantral Type jj|

b a t i o n o f c h r o n i c a l l y i n f e c t e d ear, o t h e r w i s e , r o l e o f sys-
temic antibiotics i n the treatment o f C S O M is l i m i t e d . I t i n v o l v e s p o s t e r o s u p e r i o r p a r t o f m i d d l e ear c l e f t ( a t t i c ,
antrum and posterior t y m p a n u m and mastoid) and is
4. Precautions P a t i e n t s are i n s t r u c t e d t o k e e p w a t e r o u t
a s s o c i a t e d w i t h c h o l e s t e a t o m a , w h i c h , b e c a u s e o f its b o n e
of the ear during bathing, s w i m m i n g and hair wash.
e r o d i n g p r o p e r t i e s , causes risk o f s e r i o u s complications.
F o r t h i s r e a s o n , t h e disease is also c a l l e d unsafe o r danger-
ous t y p e .
 Cholesteatoma and Chronic Otitis Media

Aetiology Signs

A e t i o l o g y o f a t t i c o a n t r a l disease is same as o f c h o l e s t e a -
1. Perforation I t is e i t h e r a t t i c o r p o s t e r o s u p e r i o r mar-
t o m a a n d has b e e n discussed e a r l i e r . I t is s e e n i n s c l e r o t i c
g i n a l t y p e . A small attic p e r f o r a t i o n m a y be missed d u e t o
m a s t o i d , a n d w h e t h e r t h e l a t t e r is t h e cause o r e f f e c t of
presence o f a small a m o u n t o f crusted discharge. Sometimes,
disease is n o t y e t clear.
t h e area o f p e r f o r a t i o n is m a s k e d b y a s m a l l g r a n u l o m a .

Pathology 2. Retraction pocket An invagination of tympanic

membrane is seen i n t h e a t t i c o r p o s t e r o s u p e r i o r area o f
A t t i c o a n t r a l diseases is associated w i t h t h e f o l l o w i n g p a t h -
pars tensa. D e g r e e o f r e t r a c t i o n a n d i n v a g i n a t i o n v a r i e s . I n
o l o g i c a l processes:
e a r l y stages, p o c k e t is s h a l l o w a n d s e l f - c l e a n s i n g b u t later
1. Cholesteatoma
w h e n p o c k e t is d e e p , i t a c c u m u l a t e s k e r a t i n mass a n d gets
2. O s t e i t i s and granulation tissue Osteitis involves infected.
outer attic w a l l and posterosuperior m a r g i n o f the tym-
3. C h o l e s t e a t o m a P e a r l y - w h i t e flakes o f cholesteatoma
panic ring. A mass o f g r a n u l a t i o n tissue s u r r o u n d s t h e area
can be sucked from the r e t r a c t i o n pockets. S u c t i o n clear-
o f osteitis a n d m a y e v e n f i l l the attic, a n t r u m , p o s t e r i o r
ance and e x a m i n a t i o n u n d e r o p e r a t i n g microscope forms
t y m p a n u m a n d m a s t o i d . A fleshy r e d p o l y p u s m a y b e seen
a n i m p o r t a n t p a r t o f t h e c l i n i c a l e x a m i n a t i o n a n d assess-
filling the meatus.
m e n t o f any type o f C S O M .
3. O s s i c u l a r necrosis I t is c o m m o n i n a t t i c o a n t r a l d i s -
ease. D e s t r u c t i o n m a y b e l i m i t e d t o t h e l o n g process of
Investigations
i n c u s o r m a y also i n v o l v e stapes s u p e r s t r u c t u r e , h a n d l e of
malleus o r t h e e n t i r e ossicular c h a i n . T h e r e f o r e , hearing 1. Examination under microscope A l l patients of

loss is a l w a y s g r e a t e r t h a n i n disease o f t u b o t y m p a n i c t y p e . chronic m i d d l e e a r l y disease s h o u l d b e e x a m i n e d under

O c c a s i o n a l l y , t h e c h o l e s t e a t o m a b r i d g e s t h e gap c a u s e d b y microscope ( F i g . 11.8). I t m a y reveal presence o f cholestea-

the destroyed ossicles, a n d h e a r i n g loss is n o t apparent t o m a , its site a n d e x t e n t , evidence o f bone destruction,

(cholesteatoma hearer). g r a n u l o m a , c o n d i t i o n o f ossicles a n d p o c k e t s o f d i s c h a r g e .

4. Cholesterol granuloma I t is a mass o f g r a n u l a t i o n 2. T u n i n g f o r k tests a n d a u d i o g r a m T h e y are essential

tissue w i t h f o r e i g n b o d y g i a n t cells s u r r o u n d i n g t h e cho- for pre-operative assessment a n d t o c o n f i r m t h e degree

l e s t e r o l crystals. I t is a r e a c t i o n t o l o n g - s t a n d i n g r e t e n t i o n a n d t y p e o f h e a r i n g loss.

o f secretions or haemorrhage, and may or may not co- 3. X-ray mastoids/CT scan temporal bone They
exist w i t h c h o l e s t e a t o m a . W h e n p r e s e n t i n t h e mesotym- indicate extent o f b o n e destruction and degree o f mastoid
p a n u m , b e h i n d a n i n t a c t d r u m , t h e l a t t e r appears b l u e . pneumatisation. T h e y are u s e f u l t o i n d i c a t e a l o w - l y i n g
d u r a o r a n a n t e p o s e d s i g m o i d sinus w h e n o p e r a t i o n is b e i n g
Bacteriology
c o n t e m p l a t e d o n a s c l e r o t i c m a s t o i d . C h o l e s t e a t o m a causes

S a m e as i n t u b o t y m p a n i c t y p e .

Symptoms

1. E a r d i s c h a r g e U s u a l l y scanty, b u t always f o u l - s m e l l i n g
d u e t o b o n e d e s t r u c t i o n . D i s c h a r g e m a y be so scanty t h a t t h e
p a t i e n t m a y n o t e v e n be a w a r e o f i t . T o t a l cessation o f d i s -
c h a r g e from an ear w h i c h has b e e n a c t i v e t i l l r e c e n t l y s h o u l d
b e v i e w e d seriously, as p e r f o r a t i o n i n these cases m i g h t b e
sealed b y c r u s t e d discharge, i n f l a m m a t o r y m u c o s a o r a p o l y p ,
o b s t r u c t i n g the free flow o f discharge. Pus, i n these cases,
m a y f i n d its w a y i n t e r n a l l y a n d cause c o m p l i c a t i o n s .

2. H e a r i n g loss H e a r i n g is n o r m a l w h e n ossicular c h a i n is
i n t a c t o r w h e n c h o l e s t e a t o m a , h a v i n g d e s t r o y e d t h e ossicles,
b r i d g e s t h e gap caused b y d e s t r o y e d ossicles (cholesteatoma
hearer). H e a r i n g loss is m o s t l y c o n d u c t i v e b u t sensorineural
element m a y be added.
Figure 11.8
3. B l e e d i n g It may occur f r o m granulations o r the p o l y p
E x a m i n a t i o n o f the ear under microscope ( E U M ) .
w h e n c l e a n i n g t h e ear.
d e s t r u c t i o n i n t h e area o f a t t i c a n d a n t r u m ( k e y area), b e t - t h e ear safe, a n d s e c o n d i n p r i o r i t y is t o p r e s e r v e o r r e c o n -
t e r seen i n l a t e r a l v i e w . C T scan o f t e m p o r a l b o n e gives s t r u c t t h e h e a r i n g b u t n e v e r at t h e cost o f t h e p r i m a r y a i m .
m o r e i n f o r m a t i o n a n d is p r e f e r r e d t o X - r a y m a s t o i d s . T w o t y p e s o f s u r g i c a l p r o c e d u r e s are d o n e t o deal w i t h
cholesteatoma:
4. C u l t u r e a n d sensitivity o f ear discharge I t helps to
select p r o p e r a n t i b i o t i c f o r l o c a l o r s y s t e m i c use. (a) Canal wall down procedures. They leave the mastoid
c a v i t y o p e n i n t o t h e e x t e r n a l a u d i t o r y canal so t h a t
Features Indicating Complications in CSOM
t h e diseased area is f u l l y e x t e r i o r i s e d . T h e commonly

1. P a i n P a i n is u n c o m m o n i n u n c o m p l i c a t e d C S O M . Its p e r f o r m e d o p e r a t i o n s f o r a t t i c o a n t r a l disease are a t t i -

p r e s e n c e is c o n s i d e r e d serious as i t m a y i n d i c a t e e x t r a d u r a l , c o t o m y , m o d i f i e d radical m a s t o i d e c t o m y a n d rarely,

p e r i s i n u s o r b r a i n abscess. S o m e t i m e s , i t is d u e t o o t i t i s t h e r a d i c a l m a s t o i d e c t o m y (see o p e r a t i v e s u r g e r y ) .

e x t e r n a associated w i t h a d i s c h a r g i n g ear. (b) Canal wall up procedures. H e r e disease is r e m o v e d b y

c o m b i n e d approach t h r o u g h the meatus and mastoid
2. Vertigo I t i n d i c a t e s e r o s i o n o f l a t e r a l s e m i c i r c u l a r canal
b u t r e t a i n i n g the posterior b o n y meatal w a l l intact,
w h i c h m a y progress t o l a b y r i n t h i t i s o r m e n i n g i t i s . Fistula
t h e r e b y a v o i d i n g a n o p e n m a s t o i d c a v i t y . I t gives d r y
test s h o u l d b e p e r f o r m e d i n a l l cases.
ear a n d p e r m i t s easy r e c o n s t r u c t i o n o f h e a r i n g m e c h -
3. Persistent h e a d a c h e I t is s u g g e s t i v e o f a n i n t r a c r a n i a l
anism. However, there is d a n g e r o f leaving some
complication.
cholesteatoma b e h i n d . Incidence o f residual o r r e c u r -
4. Facial weakness indicates e r o s i o n o f facial canal. r e n t c h o l e s t e a t o m a i n these cases is v e r y h i g h a n d t h e r e -

5. A listless child refusing to take feeds and easily f o r e l o n g - t e r m f o l l o w - u p is essential. S o m e surgeon's

g o i n g t o sleep ( e x t r a d u r a l abscess). e v e n advise r o u t i n e r e - e x p l o r a t i o n i n a l l cases after 6

6. Fever, nausea a n d v o m i t i n g
7. I r r i t a b i l i t y a n d n e c k rigidity
8. D i p l o p i a (Gradenigo's
m o n t h s o r so. C a n a l w a l l u p p r o c e d u r e s are a d v i s e d
(intracranial infection).
o n l y i n s e l e c t e d cases. I n c o m b i n e d - a p p r o a c h o r i n t a c t
(meningitis).
canal w a l l m a s t o i d e c t o m y , disease is r e m o v e d b o t h
syndrome). permeatally, and t h r o u g h cortical mastoidectomy and

9. A t a x i a ( l a b y r i n t h i t i s o r c e r e b e l l a r abscess). posterior t y m p a n o t o m y approach, i n w h i c h a w i n d o w

10. A b s c e s s r o u n d the ear (mastoiditis).
I t is n o t u n c o m m o n f o r a p a t i e n t o f C S O M , r e s i d i n g i n
a f a r - f l u n g v i l l a g e , w h e r e m e d i c a l f a c i l i t i e s are p o o r , t o g o
is c r e a t e d b e t w e e n t h e m a s t o i d a n d m i d d l e ear, t h r o u g h
t h e f a c i a l recess, t o r e a c h sinus t y m p a n i (see page 6 ) .
See T a b l e 11.2 f o r t h e c o m p a r i s o n o f canal w a l l u p a n d

to a d o c t o r f o r t h e first t i m e , p r e s e n t i n g w i t h complica- canal w a l l d o w n procedures.

tions. It then demands urgent attention and emergency 2. Reconstructive surgery H e a r i n g can be restored b y
m e d i c a l o r surgical treatment. m y r i n g o p l a s t y o r t y m p a n o p l a s t y . I t c a n b e d o n e at the
t i m e o f p r i m a r y s u r g e r y o r as a s e c o n d stage p r o c e d u r e .
Treatment
Conservative treatment I t has a l i m i t e d role i n the
1. S u r g i c a l I t is t h e m a i n s t a y o f t r e a t m e n t . P r i m a r y a i m m a n a g e m e n t o f cholesteatoma b u t can be t r i e d i n selected
i n s u r g i c a l t r e a t m e n t is t o r e m o v e t h e disease a n d r e n d e r cases, w h e n c h o l e s t e a t o m a is s m a l l a n d easily accessible t o

Table 11.2 C o m p a r i s o n o f canal wall up and canal wall d o w n procedures

C a n a l wall up p r o c e d u r e C a n a l wall d o w n p r o c e d u r e

Meatus Normal appearance Widely open meatus c o m m u n i c a t i n g w i t h mastoid

Dependence Does n o t r e q u i r e r o u t i n e c l e a n i n g D e p e n d e n c e o n d o c t o r f o r c l e a n i n g m a s t o i d cavity

o n c e o r t w i c e a year

Recurrence o r residual H i g h rate o f r e c u r r e n t o r residual L o w r a t e o f recurrence o r residual disease a n d t h u s a

disease cholesteatoma safe p r o c e d u r e

S e c o n d l o o k surgery Requires s e c o n d l o o k surgery a f t e r 6 m o n t h s Not required

o r so t o rule o u t c h o l e s t e a t o m a

Patients l i m i t a t i o n s N o l i m i t a t i o n . Patient a l l o w e d s w i m m i n g S w i m m i n g can lead t o i n f e c t i o n o f m a s t o i d cavity

a n d it is t h u s c u r t a i l e d

Auditory Easy t o w e a r a h e a r i n g a i d i f needed P r o b l e m s in f i t t i n g a h e a r i n g a i d d u e t o large meatus

rehabilitation a n d m a s t o i d cavity w h i c h s o m e t i m e s gets i n f e c t e d
 Cholesteatoma and Chronic Otitis Media

suction clearance u n d e r o p e r a t i n g microscope. Repeated 4. Facial paralysis I t is a c o m m o n c o m p l i c a t i o n a n d m a y

s u c t i o n c l e a r a n c e a n d p e r i o d i c c h e c k ups are essential. It c o m e u n e x p e c t e d l y . T h i s m a y be the presenting feature i n
c a n also b e t r i e d o u t i n e l d e r l y p a t i e n t s a b o v e 65 a n d t h o s e a child.
w h o are u n f i t f o r g e n e r a l anaesthesia o r t h o s e r e f u s i n g s u r -
g e r y . P o l y p s a n d g r a n u l a t i o n s c a n also be s u r g i c a l l y r e m o v e d
Diagnosis
b y c u p f o r c e p s o r c a u t e r i s e d b y c h e m i c a l agents l i k e s i l v e r
n i t r a t e o r t r i c h l o r o a c e t i c a c i d . O t h e r measures l i k e aural
I n the presence o f secondary pyogenic i n f e c t i o n , t u b e r -
t o i l e t a n d d r y ear p r e c a u t i o n s are also essential.
cular otitis media m a y be indistinguishable f r o m chronic
suppurative otitis media. C u l t u r e o f ear discharge for

T U B E R C U L A R OTITIS MEDIA tubercle bacilli, histopathological examination o f g r a n u -

lations a n d X - r a y chest, a n d o t h e r e v i d e n c e o f t u b e r c u l o -
sis i n t h e b o d y h e l p t o c o n f i r m t h e d i a g n o s i s .
Aetiology

I n m o s t o f t h e cases, i n f e c t i o n is s e c o n d a i y t o p u l m o n a r y Treatment

t u b e r c u l o s i s ; i n f e c t i o n reaches t h e m i d d l e ear t h r o u g h e u s t a -
c h i a n t u b e . S o m e t i m e s , i t is b l o o d - b o m e from tubercular 1. Systemic antitubercular t h e r a p y as b e i n g carried

f o c u s i n t h e l u n g s , tonsils, c e r v i c a l o r m e s e n t e r i c lymph f o r p r i m a r y disease.

n o d e s . Disease is m o s t l y seen i n children a n d young adults. 2. L o c a l t r e a t m e n t i n the f o r m o f aural toilet, and c o n -

trol o f secondaiy pyogenic infection.

3 . M a s t o i d s u r g e r y i n d i c a t e d f o r c o m p l i c a t i o n s . H e a l i n g is
Pathology
d e l a y e d i n t u b e r c u l o u s cases. W o u n d b r e a k - d o w n a n d fistula
f o r m a t i o n are c o m m o n . R e c o n s t r u c t i v e s u r g e r y o f m i d d l e
T h e p r o c e s s is s l o w a n d i n s i d i o u s . T u b e r c l e s a p p e a r i n t h e
ear is d e l a y e d t i l l a n t i t u b e r c u l a r t h e r a p y has b e e n c o m p l e t e d .
s u b m u c o s a l l a y e r s o f m i d d l e ear c l e f t a n d caseatc. T h e r e is
painless n e c r o s i s o f t y m p a n i c m e m b r a n e .
M u l t i p l e p e r f o r a t i o n s m a y f o r m w h i c h coalesce t o f o r m
a s i n g l e l a r g e p e r f o r a t i o n . M i d d l e ear a n d m a s t o i d g e t f i l l e d
SYPHILITIC OTITIS MEDIA

w i t h pale g r a n u l a t i o n s . C a r i e s o f b o n e a n d ossicles m a y
o c c u r l e a d i n g t o c o m p l i c a t i o n s . M a s t o i d i t i s , f a c i a l paralysis,
postauricular fistula, osteomyelitis w i t h f o r m a t i o n o f b o n y
sequestra a n d p r o f o u n d h e a r i n g loss are o f t e n seen i n these
cases.
Clinical Features
1 . P a i n l e s s e a r d i s c h a r g e Earache is characteristically absent
i n cases o f t u b e r c u l a r o t i t i s m e d i a . D i s c h a r g e is o f t e n f o u l -
s m e l l i n g because o f t h e u n d e r l y i n g b o n e d e s t r u c t i o n .
2. P e r f o r a t i o n M u l t i p l e perforations, 2 or 3 i n n u m b e r ,
are seen i n pars tensa a n d f o r m a classical s i g n o f disease.
T h e s e m a y coalesce i n t o a s i n g l e large p e r f o r a t i o n t h e n i t
becomes indistinguishable f r o m non-specific CSOM.
I t is a rare c o n d i t i o n . S p i r o c h a e t e s r e a c h m i d d l e ear t h r o u g h
e u s t a c h i a n t u b e w h e n s y p h i l i t i c l e s i o n s are p r e s e n t i n t h e
n o s e o r n a s o p h a r y n x . I n f e c t i o n m a y also b e b l o o d - b o r n e .
S e n s o r y e n d o r g a n s o f t h e i n n e r ear a n d t h e i r n e r v e is s o o n
i n v a d e d b y spirochaetes l e a d i n g t o p r o f o u n d sensorineural
h e a r i n g loss, t i n n i t u s a n d v e r t i g o . B o n e n e c r o s i s a n d seques-
t r u m f o r m a t i o n are c o m m o n , l e a d i n g t o f o e t i d ear discharge.
Secondaiy pyogenic infection may occur, g i v i n g a clinical
picture very m u c h like chronic suppurative otitis media.
D e f i n i t e diagnosis o f s y p h i l i t i c otitis m e d i a can o n l y be
m a d e b y s p e c i f i c t r e p o n e m a l a n t i g e n tests s u c h as t r e p o n e -
mal pallidum immobilisation (TPI) test a n d fluorescent
t r e p o n e m a l a n t i b o d y a b s o r p t i o n test ( F T A - A B S ) . VDRL
and Wasserman tests are n o n s p e c i f i c a n d m a y g i v e false
p o s i t i v e results.

3 . H e a r i n g l o s s T h e r e is s e v e r e h e a r i n g loss, o u t o f p r o - T r e a t m e n t consists o f a n t i s y p h i l i t i c t h e r a p y w i t h a t t e n -

p o r t i o n to s y m p t o m s . M o s t l y c o n d u c t i v e , it m a y have sen- t i o n t o aural t o i l e t a n d c o n t r o l o f secondaiy infection.

sorineural c o m p o n e n t due to i n v o l v e m e n t o f labyrinth. S u r g e r y m a y be r e q u i r e d f o r r e m o v a l o f sequestra.

Complications o f Suppurative
Otitis Media

T h o u g h t h e r e is a g e n e r a l d e c l i n e i n t h e i n c i d e n c e o f c o m - c o n g e n i t a l l y e n l a r g e d a q u e d u c t o f v e s t i b u l e (as i n M o n d i n i ' s
p l i c a t i o n s , t h e y are s t i l l f r e q u e n t l y seen i n o u r c o u n t r y . T h e a b n o r m a l i t y o f i n n e r ear) o r d e h i s c e n c e i n t h e floor of
causes are p o o r s o c i o - e c o n o m i c c o n d i t i o n s , l a c k o f e d u c a - m i d d l e ear.
t i o n a n d a w a r e n e s s a b o u t h e a l t h c a r e ( m i d d l e ear d i s c h a r g e 6. Cholesteatoma Osteitis or granulation tissue in
is still b e i n g c o n s i d e r e d m e r e l y a n u i s a n c e rather than a c h r o n i c otitis media destroy the b o n e and help i n f e c t i o n t o
potentially dangerous c o n d i t i o n ) , and lack o f availability o f penetrate deeper.
t r a i n e d specialists i n t h e f a r - f l u n g r u r a l areas w h e r e t r a n s -
I n a c u t e a n d c h r o n i c m i d d l e ear i n f e c t i o n , disease p r o -
p o r t a t i o n f a c i l i t i e s are still i n a d e q u a t e .
cess is l i m i t e d o n l y t o t h e m u c o p e r i o s t e a l l i n i n g o f t h e c l e f t
b u t i f i t spreads i n t o t h e b o n y w a l l s o f t h e c l e f t o r b e y o n d

Factors Influencing Development i t , v a r i o u s c o m p l i c a t i o n s c a n arise.

of Complications
1
[j Pathways o f Spread o f Infection J
1 . A g e M o s t o f the c o m p l i c a t i o n s o c c u r i n t h e first decade
o f l i f e o r i n t h e e l d e r l y w h e n t h e p a t i e n t ' s resistance is l o w .
1 . D i r e c t bone erosion I n a c u t e i n f e c t i o n s , i t is t h e p r o -
2. P o o r s o c i o - e c o n o m i c g r o u p S e v e r a l f a c t o r s s u c h as cess o f h y p e r a e m i c d e c a l c i f i c a t i o n . I n c h r o n i c i n f e c t i o n , i t
o v e r c r o w d i n g , p o o r health education and personal hygiene, m a y b e osteitis, e r o s i o n b y c h o l e s t e a t o m a o r g r a n u l a t i o n
a n d l i m i t e d access t o h e a l t h c a r e p l a y a n i m p o r t a n t p a r t . tissue.

3. V i r u l e n c e o f organisms M a n y o r g a n i s m s are d e v e l - 2. Venous thrombophlebitis V e i n s o f H a v e r s i a n canals

o p i n g resistance t o a n t i b i o t i c s a n d a c u t e i n f e c t i o n s are are c o n n e c t e d with dural veins w h i c h i n turn connect
e i t h e r n o t c o n t r o l l e d o r progress t o subacute o r c h r o n i c w i t h d u r a l v e n o u s sinuses a n d s u p e r f i c i a l v e i n s o f b r a i n .
o t i t i s m e d i a . I n s u f f i c i e n t d o s e , less e f f e c t i v e d r u g o r i n s u f - T h u s , i n f e c t i o n f r o m t h e m a s t o i d b o n e c a n cause t h r o m -
f i c i e n t p e r i o d o f a d m i n i s t r a t i o n o f a n t i b i o t i c c a n cause b o p h l e b i t i s o f v e n o u s sinuses a n d e v e n c o r t i c a l v e i n t h r o m -
complications. Streptococcus pneumoniae type I I I (earlier bosis. This mode of spread is common in acute
called p n e u m o c o c c u s t y p e I I I ) is v e r y v i r u l e n t d u e t o p r o - infections.
duction o f a u t o l y s i n a n d p n e u m o l y s i n . H. influenzae is
3. P r e f o r m e d pathways
d e v e l o p i n g resistance t o ( 3 - l a c t a m a n t i b i o t i c s a n d c h l o r -
(i) Congenital dehiscences, e.g. i n b o n y facial canal,
a m p h e n i c o l . O t h e r resistant strains are Ps. aeruginosa and
floor o f m i d d l e ear o v e r t h e j u g u l a r b u l b .
m e t h i c i l l i n resistant Staph, aureus.
(ii) Patent sutures, e.g. p e t r o s q u a m o u s suture.
4. I m m u n e - c o m p r o m i s e d host Patients s u f f e r i n g f r o m
(iii) P r e v i o u s s k u l l f r a c t u r e s . T h e f r a c t u r e sites h e a l o n l y
A I D S , u n c o n t r o l l e d diabetes, transplant patients r e c e i v i n g
b y f i b r o u s scar w h i c h p e r m i t s i n f e c t i o n .
i m m u n o s u p p r e s s i v e drugs, cancer patients r e c e i v i n g c h e -
(iv) Surgical defects, e.g. s t a p e d e c t o m y , fenestration a n d
m o t h e r a p y are m o r e p r o n e t o d e v e l o p c o m p l i c a t i o n s .
mastoidectomy w i t h exposure o f dura.
5. P r e f o r m e d pathways Infection c a n easily t r a v e l b e y o n d (v) Oval andround windows.
t h e m i d d l e ear c l e f t i f p r e f o r m e d p a t h w a y s e x i s t , e . g . d e h i s - (vi) Infection from labyrinth can travel along internal
c e n c e o f b o n y f a c i a l c a n a l , p r e v i o u s ear s u r g e r y , f r a c t u r e acoustic meatus, aqueducts o f t h e vestibule a n d that
o f temporal bone, stapedectomy, perilymph fistula o r o f the cochlea to the meninges.
 Complications of Suppurative Otitis Media

T h e last t w o are s e c o n d a r y t o loss o f h e a r i n g i n t h e d e v e l -

Classification
o p m e n t a l phase o f t h e i n f a n t o r c h i l d .

C o m p l i c a t i o n s o f o t i t i s m e d i a are classified i n t o t w o m a i n
groups (Fig. 12.1):
A. INTRATEMPORAL COMPLICATIONS

A. Infratemporal (Within the Confines of Temporal Bone)

OF OTITIS MEDIA

. Mastoiditis
2. Petrositis 1. (a) Acute Mastoiditis

3. F a c i a l paralysis
4. Labyrinthitis. I n f l a m m a t i o n o f m u c o s a l l i n i n g o f a n t r u m a n d m a s t o i d air
cell system is an i n v a r i a b l e a c c o m p a n i m e n t o f acute otitis
B. Intracranial m e d i a a n d f o r m s a p a r t o f i t . T h e t e r m " m a s t o i d i t i s " is u s e d
w h e n i n f e c t i o n spreads from t h e m u c o s a , l i n i n g t h e m a s t o i d
1. E x t r a d u r a l abscess
air cells, t o i n v o l v e b o n y w a l l s o f t h e m a s t o i d air c e l l s y s t e m .
2. S u b d u r a l abscess
3. Meningitis
Aetiology
4. B r a i n abscess
5. L a t e r a l sinus t h r o m b o p h l e b i t i s A c u t e mastoiditis usually accompanies o r f o l l o w s acute

Otitic hydrocephalus. suppurative otitis m e d i a , t h e d e t e r m i n i n g factors being

h i g h v i r u l e n c e o f o r g a n i s m s o r l o w e r e d resistance o f t h e
p a t i e n t d u e t o measles, e x a n t h e m a t o u s f e v e r s , p o o r n u t r i -
Sequelae of Otitis M e d i a t i o n o r associated s y s t e m i c disease s u c h as d i a b e t e s .
A c u t e m a s t o i d i t i s is o f t e n seen i n m a s t o i d s w i t h well-
T h e y are t h e d i r e c t r e s u l t o f m i d d l e ear i n f e c t i o n a n d s h o u l d d e v e l o p e d air c e l l s y s t e m . C h i l d r e n are a f f e c t e d m o r e . B e t a -
be differentiated f r o m complications. T h e y i n c l u d e : h a e m o l y t i c s t r e p t o c o c c u s is t h e m o s t c o m m o n causative
o r g a n i s m t h o u g h o t h e r organisms responsible for acute
1. Perforation of tympanic membrane
o t i t i s m e d i a m a y also b e seen. V e r y o f t e n , a n a e r o b i c o r g a n -
2. Ossicular erosion
isms are also associated w i t h m a s t o i d i t i s a n d n e e d antibac-
. .
;
Atelectasis a n d adhesive otitis m e d i a
t e r i a l t h e r a p y against t h e m .
4. Tympanosclerosis
5.. Cholesteatoma f o r m a t i o n
Pathology
6. C o n d u c t i v e h e a r i n g loss d u e t o ossicular e r o s i o n or
fixation T w o m a i n p a t h o l o g i c a l processes are responsible:
7 S e n s o r i n e u r a l h e a r i n g loss
I. P r o d u c t i o n o f pus u n d e r t e n s i o n .
8. Speech i m p a i r m e n t
Hypcraemic decalcification a n d osteoclastic resorp-
9. L e a r n i n g disabilities
t i o n o f b o n y walls.

Extension o f i n f l a m m a t o r y process t o mucoperiosteal

l i n i n g o f a i r c e l l s y s t e m increases t h e a m o u n t o f p u s p r o -
Cerebral abscess
d u c e d d u e t o l a r g e surface area i n v o l v e d . D r a i n a g e o f t h i s
Pia mater pus, t h r o u g h a small p e r f o r a t i o n o f t y m p a n i c membrane
Meningitis
a n d / o r eustachian t u b e , c a n n o t k e e p pace w i t h t h e a m o u n t
Arachnai
b e i n g p r o d u c e d . S w o l l e n mucosa o f the a n t r u m and attic
Cerebellar
abscess also i m p e d e t h e d r a i n a g e s y s t e m r e s u l t i n g i n a c c u m u l a t i o n
o f pus u n d e r t e n s i o n .
Extradural Dura mater
abscess H y p e r a e m i a a n d e n g o r g e m e n t o f m u c o s a causes d i s s o -
Subdural abscess l u t i o n o f c a l c i u m f r o m the b o n y walls o f the m a s t o i d air
Lateral sinus
Labyrinthitis cells ( h y p e r a e m i c decalcification).
thrombosis
B o t h these processes c o m b i n e t o cause d e s t r u c t i o n a n d
Facial paralysis
c o a l e s c e n c e o f m a s t o i d a i r cells, c o n v e r t i n g t h e m i n t o a
Coalescent mastoiditis
s i n g l e i r r e g u l a r c a v i t y f i l l e d w i t h pus (Empyema of mastoid).
Figure 12.1 Pus m a y b r e a k t h r o u g h m a s t o i d c o r t e x l e a d i n g t o s u b -
p e r i o s t e a l abscess w h i c h m a y e v e n b u r s t o n s u r f a c e l e a d i n g
C o m p l i c a t i o n s o f otitis media.
to a d i s c h a r g i n g fistula (Fig. 12.2A,B).
Clinical Features (iii) Sagging of posterosuperior meatal wall. I t is due to
periosteitis o f b o n y party w a l l b e t w e e n the antrum
Symptoms T h e y are s i m i l a r t o t h a t o f a c u t e s u p p u r a t i v e
and deeper posterosuperior part o f b o n y canal.
o t i t i s m e d i a . I n a case o f a c u t e m i d d l e ear i n f e c t i o n , i t is t h e
(iv) Perforation of tympanic membrane. Usually, a small per-
c h a n g e i n t h e c h a r a c t e r o f these s y m p t o m s w h i c h is s i g n i f i -
f o r a t i o n is seen i n pars tensa w i t h c o n g e s t i o n o f t h e rest
cant and a p o i n t e r to the d e v e l o p m e n t o f acute mastoiditis.
o f tympanic membrane. Perforation may sometimes

(i) Pain behind the ear. P a i n is seen i n a c u t e o t i t i s m e d i a a p p e a r as a n i p p l e - l i k e p r o t r u s i o n . S o m e t i m e s , t y m -

b u t i t subsides w i t h e s t a b l i s h m e n t o f perforation or p a n i c m e m b r a n e is i n t a c t b u t d u l l a n d o p a q u e especially

treatment with antibiotics. I t is t h e p e r s i s t e n c e of i n those w h o have received inadequate antibiotics.

p a i n , i n c r e a s e i n its i n t e n s i t y o r r e c u r r e n c e o f p a i n , (v) Swelling over the mastoid. I n i t i a l l y , t h e r e is o e d e m a o f

o n c e i t h a d s u b s i d e d . T h e s e are s i g n i f i c a n t p o i n t e r s o f periosteum, imparting a smooth "ironed out" feel

pain. o v e r t h e m a s t o i d . L a t e r r e t r o a u r i c u l a r sulcus b e c o m e s

(ii) Fever. I t is t h e p e r s i s t e n c e o r r e c u r r e n c e o f f e v e r i n a o b l i t e r a t e d a n d p i n n a is p u s h e d f o r w a r d a n d down-

case o f a c u t e o t i t i s m e d i a , i n spite o f a d e q u a t e a n t i - w a r d s . W h e n p u s bursts t h r o u g h b o n y c o r t e x , a s u b -

biotic treatment that points to the d e v e l o p m e n t of periosteal fluctuant abscess is f o r m e d ( F i g . 1 2 . 3 ) .

mastoiditis. (vi) Hearing loss. C o n d u c t i v e t y p e o f h e a r i n g loss is a l w a y s

(iii) Ear discharge. I n mastoiditis, discharge becomes p r o - present.

fuse a n d increases i n p u r u l e n c e . I n s o m e cases, d i s - ( v i i ) General findings. Patient appears i l l a n d t o x i c with

c h a r g e m a y cease d u e t o o b s t r u c t i o n t o its d r a i n a g e l o w - g r a d e f e v e r . I n c h i l d r e n , f e v e r is h i g h w i t h a rise

b u t o t h e r s y m p t o m s w o u l d w o r s e n . A n y persistence i n pulse rate.

o f d i s c h a r g e b e y o n d t h r e e w e e k s , i n a case o f a c u t e
investigations
otitis media, points to mastoiditis.
(a) B l o o d c o u n t s s h o w p o l y m o r p h o n u c l e a r l e u c o c y t o s i s .
Signs
(b) E S R is u s u a l l y raised.
(i) Mastoid tenderness. T h i s is a n i m p o r t a n t s i g n . T e n d e r n e s s
(c) X - r a y m a s t o i d T h e r e is c l o u d i n g o f a i r cells d u e t o
is e l i c i t e d b y pressure o v e r t h e m i d d l e o f m a s t o i d p r o -
collection o f exudate i n t h e m . B o n y partitions between air
cess, at its t i p , p o s t e r i o r b o r d e r o r t h e r o o t o f z y g o m a .
Tenderness elicited over the suprameatal triangle m a y cells b e c o m e i n d i s t i n c t , b u t t h e sinus p l a t e is seen as a d i s -

n o t b e d i a g n o s t i c o f a c u t e m a s t o i d i t i s as i t is seen e v e n t i n c t o u t l i n e . I n l a t e r stages, a c a v i t y m a y b e seen i n t h e

i n cases o f t h e a c u t e o t i t i s m e d i a d u e t o i n f l a m m a t i o n mastoid.

o f m a s t o i d a n t r u m (antritis). Tenderness s h o u l d always

(d) E a r s w a b for culture and sensitivity.
b e c o m p a r e d w i t h t h a t o f t h e h e a l t h y side.

(ii) Ear discharge. Mucopurulent or purulent discharge, Differential Diagnosis

o f t e n p u l s a t i l e (light-house effect), m a y b e seen c o m i n g (a) S u p p u r a t i o n of mastoid lymph nodes Scalp i n f e c -

t h r o u g h a c e n t r a l p e r f o r a t i o n o f pars tensa. t i o n m a y cause m a s t o i d l y m p h n o d e e n l a r g e m e n t a n d t h e n
 Complications of Suppurative Otitis M e d i a

(b) A n t i b i o t i c s I n t h e absence o f c u l t u r e a n d s e n s i t i v i t y ,
start w i t h a m o x i c i l l i n o r a m p i c i l l i n . S p e c i f i c a n t i m i c r o b i a l
is started o n t h e r e c e i p t o f s e n s i t i v i t y r e p o r t . S i n c e a n a e r o -
b i c o r g a n i s m s are o f t e n p r e s e n t , c h l o r a m p h e n i c o l o r m e t -
r o n i d a z o l e is a d d e d .

(c) M y r i n g o t o m y W h e n p u s is u n d e r t e n s i o n i t is r e l i e v e d
b y w i d e m y r i n g o t o m y (see o p e r a t i v e s u r g e r y ) . E a r l y cases o f
acute mastoiditis r e s p o n d t o conservative treatment with
antibiotics alone or c o m b i n e d w i t h m y r i n g o t o m y .

( d ) C o r t i c a l m a s t o i d e c t o m y I t is i n d i c a t e d w h e n t h e r e is:

(i) Subperiosteal abscess.

(ii) Sagging o f posterosuperior meatal w a l l .
( i i i ) P o s i t i v e r e s e r v o i r s i g n , i . e . m e a t u s i m m e d i a t e l y fills
w i t h p u s a f t e r i t has b e e n m o p p e d o u t .
(iv) N o change i n c o n d i t i o n o f patient or it worsens i n
spite o f a d e q u a t e m e d i c a l t r e a t m e n t f o r 4 8 h o u r s .
(v) M a s t o i d i t i s , l e a d i n g t o c o m p l i c a t i o n s , e.g. f a c i a l p a r a l -
Figure 12.3
ysis, l a b y r i n t h i t i s , i n t r a c r a n i a l c o m p l i c a t i o n s , etc.
Mastoid abscess. Note that pinna is pushed d o w n w a r d s and

forwards. A i m o f cortical mastoidectomy is t o e x e n t e r a t e a l l t h e

m a s t o i d a i r cells a n d r e m o v e a n y p o c k e t s o f p u s . A d e q u a t e
a n t i b i o t i c t r e a t m e n t m u s t b e c o n t i n u e d at least f o r 5 days

s u p p u r a t i o n l e a d i n g t o abscess f o r m a t i o n , b u t i n s u c h cases following mastoidectomy.

t h e r e is n o h i s t o r y o f p r e c e d i n g o t i t i s m e d i a , ear discharge
Complications of Acute Mastoiditis
o r deafness. Abscess is u s u a l l y s u p e r f i c i a l .
1. Subperiosteal abscess
(b) Furunculosis of meatus I t is d i f f e r e n t i a t e d f r o m
2. Labyrinthitis
acute mastoiditis b y :
3. F a c i a l paralysis
(i) Absence o f preceding acute otitis media. 4. Petrositis
(ii) P a i n f u l m o v e m e n t s o f p i n n a ; pressure o v e r t h e t r a - 5. E x t r a d u r a l abscess
gus o r b e l o w t h e c a r t i l a g i n o u s p a r t o f m e a t u s causes 6. S u b d u r a l abscess
excruciating pain. 7. Meningitis
(iii) S w e l l i n g o f m e a t u s is c o n f i n e d t o t h e cartilaginous S. B r a i n abscess
part o n l y . 9. L a t e r a l sinus t h r o m b o p h l e b i t i s
(iv) Discharge is never mucoid or mucopurulent. 10. Otitic hydrocephalous.
M u c o i d e l e m e n t i n discharge can o n l y c o m e f r o m
t h e m i d d l e ear a n d n o t f r o m t h e e x t e r n a l ear w h i c h Abscesses in Relation to Mastoid Infection

is d e v o i d o f m u c u s - s e c r e t i n g glands.
(a) P o s t a u r i c u l a r a b s c e s s T h i s is t h e c o m m o n e s t abscess
(v) Enlargement o f pre- or postauricular l y m p h nodes.
t h a t f o r m s o v e r t h e m a s t o i d . P i n n a is d i s p l a c e d f o r w a r d s ,
(vi) C o n d u c t i v e h e a r i n g loss is u s u a l l y m i l d a n d is d u e
o u t w a r d s a n d d o w n w a r d s . I n i n f a n t s a n d c h i l d r e n , abscess
to the occlusion o f meatus.
f o m i s o v e r t h e M a c E w e n ' s t r i a n g l e ; p u s i n these cases t r a v -
(vii) A n absolutely n o r m a l l o o k i n g t y m p a n i c membrane
els a l o n g t h e vascular c h a n n e l s o f l a m i n a c r i b r o s a .
excludes possibility o f acute mastoiditis.
(b) Zygomatic abscess I t occurs due to infection of
(viii) X - r a y m a s t o i d w i t h clear a i r - c e l l s y s t e m excludes
z y g o m a t i c a i r cells s i t u a t e d at t h e p o s t e r i o r r o o t o f z y g o m a .
a c u t e m a s t o i d i t i s . S o m e t i m e s , d i f f i c u l t y arises w h e n
S w e l l i n g appears i n f r o n t o f a n d a b o v e t h e p i n n a (Fig.
a i r - c e l l system appears h a z y d u e t o superimposed
1 2 . 4 A . B ) . T h e r e is associated o e d e m a o f t h e u p p e r e y e l i d .
soft tissue s w e l l i n g i n cases o f f u r u n c u l o s i s .
I n t h e s e cases, p u s c o l l e c t s e i t h e r s u p e r f i c i a l o r d e e p t o t h e
(c) I n f e c t e d sebaceous cyst
temporalis muscle.

(c) B e z o l d abscess I t can o c c u r f o l l o w i n g acute coalcs-

Treatment
c e n t m a s t o i d i t i s w h e n pus b r e a k s t h r o u g h t h e t h i n m e d i a l
(a) Hospitalisation o f the patient P a t i e n t is h o s p i t a l - side o f t h e t i p o f t h e m a s t o i d a n d p r e s e n t s as a s w e l l i n g i n
ised i f n o t a l r e a d y d o n e . the u p p e r part o f n e c k . T h e abscess m a y (i) l i e d e e p t o
 A B

abscess abscess abscess

Figure 12.4

( A ) Abscesses in r e l a t i o n t o m a s t o i d . 1 . Postauricular, 2. Z y g o m a t i c , 3. Bezold abscess. ( B ) Citelli's, p o s t a u r i c u l a r a n d Bezold

abscesses seen f r o m b e h i n d .

Pus (iv) p a r a p h a r y n g e a l abscess.

(v) jugular vein thrombosis.

A C T scan o f t h e m a s t o i d a n d s w e l l i n g o f t h e n e c k m a y
establish t h e d i a g n o s i s .
Treatment

(i) Cortical mastoidectomy f o r coalescent mastoiditis

with careful exploration o f the t i p f o r a fistulous
o p e n i n g i n t o t h e soft tissues o f t h e n e c k .
(ii) D r a i n a g e o f t h e n e c k abscess t h r o u g h a separate i n c i -
sion and p u t t i n g a drain i n t h e dependent part.
(iii) A d m i n i s t r a t i o n o f intravenous antibiotics guided b y
of digastric t h e c u l t u r e a n d s e n s i t i v i t y r e p o r t o f t h e p u s t a k e n at
the t i m e o f surgery.

Figure 12.5 (d) Meatal abscess (Luc's abscess) I n t h i s case, p u s

breaks t h r o u g h t h e b o n y w a l l b e t w e e n the antrum and
Bezold abscess. Pus b u r s t i n g t h r o u g h t h e m e d i a l side o f the t i p
o f m a s t o i d a n d c o l l e c t i n g u n d e r the s t e r n o m a s t o i d o r digastric e x t e r n a l osseous m e a t u s . S w e l l i n g is seen i n d e e p p a r t o f

triangle. b o n y m e a t u s . Abscess m a y b u r s t i n t o t h e m e a t u s .

(e) B e h i n d the mastoid ( C i t e l l i ' s a b s c e s s ) Abscess is

s t e r n o c l e i d o m a s t o i d , p u s h i n g t h e m u s c l e o u t w a r d s (ii) f o l - formed behind the mastoid more towards the occipital

l o w t h e p o s t e r i o r b e l l y o f d i g a s t r i c a n d p r e s e n t as a s w e l l - b o n e ( c o m p a r e p o s t a u r i c u l a r m a s t o i d abscess w h i c h f o r m s

i n g b e t w e e n t h e t i p o f m a s t o i d a n d angle o f j a w , (iii) b e over t h e m a s t o i d ) . S o m e a u t h o r s c o n s i d e r abscess o f t h e

present i n u p p e r part o f posterior triangle, ( i v ) reach t h e d i g a s t r i c t r i a n g l e , w h i c h is f o r m e d b y t r a c k i n g o f p u s from

p a r a p h a r y n g e a l space o r ( v ) t r a c k d o w n a l o n g t h e c a r o t i d t h e m a s t o i d t i p , as t h e C i t e l l i ' s abscess.

vessels ( F i g . 1 2 . 5 ) . (f) P a r a p h a r y n g e a l or retropharyngeal abscess This

Clinical features. O n s e t is s u d d e n . T h e r e is p a i n , f e v e r , results f r o m i n f e c t i o n o f t h e p e r i t u b a l cells d u e t o a c u t e
a t e n d e r s w e l l i n g i n t h e n e c k a n d t o r t i c o l l i s . Patient gives coalescent mastoiditis.
history o f purulent otorrhoea.
A B e z o l d abscess s h o u l d b e d i f f e r e n t i a t e d f r o m :
| (b) M a s k e d (Latent) Mastoiditis |
(i) acute upper j u g u l a r l y m p h a d e n i t i s .
(ii) abscess o r a mass i n t h e l o w e r p a r t o f t h e p a r o t i d g l a n d . I t is a c o n d i t i o n o f s l o w d e s t r u c t i o n o f m a s t o i d a i r cells b u t
( i i i ) a n i n f e c t e d b r a n c h i a l cyst. w i t h o u t t h e a c u t e signs a n d s y m p t o m s o f t e n seen i n a c u t e
 Complications of Suppurative Otitis Media

m a s t o i d i t i s . T h e r e is n o p a i n , n o d i s c h a r g e , n o f e v e r a n d n o I n f e c t i v e process r u n s a l o n g these c e l l tracts a n d reaches

mastoid swelling b u t mastoidectomy m a y s h o w extensive t h e p e t r o u s a p e x . P a t h o l o g i c a l p r o c e s s is s i m i l a r t o t h a t o f
d e s t r u c t i o n o f t h e a i r cells w i t h g r a n u l a t i o n tissue a n d d a r k coalescent mastoiditis f o r m i n g epidural abscess at the
g e l a t i n o u s m a t e r i a l f i l l i n g t h e m a s t o i d . I t is n o t s u r p r i s i n g petrous apex i n v o l v i n g C N V I a n d t r i g e m i n a l g a n g l i o n .
t o f i n d e r o s i o n o f the t e g m e n t y m p a n i a n d sinus plate w i t h
a n e x t r a d u r a l o r p e r i s i n u s abscess. Clinical Features

Gradenigo's syndrome is t h e classical p r e s e n t a t i o n , a n d c o n -

Aetiology
sists o f a t r i a d o f (a) e x t e r n a l r e c t u s palsy (Vlth nerve
The c o n d i t i o n o f t e n results from inadequate antibiotic p a l s y ) , (b) d e e p - s e a t e d ear o r r e t r o - o r b i t a l p a i n ( V t h n e r v e
t h e r a p y i n terms o f dose, f r e q u e n c y a n d d u r a t i o n o f a d m i n - i n v o l v e m e n t ) a n d (c) p e r s i s t e n t ear d i s c h a r g e . I t is u n c o m -
i s t r a t i o n . M o s t o f t e n i t results from use o f o r a l p e n i c i l l i n m o n t o see t h e f u l l t r i a d these days.
g i v e n i n cases o f a c u t e o t i t i s m e d i a w h e n a c u t e s y m p t o m s P e r s i s t e n t ear d i s c h a r g e with or without deep-seated
subside but smouldering infection continues in the p a i n i n spite o f a n a d e q u a t e c o r t i c a l o r m o d i f i e d r a d i c a l
mastoid. m a s t o i d e c t o m y also p o i n t s t o p e t r o s i t i s .
Fever, headache, v o m i t i n g and sometimes neck r i g i d i t y
Clinical Features m a y also b e associated. S o m e p a t i e n t s m a y get f a c i a l p a r a l y -
sis a n d r e c u r r e n t v e r t i g o d u e t o i n v o l v e m e n t o f f a c i a l a n d
P a t i e n t is o f t e n a c h i l d , n o t e n t i r e l y f e e l i n g w e l l , w i t h m i l d
statoacoustic nerves.
p a i n b e h i n d t h e ear b u t w i t h p e r s i s t e n t h e a r i n g loss.
D i a g n o s i s o f p e t r o u s a p i c i t i s r e q u i r e s b o t h C T scan a n d
T y m p a n i c m e m b r a n e appears t h i c k w i t h loss o f t r a n s l u -
M R I . C T scan o f t e m p o r a l b o n e w i l l s h o w b o n y details o f
cency. Slight tenderness m a y be e l i c i t e d o v e r t h e m a s t o i d .
t h e p e t r o u s a p e x a n d t h e a i r cells w h i l e M R I h e l p s t o d i f -
Audiometry shows conductive h e a r i n g loss o f variable
ferentiate diploic m a r r o w containing apex from fluid
d e g r e e . X - r a y o f m a s t o i d w i l l r e v e a l c l o u d i n g o f a i r cells
o r pus.
w i t h loss o f c e l l o u t l i n e .

Treatment
Treatment

C o r t i c a l , m o d i f i e d r a d i c a l o r r a d i c a l m a s t o i d e c t o m y is o f t e n
C o r t i c a l m a s t o i d e c t o m y w i t h f u l l doses o f a n t i b i o t i c s is t h e
r e q u i r e d i f n o t already d o n e . T h e fistulous tract s h o u l d be
t r e a t m e n t o f c h o i c e . T h i s m a y cause t y m p a n i c membrane
f o u n d o u t , w h i c h is t h e n c u r e t t e d a n d e n l a r g e d t o p r o v i d e
to r e t u r n to n o r m a l w i t h i m p r o v e m e n t i n hearing.
free drainage. T r a c t o f posterosuperior cells starts i n t h e
T r a u t m a n n ' s t r i a n g l e o r t h e a t t i c . T r a c t o f a n t e r i o r cells is
situated near the t y m p a n i c o p e n i n g o f eustachian tube and
I 2. Petrositis | passes a b o v e t h e c a r o t i d a r t e r y , a n t e r i o r t o t h e c o c h l e a . I n
t h e l a t t e r case, r a d i c a l m a s t o i d e c t o m y is r e q u i r e d .
S p r e a d o f i n f e c t i o n f r o m m i d d l e ear a n d m a s t o i d t o the
Suitable intravenous antibacterial therapy should p r e -
p e t r o u s p a r t o f t e m p o r a l b o n e is c a l l e d p e t r o s i t i s . I t m a y b e
c e d e a n d f o l l o w s u r g i c a l i n t e r v e n t i o n . M o s t cases o f a c u t e
associated w i t h a c u t e c o a l e s c e n t m a s t o i d i t i s , l a t e n t mas-
petrositis can now be cured w i t h antibacterial therapy
t o i d i t i s o r c h r o n i c m i d d l e ear i n f e c t i o n s .
a l o n e . I t s h o u l d b e g i v e n i n i n i t i a l h i g h doses a n d c o n t i n -
u e d f o r 4—5 days, e v e n a f t e r c o m p l e t e disappearance of
Pathology
symptoms.
L i k e m a s t o i d , petrous b o n e m a y be o f three types: pneuma-
tised w i t h a i r cells e x t e n d i n g t o t h e p e t r o u s a p e x , diploic
c o n t a i n i n g o n l y m a r r o w space a n d sclerotic. Pneumatisation
3. Facial Paralysis J
o f petrous apex occurs i n o n l y 3 0 % o f cases w i t h cells
e x t e n d i n g f r o m t h e m i d d l e ear o r m a s t o i d t o t h e p e t r o u s I t c a n o c c u r as a c o m p l i c a t i o n o f b o t h a c u t e a n d chronic
a p e x . U s u a l l y t w o c e l l tracts are recognised: otitis media.

(a) Posterosuperior t r a c t w h i c h starts i n t h e m a s t o i d a n d

Acute Otitis Media
runs b e h i n d or above the b o n y l a b y r i n t h to the petrous
a p e x ; s o m e cells e v e n pass t h r o u g h t h e a r c h o f s u p e - F a c i a l n e r v e is n o r m a l l y w e l l p r o t e c t e d i n its b o n y canal.
r i o r s e m i c i r c u l a r canal t o reach the apex. S o m e t i m e s , t h e b o n y c a n a l is d e h i s c e n t , a n d t h e n e r v e lies
fb) A n t e r o i n f e r i o r tract w h i c h starts at t h e hypotym- j u s t u n d e r t h e m i d d l e ear m u c o s a . I t is i n these cases t h a t
panum near the eustachian tube runs around the inflammation o f m i d d l e ear spreads t o epi- and peri-
cochlea to reach the petrous apex. neurium, causing f a c i a l paralysis. Facial n e r v e function
f u l l y r e c o v e r s i f a c u t e o t i t i s m e d i a is c o n t r o l l e d w i t h sys- (b) Siegle's speculum. W h e n p o s i t i v e pressure is a p p l i e d t o
temic antibiotics. M y r i n g o t o m y or cortical mastoidectomy ear canal, p a t i e n t c o m p l a i n s o f v e r t i g o u s u a l l y w i t h n y s -
m a y sometimes be r e q u i r e d . t a g m u s . T h e q u i c k c o m p o n e n t o f n y s t a g m u s w o u l d be
t o w a r d s t h e a f f e c t e d ear ( a m p u l l o p e t a l d i s p l a c e m e n t of
Chronic Otitis Media cupula).

Facial paralysis i n c h r o n i c o t i t i s m e d i a e i t h e r results from Ampullopetal flow o f e n d o l y m p h (as also a m p u l l o p e t a l

cholesteatoma or from penetrating granulation tissue. displacement o f cupula) w h e t h e r i n r o t a t i o n , caloric o r fis-
C h o l e s t e a t o m a destroys b o n y canal a n d t h e n causes pressure t u l a test causes n y s t a g m u s t o same side.
o n t h e n e r v e , f u r t h e r a i d e d b y o e d e m a o f associated i n f l a m - I f n e g a t i v e pressure is a p p l i e d , a g a i n i t w o u l d induce
m a t o r y process. Facial paralysis is i n s i d i o u s b u t s l o w l y p r o - v e r t i g o and nystagmus b u t this t i m e the q u i c k c o m p o n e n t
gressive. T r e a m i e n t is u r g e n t e x p l o r a t i o n o f t h e m i d d l e ear o f nystagmus w o u l d be directed to the (opposite) healthy
a n d m a s t o i d . Facial canal is i n s p e c t e d from the geniculate side d u e t o a m p u l l o f u g a l d i s p l a c e m e n t o f c u p u l a .
g a n g l i o n t o t h e s t y l o m a s t o i d f o r a m e n . I f g r a n u l a t i o n tissue
Treatment I n chronic suppurative otitis media or cho-
o r c h o l e s t e a t o m a has e n t e r e d t h e b o n y canal, t h e l a t t e r is
l e s t e a t o m a , m a s t o i d e x p l o r a t i o n is o f t e n r e q u i r e d t o e l i m i -
u n c a p p e d i n t h e area o f i n v o l v e m e n t . G r a n u l a t i o n tissue s u r -
nate the cause. S y s t e m i c antibiotic therapy should be
r o u n d i n g t h e n e r v e is r e m o v e d b u t i f i t a c t u a l l y i n v a d e s t h e
i n s t i t u t e d b e f o r e a n d a f t e r o p e r a t i o n t o p r e v e n t spread of
n e r v e sheath, i t is l e f t i n p l a c e . I f a s e g m e n t o f t h e n e r v e has
infection i n t o the labyrinth.
b e e n d e s t r o y e d b y t h e g r a n u l a t i o n tissue, r e s e c t i o n o f n e r v e
a n d g r a f t i n g are b e t t e r l e f t t o a s e c o n d stage w h e n i n f e c t i o n
has b e e n c o n t r o l l e d a n d fibrosis has m a t u r e d . Diffuse Serous Labyrinthitis

I t is d i f f u s e i n t r a l a b y r i n t h i n e i n f l a m m a t i o n w i t h o u t pus
f o r m a t i o n a n d is a r e v e r s i b l e c o n d i t i o n i f t r e a t e d e a r l y .
| 4. Labyrinthitis H
Aetiology

T h e r e are t h r e e t y p e s o f l a b y r i n t h i t i s : (a) M o s t o f t e n i t arises f r o m p r e - e x i s t i n g c i r c u m s c r i b e d

l a b y r i n t h i t i s associated w i t h c h r o n i c m i d d l e ear s u p -
(a) Circumscribed labyrinthitis
puration or cholesteatoma.
(b) D i f f u s e serous l a b y r i n t h i t i s
(b) I n a c u t e i n f e c t i o n s o f m i d d l e ear, c l e f t i n f l a m m a -
(c) Diffuse suppurative labyrinthitis
t i o n spreads t h r o u g h a n n u l a r l i g a m e n t o r t h e r o u n d

Circumscribed Labyrinthitis (Fistula of Labyrinth) window.

(c) I t can f o l l o w stapedectomy o r fenestration o p e r a t i o n .
T h e r e is t h i n n i n g o r e r o s i o n o f b o n y c a p s u l e o f l a b y r i n t h ,
usually o f the h o r i z o n t a l semicircular canal. Clinical features M i l d cases c o m p l a i n o f v e r t i g o and
nausea b u t i n severe cases, v e r t i g o is w o r s e w i t h m a r k e d
Aetiology T h e causes are:
nausea, v o m i t i n g a n d e v e n s p o n t a n e o u s n y s t a g m u s . Q u i c k
(a) C h r o n i c suppurative otitis media w i t h cholesteatoma c o m p o n e n t o f n y s t a g m u s is t o w a r d s t h e a f f e c t e d ear.
is t h e m o s t c o m m o n cause. A s t h e i n f l a m m a t i o n is d i f f u s e , c o c h l e a is also affected
(b) N e o p l a s m s o f m i d d l e ear, e . g . c a r c i n o m a o r g l o m u s w i t h s o m e d e g r e e o f s e n s o r i n e u r a l h e a r i n g loss.
tumour. S e r o u s l a b y r i n t h i t i s , i f n o t c h e c k e d , m a y pass o n t o s u p -
(c) Surgical o r accidental trauma t o l a b y r i n t h . purative labyrinthitis w i t h t o t a l loss o f v e s t i b u l a r and
cochlear f u n c t i o n .
Clinical features A part o f m e m b r a n o u s labyrinth is
e x p o s e d a n d b e c o m e s s e n s i t i v e t o pressure c h a n g e s . P a t i e n t Treatment Aiedkal.
complains o f transient v e r t i g o often i n d u c e d b y pressure
on t r a g u s , c l e a n i n g t h e ear o r w h i l e p e r f o r m i n g V a l s a l v a (a) P a t i e n t is p u t t o b e d , his h e a d i n m i o b i l i s e d w i t h a f f e c t e d

manoeuvre. ear a b o v e .
(b) A n t i b a c t e r i a l t h e r a p y is g i v e n i n f u l l doses t o c o n t r o l
I t is d i a g n o s e d b y " f i s t u l a t e s t " w h i c h c a n b e p e r f o r m e d
infection.
in t w o ways.
(c) L a b y r i n t h i n e sedatives, e . g . p r o c h l o r p e r a z i n e ( S t e m e t i l )
(a) Pressure on tragus. S u d d e n i n w a r d pressure is a p p l i e d o n o r d i m e n h y d r i n a t e ( D r a m a m i n e ) , are g i v e n f o r s y m p -
t h e t r a g u s . T h i s increases a i r pressure i n t h e ear canal tomatic relief o f vertigo.
and stimulates the l a b y r i n t h . Patient w i l l c o m p l a i n o f (d) M y r i n g o t o m y is d o n e i f l a b y r i n t h i t i s has f o l l o w e d
v e r t i g o . N y s t a g m u s m a y also b e i n d u c e d w i t h q u i c k a c u t e o t i t i s m e d i a a n d t h e d r u m is b u l g i n g . Pus is c u l -
c o m p o n e n t t o w a r d s t h e ear u n d e r test. t u r e d f o r specific antibacterial therapy.
 Complications of Suppurative Otitis Media

Surgical. Cortical mastoidectomy (in acute mastoiditis) (iii) G e n e r a l malaise w i t h l o w - g r a d e f e v e r .

o r m o d i f i e d r a d i c a l m a s t o i d e c t o m y ( i n c h r o n i c m i d d l e ear (iv) P u l s a t i l e p u r u l e n t ear d i s c h a r g e .
i n f e c t i o n o r cholesteatoma) w i l l o f t e n be r e q u i r e d to treat (v) Disappearance o f headache w i t h free flow o f pus
the source o f i n f e c t i o n . M e d i c a l t r e a t m e n t s h o u l d always f r o m t h e ear ( s p o n t a n e o u s abscess d r a i n a g e ) .
precede surgical i n t e r v e n t i o n .
D i a g n o s i s is m a d e o n c o n t r a s t - e n h a n c e d C T or M R I .

Diffuse Suppurative Labyrinthitis Treatment

T h i s is d i f f u s e p y o g e n i c i n f e c t i o n o f t h e l a b y r i n t h with (a) C o r t i c a l o r m o d i f i e d r a d i c a l o r r a d i c a l m a s t o i d e c -
p e r m a n e n t loss o f v e s t i b u l a r a n d c o c h l e a r f u n c t i o n s . tomy I t is o f t e n r e q u i r e d t o deal w i t h t h e causative disease

Aetiology I t u s u a l l y f o l l o w s serous l a b y r i n t h i t i s , p y o g e n i c process. E x t r a d u r a l abscess is e v a c u a t e d b y r e m o v i n g o v e r l y -

o r g a n i s m s e n t e r i n g t h r o u g h a p a t h o l o g i c a l o r surgical fistula. i n g b o n e t i l l t h e l i m i t s o f h e a l t h y d u r a are r e a c h e d . Cases

w h e r e b o n y plate o f t e g m e n t y m p a n i o r sinus p l a t e is i n t a c t
C l i n i c a l f e a t u r e s T h e r e is severe v e r t i g o w i t h nausea a n d
b u t t h e r e is s u s p i c i o n o f a n abscess, t h e i n t a c t b o n y p l a t e is
v o m i t i n g due to acute vestibular failure. Spontaneous nys-
deliberately r e m o v e d t o evacuate any c o l l e c t i o n o f pus.
t a g m u s w i l l be o b s e r v e d w i t h its q u i c k c o m p o n e n t t o w a r d s
t h e h e a l t h y s i d e . P a t i e n t is m a r k e d l y t o x i c . T h e r e is t o t a l (b) A n antibiotic cover s h o u l d be p r o v i d e d f o r a m i n i -

loss o f h e a r i n g . R e l i e f f r o m v e r t i g o is seen a f t e r 3—6 w e e k s mum o f 5 days a n d p a t i e n t c l o s e l y o b s e r v e d f o r a n y f u r -

due to adaptation. t h e r c o m p l i c a t i o n s , s u c h as s i n u s t h r o m b o s i s , m e n i n g i t i s
o r b r a i n abscess.
Treatment I t is s a m e as f o r serous l a b y r i n t h i t i s . R a r e l y ,
d r a i n a g e o f t h e l a b y r i n t h is r e q u i r e d , i f i n t r a l a b y r i n t h i n e
s u p p u r a t i o n is a c t i n g as a s o u r c e o f i n t r a c r a n i a l c o m p l i c a - 2. Subdural Abscess Jjj||
t i o n s , e . g . m e n i n g i t i s o r b r a i n abscess.

T h i s is c o l l e c t i o n o f p u s b e t w e e n d u r a a n d a r a c h n o i d .

Pathology
B. INTRACRANIAL COMPLICATIONS OF
OTITIS MEDIA I n f e c t i o n spreads f r o m t h e ear b y e r o s i o n o f b o n e a n d d u r a
o r b y t h r o m b o p h l e b i t i c p r o c e s s i n w h i c h case i n t e r v e n i n g
b o n e r e m a i n s i n t a c t . Pus r a p i d l y spreads i n s u b d u r a l space
J 1. Extradural Abscess [ and c o n i e s t o l i e against t h e c o n v e x surface o f cerebral
h e m i s p h e r e c a u s i n g pressure s y m p t o m s . W i t h t i m e , t h e p u s
I t is c o l l e c t i o n o f p u s b e t w e e n t h e b o n e a n d d u r a . I t m a y m a y g e t l o c u l a t e d at v a r i o u s places i n s u b d u r a l space.
o c c u r b o t h i n a c u t e a n d c h r o n i c i n f e c t i o n s o f m i d d l e ear.
Clinical Features
Pathology
Signs and symptoms of subdural abscess are due to
I n a c u t e o t i t i s m e d i a , b o n e o v e r t h e d u r a is d e s t r o y e d b y (a) m e n i n g e a l i r r i t a t i o n , (b) t h r o m b o p h l e b i t i s o f c o r t i c a l
hyperaemic decalcification, w h i l e i n chronic otitis media it v e i n s o f c e r e b r u m , (c) raised i n t r a c r a n i a l t e n s i o n .
is d e s t r o y e d b y c h o l e s t e a t o m a a n d i n s u c h a case t h e p u s
(a) Meningeal irritation There is headache, fever
comes to lie directly i n contact w i t h dura. Spread o f infec-
(102°F or more), malaise, increasing drowsiness, neck
t i o n c a n also o c c u r b y v e n o u s t h r o m b o p h l e b i t i s ; i n t h i s
rigidity and positive Kernig's sign.
case, b o n e o v e r t h e d u r a r e m a i n s i n t a c t . A n e x t r a d u r a l
(b) C o r t i c a l v e n o u s t h r o m b o p h l e b i t i s Veins over the
abscess m a y h e i n r e l a t i o n t o d u r a o f m i d d l e o r p o s t e r i o r
cerebral hemisphere u n d e r g o t h r o m b o p h l e b i t i s l e a d i n g to
c r a n i a l fossa o r o u t s i d e t h e d u r a o f l a t e r a l v e n o u s sinus
aphasia, h e m i p l e g i a , h e m i a n o p i a . T h e r e m a y b e J a c k s o n i a n
( p e r i s i n u s abscess). T h e a f f e c t e d d u r a m a y b e c o v e r e d w i t h
t y p e o f e p i l e p t i c fits w h i c h m a y i n c r e a s e t o g i v e a p i c t u r e
g r a n u l a t i o n s o r appear u n h e a l t h y a n d d i s c o l o u r e d .
o f status e p i l e p t i c u s .

Clinical Features (c) R a i s e d i n t r a c r a n i a l t e n s i o n T h e r e is p a p i l l o e d e n i a ,

ptosis a n d d i l a t e d p u p i l ( I l l r d nerve i n v o l v e m e n t ) , and
M o s t o f t h e t i m e , e x t r a d u r a l o r p e r i s i n u s abscesses are
i n v o l v e m e n t o f o t h e r c r a n i a l n e r v e s . C T scan o r M R I are
asymptomatic a n d s i l e n t , a n d are d i s c o v e r e d accidendy
r e q u i r e d f o r diagnosis.
d u r i n g cortical or m o d i f i e d radical mastoidectomy.
H o w e v e r , t h e i r p r e s e n c e is s u s p e c t e d w h e n t h e r e is: Treatment

(i) P e r s i s t e n t h e a d a c h e o n t h e side o f o t i t i s m e d i a .

c
L u m b a r p u n c t u r e should n o t be done as i t c a n cause
(ii) S e v e r e p a i n i n t h e ear. h e r n i a t i o n o f t h e c e r e b e l l a r t o n s i l s . I t is a n e u r o l o g i c a l
emergency. A series o f b u r r h o l e s o r a c r a n i o t o m y is reach 1000/ml w i t h predominance o f p o l y m o r p h s ; protein
done to drain subdural empyema. Intravenous antibiotics l e v e l is raised, sugar is r e d u c e d a n d c h l o r i d e s are d i m i n i s h e d .
a r e a d m i n i s t e r e d t o c o n t r o l i n f e c t i o n . O n c e i n f e c t i o n is CSF is a l w a y s c u l t u r e d t o f i n d t h e c a u s a t i v e organisms
u n d e r c o n t r o l , a t t e n t i o n is p a i d t o c a u s a t i v e ear disease and their antibiotic sensitivity.
w h i c h may require mastoidectomy.

Treatment

M e d i c a l M e d i c a l t r e a t m e n t takes p r e c e d e n c e o v e r s u r g e r y .
3. Meningitis J Antimicrobial therapy directed against aerobic and
anaerobic organisms should be instituted. C u l t u r e a n d sen-
I t is i n f l a m m a t i o n o f l e p t o m e n i n g e s (pia a n d arachnoid)
sitivity o f CSF w i l l further aid i n the choice o f antibiotics.
usually w i t h bacterial invasion o f CSF in subarachnoid
Corticosteroids c o m b i n e d w i t h antibiotic therapy further
space. I t is t h e m o s t c o m m o n i n t r a c r a n i a l c o m p l i c a t i o n o f
helps t o r e d u c e n e u r o l o g i c a l o r a u d i o l o g i c a l c o m p l i c a t i o n s .
o t i t i s m e d i a . I t can o c c u r i n b o t h a c u t e a n d c h r o n i c o t i t i s
Surgical Meningitis following acute otitis media may
m e d i a . I n infants and c h i l d r e n , otogenic m e n i n g i t i s usually
require m y r i n g o t o m y o r cortical mastoidectomy. Meningitis
f o l l o w s a c u t e o t i t i s m e d i a w h i l e i n a d u l t s i t is d u e t o c h r o n i c
f o l l o w i n g c h r o n i c otitis m e d i a w i t h c h o l e s t e a t o m a w i l l r e q u i r e
m i d d l e ear i n f e c t i o n .
radical o r m o d i f i e d radical m a s t o i d e c t o m y .

Mode of infection S u r g e r y is u n d e r t a k e n as s o o n as g e n e r a l c o n d i t i o n o f
p a t i e n t p e r m i t s . I t m a y b e d o n e u r g e n t l y , i f t h e r e has b e e n
B l o o d - b o r n e i n f e c t i o n is c o m m o n i n i n f a n t s a n d c h i l d r e n ;
n o satisfactory r e s p o n s e t o m e d i c a l t r e a t m e n t .
i n a d u l t s , i t f o l l o w s c h r o n i c ear disease, w h i c h spreads b y
b o n e erosion o r retrograde t h r o m b o p h l e b i t i s . I n the latter
case i t m a y b e associated w i t h an e x t r a d u r a l abscess o r
g r a n u l a t i o n tissue.
| 4 . O t o g e n i c Brain A b s c e s s J
I n o n e - t h i r d o f the patients w i t h m e n i n g i t i s , another
intracranial c o m p l i c a t i o n m a y coexist. F i f t y p e r c e n t o f b r a i n abscesses i n a d u l t s a n d 2 5 % i n c h i l -
d r e n are o t o g e n i c i n o r i g i n . I n a d u l t s , abscess u s u a l l y f o l -
Clinical Features lows chronic suppurative otitis media w i t h cholesteatoma,
w h i l e i n c h i l d r e n , i t is u s u a l l y t h e r e s u l t o f a c u t e o t i t i s
S y m p t o m s a n d signs o f m e n i n g i t i s are d u e t o (a) p r e s e n c e
m e d i a . C e r e b r a l abscess is seen t w i c e as f r e q u e n t l y as c e r -
o f i n f e c t i o n , (b) raised i n t r a c r a n i a l t e n s i o n a n d (c) m e n i n -
e b e l l a r abscess.
geal a n d c e r e b r a l i r r i t a t i o n . T h e i r s e v e r i t y w i l l v a r y w i t h
t h e e x t e n t o f disease.
Route of Infection
(i) T h e r e is rise i n t e m p e r a t u r e ( 1 0 2 — 1 0 4 ° F ) o f t e n w i t h
chills a n d rigors. C e r e b r a l abscess d e v e l o p s as a r e s u l t o f d i r e c t e x t e n s i o n of

(ii) Headache. m i d d l e ear i n f e c t i o n t h r o u g h t h e t e g m e n o r b y r e t r o g r a d e

(iii) N e c k rigidity. t h r o m b o p h l e b i t i s , i n w h i c h case t h e t e g m e n w i l l b e i n t a c t .

(iv) Photophobia and mental irritability. O f t e n i t is associated w i t h e x t r a d u r a l abscess.

(v) Nausea and v o m i t i n g (sometimes projectile). C e r e b e l l a r abscess also d e v e l o p s as a d i r e c t extension

i D r o w s i n e s s w h i c h m a y progress t o d e l i r i u m o r c o m a , t h r o u g h the T r a u t m a n n ' s triangle o r by retrograde t h r o m -

( v i i ) C r a n i a l n e r v e palsies a n d h e m i p l e g i a . bophlebitis. This is often associated with extradural

abscess, p e r i s i n u s abscess, s i g m o i d s i n u s t h r o m b o p h l e b i t i s
E x a m i n a t i o n w i l l s h o w : (i) n e c k r i g i d i t y , ( i i ) p o s i t i v e or labyrinthitis.
K e r n i g ' s sign (extension o f leg w i t h t h i g h flexed o n abdo-
m e n causing pain), (iii) positive Brudzinski's sign ( f l e x i o n
Bacteriology
o f n e c k causes flexion o f h i p a n d k n e e ) , ( i v ) t e n d o n r e f l e x e s
are exaggerated initially but later become sluggish or B o t h aerobic and anaerobic organisms are seen. Aerobic

absent, (v) p a p i l l o e d e m a ( u s u a l l y seen i n l a t e stages). ones i n c l u d e p y o g e n i c s t a p h y l o c o c c i , Strep, pneumoniae, Strep,

haemolyticus, Proteus mirabilis, Esch. coii a n d Ps. aeruginosa.
Diagnosis C o m m o n a m o n g t h e a n a e r o b i c ones are t h e Peptostreptococcus
a n d Bacteroidesfragilis. H. influenzae is r a r e l y seen.
C T or M R I w i t h contrast w i l l help to m a k e the diagnosis.
I t m a y also r e v e a l a n o t h e r associated i n t r a c r a n i a l l e s i o n .
Pathology
Lumbar puncture and CSF examination establish the
diagnosis. C S F is t u r b i d , c e l l c o u n t is raised a n d m a y even B r a i n abscess d e v e l o p s t h r o u g h f o u r stages.
 Complications of Suppurative Otitis Media

(a) Stage of invasion (initial encephalitis) It often o f l e s i o n , is l o s t . I t c a n b e e l i c i t e d b y c o n f r o n t a t i o n

passes u n n o t i c e d as s y m p t o m s are s l i g h t . P a t i e n t m a y h a v e test, b y s t a n d i n g i n front o f t h e p a t i e n t a n d c o m p a r -
h e a d a c h e , l o w - g r a d e f e v e r , malaise a n d d r o w s i n e s s . i n g his visual f i e l d w i t h that o f the e x a m i n e r , o r b y
perimetry. T h e defect is u s u a l l y i n t h e u p p e r , b u t
( b ) S t a g e o f l o c a l i s a t i o n ( l a t e n t a b s c e s s ) T h e r e are n o
sometimes i n the l o w e r quadrants.
s y m p t o m s d u r i n g t h i s stage. N a t u r e tries t o l o c a l i s e t h e p u s
(iii) Contralateral motor paralysis. I n t h e u s u a l u p w a r d spread
b y f o r m a t i o n o f a capsule. T h e stage m a y last f o r several
o f abscess, face is i n v o l v e d f i r s t f o l l o w e d b y t h e a r m
weeks.
and leg. I n w a r d spread, towards internal capsule,
( c ) S t a g e o f e n l a r g e m e n t ( m a n i f e s t a b s c e s s ) Abscess i n v o l v e s the leg first f o l l o w e d b y t h e a r m a n d the
b e g i n s t o e n l a r g e . A z o n e o f o e d e m a appears r o u n d t h e face.
abscess a n d is r e s p o n s i b l e for aggravation o f symptoms. (iv) Epileptic fits. I n v o l v e m e n t o f u n c i n a t e g y r u s causes
C l i n i c a l f e a t u r e s at t h i s stage are d u e t o : hallucinations o f taste, and small and i n v o l u n t a r y
s m a c k i n g m o v e m e n t s o f lips a n d t o n g u e . Generalised
(i) Raised intracranial tension. fits m a y o c c u r .
(ii) Disturbance o f f u n c t i o n i n the c e r e b r u m or cerebel- (v) Pupillary changes and oculomotor palsy. I t indicates t r a n -
l u m , c a u s i n g f o c a l s y m p t o m s a n d signs. stentorial herniation.

(d) Stage of termination (rupture o f abscess) An C e r e b e l l a r abscess (Fig. 12.6)

e x p a n d i n g abscess i n t h e w h i t e m a t t e r o f b r a i n r u p t u r e s
(i) Headache involves suboccipital region and m a y be
i n t o t h e v e n t r i c l e o r s u b a r a c h n o i d space r e s u l t i n g i n f a t a l
associated w i t h n e c k r i g i d i t y .
meningitis.
(ii) Spontaneous nystagmus is c o m m o n a n d i r r e g u l a r a n d
g e n e r a l l y t o t h e side o f l e s i o n .
Clinical Features (iii) Ipsilateral hypotonia and weakness.
(iv) Ipsilateral ataxia. P a t i e n t staggers t o t h e side o f l e s i o n .
B r a i n abscess is o f t e n associated w i t h o t h e r c o m p l i c a t i o n s ,
(v) Past-pointing and intention tremor c a n b e e l i c i t e d b y f i n -
such as e x t r a d u r a l abscess, p e r i s i n u s abscess, m e n i n g i t i s ,
g e r n o s e test.
sinus t h r o m b o s i s a n d l a b y r i n t h i t i s , a n d thus the c l i n i c a l
(vi) Dysdiadokokinesia. R a p i d pronation and supination of
p i c t u r e m a y be o v e r l a p p i n g .
the f o r e a r m shows slow and irregular m o v e m e n t s o n
C l i n i c a l features can be d i v i d e d i n t o :
t h e a f f e c t e d side.
(i) those d u e t o raised i n t r a c r a n i a l t e n s i o n ,
(ii) t h o s e d u e t o area o f b r a i n a f f e c t e d . T h e y are t h e l o c a l - Investigations
i s i n g features.
(a) S k u l l X - r a y s are u s e f u l t o see m i d l i n e s h i f t , i f p i n e a l
(a) S y m p t o m s a n d signs o f raised intracranial tension g l a n d is c a l c i f i e d , a n d also reveals gas i n t h e abscess c a v i t y .

(i) Headache. O f t e n severe a n d g e n e r a l i s e d , w o r s e i n t h e

morning.
(ii) Nausea and vomiting. T h e l a t t e r is u s u a l l y p r o j e c t i l e .
Seen m o r e o f t e n i n cerebellar lesions.
(iii) Level of consciousness. L e t h a r g y , w h i c h progresses t o
drowsiness, c o n f u s i o n , stupor and finally coma.
(iv) Papilloedema is absent i n e a r l y cases. A p p e a r s late
w h e n r a i s e d i n t r a c r a n i a l t e n s i o n has p e r s i s t e d f o r 2—3
w e e k s . A p p e a r s e a r l y i n c e r e b e l l a r abscess.
(v) Slow pulse and subnormal temperature.

(b) L o c a l i s i n g features

T e m p o r a l lobe abscess

(i) Nominal aphasia. I f abscess i n v o l v e s d o m i n a n t h e m i -

sphere, i.e. left hemisphere i n right-handed persons,
p a t i e n t fails t o t e l l t h e n a m e s o f c o m m o n o b j e c t s s u c h
as k e y , p e n , etc. b u t c a n d e m o n s t r a t e t h e i r use. Figure 12.6
(ii) Homonymous hemianopia. T h i s is d u e t o pressure on
C T scan o f right-sided otogenic cerebral abscess.
t h e o p t i c r a d i a t i o n s . V i s u a l f i e l d , o p p o s i t e t o t h e side
 b u r r h o l e , ( i i ) e x c i s i o n o f abscess, ( i i i ) o p e n i n c i s i o n o f t h e
abscess a n d e v a c u a t i o n o f p u s . T h e c h o i c e o f s u r g i c a l p r o -
cedure is l e f t t o t h e j u d g e m e n t o f the neurosurgeon. If
abscess is t r e a t e d b y a s p i r a t i o n , i t s h o u l d be f o l l o w e d b y
r e p e a t C T o r M R I scans t o see i f i t d i m i n i s h e s i n size. A n
e x p a n d i n g abscess, o r o n e t h a t does n o t decrease i n size,
may require excision. Pus recovered from the abscess
s h o u l d b e c u l t u r e d a n d its s e n s i t i v i t y d i s c o v e r e d . P e n i c i l l i n
c a n b e i n s t i l l e d i n t o t h e abscess a f t e r a s p i r a t i o n .

O t o l o g i c Associated ear disease w h i c h caused t h e b r a i n

abscess needs a t t e n t i o n . A c u t e otitis media might have
r e s o l v e d w i t h t h e a n t i b i o t i c s g i v e n f o r t h e abscess. C h r o n i c
otitis m e d i a w o u l d require radical m a s t o i d e c t o m y t o r e m o v e
t h e i r r e v e r s i b l e disease a n d t o e x t e r i o r i s e t h e i n f e c t e d area.
S u r g e r y o f t h e ear is u n d e r t a k e n o n l y after t h e abscess has
Figure 12.7 been c o n t r o l l e d b y antibiotics and neurosurgical treatment.

CT scan showing left-sided cerebellar abscess.

5. Lateral Sinus Thrombophlebitis

H (Syn. Sigmoid Sinus Thrombosis)
(b) C T scan is t h e s i n g l e m o s t i m p o r t a n t m e a n s o f i n v e s -
t i g a t i o n a n d h e l p s t o f i n d t h e site a n d size o f an abscess
I t is a n i n f l a m m a t i o n o f i n n e r w a l l o f l a t e r a l v e n o u s sinus
( F i g . 1 2 . 7 ) . I t also reveals associated c o m p l i c a t i o n s s u c h as
w i t h formation o f a thrombus.
e x t r a d u r a l abscess, s i g m o i d sinus t h r o m b o s i s , etc. M R I has
f u r t h e r i m p r o v e d the diagnosis. Aetiology

(c) X - r a y m a s t o i d s o r C T scan o f the temporal b o n e I t o c c u r s as a c o m p l i c a t i o n o f a c u t e c o a l e s c e n t m a s t o i d i t i s ,

f o r e v a l u a t i o n o f associated ear disease. m a s k e d m a s t o i d i t i s o r c h r o n i c s u p p u r a t i o n o f m i d d l e ear

(d) Lumbar puncture G r e a t care s h o u l d be exercised and cholesteatoma.

w h i l e d o i n g l u m b a r p u n c t u r e because o f t h e r i s k o f c o n -
Pathology
i n g . C S F w i l l s h o w s o m e rise i n p r e s s u r e , i n c r e a s e i n p r o -
t e i n c o n t e n t b u t n o r m a l glucose level. W h i t e cell c o u n t o f T h e p a t h o l o g i c a l process c a n b e d i v i d e d i n t o t h e f o l l o w i n g
C S F is raised b u t is m u c h less t h a n seen i n cases o f m e n i n - stages:
gitis. C S F contains p o l y m o r p h s o r l y m p h o c y t e s d e p e n d i n g (a) Formation of perisinus a b s c e s s Abscess f o r m s i n
o n t h e acuteness o f l e s i o n . r e l a t i o n t o o u t e r d u r a l w a l l o f t h e sinus. O v e r l y i n g b o n y
d u r a l plate m a y have b e e n destroyed b y coalescent b o n e
Treatment
erosion or cholesteatoma. Sometimes, it remains intact
w h e n r o u t e o f i n f e c t i o n was b y t h r o m b o p h l e b i t i c process.
Medical H i g h doses o f a n t i b i o t i c s are g i v e n p a r e n t e r a l l y .
A s t h e i n f e c t i o n is o f t e n m i x e d , a n t i b i o t i c s m a y b e com- (b) Endophlebitis and mural thrombus formation

bined. Chloramphenicol and third generation cepha- I n f l a m m a t i o n spreads t o i n n e r w a l l o f t h e v e n o u s sinus

losporins are usually effective. Bacteroides fragilis, an w i t h d e p o s i t i o n o f f i b r i n , p l a t e l e t s , a n d b l o o d cells l e a d i n g

o b l i g a t e a n a e r o b e , o f t e n seen i n b r a i n abscess, r e s p o n d s t o t o t h r o m b u s f o r m a t i o n w i t h i n t h e l u m e n o f sinus.

m e t r o n i d a z o l e . A m i n o g l y c o s i d e a n t i b i o t i c s , e.g. gentami- (c) O b l i t e r a t i o n o f sinus l u m e n a n d i n t r a s i n u s abscess

c i n , m a y b e r e q u i r e d i f i n f e c t i o n s u s p e c t e d is pseudomonas M u r a l t h r o m b u s enlarges t o o c c l u d e t h e sinus l u m e n c o m -
o r p r o t e u s . C u l t u r e o f d i s c h a r g e from t h e ear m a y be h e l p f u l pletely. Organisms may invade the thrombus causing
in the choice o f antibiotic. i n t r a s i n u s abscess w h i c h m a y release i n f e c t e d e m b o l i i n t o
Raised intracranial tension can be l o w e r e d b y dexame- the b l o o d stream causing septicaemia.
t h a s o n e , 4 m g i . v . 6 h o u r l y o r m a n n i t o l 2 0 % i n doses o f
(d) Extension of thrombus Though central part of
0.5 g / k g b o d y w e i g h t .
t h r o m b u s breaks d o w n d u e t o i n t r a s i n u s abscess, t h r o m b o t i c
Discharge f r o m t h e ear s h o u l d b e t r e a t e d b y suction
process c o n t i n u e s b o t h p r o x i m a l l y a n d d i s t a l l y . P r o x i m a l l y , i t
c l e a r a n c e a n d use o f t o p i c a l ear d r o p s .
m a y spread t o c o n f l u e n c e o f sinuses a n d t o s u p e r i o r sagittal
Neurosurgical Abscess is a p p r o a c h e d t h r o u g h a sterile sinus o r c a v e r n o u s sinus, a n d d i s t a l l y , i n t o m a s t o i d emissary
f i e l d . O p t i o n s i n c l u d e : (i) r e p e a t e d aspiration t h r o u g h a vein, to jugular bulb or jugular vein.
 Complications of Suppurative Otitis Media

Bacteriology (b) B l o o d culture is d o n e t o f i n d causative organisms.

C u l t u r e s h o u l d be t a k e n at t h e t i m e o f c h i l l w h e n o r g a n i s m s
I n a c u t e i n f e c t i o n s , h a e m o l y t i c streptococcus, pneumococcus or
enter the b l o o d stream. R e p e a t e d cultures m a y be r e q u i r e d
staphylococcus are c o m m o n . T h e s e days, m a j o r i t y o f cases o f
to i d e n t i f y the organisms.
t h r o m b o p h l e b i t i s are seen i n c h r o n i c i n f e c t i o n w i t h cho-
l e s t e a t o m a s , a n d t h e o r g a n i s m s f o u n d are B. proteus, Ps. pyo- (c) C S F examination—CSF is n o r m a l e x c e p t f o r rise
cyaneus, Esch. coli a n d staphylococci. i n p r e s s u r e . I t also h e l p s t o e x c l u d e m e n i n g i t i s .

(d) X - r a y m a s t o i d s m a y s h o w c l o u d i n g o f air cells (acute

Clinical Features
mastoiditis) o r destruction o f b o n e (cholesteatoma).
(a) Hectic Picket-fence type o f fever w i t h rigors
(e) Imaging studies Contrast-enhanced CT scan can
T h i s is d u e t o s e p t i c a e m i a , o f t e n c o i n c i d i n g w i t h release
s h o w sinus t h r o m b o s i s b y t y p i c a l delta sign. I t is a t r i a n g u l a r
o f septic e m b o l i i n t o b l o o d stream. F e v e r is i r r e g u l a r
area w i t h r i m e n h a n c e m e n t , a n d c e n t r a l l o w d e n s i t y area is
h a v i n g o n e o r m o r e p e a k s a d a y . I t is u s u a l l y a c c o m p a -
seen i n p o s t e r i o r c r a n i a l fossa o n a x i a l c u t s . M R i m a g i n g
n i e d b y chills a n d rigors. Profuse sweating f o l l o w s fall o f
b e t t e r d e l i n e a t e s t h r o m b u s . " D e l t a s i g n " m a y also b e s e e n
t e m p e r a t u r e . C l i n i c a l p i c t u r e resembles m a l a r i a b u t lacks
o n c o n t r a s t - e n h a n c e d M R I . M R v e n o g r a p h y is u s e f u l t o
regularity.
assess p r o g r e s s i o n o r r e s o l u t i o n o f t h r o m b u s .
I n b e t w e e n t h e b o u t s o f f e v e r , p a t i e n t is a l e r t w i t h a
sense o f w e l l - b e i n g . P a t i e n t s r e c e i v i n g a n t i b i o t i c s m a y n o t
(f) C u l t u r e a n d s e n s i t i v i t y o f ear s w a b .
s h o w this p i c t u r e .

(b) H e a d a c h e I n e a r l y stage, i t m a y b e d u e t o p e r i s i n u s
abscess a n d is m i l d . L a t e r , i t m a y b e s e v e r e w h e n i n t r a - Complications

c r a n i a l p r e s s u r e rises d u e t o v e n o u s o b s t r u c t i o n . 1. Septicaemia and pyaemic abscesses i n l u n g , bone,

(c) Progressive anaemia and emaciation. j o i n t s o r subcutaneous tissue.
2. M e n i n g i t i s a n d s u b d u r a l abscess.
( d ) G r i e s m g e r ' s s i g n T h i s is d u e t o t h r o m b o s i s o f m a s -
3. C e r e b e l l a r abscess.
t o i d e m i s s a r y v e i n . O e d e m a appears o v e r t h e p o s t e r i o r p a r t
4. Thrombosis o f jugular bulb and jugular vein with
of mastoid.
i n v o l v e m e n t o f I X t h , X t h a n d X l t h cranial nerves.
(e) Papilloedema Its p r e s e n c e d e p e n d s on obstruc-
5. C a v e r n o u s sinus t h r o m b o s i s . T h e r e w o u l d b e c h e m o -
t i o n t o v e n o u s r e t u r n . I t is o f t e n s e e n w h e n r i g h t s i n u s
sis, p r o p t o s i s , f i x a t i o n o f e y e b a l l a n d p a p i l l o e d e m a .
( w h i c h is l a r g e r t h a n l e f t ) is t h r o m b o s e d o r w h e n c l o t
6. O t i t i c h y d r o c e p h a l u s , w h e n t h r o m b u s e x t e n d s t o sag-
extends t o s u p e r i o r sagittal sinus. Fundus may show
i t t a l sinus v i a c o n f l u e n s o f sinuses.
b l u r r i n g o f disc m a r g i n s , r e t i n a l h a e m o r r h a g e s o r d i l a t e d
v e i n s . F u n d u s changes m a y be absent w h e n collateral
Treatment
c i r c u l a t i o n is g o o d .
(a) I n t r a v e n o u s a n t i b a c t e r i a l t h e r a p y Choice o f anti-
( f ) T o b e y - A y e r t e s t T h i s is t o r e c o r d C S F pressure b y
b i o t i c w i l l depend o n sensitivity o f organism and tolerance
m a n o m e t e r a n d t o see t h e e f f e c t o f m a n u a l c o m p r e s s i o n o f
o f t h e p a t i e n t . A n t i b i o t i c can be changed after c u l t u r e a n d
one o r b o t h jugular veins.
s e n s i t i v i t y r e p o r t is a v a i l a b l e . A n t i b i o t i c s s h o u l d b e c o n t i n -
C o m p r e s s i o n o f v e i n o n t h e t h r o m b o s e d side p r o d u c e s
u e d at least f o r a w e e k a f t e r t h e o p e r a t i o n , w h i c h is i n v a r i -
n o e f f e c t w h i l e c o m p r e s s i o n o f v e i n o n h e a l t h y side p r o -
ably required.
d u c e s r a p i d rise i n C S F pressure w h i c h w i l l be equal t o
bilateral compression of j u g u l a r veins. (b) M a s t o i d e c t o m y a n d exposure o f sinus A complete
c o r t i c a l o r m o d i f i e d r a d i c a l m a s t o i d e c t o m y is p e r f o r m e d ,
(g) C r o w e - B e c k test Pressure o n j u g u l a r v e i n o f h e a l t h y
d e p e n d i n g o n w h e t h e r sinus t h r o m b o s i s has c o m p l i c a t e d
side p r o d u c e s e n g o r g e m e n t o f r e t i n a l v e i n s (seen b y o p h -
a c u t e o r c h r o n i c m i d d l e ear disease. Sinus b o n y plate is
thalmoscopy) and supraorbital veins. E n g o r g e m e n t o f veins
removed to expose the dura and drain the perisinus
s u b s i d e o n release o f p r e s s u r e .
abscess.
( h ) T e n d e r n e s s a l o n g j u g u l a r v e i n T h i s is seen w h e n An i n f e c t e d c l o t o r i n t r a s i n u s abscess m a y b e present
t h r o m b o p h l e b i t i s extends a l o n g the j u g u l a r v e i n . There and m u s t b e d r a i n e d . I n s u c h cases, sinus d u r a is a l r e a d y
may b e associated e n l a r g e m e n t a n d i n f l a m m a t i o n o f j u g u - d e s t r o y e d o r m a y appear u n h e a l t h y and d i s c o l o u r e d w i t h
lar c h a i n o f l y m p h n o d e s a n d t o r t i c o l l i s . g r a n u l a t i o n s o n its s u r f a c e . D u r a is i n c i s e d a n d t h e i n f e c t e d
c l o t a n d abscess d r a i n e d . B e f o r e i n c i s i o n i n t h e d u r a , sinus
Investigations
is p a c k e d , a b o v e a n d b e l o w , b y i n s e r t i n g a p a c k b e t w e e n
(a) B l o o d s m e a r is d o n e t o r u l e o u t m a l a r i a . t h e b o n e a n d d u r a o f sinus t o c o n t r o l b l e e d i n g .
 H e a l t h y r e d c l o t b e y o n d t h e abscess at e i t h e r e n d of Clinical Features
sinus s h o u l d n o t be d i s t u r b e d . P a c k is r e m o v e d 5 - 6 days
Symptoms
p o s t o p e r a t i v e l y and w o u n d secondarily closed.
{a I S e v e r e h e a d a c h e , s o m e t i m e s i n t e r m i t t e n t , is t h e p r e -
(c) Ligation of internal jugular vein I t is rarely
s e n t i n g f e a t u r e . I t m a y b e a c c o m p a n i e d b y nausea a n d
r e q u i r e d these d a y s . I t is i n d i c a t e d w h e n a n t i b i o t i c a n d
vomiting.
surgical treatment have failed to c o n t r o l e m b o l i c phe-
(b) D i p l o p i a d u e t o paralysis o f V l t h c r a n i a l n e r v e .
nomenon a n d rigors, o r tenderness a n d s w e l l i n g a l o n g
(c) Blurring of vision due to papilloedema or optic
j u g u l a r v e i n is s p r e a d i n g .
atrophy.
(d) A n t i c o a g u l a n t therapy I t is r a r e l y r e q u i r e d a n d u s e d
Signs
w h e n t h r o m b o s i s is e x t e n d i n g t o c a v e r n o u s sinus.

(a) Papilloedema may be 5 - 6 diopters, sometimes with

(e) S u p p o r t i v e treatment R e p e a t e d b l o o d transfusions
patches o f exudates a n d haemorrhages.
m a y be r e q u i r e d to c o m b a t anaemia and i m p r o v e patient's
(b) N y s t a g m u s d u e t o raised i n t r a c r a n i a l t e n s i o n .
resistance.
(c) L u m b a r puncture. CSF pressure e x c e e d s 3 0 0 m m of
w a t e r ( n o r m a l 70—120 m m H ^ O ) . I t is o t h e r w i s e n o r -
m a l i n c e l l , p r o t e i n a n d sugar c o n t e n t a n d is b a c t e r i o -

J 6. Otitic Hydrocephalus J logically sterile.

I t is c h a r a c t e r i s e d b y raised i n t r a c r a n i a l pressure w i t h n o r -
mal CSF f i n d i n g s . I t is seen i n c h i l d r e n a n d a d o l e s c e n t s Treatment

w i t h a c u t e o r c h r o n i c m i d d l e ear i n f e c t i o n s .
T h e a i m is t o r e d u c e C S F pressure t o p r e v e n t o p t i c a t r o -
p h y a n d b l i n d n e s s . T h i s is a c h i e v e d m e d i c a l l y b y acetazol-
Mechanism
amide and corticosteroids and repeated l u m b a r p u n c t u r e
L a t e r a l sinus t h r o m b o s i s a c c o m p a n y i n g m i d d l e ear i n f e c - or placement o f a lumbar drain. Sometimes, draining CSF
t i o n causes o b s t r u c t i o n t o v e n o u s return. I f thrombosis into the peritoneal cavity (lumbopcritoneal shunt) is
e x t e n d s t o s u p e r i o r sagittal s i n u s , i t w i l l also i m p e d e the necessary.
f u n c t i o n o f a r a c h n o i d v i l l i t o a b s o r b C S F . B o t h these f a c - M i d d l e ear i n f e c t i o n m a y r e q u i r e a n t i b i o t i c t h e r a p y a n d
tors result i n raised i n t r a c r a n i a l t e n s i o n . m a s t o i d e x p l o r a t i o n t o d e a l w i t h sinus t h r o m b o s i s .
Otosclerosis (Syn. O t o s p o n g i o s i s )

Anatomical basis. B o n y l a b y r i n t h is m a d e o f e n c h o n d r a l
Anatomy
b o n e w h i c h is s u b j e c t t o l i t t l e c h a n g e i n l i f e . B u t s o m e t i m e s ,
i n t h i s h a r d b o n e , t h e r e are areas o f c a r t i l a g e rests w h i c h
It m a y be p e r t i n e n t to r e v i e w the a n a t o m y o f the l a b y r i n t h
d u e t o c e r t a i n n o n - s p e c i f i c f a c t o r s , are a c t i v a t e d t o f o r m a
a n d i n t r o d u c e the t e r m i n o l o g y o f t e n used to describe i t :
n e w s p o n g y b o n e . O n e s u c h area is thefissuta antefenestram
Otic l a b y r i n t h Also called m e m b r a n o u s labyrinth l y i n g i n f r o n t o f t h e o v a l w i n d o w — t h e site o f p r e d i l e c t i o n
o r e n d o l y m p h a t i c l a b y r i n t h . I t consists o f u t r i c l e , sac- for stapedial t y p e o f otospongiosis.
cule, cochlea, semicircular ducts, e n d o l y m p h a t i c d u c t Heredity. A b o u t 5 0 % o f otosclerotics have positive f a m -
a n d sac. I t is f i l l e d w i t h e n d o l y m p h . i l y h i s t o r y ; rest are s p o r a d i c . G e n e t i c studies r e v e a l t h a t i t
(ii) Periotic labyrinth or perilymphatic labyrinth is an a u t o s o m a l d o m i n a n t t r a i t w i t h i n c o m p l e t e p e n e t r a n c e
( o r s p a c e ) I t s u r r o u n d s t h e o t i c l a b y r i n t h a n d is f i l l e d and a variable expressivity.
w i t h p e r i l y m p h . I t i n c l u d e s v e s t i b u l e , scala t y m p a n i , Race. W h i t e races are a f f e c t e d m o r e t h a n N e g r o s . I t is
scala v e s t i b u l i , p e r i l y m p h a t i c space o f s e m i c i r c u l a r c o m m o n i n I n d i a n s b u t rare a m o n g C h i n e s e a n d Japanese.
canals a n d t h e p e r i o t i c d u c t , w h i c h s u r r o u n d s t h e Sex. F e m a l e s are a f f e c t e d t w i c e as o f t e n as m a l e s b u t i n
endolymphatic duct o f otic labyrinth. o u r c o u n t r y , o t o s c l e r o s i s seems t o p r e d o m i n a t e i n m a l e s .
(iii) Otic c a p s u l e I t is t h e b o n y l a b y r i n t h . I t has three Age of onset. D e a f n e s s u s u a l l y starts b e t w e e n 2 0 a n d 3 0
layers. years o f age a n d is r a r e b e f o r e 10 a n d after 4 0 years.

Endosteal. T h e i n n e n n o s t layer. I t lines t h e b o n y l a b y r i n t h . Effect of other factors. Deafness d u e t o otosclerosis m a y be

Enchondral. D e v e l o p s f r o m t h e c a r t i l a g e a n d l a t e r ossifies i n i t i a t e d o r m a d e w o r s e b y p r e g n a n c y . S i m i l a r l y , deafness

i n t o b o n e . I t is i n t h i s l a y e r t h a t s o m e islands o f c a r t i l a g e m a y increase d u r i n g m e n o p a u s e , after a n a c c i d e n t or a

are l e f t u n o s s i f i e d t h a t l a t e r g i v e rise t o otosclerosis. major operation.

Periosteal. Covers the b o n y labyrinth. T h e disease m a y b e associated w i t h osteogenesis imperfecta

O t i c c a p s u l e o r t h e b o n y l a b y r i n t h ossifies f r o m 14 c e n - w i t h h i s t o r y o f m u l t i p l e fractures. T h e triad o f s y m p t o m s

tres, t h e f i r s t o n e appears i n t h e r e g i o n o f c o c h l e a at 16 o f o s t e o g e n e s i s i m p e r f e c t a , o t o s c l e r o s i s a n d b l u e sclera, is

w e e k s a n d t h e last o n e appears i n t h e p o s t e r o l a t e r a l p a r t o f c a l l e d van der Hoeve syndrome. L e s i o n s o f o t i c capsule seen

p o s t e r i o r s e m i c i r c u l a r c a n a l at 2 0 t h w e e k . i n osteogenesis i m p e r f e c t a are h i s t o l o g i c a l l y i n d i s t i n g u i s h -

O t o s c l e r o s i s , m o r e a p t l y c a l l e d otospongiosis, is a p r i m a r y able f r o m t h o s e o f o t o s c l e r o s i s a n d b o t h are d u e t o genes

disease o f t h e b o n y l a b y r i n t h . I n t h i s , o n e o r m o r e f o c i o f e n c o d i n g type I collagen.

i r r e g u l a r l y l a i d s p o n g y b o n e replace part o f n o r m a l l y dense Viral infection. Electron microscopic and i m m u n o h i s -

e n c h o n d r a l layer o f b o n y o t i c capsule. M o s t o f t e n , o t o - t o c h e m i c a l studies have s h o w n R N A related t o measle

s c l e r o t i c f o c u s i n v o l v e s t h e stapes r e g i o n l e a d i n g t o stapes v i r u s . I t is l i k e l y t h a t o t o s c l e r o s i s is a v i r a l disease as has

f i x a t i o n a n d c o n d u c t i v e deafness. H o w e v e r , i t m a y i n v o l v e b e e n s u g g e s t e d f o r Paget's disease.

c e r t a i n o t h e r areas o f t h e b o n y l a b y r i n t h w h e r e i t m a y
cause n e u r o s e n s o r y loss, o r n o s y m p t o m s at a l l .
Types of Otosclerosis

Aetiology 1. Stapedial otosclerosis Stapedial otosclerosis causing

stapes f i x a t i o n a n d c o n d u c t i v e deafness is t h e m o s t com-
T h e e x a c t cause o f otosclerosis is n o t k n o w n ; h o w e v e r t h e m o n v a r i e t y . H e r e l e s i o n starts j u s t i n f r o n t o f t h e o v a l
f o l l o w i n g facts h a v e b e e n d o c u m e n t e d . w i n d o w i n a n area c a l l e d 'fissula a n t e f e n e s t r a m ' . T h i s is t h e
site o f p r e d i l e c t i o n (anterior focus). L e s i o n m a y start b e h i n d
Symptoms
t h e o v a l w i n d o w (posterior focus), a r o u n d the m a r g i n o f the
stapes f o o t p l a t e (circumferential), i n the footplate b u t annular
1. Hearing loss T h i s is t h e p r e s e n t i n g s y m p t o m a n d
l i g a m e n t b e i n g f r e e (biscuit type). Sometimes, it may c o m -
u s u a l l y starts i n t w e n t i e s . I t is painless a n d p r o g r e s s i v e w i t h
p l e t e l y o b l i t e r a t e t h e o v a l w i n d o w n i c h e (obliterative type)
i n s i d i o u s o n s e t . O f t e n i t is b i l a t e r a l c o n d u c t i v e t y p e .
(Fig. 13.1).
2. Paracusis wilHsii A n o t o s c l e r o t i c p a t i e n t hears b e t t e r
2. C o c h l e a r otosclerosis C o c h l e a r otosclerosis i n v o l v e s
i n n o i s y t h a n q u i e t s u r r o u n d i n g s . T h i s is b e c a u s e a n o r m a l
r e g i o n o f r o u n d w i n d o w o r o t h e r areas i n t h e o t i c capsule,
p e r s o n w i l l raise his v o i c e i n n o i s y s u r r o u n d i n g s .
a n d m a y cause s e n s o r i n e u r a l h e a r i n g loss p r o b a b l y d u e t o
3 . T i n n i t u s I t is m o r e c o m m o n l y seen i n c o c h l e a r oto-
l i b e r a t i o n o f t o x i c m a t e r i a l s i n t o t h e i n n e r ear f l u i d .
sclerosis a n d i n a c t i v e l e s i o n s .
3. Histologic otosclerosis This type of otosclerosis
4. Vertigo I t is a n u n c o m m o n s y m p t o m .
r e m a i n s a s y m p t o m a t i c a n d causes n e i t h e r c o n d u c t i v e n o r
s e n s o r i n e u r a l h e a r i n g loss. 5. S p e e c h P a t i e n t has a m o n o t o n o u s , w e l l m o d u l a t e d s o f t
speech.

[ Pathology J
Signs
Grossly, o t o s c l e r o t i c l e s i o n appears c h a l k y w h i t e , g r e y i s h o r
y e l l o w . S o m e t i m e s , i t is r e d i n c o l o u r d u e t o i n c r e a s e d v a s - Tympanic membrane is q u i t e n o r m a l a n d m o b i l e .
c u l a r i t y , i n w h i c h case, t h e o t o s c l e r o t i c f o c u s is a c t i v e a n d S o m e t i m e s , a r e d d i s h h u e m a y b e seen o n t h e p r o m -
rapidly progressive. ontory through the tympanic membrane (Schwartze
Microscopically, spongy bone appears i n the normally sign). T h i s is i n d i c a t i v e o f a c t i v e f o c u s w i t h increased
dense e n c h o n d r a l layer o f o t i c capsule. I n i m m a t u r e active vascularity.
l e s i o n s , t h e r e are n u m e r o u s m a r r o w a n d v a s c u l a r spaces E u s t a c h i a n t u b e f u n c t i o n is n o r m a l .
with p l e n t y o f osteoblasts a n d osteoclasts a n d a l o t of 3. T u n i n g f o r k tests s h o w n e g a t i v e R i n n e ( i . e . B C > A C )
c e m e n t s u b s t a n c e w h i c h stains b l u e ( b l u e m a n t l e s ) with f i r s t f o r 2 5 6 H z a n d t h e n 5 1 2 H z a n d s t i l l later, w h e n
h a e m a t o x y l i n - e o s i n s t a i n . M a t u r e f o c i s h o w less v a s c u l a r i t y stapes f i x a t i o n is c o m p l e t e , f o r 1 0 2 6 H z . W e b e r test
and l a y i n g o f m o r e b o n e a n d m o r e o f f i b r i l l a r substance w i l l b e l a t e r a l i s e d t o t h e ear w i t h g r e a t e r c o n d u c t i v e
t h a n c e m e n t u m , a n d is s t a i n e d r e d . loss. A b s o l u t e b o n e c o n d u c t i o n m a y b e n o r m a l . I t is

Figure 13.1

Types o f stapedial otosclerosis. (A) Anterior focus. (B) Posterior focus. (C) Circumferential. (D) Biscuit type (thick plate).

(E) Obliterative.
 Otosclerosis (Syn. Otospongiosis)

decreased i n cochlear otosclerosis w i t h sensorineural but c o n t r o v e r s i e s e x i s t a n d t h i s t r e a t m e n t is n o t r e c o m -

loss. m e n d e d generally.
Pure tone audiometry s h o w s loss o f air c o n d u c t i o n , m o r e
Surgical Stapedectomy w i t h a p l a c e m e n t o f p r o s t h e s i s is
for l o w e r frequencies.
t h e t r e a t m e n t o f c h o i c e . H e r e t h e f i x e d o t o s c l e r o t i c stapes
B o n e c o n d u c t i o n is n o r m a l . I n s o m e cases, t h e r e is a d i p
is r e m o v e d a n d a p r o s t h e s i s i n s e r t e d b e t w e e n t h e i n c u s a n d
i n b o n e c o n d u c t i o n c u r v e . I t is d i f f e r e n t at d i f f e r e n t fre-
o v a l w i n d o w ( F i g . 1 3 . 3 ) . Prosthesis e m p l o y e d m a y b e a
quencies but maximum at 2000 H z a n d is c a l l e d the
t e f l o n p i s t o n , stainless steel p i s t o n , p l a t i n u m t e f l o n o r t i t a -
Carhart's notch. ( 5 d B at 5 0 0 H z , l O d B at 1 0 0 0 H z , 1 5 d B at
n i u m t e f l o n p i s t o n ( F i g . 1 3 , 4 ) . I n 9 0 % o f p a t i e n t s , t h e r e is
2 0 0 0 H z a n d 5 d B at 4 0 0 0 H z ) ( F i g . 1 3 . 2 ) . C a r h a r t ' s n o t c h
g o o d i m p r o v e m e n t i n h e a r i n g after stapedectomy.
disappears a f t e r successful s t a p e d e c t o m y .
M i x e d h e a r i n g loss is n o t u n c o m m o n i n o t o s c l e r o s i s . Selection of patients for stapes surgery Hearing

T h e r e is loss i n b o n e c o n d u c t i o n w i t h a i r - b o n e g a p . t h r e s h o l d s h o u l d be 3 0 d B o r w o r s e ( I t is t h i s l e v e l w h e n

S p e e c h a u d i o m e t r y reveals n o r m a l d i s c r i m i n a t i o n s c o r e p a t i e n t starts f e e l i n g s o c i a l l y h a n d i c a p p e d ) .

except i n those w i t h cochlear i n v o l v e m e n t . Average a i r - b o n e gap s h o u l d be at least 15dB with

T y m p a n o m e t r y m a y b e n o r m a l i n e a r l y cases b u t l a t e r R i n n e negative f o r 256 and 512 H z .

s h o w s a c u r v e o f o s s i c u l a r stiffness. S t a p e d i a l r e f l e x b e c o m e s Speech d i s c r i m i n a t i o n score s h o u l d be 6 0 % o r m o r e .

absent w h e n stapes is f i x e d (see page 2 9 ) .

Differential Diagnosis

O t o s c l e r o s i s s h o u l d b e d i f f e r e n t i a t e d f r o m o t h e r causes
o f c o n d u c t i v e deafness p a r t i c u l a r l y serous o t i t i s m e d i a ,
adhesive otitis m e d i a , tympanosclerosis, attic f i x a t i o n of
h e a d o f m a l l e u s , ossicular d i s c o n t i n u i t y or congenital
stapes f i x a t i o n .

Treatment

Medical T h e r e is n o m e d i c a l t r e a t m e n t t h a t c u r e s o t o -
sclerosis. Sodium fluoride has b e e n t r i e d t o hasten the Figure 13.3
m a t u r i t y o f a c t i v e f o c u s a n d arrest f u r t h e r c o c h l e a r loss,
(A) Before removal o f stapes. (B) Stapes removed and replaced

by a teflon piston.

Frequency in Hertz

125 250 500 1000 2000 4000 8000

0
J
]
10

20

30

40

50
f* \
\ )
60

70

80

90

100

110

Figure 13.2 Figure 13.4

Otosclerosis left ear. Note dip at 2000 Hz in b o n e conduction Stapes prostheses: (A) Teflon piston. (B) Platinum-teflon

(Carhart's notch). piston. (C) Titanium-teflon piston.

 Incision Tympanomeatal flap raised and Posterosuperior overhang
reflected forward. Posterosuperior bony removed to expose facial

Stapedial tendon cut and Small fenestra made in the footplate

stapes superstructure removed and teflon piston inserted

Figure 13.5

Seeps o f s t a p e d e c t o m y (see t e x t ) .

Contraindications to stapes s u r g e r y Steps o f stapedectomy ( F i g . 13.5) i n c l u d e :

(i) T h e only hearing ear.

1. Meatal incision and elevation o f the tympanomeatal
(ii) Associated Meniere's disease. W h e n t h e r e is h i s t o r y o f
flap.
v e r t i g o w i t h c l i n i c a l e v i d e n c e o f M e n i e r e ' s disease i n
2. E x p o s u r e o f stapes area. T h i s m a y r e q u i r e r e m o v a l o f
an otosclerotic patient, there are m o r e c h a n c e s of
p o s t e r o s u p e r i o r b o n y o v e r h a n g o f the canal.
s e n s o r i n e u r a l h e a r i n g loss a f t e r stapedectomy.
3. R e m o v a l o f stapes s u p e r s t r u c t u r e .
(iti) Young children. Recurrent eustachian tube dysfunc-
4. C r e a t i o n o f a h o l e i n t h e stapes f o o t p l a t e ( s t a p e d o t o m y )
t i o n is c o m m o n i n c h i l d r e n . I t c a n d i s p l a c e t h e p r o s -
or r e m o v a l o f a part o f footplate (stapedectomy).
thesis o r cause a c u t e o t i t i s m e d i a . A l s o t h e g r o w t h o f
5. P l a c e m e n t o f prosthesis.
otosclerotic focus is faster i n c h i l d r e n l e a d i n g to
6. R e p o s i t i o n i n g the t y m p a n o m e a t a l flap.
reclosure o f oval w i n d o w .
(iv) Professional athletes, high construction workers, divers, and Two percent o f patients u n d e r g o i n g this o p e r a t i o n m a y

frequent air-travellers. Stapes s u r g e r y has t h e risk t o cause s u f f e r s e n s o r i n e u r a l loss. S l o w l y p r o g r e s s i v e h i g h f r e q u e n c y

p o s t - o p e r a t i v e v e r t i g o a n d / o r dizziness a n d t h u s i n t e r - loss is seen i n l o n g - t e r m f o l l o w u p . O n e i n 2 0 0 patients

fere w i t h t h e i r profession; o r frequent air pressure changes m a y g e t a t o t a l l y " d e a d " ear.

m a y d a m a g e t h e h e a r i n g o r cause severe v e r t i g o . Stapes mobilisation is n o l o n g e r d o n e these days as i t g i v e s

(v) Those who work in noisy surroundings. A f t e r stapedec- t e m p o r a r y results; r e f i x a t i o n b e i n g q u i t e c o m m o n .

t o m y , they w o u l d be m o r e vulnerable to get sensori- Lempert's fenestration operation is a l m o s t o u t d a t e d n o w .

n e u r a l h e a r i n g loss d u e t o n o i s e t r a u m a . H e r e a n a l t e r n a t i v e w i n d o w is c r e a t e d i n t h e l a t e r a l s e m i -

( v i ) Otitis externa, tympanic membrane perforation and circular canal t o f u n c t i o n f o r the o b l i t e r a t e d o v a l w i n d o w .

e x o s t o s i s are r e l a t i v e c o n t r a i n d i c a t i o n s . Stapedectomy I t has t h e d i s a d v a n t a g e o f a p o s t - o p e r a t i v e m a s t o i d c a v i t y

can be done after t h e y have b e e n treated first f o r and a n i n h e r e n t h e a r i n g loss o f 2 5 d B w h i c h c a n n o t be

above conditions. Similarly, stapedectomy is a v o i d e d corrected.

during pregnancy.
H e a r i n g a i d P a t i e n t s w h o refuse s u r g e r y o r are u n f i t f o r
T h e o p e r a t i o n is p r e f e r a b l y d o n e u n d e r l o c a l anaesthesia. s u r g e r y c a n use h e a r i n g a i d . I t is a n e f f e c t i v e a l t e r n a t i v e .
Facial Nerve a n d Its Disorders

f i b r e s f r o m o n e h e m i s p h e r e . T h e f u n c t i o n o f f o r e h e a d is
ANATOMY AND FUNCTIONS OF
p r e s e r v e d i n supranuclear lesions because o f b i l a t e r a l i n n e r -
FACIAL NERVE
v a t i o n . F a c i a l n u c l e u s also r e c e i v e s f i b r e s f r o m t h e t h a l a -
m u s b y alternate routes and provides i n v o l u n t a r y c o n t r o l

F a c i a l n e r v e is a m i x e d n e r v e h a v i n g m o t o r a n d a s e n - t o f a c i a l m u s c l e s . T h e e m o t i o n a l m o v e m e n t s s u c h as s m i l -

s o r y r o o t . T h e l a t t e r is also c a l l e d t h e n e r v e o f W r i s b e r g i n g a n d c r y i n g are t h u s p r e s e r v e d i n s u p r a n u c l e a r palsies

a n d carries s e c r e t o m o t o r fibres t o the l a c r i m a l g l a n d a n d b e c a u s e o f these f i b r e s f r o m t h e t h a l a m u s ( F i g . 1 4 . 1 ) .

s a l i v a r y g l a n d s , a n d b r i n g s f i b r e s o f taste a n d g e n e r a l s e n -
s a t i o n . T h u s t h e r e are t w o e f f e r e n t a n d t w o a f f e r e n t p a t h -
C o u r s e of Facial Nerve
ways. C o m p o n e n t s o f the facial n e r v e i n c l u d e :

S p e c i a l v i s c e r a l efferent forms the m o t o r r o o t and M o t o r fibres take o r i g i n f r o m the nucleus o f V I I t h n e r v e ,

supplies all the muscles d e r i v e d f r o m t h e second b r a n - h o o k r o u n d t h e n u c l e u s o f V l t h n e r v e a n d are j o i n e d b y
chial arch, i.e. all the muscles o f facial expression, t h e s e n s o r y r o o t ( n e r v e o f W r i s b e r g ) . F a c i a l n e r v e leaves
auricular muscles ( n o w vestigial), s t y l o h y o i d , poste- t h e b r a i n s t e m at p o n t o m e d u l l a r y j u n c t i o n - t r a v e l s t h r o u g h
r i o r b e l l y o f digastric a n d the stapedius. posterior c r a n i a l fossa a n d e n t e r s the internal acoustic
2. General visceral efferent supplies secretomotor meatus. A t the fundus o f the meatus (lateralmost part o f
f i b r e s t o l a c r i m a l , s u b m a n d i b u l a r a n d s u b l i n g u a l glands meatus), t h e n e r v e enters t h e b o n y facial canal, traverses
a n d t h e s m a l l e r s e c r e t o r y g l a n d s i n t h e nasal mucosa
and the palate.
3. S p e c i a l v i s c e r a l a f f e r e n t b r i n g s taste f r o m t h e a n t e -
rior t w o - t h i r d s o f t o n g u e via c h o r d a t y m p a n i a n d soft
a n d h a r d palate via greater superficial petrosal n e r v e .
Lesion
T a s t e is c a r r i e d t o t h e n u c l e u s o f t r a c t u s s o l i t a r i u s .
4. G e n e r a l s o m a t i c afferent brings general sensation
from the concha, posterosuperior part o f external Motor cortex

canal and the tympanic membrane. These fibres

N u c l e u s o f C N VII
a c c o u n t f o r vesicular e r u p t i o n i n herpes zoster i n f e c -
t i o n o f t h e g e n i c u l a t e g a n g l i o n . I t also b r i n g s p r o p r i o -
ceptive sensation f r o m the facial muscles.

Nucleus o f Facial Nerve

M o t o r n u c l e u s o f t h e n e r v e is s i t u a t e d i n t h e p o n s . I t Figure 14.1
receives fibres f r o m the precentral gyrus. U p p e r part o f the
Forehead receives bilateral innervation and is thus saved in
nucleus w h i c h innervates f o r e h e a d muscles receives fibres
supranuclear paralysis. Emotional movements controlled by
f r o m b o t h the cerebral hemispheres, w h i l e the l o w e r part
t h a l a m o n u c l e a r fibres are also preserved.
o f nucleus w h i c h s u p p l i e s l o w e r face gets o n l y crossed
 A above the oval w i n d o w and b e l o w the lateral semicir-
Intracranial part Intratemporal part cular canal (11.0 m m ) ,
(d) Mastoid or vertical segment. F r o m the p y r a m i d to stylo-
mastoid f o r a m e n . B e t w e e n the t y m p a n i c a n d mastoid
s e g m e n t s is t h e s e c o n d g e n u o f t h e n e r v e (13.0mm).

3. Extracranial p a r t F r o m stylomastoid f o r a m e n t o the

t e r m i n a t i o n o f its p e r i p h e r a l b r a n c h e s .

J Branches o f Facial Nerve

1. Greater superficial petrosal nerve I t arises from

g e n i c u l a t e g a n g l i o n a n d carries s e c r e t o m o t o r f i b r e s t o l a c -
r i m a l g l a n d a n d t h e glands o f nasal mucosa.

2. N e r v e to stapedius I t arises at t h e l e v e l o f s e c o n d
Temporofacial di
g e n u a n d s u p p l i e s t h e stapedius muscle.
- Tempora
- Zygomatic 3. C h o r d a t y m p a n i I t arises f r o m t h e m i d d l e o f v e r t i c a l
s e g m e n t , passes b e t w e e n t h e i n c u s a n d n e c k o f m a l l e u s ,
a n d leaves t h e t y m p a n i c c a v i t y t h r o u g h p e t r o t y m p a n i c f i s -
Cervicofacii
- Bucca s u r e . I t carries s e c r e t o m o t o r fibres t o s u b m a n d i b u l a r and
- Mandibula s u b l i n g u a l g l a n d s a n d b r i n g s taste from a n t e r i o r t w o - t h i r d s
- Cervical
o f tongue.

4. C o m m u n i c a t i n g branch It joins auricular branch

o f vagus a n d supplies the c o n c h a , r e t r o a u r i c u l a r g r o o v e ,
posterior meatus and the outer surface of tympanic

( A ) Course o f facial nerve. I n t r a t e m p o r a l p a r t consists o f f o u r membrane.

segments: M e a t a l ( 1 ) , L a b y r i n t h i n e ( 2 ) , T y m p a n i c ( 3 ) , M a s t o i d 5. Posterior auricular nerve I t supplies muscles of

( 4 ) . (B) Branches o f facial nerve o n face. pinna, occipital belly o f occipitofrontalis and c o m m u n i -
cates w i t h a u r i c u l a r b r a n c h o f v a g u s .

6. M u s c u l a r b r a n c h e s to stylohyoid and posterior belly

the temporal b o n e a n d comes o u t o f the stylomastoid fora- o f digastric.
m e n . H e r e i t crosses t h e s t y l o i d p r o c e s s a n d d i v i d e s i n t o
7. P e r i p h e r a l b r a n c h e s T h e n e r v e t r u n k , after c r o s s i n g
t e r m i n a l b r a n c h e s . T h e c o u r s e o f t h e n e r v e ( F i g . 14.2) can
the s t y l o i d process, f o r m s t w o d i v i s i o n s , a n u p p e r t e m -
thus be d i v i d e d i n t o :
porofacial and a l o w e r cervicofacial, w h i c h f u r t h e r divide
1. Intracranial part From pons to internal acoustic
i n t o s m a l l e r b r a n c h e s . T h e s e are t h e t e m p o r a l , z y g o m a t i c ,
meatus ( 1 5 - 1 7 m m ) .
buccal, m a n d i b u l a r and cervical and together form pes
2. I n t r a t e m p o r a l part F r o m i n t e r n a l acoustic meatus t o anserinus ( g o o s e - f o o t ) . T h e y supply all t h e muscles o f facial
s t y l o m a s t o i d f o r a m e n . I t is f u r t h e r d i v i d e d i n t o : expression.

(a) Meatal segment. Within internal acoustic meatus

(8-10 mm).
(b) Labyrinthine segment. F r o m fundus o f meatus to the
J_ B l o o d Supply o f Facial Nerve
g e n i c u l a t e g a n g l i o n w h e r e n e r v e takes a t u r n p o s t e r i -
orly f o r m i n g a " g e n u " . T h e nerve in the labyrinthine I t is d e r i v e d f r o m f o u r b l o o d vessels: (i) A n t e r i o r - i n f e r i o r
s e g m e n t has t h e n a r r o w e s t d i a m e t e r (0.61-0.68mm) cerebellar artery supplies the n e r v e i n C P angle; (ii) l a b y -
a n d t h e b o n y c a n a l i n t h i s s e g m e n t is also t h e n a r r o w - r i n t h i n e artery, b r a n c h o f anterior i n f e r i o r cerebellar artery,
est. T h u s o e d e m a o r i n f l a m m a t i o n c a n easily com- supplies t h e n e r v e i n i n t e r n a l a u d i t o r y canal; (iii) s u p e r f i -
press t h e n e r v e a n d cause paralysis. T h i s is also t h e cial petrosal artery, a b r a n c h o f m i d d l e m e n i n g e a l artery,
shortest s e g m e n t o f t h e n e r v e — o n l y 4.0 m m . w h i c h supplies geniculate g a n g l i o n a n d the adjacent r e g i o n ;
(c) Tympanic or horizontal segment. F r o m geniculate gan- a n d (iv) s t y l o m a s t o i d artery, b r a n c h o f p o s t e r i o r auricular
g l i o n to just above the p y r a m i d a l eminence. I t lies a r t e r y , w h i c h s u p p l i e s t h e m a s t o i d s e g m e n t . A l l t h e arteries
 F a c i a l N e r v e a n d its D i s o r d e r s

Figure 14.3

B l o o d s u p p l y o f facial nerve. ( 1 ) C e r e b e l l o p o n t i n e angle: A n t e r i o r - i n f e r i o r cerebellar artery. ( 2 ) Internal a u d i t o r y c a n a l : L a b y r i n t h i n e

artery. ( 3 ) G e n i c u l a t e g a n g l i o n a n d a d j a c e n t facial nerve: Superficial petrosal. ( 4 ) M a s t o i d segment: S t y l o m a s t o i d artery.

f o r m a n external plexus w h i c h lies i n t h e e p i n e u r i u m a n d

feeds a d e e p e r i n t r a n e u r a l internal plexus (Fig. 14.3). Parotid glanc

J Surgical L a n d m a r k s o f Facial Nerve Cartilaginous

pointer
F o r m i d d l e ear a n d m a s t o i d s u r g e r y
Styloid process
Processus cochleariformis. I t demarcates the geniculate Outline of
g a n g l i o n w h i c h lies j u s t a n t e r i o r t o i t . T y m p a n i c s e g - mostoid CN VII
m e n t o f t h e n e r v e starts at t h i s l e v e l . Sterno-
cleidomastoid
2. Oval window and horizontal canal. T h e f a c i a l n e r v e r u n s
muscle Digastric muscle
a b o v e t h e o v a l w i n d o w (stapes) a n d b e l o w t h e h o r i -
zontal canal.
3. Short process of incus. F a c i a l n e r v e lies m e d i a l t o the
s h o r t p r o c e s s o f i n c u s at t h e l e v e l o f a d i t u s .
4. Pyramid. N e r v e runs b e h i n d the p y r a m i d and the pos- Figure 14.4
t e r i o r t y m p a n i c sulcus.
Surgical l a n d m a r k s o f the facial nerve in p a r o t i d surgery.
5. Tympanomastoid suture. I n vertical or mastoid segment,
n e r v e runs b e h i n d this suture.
6. Digastric ridge. The n e r v e leaves t h e m a s t o i d at the
a n t e r i o r e n d o f digastric ridge. Structure o f Nerve

For p a r o t i d surgery (Fig. 14.4)

F r o m inside o u t , a n e r v e f i b r e consists o f a x o n , m y e l i n sheath,
!. Cartilaginous pointer. The n e r v e lies 1 c m d e e p a n d n e u r i l e m m a a n d endoneurium. A g r o u p o f n e r v e f i b r e s is
sightly anterior and i n f e r i o r to the pointer. C a r t i l a g i - enclosed i n a sheath called perineurium t o f o r m a fascicle, a n d
n o u s p o i n t e r is a sharp t r i a n g u l a r p i e c e o f c a r t i l a g e of t h e fascicles are b o u n d t o g e t h e r b y epineurium (Fig. 14.5).
the p i n n a and " p o i n t s " to the nerve.
2. Tympanomastoid suture. N e r v e lies 6—8 m m d e e p t o t h i s
Severity of Nerve Injury
suture.
3. Styloid process. The nerve crosses l a t e r a l t o s t y l o i d
Degree o f nerve injury w i l l determine the regeneration of
process.
n e r v e a n d its f u n c t i o n . E a r l i e r n e r v e i n j u r i e s w e r e d i v i d e d
4. Posterior belly of digastric. I f p o s t e r i o r b e l l y o f digastric
into:
m u s c l e is t r a c e d b a c k w a r d s a l o n g its u p p e r b o r d e r t o
its a t t a c h m e n t t o t h e d i g a s t r i c g r o o v e , n e r v e is f o u n d (a) Neurapraxia, a conduction block, where flow o f axo-
t o lie b e t w e e n i t a n d t h e s t y l o i d process. p l a s m t h r o u g h t h e a x o n s was p a r t i a l l y o b s t r u c t e d .
 A B

Figure 14.5

Structure o f a nerve. (A) Cross section o f nerve. (B) Structure o f nerve fibre, longitudinal and cross-sectional views.

(b) Axonotmesis—injury to axons. 2. M a x i m a l s t i m u l a t i o n test ( M S T ) T h i s test is s i m i l a r

(c) Neurotmesis—injury to nerve. t o t h e m i n i m a l n e r v e e x c i t a b i l i t y test b u t i n s t e a d o f m e a -
suring the threshold o f stimulation, the current level w h i c h
S u n d e r l a n d classified n e r v e i n j u r i e s i n t o f i v e degrees o f
g i v e s m a x i m u m f a c i a l m o v e m e n t is d e t e r m i n e d a n d c o m -
severity based o n a n a t o m i c a l s t r u c t u r e o f t h e n e r v e , a n d
p a r e d w i t h t h e n o r m a l side. R e s p o n s e is v i s u a l l y g r a d e d as
t h i s c l a s s i f i c a t i o n is n o w w i d e l y accepted.
e q u a l , d e c r e a s e d o r absent. R e d u c e d o r absent response
1°= Partial b l o c k to f l o w o f axoplasm; n o m o r p h o -
w i t h m a x i m a l s t i m u l a t i o n indicates degeneration a n d is
l o g i c a l c h a n g e s are seen. R e c o v e r y o f f u n c t i o n is
f o l l o w e d b y incomplete recovery.
complete (neurapraxia).
2° = Loss o f a x o n s , b u t e n d o n e u r i a l t u b e s r e m a i n i n t a c t . 3. E l e c t r o n e u r o n o g r a p h y (ENoG) I t is a s o r t o f e v o k e d
D u r i n g r e c o v e r y , a x o n s w i l l g r o w i n t o t h e i r respec- electromyography. The f a c i a l n e r v e is s t i m u l a t e d at t h e
t i v e t u b e s , a n d t h e r e s u l t is g o o d ( a x o n o t m e s i s ) . stylomastoid f o r a m e n a n d the c o m p o u n d muscle action
3° — I n j u r y to e n d o n e u r i u m . D u r i n g recovery, axons p o t e n t i a l s are p i c k e d u p b y t h e surface e l e c t r o d e s . Supra-
o f o n e t u b e can g r o w i n t o another. Synkinesis can maximal s t i m u l a t i o n is u s e d t o obtain maximal action
occur (neurotmesis). potentials. T h e response o f a c t i o n potentials o f t h e para-
4° = Injury to perineurium in addition to above. l y s e d side are c o m p a r e d w i t h t h a t o f t h e n o r m a l s i d e o n
Scarring w i l l i m p a i r regeneration o f fibres (partial similar s t i m u l a t i o n and thus percentage of degenerating
transection). f i b r e s is c a l c u l a t e d . S t u d i e s r e v e a l t h a t d e g e n e r a t i o n o f 9 0 %
5° = I n j u r y to e p i n e u r i u m i n addition to above (com- o c c u r r i n g i n t h e f i r s t 14 days i n d i c a t e s p o o r r e c o v e r y of
plete nerve transection). f u n c t i o n . Faster r a t e o f d e g e n e r a t i o n o c c u r r i n g i n less t h a n
T h e f i r s t t h r e e degrees are s e e n i n v i r a l a n d i n f l a m m a - 14 days has a s t i l l p o o r e r p r o g n o s i s . E N o G is m o s t u s e f u l
t o r y d i s o r d e r s w h i l e f o u r t h a n d f i f t h are seen i n s u r g i c a l o r b e t w e e n 4 a n d 2 1 days o f t h e o n s e t o f c o m p l e t e p a r a l y s i s .
accidental trauma to the nerve o r i n neoplasms.
4. Electromyography ( E M G ) This tests the motor
activity o f facial muscles b y d i r e c t i n s e r t i o n o f needle elec-
Electrodiagnostic Tests
trodes usually i n o r b i c u l a r o c u l i a n d orbicularis oris m u s -
cles a n d t h e r e c o r d i n g s are m a d e d u r i n g rest a n d v o l u n t a r y
T h e s e tests are u s e f u l t o d i f f e r e n t i a t e b e t w e e n n e u r a p r a x i a contraction o f muscle.
and d e g e n e r a t i o n o f t h e n e r v e . T h e y also h e l p t o p r e d i c t
I n a n o r m a l resting muscle, biphasic or triphasic p o t e n -
prognosis and indicate t i m e f o r surgical decompression of
tials are s e e n e v e r y 3 0 - 5 0 m i l l i s e c o n d s .
the nerve.
I n a denervated muscle spontaneous i n v o l u n t a r y action
1 . M i n i m a l nerve excitability t e s t T h e n e r v e is s t i m u - p o t e n t i a l s called fibrillation potentials are seen. T h e y appear
l a t e d at s t e a d i l y i n c r e a s i n g i n t e n s i t y t i l l f a c i a l t w i t c h is j u s t 14—21 days after d e n e r v a t i o n . W i t h r e g e n e r a t i o n o f t h e
n o t i c e a b l e . T h i s is c o m p a r e d w i t h t h e n o r m a l side. T h e r e is n e r v e after i n j u r y , polyphasic reinnervation potentials replace
n o d i f f e r e n c e b e t w e e n t h e n o r m a l a n d p a r a l y s e d side i n f i b r i l l a t i o n p o t e n t i a l s . T h e y appear 6 - 1 2 weeks p r i o r to
c o n d u c t i o n block. I n other injuries, w h e r e degeneration clinical evidence o f facial f u n c t i o n a n d thus p r o v i d e the
sets i n , n e r v e e x c i t a b i l i t y is g r a d u a l l y l o s t . W h e n t h e d i f f e r - earliest e v i d e n c e o f r e c o v e r y .
e n c e b e t w e e n t w o sides e x c e e d 3.5 m i l l i a m p e r e s , t h e test is V o l u n t a r y c o n t r a c t i o n causes m o t o r d i s c h a r g e . Dimin-
p o s i t i v e f o r d e g e n e r a t i o n . D e g e n e r a t i o n o f f i b r e s c a n n o t be i s h e d o r n o r e s p o n s e t o v o l u n t a r y c o n t r a c t i o n is seen a f t e r
d e t e c t e d e a r l i e r t h a n 48—72 h o u r s o f its commencement. nerve injury.
 F a c i a l N e r v e a n d Its D i s o r d e r s

Electromyography is u s e f u l i n p l a n n i n g r e a n i m a t i o n
Table 14.1 Causes o f facial paralysis
procedures. Presence o f n o r m a l or polyphasic potentials
after 1 y e a r o f i n j u r y i n d i c a t e s t h a t r e i n n e r v a t i o n is t a k i n g 1. Central

p l a c e a n d t h e r e is n o n e e d f o r r e a n i m a t i o n p r o c e d u r e . I f Brain abscess

Pontine gliomas
f i b r i l l a t i o n p o t e n t i a l s are seen, i t i n d i c a t e s i n t a c t m o t o r e n d
Poliomyelitis
plates b u t n o e v i d e n c e o f r e i n n e r v a t i o n a n d n e e d f o r n e r v e
Multiple sclerosis
s u b s t i t u t i o n . Electrical silence indicates a t r o p h y o f m o t o r
e n d plates a n d n e e d f o r m u s c l e transfer p r o c e d u r e s rather 2. Intracranial part (cerebellopontine angle)

than nerve substitution. Acoustic n e u r o m a

M e n i n g i o m a
T h u s E N o G a n d E M G are c o m p l i m e n t a r y a n d h e l p t o
Congenital cholesteatoma
p r o g n o s t i c a t e i n cases o f f a c i a l paralysis a n d i n d e c i d i n g t h e
Metastatic c a r c i n o m a
p r o c e d u r e f o r r e a n i m a t i o n , i . e . n e r v e s u b s t i t u t i o n versus
Meningitis
muscle transposition or sling operation.
3. Intratemporal part
(a) Idiopathic

Bell's palsy
CAUSES O F FACIAL PARALYSIS Melkersson's s y n d r o m e

(b) infections

T h e cause m a y b e central o r peripheral. T h e peripheral lesion Acute suppurative otitis media

Chronic suppurative otitis media

m a y i n v o l v e t h e n e r v e i n its i n t r a c r a n i a l , i n t r a t e m p o r a l o r
Herpes zoster oticus
e x t r a t e m p o r a l p a r t s . P e r i p h e r a l lesions are m o r e common
Malignant otitis externa
a n d a b o u t t w o - t h i r d s o f t h e m are o f t h e i d i o p a t h i c v a r i e t y
(c) T r a u m a
(Table 14.1).
Surgical: M a s t o i d e c t o m y

S t a p e d e c t o m y

Accidental: Fractures o f temporal bone

A. IDIOPATHIC (d) Neoplasms

Malignancies o f external and middle ear

G l o m u s jugulare t u m o u r

1. Bell's Palsy Facial nerve n e u r o m a

Metastasis to t e m p o r a l bone (from cancer o f

S i x t y t o s e v e n t y - f i v e p e r c e n t o f f a c i a l paralysis is d u e t o breast, bronchus, prostate)

B e l l ' s p a l s y . I t is d e f i n e d as idiopathic, peripheralfacial paralysis 4. Extracranial part

or paresis of acute onset. B o t h sexes are a f f e c t e d w i t h equal Malignancy o f parotid

f r e q u e n c y . A n y age g r o u p m a y b e a f f e c t e d t h o u g h i n c i - Surgery o f parotid

d e n c e rises w i t h i n c r e a s i n g age. A p o s i t i v e f a m i l y h i s t o r y is Accidental injury in p a r o t i d region

p r e s e n t i n 6—8% o f p a t i e n t s . R i s k o f B e l l ' s palsy is m o r e i n Neonatal facial injury (obstetrical forceps)

diabetics (angiopathy) a n d pregnant w o m e n ( r e t e n t i o n o f 5. Systemic diseases

fluid). Diabetes mellitus

Hypothyroidism

Aetiology U r a e m i a

Polyarteritis n o d o s a
(a) V i r a l infection M o s t o f the evidence supports the Wegener's granulomatosis
viral a e t i o l o g y d u e t o herpes s i m p l e x , herpes zoster o r the Sarcoidosis (Heerfordt's syndrome)

Epstein-Barr virus. Other cranial nerves may also be Leprosy

i n v o l v e d i n B e l l ' s palsy w h i c h is t h u s c o n s i d e r e d a p a r t o f Leukaemia

the total picture o f polyneuropathy. Demyelinating disease

(b) V a s c u l a r i s c h a e m i a I t m a y be p r i m a r y o r secondary.
Primary ischaemia is i n d u c e d b y c o l d o r e m o t i o n a l stress.
Secondary ischaemia is t h e r e s u l t o f p r i m a r y i s c h a e m i a which
causes i n c r e a s e d capillary permeability leading to exuda- susceptible to early compression with the slightest
t i o n o f fluid, o e d e m a a n d c o m p r e s s i o n o f m i c r o c i r c u l a t i o n oedema. T e n p e r c e n t o f t h e cases o f B e l l ' s palsy h a v e a
o f the nerve. positive family history.

(c) Hereditary T h e f a l l o p i a n c a n a l is n a r r o w b e c a u s e (d) A u t o i m m u n e disorder T - l y m p h o c y t e changes have

o f hereditary predisposition and this makes the nerve been observed.
Clinical Features ( F i g . 14.6) shown to influence recovery. A c t i v e facial move-
m e n t s are e n c o u r a g e d w h e n t h e r e is r e t u r n o f s o m e
O n s e t is s u d d e n . P a t i e n t is u n a b l e t o c l o s e h i s e y e . On
m o v e m e n t t o the facial muscles.
a t t e m p t i n g t o close t h e e y e , e y e b a l l t u r n s u p a n d o u t ( B e l l ' s
p h e n o m e n o n ) . Saliva d r i b b l e s f r o m t h e a n g l e o f m o u t h . Medical management

Face b e c o m e s a s y m m e t r i c a l . T e a r s f l o w d o w n f r o m t h e e y e Steroids. T h e i r u t i l i t y has n o t b e e n p r o v e d b e y o n d d o u b t i n

( e p i p h o r a ) . P a i n i n t h e ear m a y p r e c e d e o r a c c o m p a n y t h e
n e r v e p a r a l y s i s . S o m e c o m p l a i n o f n o i s e i n t o l e r a n c e (stape-
d i a l paralysis) o r loss o f taste ( i n v o l v e m e n t o f c h o r d a t y m -
p a n i ) . Paralysis m a y b e c o m p l e t e o r i n c o m p l e t e . B e l l ' s palsy
is r e c u r r e n t i n 3—10% o f p a t i e n t s .
Diagnosis
c a r e f u l l y c o n t r o l l e d s t u d i e s . P r e d n i s o l o n e is t h e d r u g of
c h o i c e . I f p a t i e n t r e p o r t s w i t h i n 1 w e e k , t h e a d u l t dose o f
p r e d n i s o l o n e is 1 m g / k g / d a y d i v i d e d i n t o m o r n i n g and
e v e n i n g doses f o r 5 days. P a t i e n t is seen o n t h e 5 t h d a y . I f
paralysis is i n c o m p l e t e o r is r e c o v e r i n g , dose is t a p e r e d
d u r i n g t h e n e x t 5 days. I f paralysis r e m a i n s c o m p l e t e , t h e
s a m e dose is c o n t i n u e d f o r a n o t h e r 10 days a n d t h e r e a f t e r

D i a g n o s i s is a l w a y s b y e x c l u s i o n . A l l o t h e r k n o w n causes t a p e r e d i n n e x t 5 days, ( t o t a l o f 2 0 d a y s ) . C o n t r a i n d i c a t i o n s

o f p e r i p h e r a l f a c i a l paralysis s h o u l d b e excluded. This t o use o f s t e r o i d s i n c l u d e p r e g n a n c y , d i a b e t e s , h y p e r t e n s i o n ,

requires careful history, complete o t o l o g i c a l a n d head and peptic ulcer, pulmonary tuberculosis and glaucoma.

n e c k e x a m i n a t i o n , X - r a y s t u d i e s , b l o o d tests s u c h as t o t a l Steroids have been f o u n d useful to p r e v e n t i n c i d e n c e of

c o u n t , p e r i p h e r a l s m e a r , s e d i m e n t a t i o n r a t e , b l o o d sugar s y n k i n e s i s , c r o c o d i l e tears a n d t o s h o r t e n t h e r e c o v e r y t i m e

and serology. o f f a c i a l paralysis. S t e r o i d s can b e c o m b i n e d w i t h a c y c l o v i r

N e r v e e x c i t a b i l i t y tests are d o n e d a i l y o r o n a l t e r n a t e f o r H e r p e s z o s t e r o t i c u s o r B e l l ' s palsy.

days a n d c o m p a r e d w i t h t h e n o r m a l side t o m o n i t o r n e r v e Other drugs. V a s o d i l a t o r s , v i t a m i n s , m a s t c e l l i n h i b i t o r s ,

degeneration. antihistaminics have n o t been f o u n d useful.

L o c a l i s i n g t h e site o f l e s i o n ( t o p o d i a g n o s i s ) h e l p s i n estab- Surgical treatment N e r v e d e c o m p r e s s i o n relieves pres-

l i s h i n g t h e a e t i o l o g y a n d also t h e site o f s u r g i c a l d e c o m p r e s - sure o n t h e n e r v e f i b r e s a n d t h u s i m p r o v e s t h e m i c r o c i r c u -
s i o n o f n e r v e , i f t h a t b e c o m e s necessary. l a t i o n o f t h e n e r v e . V e r t i c a l a n d t y m p a n i c segments of
n e r v e are d e c o m p r e s s e d . S o m e w o r k e r s have suggested
Treatment total decompression i n c l u d i n g labyrinthine segment by

General p o s t a u r a l a n d m i d d l e fossa a p p r o a c h .

1. Reassurance.
Prognosis
2. R e l i e f o f ear p a i n b y analgesics.
3. C a r e o f t h e e y e as o u t l i n e d o n page 1 0 9 . E y e m u s t b e E i g h t y - f i v e t o n i n e t y percent o f the patients recover fully.
p r o t e c t e d against e x p o s u r e k e r a t i t i s . 1 0 - 1 5 % recover i n c o m p l e t e l y and m a y be left w i t h some
-1. P h y s i o t h e r a p y o r massage o f t h e f a c i a l m u s c l e s gives stigmata o f r e g e n e r a t i o n . R e c u r r e n t facial palsy m a y n o t
p s y c h o l o g i c a l s u p p o r t t o t h e p a t i e n t . I t has n o t b e e n r e c o v e r f u l l y . P r o g n o s i s is g o o d i n i n c o m p l e t e B e l l ' s palsy
(95%) complete recovery) a n d i n those w h e r e clinical
r e c o v e r y starts w i t h i n 3 w e e k s o f o n s e t (75% complete
recovery).

2. Melkersson's Syndrome

I t is also a n i d i o p a t h i c d i s o r d e r c o n s i s t i n g o f a t r i a d o f facial
paralysis, s w e l l i n g o f l i p s a n d f i s s u r e d t o n g u e . Paralysis m a y
b e r e c u r r e n t . T r e a t m e n t is t h e same as f o r B e l l ' s palsy.

Recurrent facial palsy R e c u r r e n t f a c i a l p a l s y is seen i n

B e l l ' s palsy ( 3 - 1 0 % cases), M e l k e r s s o n ' s s y n d r o m e , d i a b e t e s ,
s a r c o i d o s i s a n d t u m o u r s . R e c u r r e n t palsy o n t h e same side
m a y b e caused b y a t u m o u r i n 3 0 % o f cases.

Bilateral facial paralysis S i m u l t a n e o u s b i l a t e r a l facial

Figure 14.6 paralysis m a y b e seen i n G u i l l a i n - B a r r e s y n d r o m e , s a r c o i -
dosis, s i c k l e c e l l disease, a c u t e l e u k a e m i a , b u l b a r palsy, l e p -
Facial paralysis left side. C o m p a r e w i t h normal side.
rosy a n d some o t h e r systemic disorders.
 F a c i a l N e r v e a n d Its D i s o r d e r s

B. INFECTIONS

Herpes Zoster Oticus

I (Ramsay-Hunt Syndrome)
I Roof of external
and middle ear
T h e r e is f a c i a l paralysis a l o n g w i t h v e s i c u l a r rash i n t h e and antrum
e x t e r n a l a u d i t o r y canal and p i n n a ( F i g . 14.7). T h e r e m a y
also b e anaesthesia o f face, g i d d i n e s s a n d h e a r i n g i m p a i r -
Parietal or
ment due to involvement o f V t h and V I H t h nerves. temporal blow
T r e a t m e n t is t h e s a m e as f o r B e l l ' s palsy. causes
ongitudinal
Infections of Middle Ear (see page 9 0 ) fracture
Malignant Otitis Externa (see p a g e 5 8 )

C. TRAUMA Occipital blow causes

transverse fracture

1. Fractures of Temporal Bone

Figure 14.8

F r a c t u r e s o f t e m p o r a l b o n e m a y b e longitudinal, transverse or (A) Longitudinal fracture runs along the axis o f p e t r o u s pyra-

mixed ( F i g . 1 4 . 8 ) . F a c i a l p a l s y is seen m o r e o f t e n i n t r a n s - mid. Typically, it s t a r t s at s q u a m o u s part o f temporal bone,

verse f r a c t u r e s ( 5 0 % ) . Paralysis is d u e t o i n t r a n e u r a l h a e m a - runs through r o o f o f external ear canal and m i d d l e ear towards

the petrous apex, and to foramen lacerum. (B) Transverse frac-

toma, compression b y a b o n y spicule o r transection of
ture. It r u n s across the axis o f petrous. Typically, it b e g i n s at
n e r v e . I n these cases, i t is i m p o r t a n t t o k n o w whether
foramen m a g n u m , passes through occipital bone, jugular
paralysis w a s o f i m m e d i a t e o r d e l a y e d o n s e t . D e l a y e d o n s e t
fossa, petrous pyramid ending in middle cranial fossa. It may
paralysis is t r e a t e d c o n s e r v a t i v e l y l i k e B e l l ' s p a l s y w h i l e
pass medial, lateral or t h r o u g h the labyrinth.
i m m e d i a t e o n s e t paralysis m a y r e q u i r e s u r g e r y i n t h e f o r m
o f decompression, re-anastomosis o f c u t ends or cable
nerve graft (Table 14.2).

Figure 14.7

Ramsay-Hunt syndrome. N o t e facial palsy and small vesicles in the concha o f the right side.
 | D i f f e r e n c e s in l o n g i t u d i n a l a n d transverse fractures o f temporal bone

Longitudinal Transverse

• Frequency M o r e c o m m o n (80%) Less c o m m o n (20%)

• Type o f injury Parietal b l o w Occipital b l o w

• Fracture line Runs parallel to l o n g axis o f p e t r o u s pyramid. Runs across the p e t r o u s Starts at foramen

Starts at s q u a m o u s part o f temporal bone to end m a g n u m or jugular foramen t o w a r d s the foramen

at foramen lacerum s p i n o s u m

• Bleeding from ear C o m m o n , due to injury to tegmen and tympanic Absent because t y m p a n i c m e m b r a n e is intact.

m e m b r a n e H a e m o t y m p a n u m may be seen

• C.S.F. otorrhoea Present, often mixed with blood Absent or unmanifested

• Structures injured T e g m e n , ossicles and t y m p a n i c m e m b r a n e Labyrinth o r C N VIII

• Hearing loss Conductive Sensorineural

• Vertigo Less o f t e n ; due to concussion Severe, due to injury to labyrinth or C N VIII

• Facial paralysis Less ( 2 0 % ) , delayed onset. N e r v e is i n j u r e d in M o s t c o m m o n (50%). Immediate onset. Injury to

t y m p a n i c segment, distal to geniculate ganglion nerve in m e a t a l or labyrinthine segment proximal to

geniculate ganglion.

paralysis i n t h e n e o n a t e d u e t o pressure o n t h e e x t r a t e m -
2. Ear or Mastoid Surgery
poral part o f n e r v e .

F a c i a l n e r v e is i n j u r e d d u r i n g s t a p e d e c t o m y , t y m p a n o p l a s t y
o r m a s t o i d s u r g e r y . Paralysis m a y be i m m e d i a t e o r d e l a y e d
and t r e a t m e n t is t h e s a m e as i n t e m p o r a l b o n e trauma. D. NEOPLASMS
S o m e t i m e s , n e r v e is p a r a l y s e d d u e t o pressure o f p a c k i n g
o n the exposed n e r v e a n d this s h o u l d be r e l i e v e d first.
1. Intratemporal Neoplasms
Operative injuries to facial nerve can be avoided if
a t t e n t i o n is p a i d t o t h e f o l l o w i n g :
Carcinoma o f external o r m i d d l e ear, glomus tumour,
(i) A n a t o m i c a l k n o w l e d g e o f the course o f facial n e r v e , rhabdomyosarcoma a n d metastatic tumours o f temporal
possible variations and anomalies a n d its surgical b o n e , a l l r e s u l t i n f a c i a l paralysis. F a c i a l n e r v e neuroma
l a n d m a r k s . C a d a v e r dissections s h o u l d be an i m p o r - occurs a n y w h e r e along the course o f nerve and produces
t a n t p a r t o f t h e t r a i n i n g i n ear s u r g e r y . paralysis o f g r a d u a l o r s u d d e n o n s e t . I t is t r e a t e d b y e x c i -
(ii) A l w a y s w o r k i n g a l o n g the course o f nerve and never sion and nerve grafting. H i g h resolution C T scan and
across i t . g a d o l i n i u m - e n h a n c e d M R I is v e r y u s e f u l f o r f a c i a l n e r v e
(iii) Constant irrigation w h e n drilling, to avoid thermal tumour.
injury. Use d i a m o n d b u r r w h e n w o r k i n g near the
nerve.
(iv) Gentle h a n d l i n g o f t h e n e r v e w h e n i t is exposed, 2. T u m o u r s of Parotid

a v o i d i n g a n y pressure o f i n s t r u m e n t s o n t h e n e r v e .
(v) N o t t o r e m o v e any granulations that penetrate the F a c i a l paralysis w i t h t u m o u r o f t h e p a r o t i d a l m o s t a l w a y s

nerve. i m p l i e s m a l i g n a n c y (see T u m o u r s o f s a l i v a r y g l a n d s ) .

(vi) U s i n g m a g n i f i c a t i o n ; n e v e r t o w o r k o n facial n e r v e
w i t h o u t an o p e r a t i n g microscope.

E. S Y S T E M I C D I S E A S E S AND
FACIAL PARALYSIS
3. Parotid Surgery and T r a u m a to Face

Facial n e r v e m a y be i n j u r e d i n surgery o f p a r o t i d t u m o u r s P e r i p h e r a l f a c i a l paralysis is m o s t l y o f i d i o p a t h i c v a r i e t y

o r deliberately excised i n m a l i g n a n t t u m o u r s . A c c i d e n t a l but always needs e x c l u s i o n o f diabetes, h y p o t h y r o i d i s m ,
i n j u r i e s i n t h e p a r o t i d r e g i o n c a n also cause f a c i a l paralysis. leukaemia, sarcoidosis, periarteritis nodosa, Wegener's
A p p l i c a t i o n o f o b s t e t r i c a l f o r c e p s m a y also r e s u l t i n f a c i a l g r a n u l o m a t o s i s , l e p r o s y , s y p h i l i s a n d d e m y e l i n a t i n g disease.
 F a c i a l N e r v e a n d Its D i s o r d e r s

Taste fibres (Green]

LOCALISATION O F FACIAL LESION Secretomotor
fibres (Red)
Motor fibres

1. Centra] Facia) Paralysis

I t is caused b y cerebrovascular accidents (haemorrhage,

t h r o m b o s i s o r e m b o l i s m ) , t u m o u r o r a n abscess. I t causes
paralysis o f o n l y t h e l o w e r h a l f o f face o n t h e c o n t r a l a t e r a l
side. F o r e h e a d movements are r e t a i n e d d u e t o b i l a t e r a l
innervation o f frontalis muscle. Involuntary emotional
m o v e m e n t s a n d t h e t o n e o f f a c i a l m u s c l e s are also r e t a i n e d .

Sublingual and
submandibular
2. Peripheral Facial Paralysis
glands

A l l t h e m u s c l e s o f t h e face o n t h e i n v o l v e d side are p a r a l y -

sed. P a t i e n t is u n a b l e t o f r o w n , close t h e e y e , p u r s e t h e lips Motor fibres
or Whistle. to face

A l e s i o n at the level of nucleus is i d e n t i f i e d b y associated

paralysis o f V l t h n e r v e . Figure 14.9
A l e s i o n at cerebellopontine angle is i d e n t i f i e d b y t h e p r e s -
Topographical localisation o f V M t h nerve lesions. ( A ) Supragen-
e n c e o f v e s t i b u l a r a n d a u d i t o r y defects a n d i n v o l v e m e n t o f
iculate ortransgeniculate lesion. Secretomotorfibres t o the lac-
o t h e r c r a n i a l n e r v e s s u c h as V t h , I X t h , X t h a n d X l t h .
rimal gland leave at the geniculate ganglion and are interrupted
A lesion in the bony canal, from i n t e r n a l acoustic meatus in lesions situated at/or proximal to geniculate ganglion. (B)

to stylomastoid f o r a m e n , can be localised b y t o p o d i a g n o s - Suprastapedial lesions cause loss o f stapedial reflex and taste

t i c tests. but preserve lacrimation. (C) lnfrastapedial lesions cause loss

A lesion outside the temporal b o n e , i n t h e p a r o t i d area, o f taste but preserve stapedial reflex and lacrimation. (D)

affects o n l y t h e m o t o r f u n c t i o n s o f n e r v e . I t m a y some- Infrachordal lesions cause loss o f facial m o t o r function only.

t i m e s b e i n c o m p l e t e as s o m e b r a n c h e s o f t h e n e r v e m a y
n o t be i n v o l v e d i n t u m o u r or t r a u m a . during one minute period. Decreased salivation shows
i n j u r y above the chorda.

T o p o d i a g n o s t i c T e s t s f o r L e s i o n s in

I Intratemporal Part (Fig. 14.9)

1 COMPLICATIONS FOLLOWING
T h e f o l l o w i n g tests are u s e f u l i n f i n d i n g t h e site o f l e s i o n FACIAL PARALYSIS
i n paralysis o f l o w e r m o t o r n e u r o n .

1. Schirmer's test I t compares l a c r i m a t i o n o f the t w o P e r i p h e r a l f a c i a l paralysis d u e t o a n y cause m a y r e s u l t i n

sides. A s t r i p o f f i l t e r p a p e r is h o o k e d i n t h e l o w e r f o r n i x any o f the f o l l o w i n g complications:
o f each eye a n d t h e a m o u n t o f w e t t i n g o f strip m e a s u r e d . 1. Incomplete recovery F a c i a l a s y m m e t r y persists. E y e
Decreased l a c r i m a t i o n indicates lesion p r o x i m a l to the c a n n o t be c l o s e d r e s u l t i n g i n e p i p h o r a . A w e a k o r a l s p h i n c -
g e n i c u l a t e g a n g l i o n as t h e s e c r e t o m o t o r f i b r e s t o l a c r i m a l t e r causes d r o o l i n g a n d d i f f i c u l t y i n t a k i n g f o o d .
g l a n d l e a v e at t h e g e n i c u l a t e g a n g l i o n v i a g r e a t e r s u p e r f i -
2. E x p o s u r e keratitis Eye c a n n o t be closed, tear f i l m
cial petrosal nerve.
f r o m the cornea evaporates causing dryness, e x p o s u r e k e r -
2. S t a p e d i a l reflex S t a p e d i a l r e f l e x is l o s t i n l e s i o n s a b o v e a t i t i s a n d c o r n e a l u l c e r . T h i s is w o r s e w h e n t e a r p r o d u c t i o n
t h e n e r v e t o s t a p e d i u s . I t is t e s t e d b y t y m p a n o m e t r y . is also a f f e c t e d . I t c a n b e p r e v e n t e d b y use o f a r t i f i c i a l tears
3 . T a s t e t e s t I t c a n b e m e a s u r e d b y a d r o p o f salt o r sugar ( m e t h y l c e l l u l o s e d r o p s ) e v e r y 1—2 h o u r s , e y e o i n t m e n t a n d
s o l u t i o n p l a c e d o n o n e side o f t h e p r o t r u d e d t o n g u e , o r b y p r o p e r c o v e r f o r t h e e y e at n i g h t .
electrogustometry. I m p a i r m e n t o f taste i n d i c a t e s lesion T e m p o r a r y t a r s o r r h a p h y m a y also be i n d i c a t e d . E y e c l o -
above the chorda t y m p a n i . sure can also b e i m p r o v e d b y u s i n g g o l d - w e i g h t i m p l a n t
s u t u r e d t o t h e tarsal p l a t e d e e p t o l e v a t o r p a l p e b r a e m u s c l e .
4. S u b m a n d i b u l a r salivary flow t e s t I t also m e a s u r e s
f u n c t i o n o f c h o r d a t y m p a n i . P o l y t h e n e t u b e s are passed 3. Synkinesis (mass movement) When the patient
i n t o b o t h W h a r t o n ' s d u c t s a n d d r o p s o f saliva c o u n t e d w i s h e s t o close t h e e y e , c o r n e r o f m o u t h also t w i t c h e s o r
v i c e versa. I t is d u e t o cross i n n e r v a t i o n o f f i b r e s ; t h e r e is
no treatment.

4. T i c s and spasms T h e y are t h e r e s u l t o f f a u l t y r e g e n -

e r a t i o n o f f i b r e s . I n v o l u n t a r y m o v e m e n t s are seen o n t h e
a f f e c t e d side o f t h e face.

5. C o n t r a c t u r e s T h e y result f r o m fibrosis o f a t r o p h i e d
muscles o r f i x e d c o n t r a c t i o n o f a g r o u p o f muscles. They
affect m o v e m e n t s o f face b u t facial s y m m e t r y at rest is g o o d .

6. C r o c o d i l e tears ( g u s t a t o r y l a c r i m a t i o n ) T h e r e is
unilateral l a c r i m a t i o n w i t h mastication. This is d u e to
faulty regeneration o f parasympathetic fibres w h i c h now
supply l a c r i m a l g l a n d instead o f the salivary glands. I t can
be treated b y section o f greater superficial petrosal nerve o r
tympanic neurectomy.

7. Frey's syndrome (gustatory sweating) There is

sweating and flushing o f s k i n o v e r t h e p a r o t i d area d u r i n g
Figure 14.10
m a s t i c a t i o n . I t results f r o m p a r o t i d s u r g e r y .

8. P s y c h o l o g i c a l and social problems Drooling dur- Hemifacial spasm. N o t e all the facial muscles and platysma in

spasm. Picture taken during paroxysm o f clonic contractions.

i n g e a t i n g a n d d r i n k i n g a n d i m p a i r m e n t o f s p e e c h cause
social p r o b l e m s .

S U R G E R Y O F FACIAL NERVE
HYPERKINETIC DISORDERS OF
FACIAL NERVE
1. Decompression The nerve m a y be compressed by
o e d e m a , h a e m a t o m a o r a fractured b o n e i n its i n f r a t e m p o -
T h e y are c h a r a c t e r i s e d b y i n v o l u n t a r y t w i t c h i n g o f facial
r a l p a r t . T h e b o n y c a n a l is e x p o s e d a n d u n c a p p e d . The
m u s c l e s o n o n e o r b o t h sides.
s h e a t h o f n e r v e is also slit t o r e l i e v e pressure d u e t o o e d e m a
1. Hemifacial spasm I t is characterised b y repeated, u n c o n - or intraneural haematoma.
t r o l l a b l e t w i t c h i n g s o f facial muscles o n o n e side ( F i g . 1 4 . 1 0 ) .
2. E n d to e n d anastomosis T h i s is d o n e w h e n t h e gap
I t is o f t w o types (a) essential o r idiopathic, w h e r e cause is n o t
b e t w e e n severed ends o f t h e nerves is o n l y a f e w i r i i l l i m e t r e s .
k n o w n a n d (b) secondary, w h e r e cause is acoustic n e u r o m a ,
I t is a s u i t a b l e p r o c e d u r e f o r e x t r a t e m p o r a l p a r t o f t h e n e r v e .
c o n g e n i t a l c h o l e s t e a t o m a o r g l o m u s t u m o u r . M a n y cases o f
T h e r e s h o u l d n o t be a n y t e n s i o n i n t h e a p p r o x i m a t e d ends.
h e m i f a c i a l spasm are d u e t o i r r i t a t i o n o f t h e n e r v e because o f
a vascular l o o p at the c e r e b e l l o p o n t i n e angle. M i c r o v a s c u l a r 3 . N e r v e g r a f t ( c a b l e g r a f t ) W h e n t h e gap b e t w e e n s e v -

d e c o m p r e s s i o n t h r o u g h p o s t e r i o r fossa c r a n i o t o m y has m e t e r e d ends c a n n o t be c l o s e d b y e n d t o e n d a n a s t o m o s i s , a

w i t h h i g h success rate i n these cases. I d i o p a t h i c t y p e has b e e n n e r v e g r a f t is m o r e s u i t a b l e t h a n e x t e n s i v e r e - r o u t i n g o r

t r e a t e d b y selective s e c t i o n o f the branches o f facial n e r v e i n m o b i l i s a t i o n o f n e r v e . N e r v e g r a f t is t a k e n from greater

t h e p a r o t i d o r b y p u n c t u r i n g t h e facial n e r v e w i t h a n e e d l e i n auricular, lateral cutaneous n e r v e o f t h i g h o r the sural n e r v e .

its t y m p a n i c s e g m e n t . I n t h e b o n y canal, the graft m a y n o t r e q u i r e any s u t u r i n g .

B o t u l i n u m t o x i n has b e e n u s e d i n t h e a f f e c t e d m u s c l e . 4. Hypoglossal-facial anastomosis Hypoglossal nerve

I t b l o c k s t h e n e u r o m u s c u l a r j u n c t i o n b y p r e v e n t i n g release is a n a s t o m o s e d t o t h e s e v e r e d p e r i p h e r a l e n d o f t h e f a c i a l
o f acetylcholine. nerve. I t improves the muscle tone and permits some

2. B l e p h a r o s p a s m T w i t c h i n g s a n d spasms are l i m i t e d t o m o v e m e n t s o f f a c i a l m u s c l e s , b u t at t h e e x p e n s e o f a t r o p h y

o r b i c u l a r s o c u l i m u s c l e s o n b o t h sides. T h e eyes are c l o s e d o f t o n g u e o n t h a t side. H o w e v e r , d i s a b i l i t y o f t o n g u e d u e

due t o m u s c l e spasms c a u s i n g f u n c t i o n a l b l i n d n e s s . The t o a t r o p h y is n o t so severe a n d p a t i e n t adjusts t o t h e d i f f i -

cause is u n c e r t a i n , b u t p r o b a b l y lies i n t h e basal g a n g l i a . I t c u l t y i n c h e w i n g a n d a r t i c u l a t i o n after a f e w w e e k s .

is t r e a t e d b y s e l e c t i v e s e c t i o n o f n e r v e s s u p p l y i n g m u s c l e s
a r o u n d t h e e y e o n b o t h sides.
B o t u l i n u m - A t o x i n i n j e c t e d i n t o the p e r i o r b i t a l muscles
gives r e l i e f f o r 3—6 m o n t h s . I n j e c t i o n c a n b e r e p e a t e d i f
necessary.
5. P l a s t i c p r o c e d u r e s T h e y are u s e d t o i m p r o v e c o s m e t i c
a p p e a r a n c e w h e n n e r v e g r a f t i n g is n o t feasible o r has f a i l e d .
T h e p r o c e d u r e s i n c l u d e facial slings, face l i f t o p e r a t i o n o r
slings o f masseter a n d t e m p o r a l i s m u s c l e . T h e l a t t e r also
g i v e s s o m e m o v e m e n t t o face i n a d d i t i o n t o s y m m e t r y .
Meniere's Disease

M e n i e r e ' s Disease, also c a l l e d endolymphatic hydrops, is a d i s -

Aetiology
o r d e r o f t h e i n n e r ear w h e r e t h e e n d o l y m p h a t i c system is
d i s t e n d e d w i t h e n d o l y m p h . I t is c h a r a c t e r i s e d b y (i) v e r t i g o ,
T h e m a i n p a t h o l o g y i n M e n i e r e ' s disease is d i s t e n s i o n of
(ii) s e n s o r i n e u r a l h e a r i n g loss a n d ( i i i ) t i n n i t u s a n d ( i v ) a u r a l
e n d o l y m p h a t i c system due to increased v o l u m e o f e n d o -
fullness.
l y m p h . T h i s can result either f r o m increased p r o d u c t i o n o f
endolymph o r its f a u l t y a b s o r p t i o n o r b o t h . N o r m a l l y ,

| Pathology | e n d o l y m p h is s e c r e t e d b y stria v a s c u l a r i s , fills t h e m e m b r a -

n o u s l a b y r i n t h a n d is a b s o r b e d t h r o u g h t h e e n d o l y m p h a t i c

T h e m a i n p a t h o l o g y is d i s t e n s i o n o f e n d o l y m p h a t i c s y s - sac (see p a g e 1 2 f o r i n n e r ear f l u i d s ) .

tem, m a i n l y affecting the c o c h l e a r d u c t (scala media) T h e e x a c t cause o f M e n i e r e ' s disease is n o t y e t k n o w n .

a n d t h e s a c c u l e , a n d t o a lesser e x t e n t the utricle and Various theories have b e e n postulated (Fig. 15.2).

s e m i c i r c u l a r canals. T h e d i l a t a t i o n o f c o c h l e a r d u c t is 1. Defective absorption by endolymphatic sac

s u c h t h a t , i t m a y c o m p l e t e l y f d l t h e scala v e s t i b u l i ; t h e r e
is m a r k e d b u l g i n g o f R e i s s n e r ' s m e m b r a n e which may
even herniate t h r o u g h the helicotrema i n t o the apical
p a r t o f scala t y m p a n i ( F i g . 1 5 . 1 ) . T h e d i s t e n d e d s a c c u l e
m a y c o m e t o l i e a g a i n s t t h e stapes f o o t p l a t e . T h e u t r i c l e
and saccule m a y s h o w o u t - p o u c h i n g s i n t o the semicir-
c u l a r canals.
Normally, e n d o l y m p h is c a r r i e d b y t h e endolymphatic
d u c t t o t h e sac w h e r e i t is a b s o r b e d . D e f e c t i v e a b s o r p t i o n
b y t h e sac m a y b e r e s p o n s i b l e f o r r a i s e d e n d o l y m p h p r e s -
s u r e . E x p e r i m e n t a l o b s t r u c t i o n o f e n d o l y m p h a t i c sac a n d
its d u c t also p r o d u c e s h y d r o p s . I s c h a e m i a o f sac has b e e n
o b s e r v e d i n cases o f M e n i e r e ' s disease u n d e r g o i n g sac s u r -
gery, i n d i c a t i n g p o o r vascularity and thus p o o r absorption
 Defective disease is u n i l a t e r a l b u t t h e o t h e r ear m a y b e a f f e c t e d after
absorption by sac
Food a f e w years.
inhalant allergy Episodic vertigo Cardinal, symptoms o f M e n i e r e ' s disease are: (1) Episodic
v e r t i g o , (2) F l u c t u a t i n g h e a r i n g loss, (3) T i n n i t u s a n d (4)
Autoimmune Fluctuating
process hearing loss Sense o f f u l l n e s s o r pressure i n t h e i n v o l v e d ear.
Meniere's disease
Viral infection 1. Vertigo It comes i n attacks. The o n s e t is sudden.
(endolymphatic Tinnitus
(herpes family)
hydrops) P a t i e n t gets a f e e l i n g o f r o t a t i o n o f h i m s e l f o r h i s e n v i r o n -
m e n t . S o m e t i m e s , t h e r e is f e e l i n g o f " t o a n d f r o " o r " u p
Stress (vasomotor Aural fullness and down" movement. A t t a c k s c o m e i n clusters, with
disturbance)
Sodium and Endocrinol periods o f spontaneous remission lasting f o r weeks, m o n t h s
water retention (hypothyroidism) o r years. U s u a l l y , a n a t t a c k is a c c o m p a n i e d b y nausea a n d
v o m i t i n g w i t h ataxia a n d n y s t a g m u s . S e v e r e a t t a c k s m a y
Figure 15.2
be a c c o m p a n i e d b y other s y m p t o m s o f vagal disturbances
Aetiologic factors and s y m p t o m a t o l o g y o f Meniere's disease s u c h as a b d o m i n a l c r a m p s , d i a r r h o e a , c o l d sweats, p a l l o r
(endolymphatic hydrops). a n d b r a d y c a r d i a . U s u a l l y , t h e r e is n o w a r n i n g s y m p t o m o f
an o n c o m i n g attack o f v e r t i g o b u t sometimes t h e p a t i e n t
m a y f e e l a sense o f fullness i n t h e ear. c h a n g e i n c h a r a c t e r
o f t i n n i t u s o r d i s c o m f o r t i n t h e ear w h i c h h e r a l d an a t t a c k .
b y t h e sac. D i s t e n s i o n o f m e m b r a n o u s l a b y r i n t h leads t o S o m e cases o f M e n i e r e ' s disease s h o w Tullio phenome-
r u p t u r e o f Reissner's m e m b r a n e a n d thus m i x i n g o f p e r i - non. I t is a c o n d i t i o n w h e r e l o u d s o u n d s o r n o i s e p r o d u c e
l y m p h w i t h e n d o l y m p h , w h i c h is t h o u g h t t o b r i n g a b o u t v e r t i g o a n d is d u e t o t h e d i s t e n d e d saccule l y i n g against
an attack o f v e r t i g o . t h e stapes f o o t p l a t e . T h i s p h e n o m e n o n is also s e e n w h e n

2. V a s o m o t o r disturbance There is s y m p a t h e t i c over- t h e r e are t h r e e f u n c t i o n i n g w i n d o w s i n t h e ear, e . g . a f e n e s -

a c t i v i t y r e s u l t i n g i n spasm o f i n t e r n a l a u d i t o r y a r t e r y a n d / t r a t i o n o f h o r i z o n t a l canal i n the presence o f a m o b i l e stapes.

or its b r a n c h e s , thus interfering w i t h the function of

2. H e a r i n g loss It usually accompanies v e r t i g o o r m a y
cochlear o r vestibular sensory n e u r o e p i t h e l i u m . T h i s is
precede i t . H e a r i n g i m p r o v e s after the attack a n d m a y be
r e s p o n s i b l e f o r deafness a n d v e r t i g o . A n o x i a o f capillaries o f
n o r m a l d u r i n g the periods o f remission. This fluctuating
stria vascularis also causes i n c r e a s e d p e r m e a b i l i t y , w i t h t r a n -
n a t u r e o f h e a r i n g loss is q u i t e c h a r a c t e r i s t i c o f t h e disease.
s u d a t i o n o f fluid a n d i n c r e a s e d p r o d u c t i o n o f e n d o l y m p h .
W i t h r e c u r r e n t attacks, improvement i n hearing during
3. Allergy T h e o f f e n d i n g allergen m a y be a f o o d s t u f f or r e m i s s i o n m a y n o t b e c o m p l e t e ; s o m e h e a r i n g loss b e i n g
a n i n h a l a n t . I n these cases, i n n e r ear acts as t h e "shock added i n every attack l e a d i n g t o s l o w a n d progressive dete-
o r g a n " p r o d u c i n g excess o f e n d o l y m p h . N e a r l y 5 0 % of rioration o f h e a r i n g w h i c h is p e r m a n e n t .
p a t i e n t s w i t h M e n i e r e ' s disease h a v e c o n c o m i t a n t i n h a l a n t Distortion of sound. S o m e patients c o m p l a i n o f d i s t o r t e d
and/or f o o d allergy. h e a r i n g . A t o n e o f a p a r t i c u l a r f r e q u e n c y m a y appear n o r -
I t is p o s s i b l e that M e n i e r e ' s disease is m u l t i f a c t o r i a l , m a l i n o n e ear a n d o f h i g h e r p i t c h i n t h e o t h e r l e a d i n g t o
resulting i n the common end point of endolymphatic diplacusis. M u s i c appears d i s c o r d a n t .
h y d r o p s w i t h classical p r e s e n t a t i o n . Intolerance to loud sounds. Patients o f M e n i e r e ' s disease

4. S o d i u m and water retention Excessive a m o u n t s of cannot tolerate amplification o f sound due to r e c r u i t m e n t

fluid are r e t a i n e d l e a d i n g t o e n d o l y m p h a t i c h y d r o p s . p h e n o m e n o n . T h e y are p o o r c a n d i d a t e s f o r h e a r i n g aids.

3. T i n n i t u s I t is l o w - p i t c h e d r o a r i n g t y p e , a n d is a g g r a -
5. H y p o t h y r o i d i s m A b o u t 3%> o f cases o f M e n i e r e ' s d i s -
v a t e d d u r i n g a c u t e attacks. S o m e t i m e s , i t has a h i s s i n g
ease are d u e t o h y p o t h y r o i d i s m . S u c h cases b e n e f i t from
character. It may persist during periods of remission.
thyroid replacement therapy.
C h a n g e i n intensity and p i t c h o f tinnitus m a y be the w a r n -
6. A u t o i m m u n e and viral aetiologies h a v e also b e e n i n g s y m p t o m o f attack.
s u g g e s t e d o n t h e basis o f e x p e r i m e n t a l , laboratory and
4. Sense o f fullness or pressure Like other symptoms,
clinical observations.
i t also f l u c t u a t e s . I t m a y a c c o m p a n y o r p r e c e d e an a t t a c k o f
vertigo.

5. Other features Patients o f Meniere's disease often

| Clinical Features J
s h o w signs o f e m o t i o n a l upset d u e t o a p p r e h e n s i o n o f t h e
Age and sex. Disease is c o m m o n l y seen i n t h e age g r o u p o f r e p e t i t i o n o f attacks. E a r l i e r , t h e e m o t i o n a l stress w a s c o n -
35—60 years. M a l e s are a f f e c t e d m o r e t h a n f e m a l e s . U s u a l l y , s i d e r e d t o b e t h e cause o f M e n i e r e ' s disease.
 5 . C a l o r i c test I t s h o w s r e d u c e d response o n the affected
Examination
side i n 75%> o f cases. O f t e n , i t reveals a c a n a l paresis o n t h e
a f f e c t e d side ( m o s t c o m m o n ) b u t s o m e t i m e s t h e r e is d i r e c -
Otoscopy No a b n o r m a l i t y is seen in the tympanic
t i o n a l p r e p o n d e r a n c e t o h e a l t h y side o r a c o m b i n a t i o n o f
membrane.
b o t h canal paresis o n t h e a f f e c t e d side a n d d i r e c t i o n a l p r e -
Nystagmus I t is seen o n l y d u r i n g a c u t e a t t a c k . T h e q u i c k
p o n d e r a n c e o n t h e o p p o s i t e side.
c o m p o n e n t o f n y s t a g m u s is t o w a r d s t h e u n a f f e c t e d ear.
6. G l y c e r o l test G l y c e r o l is a d e h y d r a t i n g a g e n t . W h e n
Tuning f o r k tests T h e y indicate sensorineural hearing
g i v e n o r a l l y , i t r e d u c e s e n d o l y m p h p r e s s u r e a n d t h u s causes
loss. R i n n e test is p o s i t i v e , a b s o l u t e b o n e c o n d u c t i o n is
an i m p r o v e m e n t i n h e a r i n g .
r e d u c e d i n t h e a f f e c t e d ear a n d W e b e r is l a t e r a l i s e d t o t h e
Patient is g i v e n g l y c e r o l (1.5 m l / k g ) with an equal
b e t t e r ear.
a m o u n t o f w a t e r and a little flavouring agent o r l e m o n
juice. Audiogram a n d speech d i s c r i m i n a t i o n scores are

Investigations r e c o r d e d b e f o r e a n d 1—2 h o u r s a f t e r i n g e s t i o n o f g l y c e r o l .
An improvement of lOdB i n t w o or more adjacent

1. Pure tone audiometry T h e r e is s e n s o r i n e u r a l h e a r - octaves o r gain o f 1 0 % i n d i s c r i m i n a t i o n score makes t h e

i n g loss. I n e a r l y stages, l o w e r f r e q u e n c i e s are a f f e c t e d a n d

t h e c u r v e is o f r i s i n g t y p e . W h e n h i g h e r f r e q u e n c i e s are F r e q u e n c y in Hertz

i n v o l v e d c u r v e b e c o m e s flat o r a f a l l i n g t y p e ( F i g . 1 5 . 3 ) . 125 250 500 1000 2000 4000 8000

750 1500 3000 6000
2. Speech audiometry D i s c r i m i n a t i o n s c o r e is u s u a l l y -10
0
5 5 - 8 5 % b e t w e e n t h e attacks b u t d i s c r i m i n a t i o n a b i l i t y is
10
< <

much impaired during and immediately f o l l o w i n g an 20

attack. 30
</
/
40
< <
3. S p e c i a l a u d i o m e t r y tests T h e y indicate the cochlear 50 <
60
<
n a t u r e o f disease a n d t h u s h e l p t o d i f f e r e n t i a t e f r o m r e t r o -
70
c o c h l e a r lesions, e.g. acoustic n e u r o m a ( T a b l e 15.1).
80
90
(a) Recruitment test is p o s i t i v e .
100
(b) SISI (short increment sensitivity index) test. S I S I s c o r e is no
better than 7 0 % i n t w o - t h i r d s o f the patients ( N o r m a l 120
15%). 130

(c) Tone decay test. N o r m a l l y , t h e r e is d e c a y o f less t h a n

Figure 15.3
20 d B .
(A) Audiogram in early M e n i e r e ' s disease. N o t e : H e a r i n g loss is
4. E l e c t r o c o c h l e o g r a p h y I t shows changes diagnostic o f
sensorineural and more in lower frequencies—the rising curve.
M e n i e r e ' s disease. N o r m a l l y , r a t i o o f s u m m a t i n g p o t e n t i a l
As the disease progresses, middle and higher frequencies get
(SP) t o a c t i o n p o t e n t i a l ( A P ) is 30%). I n M e n i e r e ' s disease,
involved and audiogram b e c o m e s flat or falling type (B & C).
S P / A P r a t i o is g r e a t e r t h a n 3 0 % ( F i g . 1 5 . 4 ) .

flflSdLjB Results o f various tests to differentiate a cochlear from a retrocochlear lesion

Normal Cochlear lesion Retrocochlear lesion

• Pure tone a u d i o g r a m N o r m a l Sensorineural hearing loss Sensorineural hearing loss

• Speech discrimination score 9 0 - 1 0 0 % Below 90% Very p o o r

• Roll over p h e n o m e n o n Absent Absent Present

• Recruitment Absent Present Absent

• SISI score 0-15% Over 70% 0-20%

• Threshold tone decay test 0 - 1 5 d B Less t h a n 25 d B Above 25 d B

• Stapedial reflex Present Present Absent

• Stapedial reflex decay (page 1 09) N o r m a l N o r m a l A b n o r m a l

• E.R.A N o r m a l interval between N o r m a l interval between W a v e V delayed or absent

wave I & V wave I & V

 Milliseconds Ductus reuniens

Figure 15.5
Left m e m b r a n o u s labyrinth.

m e m b r a n e o f t h e u t r i c l e o r saccule d u e t o c h a n g e s i n t h e
endolymphatic pressure.
Baseline
Lermoyez syndrome Here symptoms o f Meniere's dis-
ease are seen i n r e v e r s e o r d e r . F i r s t t h e r e is progressive

Figure 15.4 d e t e r i o r a t i o n o f h e a r i n g , f o l l o w e d b y an attack o f v e r t i g o ,

at w h i c h time t h e h e a r i n g r e c o v e r s .
Electrocochleography. (A) N o r m a l ear; (B) Ear with Meniere's

disease. V o l t a g e o f s u m m a t i n g p o t e n t i a l (SP) is c o m p a r e d with

that o f action potential (AP). Normally SP is 3 0 % o f AP. This Meniere's D i s e a s e vs Meniere's Syndrome
r a t i o is e n h a n c e d in M e n i e r e ' s disease.

Meniere's disease is an idiopathic condition while

test p o s i t i v e . T h e r e is also i m p r o v e m e n t i n t i n n i t u s a n d i n
t h e sense o f fullness i n t h e ear. T h e test has a d i a g n o s t i c
a n d p r o g n o s t i c v a l u e . T h e s e days, g l y c e r o l test is
bined with electrocochleography.
M e n i e r e ' s s y n d r o m e , t h o u g h r e s e m b l i n g M e n i e r e ' s disease
c l i n i c a l l y ( e p i s o d i c v e r t i g o , f l u c t u a t i n g h e a r i n g loss, tinni-
tus a n d ear f u l l n e s s ) , results f r o m a v a r i e t y o f c o n d i t i o n s
com-
s u c h as t r a u m a ( h e a d i n j u r y o r ear s u r g e r y ) , v i r a l i n f e c t i o n s
( f o l l o w i n g measles o r m u m p s ) , s y p h i l i s ( c o n g e n i t a l o r late
acquired), C o g a n ' s s y n d r o m e , otosclerosis o r a u t o i m m u n e

J Variants of Meniere's Disease d i s o r d e r s . I t is also c a l l e d s e c o n d a r y M e n i e r e ' s disease.

Cochlear hydrops Here, o n l y the cochlear symptoms Diagnosis of Meniere's Disease

a n d signs o f M e n i e r e ' s disease are p r e s e n t . V e r t i g o is absent.
I t is o n l y a f t e r several years t h a t v e r t i g o w i l l m a k e its a p p e a r - C o m m i t t e e o n H e a r i n g and E q u i l i b r i u m o f the A m e r i c a n
a n c e . I t is b e l i e v e d t h a t i n these cases, t h e r e is b l o c k at t h e Academy of Otolaryngology—Head and N e c k Surgery
level o f ductus reuniens, thereby c o n f i n i n g the increased ( A A O H N S ) classified t h e d i a g n o s i s o f M e n i e r e ' s disease as
e n d o l y m p h pressure t o t h e c o c h l e a o n l y ( F i g . 1 5 . 5 ) . follows:
Vestibular hydrops P a t i e n t gets t y p i c a l attacks o f e p i -
1. Certain: Definite Meniere's disease confirmed by
s o d i c v e r t i g o w h i l e c o c h l e a r f u n c t i o n s r e m a i n n o r m a l . I t is
histopathology.
o n l y w i t h t i m e that a typical picture o f Meniere's disease
2. D e f i n i t e : T w o or m o r e definitive spontaneous e p i -
w i l l d e v e l o p . M a n y o f t h e cases o f v e s t i b u l a r M e n i e r e ' s d i s -
sodes o f v e r t i g o l a s t i n g 2 0 m i n u t e s o r l o n g e r .
ease are l a b e l l e d " r e c u r r e n t v e s t i b u l o p a t h y " as e n d o l y m -
A u d i o m e t r i c a l l y d o c u m e n t e d h e a r i n g loss o n at least
phatic h y d r o p s c o u l d n o t be demonstrated i n the study o f
one occasion.
t e m p o r a l b o n e s i n s u c h cases.
• T i n n i t u s o r a u r a l fullness i n t h e a f f e c t e d ear.
Drop attacks (Tumarkin's otolithic crisis) In this, • A l l o t h e r causes e x c l u d e d .
t h e r e is a s u d d e n d r o p a t t a c k w i t h o u t loss o f c o n s c i o u s n e s s . 3. Probable
T h e r e is n o v e r t i g o o r f l u c t u a t i o n s i n h e a r i n g loss. P a t i e n t a
O n e d e f i n i t i v e episode o f v e r t i g o .
gets a f e e l i n g o f h a v i n g b e e n p u s h e d t o t h e g r o u n d o r • Audiometrically documented hearing loss o n at
p o l e a x e d . I t is an u n c o m m o n m a n i f e s t a t i o n o f Meniere's least o n e o c c a s i o n .
disease a n d o c c u r s e i t h e r i n t h e e a r l y o r l a t e c o u r s e o f d i s - • T i n n i t u s o r a u r a l fullness i n t h e t r e a t e d ear.
ease. P o s s i b l e m e c h a n i s m is d e f o r m a t i o n o f t h e o t o l i t h i c O t h e r causes e x c l u d e d .
 2. B e d rest w i t h head supported o n p i l l o w s to p r e v e n t
Table 15.2 Staging o f Meniere's disease
excessive m o v e m e n t s .
Stage Pure tone average in d B in previous 6 months
3. V e s t i b u l a r sedatives to relieve v e r t i g o . T h e y s h o u l d
1 <25
be administered intramuscularly or intravenously i f v o m i t -
2 26-40
i n g precludes oral a d m i n i s t r a t i o n . D r u g s useful i n acute
3 41-70 attack are dimenhydrinate (Dramamine), promethazine
4 >70 theoclate ( A v o m i n e ) or prochlorperazine (Stemetil).
D i a z e p a m ( V a l i u m or Calmpose) 5 - 1 0 m g m a y be g i v e n
4. Possible i n t r a v e n o u s l y . I t has a t r a n q u i l l i z i n g e f f e c t a n d also s u p -
• Episodic vertigo o f Meniere's type w i t h o u t d o c u - presses t h e a c t i v i t y o f m e d i a l v e s t i b u l a r n u c l e u s .
m e n t e d h e a r i n g loss ( v e s t i b u l a r v a r i a n t ) o r I n some patients, acute attack can be stopped b y a t r o -
• Sensorineural hearing loss, fluctuating or fixed, p i n e , 0.4 m g , g i v e n subcutaneously.
w i t h d i s e q u i l i b r i u m b u t w i t h o u t d e f i n i t i v e episodes
4. Vasodilators
(cochlear variant).
• O t h e r causes e x c l u d e d . (i) Inhalation of carbogen ( 5 % C O w i t h 9 5 % O ) . I t is a
g o o d cerebral vasodilator and improves l a b y r i n t h i n e
circulation.
Staging o f Meniere's Disease
(ii) Histamine drip. H i s t a m i n e d i p h o s p h a t e , 2.75 m g dissolved
T h i s can b e d o n e i n c e r t a i n a n d d e f i n i t e cases o f M e n i e r e ' s i n 5 0 0 m l o f g l u c o s e , g i v e n as i . v . d r i p at a s l o w rate is
disease. I t is b a s e d o n a v e r a g e o f t h e p u r e t o n e thresholds also a g o o d v a s o d i l a t o r a n d helps t o c o n t r o l acute attacks.
at 0 . 5 , 1 , 2, 3 k H z ( r o u n d e d t o nearest w h o l e ) o f t h e w o r s t A d v e r s e effects o f h i s t a m i n e i n c l u d e t a c h y c a r d i a , d i s -
audiogram d u r i n g interval o f 6 m o n t h s before treatment turbances o f cardiac rhythm, hypotension, hyper-
(see T a b l e 15.2). t h e r m i a a n d b r o n c h o s p a s m . I t s h o u l d n o t be u s e d o n
e m p t y s t o m a c h a n d is c o n t r a i n d i c a t e d i n a s t h m a t i c s .

Treatment
C. Management of Chronic Phase

A. General Measures W h e n p a t i e n t presents after t h e acute attack, t h e t r e a t m e n t

consists o f :
1. R e a s s u r a n c e P a t i e n t ' s a n x i e t y c a n be r e l i e v e d b y reas-
s u r a n c e a n d b y e x p l a i n i n g t h e t r u e n a t u r e o f disease. T h i s is 1. V e s t i b u l a r s e d a t i v e s P r o c h l o r p e r a z i n e (Stemetil) l O m g ,
particularly i m p o r t a n t i n acute attack. thrice a day, orally f o r t w o m o n t h s a n d t h e n r e d u c e d to
5 m g t h r i c e a day f o r a n o t h e r m o n t h .
2. Cessation of smoking N i c o t i n e causes v a s o s p a s m .
S m o k i n g s h o u l d be c o m p l e t e l y s t o p p e d . F o r s o m e p a t i e n t s , 2. V a s o d i l a t o r s N i c o t i n i c a c i d , 5 0 m g , is t a k e n a b o u t a n
t h i s m a y b e t h e o n l y t r e a t m e n t necessary. h o u r b e f o r e m e a l s t h r i c e a d a y . T h e dose c a n b e increased

3. L o w salt d i e t P a t i e n t s h o u l d t a k e s a l t - f r e e d i e t as f a r as slowly to achieve flushing o f skin.

possible. No e x t r a salt s h o u l d b e p e r m i t t e d . Salt i n t a k e Betahistine ( V e r t i n ) 8 - 1 6 m g , thrice a day, g i v e n orally,

s h o u l d n o t e x c e e d 1.5—2.0 g / d a y . also increases l a b y r i n t h i n e b l o o d flow b y releasing hista-
mine i n the body.
4 . A v o i d excessive i n t a k e o f w a t e r

5 . A v o i d o v e r - i n d u l g e n c e i n c o f f e e , tea a n d a l c o h o l 3. D i u r e t i c s Sometimes, diuretic Furosemide, 40 m g

t a b l e t , t a k e n o n a l t e r n a t e days w i t h p o t a s s i u m s u p p l e m e n t
6 . A v o i d stress a n d b r i n g a c h a n g e i n l i f e - s t y l e M e n t a l
helps t o c o n t r o l r e c u r r e n t attacks, if not controlled by
r e l a x a t i o n exercises a n d y o g a are h e l p f u l t o decrease stress.
v a s o d i l a t o r s o r v e s t i b u l a r sedatives.
7. A v o i d activities requiring good body balance As
t h e a t t a c k o f M e n i e r e ' s disease is a b r u p t , s o m e t i m e s w i t h n o 4. Propantheline bromide (Probanthine), 1 5 m g , thrice

w a r n i n g s y m p t o m , professions s u c h as flying, under-water a day, can be g i v e n alone o r i n c o m b i n a t i o n w i t h vasodila-

d i v i n g o r w o r k i n g at great h e i g h t s s h o u l d b e a v o i d e d . t o r a n d is q u i t e e f f e c t i v e .

5. E l i m i n a t i o n o f a l l e r g e n Sometimes, a f o o d or inhal-
B. Management of Acute Attack
a n t a l l e r g e n is r e s p o n s i b l e f o r s u c h attacks. It should be

D u r i n g t h e a c u t e a t t a c k , t h e r e is severe v e r t i g o w i t h nausea f o u n d a n d e l i m i n a t e d o r desensitisation done.

a n d v o m i t i n g . P a t i e n t is a p p r e h e n s i v e . Head movements 6. H o r m o n e s I n v e s t i g a t i o n s s h o u l d be d i r e c t e d t o f i n d
p r o v o k e g i d d i n e s s . T h e r e f o r e , t r e a t m e n t w o u l d consist o f : any endocrinal disorder such as h y p o t h y r o i d i s m , and
1. R e a s s u r a n c e a n d p s y c h o l o g i c a l s u p p o r t t o allay w o r r y appropriate replacement t h e r a p y g i v e n . C o n t r o l o f stress
and anxiety. b y c h a n g e i n l i f e - s t y l e is i m p o r t a n t t o p r e v e n t recurrent
 ®
Eustachian tube Cochlear aqueduct

Figure 15.6

M e c h a n i s m o f i n t e r m i t t e n t l o w pressure pulse t h e r a p y . Pressure waves pass t h r o u g h v e n t i l a t i o n t u b e ( 1 ) t o r o u n d w i n d o w m e m b r a n e

( 2 ) a n d t r a n s m i t t e d t o p e r i l y m p h ( y e l l o w ) a n d c o m p r e s s e n d o l y m p h a t i c l a b y r i n t h ( b l u e ) t o r e d i s t r i b u t e e n d o l y m p h pressure t o sac
( 3 ) a n d b l o o d vessels ( 4 ) .

attacks. A b o u t 8 0 % o f t h e p a t i e n t s c a n b e e f f e c t i v e l y m a n - (iv) Section of vestibular nerve. The n e r v e is e x p o s e d by

aged b y m e d i c a l therapy alone. r e t r o s i g m o i d o r m i d d l e c r a n i a l fossa a p p r o a c h and

Intratympanic gentamicin therapy (chemical laby- selectively sectioned. It controls vertigo but pre-

rinthectomy). G e n t a m i c i n is m a i n l y v e s t i b u l o t o x i c . I t has serves h e a r i n g .

b e e n used i n daily o r b i w e e k l y injections i n t o the m i d d l e (v) Ultrasonic destruction of vestibular labyrinth. Cochlear

ear. D r u g is a b s o r b e d t h r o u g h the r o u n d w i n d o w and f u n c t i o n is p r e s e r v e d .

causes d e s t r u c t i o n o f t h e v e s t i b u l a r l a b y r i n t h . T o t a l c o n -
2. D e s t r u c t i v e p r o c e d u r e s T h e y totally destroy cochlear
trol o f v e r t i g o spells has b e e n r e p o r t e d i n 60—80% of
and vestibular f u n c t i o n a n d are thus used only when
patients w i t h some r e l i e f f r o m s y m p t o m s i n others. H e a r i n g
c o c h l e a r f u n c t i o n is n o t serviceable.
loss, s o m e t i m e s severe a n d p r o f o u n d , has b e e n r e p o r t e d i n
Labyrinthectomy. Membranous l a b y r i n t h is completely
4-30% o f patients treated w i t h this m o d e o f therapy.
d e s t r o y e d either b y o p e n i n g t h r o u g h the lateral s e m i c i r c u -
lar c a n a l b y t r a n s m a s t o i d r o u t e o r t h r o u g h t h e o v a l w i n -
D. Surgical Treatment
dow b y a transcanal a p p r o a c h . T h i s gives r e l i e f f r o m the
I t is u s e d o n l y w h e n m e d i c a l t r e a t m e n t fails. attacks o f v e r t i g o .
Intermittent low pressure pulse therapy [Meniett device therapy
1. Conservative procedures They are used i n cases
(Fig. 1 5 . 6 ) ] . I t is o b s e r v e d t h a t i n t e r m i t t e n t p o s i t i v e p r e s -
w h e r e v e r t i g o is d i s a b l i n g b u t h e a r i n g is s t i l l u s e f u l a n d
sure d e l i v e r e d t o i n n e r ear f l u i d s b r i n g s r e l i e f f r o m the
needs t o be preserved. T h e y are:
s y m p t o m s o f M e n i e r e ' s disease. N o t o n l y t h e r e is i m p r o v e -
(i) Decompression of endolymphatic sac. m e n t i n v e r t i g o , t i n n i t u s a n d ear f u l l n e s s , b u t h e a r i n g m a y
(ii) Endolymphatic shunt operation. A t u b e is p u t , c o n n e c t - also i m p r o v e . I n t e r m i t t e n t p o s i t i v e pressure w a v e s c a n be
i n g e n d o l y m p h a t i c sac w i t h s u b a r a c h n o i d space, t o delivered t h r o u g h an i n s t r u m e n t called M e n i e t t device
d r a i n excess e n d o l y m p h . w h i c h has b e e n a p p r o v e d b y F D A . A p r e r e q u i s i t e f o r s u c h
(iii) Sacculotomy (Fick's o p e r a t i o n ) . I t is p u n c t u r i n g t h e a t h e r a p y is t o p e r f o r m a m y r i n g o t o m y a n d i n s e r t a v e n t i -
saccule w i t h a n e e d l e t h r o u g h stapes f o o t p l a t e . A d i s - l a t i o n t u b e so t h a t t h e d e v i c e w h e n c o u p l e d t o t h e exter-
t e n d e d saccule lies close t o stapes f o o t p l a t e a n d c a n nal ear c a n a l can d e l i v e r pressure waves t o the round
b e easily p e n e t r a t e d . C o d y ' s t a c k p r o c e d u r e consists o f w i n d o w m e m b r a n e v i a t h e v e n t i l a t i o n t u b e . Pressure w a v e s
p l a c i n g a stainless steel tack t h r o u g h t h e stapes f o o t p l a t e . pass t h r o u g h t h e p e r i l y m p h a n d cause r e d u c t i o n i n e n d o -
T h e t a c k w o u l d cause p e r i o d i c d e c o m p r e s s i o n o f the l y m p h pressure b y r e d i s t r i b u t i n g i t t h r o u g h v a r i o u s c o m -
saccule w h e n i t gets d i s t e n d e d . B o t h these o p e r a t i o n s m u n i c a t i o n c h a n n e l s s u c h as t h e e n d o l y m p h a t i c sac o r t h e
w e r e c l a i m e d t o have s h o w n g o o d results b u t they b l o o d vessels ( F i g . 1 5 . 6 ) . S o m e b e l i e v e t h e y r e g u l a t e s e c r e -
c o u l d n o t be r e p r o d u c e d b y others a n d thus abandoned. t i o n o f e n d o l y m p h b y t h e stria vascularis.
Cochleosacculotomy is a n o t h e r s i m i l a r p r o c e d u r e i n Patient c a n s e l f - a d m i n i s t e r t h e t r e a t m e n t at h o m e . It
w h i c h , instead o f saccule, c o c h l e a r d u c t is p u n c t u r e d may require a f e w m o n t h s before complete remission of
and drained i n t o the p e r i l y m p h (otic-periotic shunt). disease is o b t a i n e d . M e n i e t t d e v i c e t h e r a p y has b e e n r e c -
T h e p r o c e d u r e is p e r f o n n e d w i t h a c u r v e d needle passed o m m e n d e d f o r patients w h o have failed m e d i c a l t r e a t m e n t
t h r o u g h the r o u n d w i n d o w to p u n c t u r e cochlear duct. a n d t h e s u r g i c a l o p t i o n s are b e i n g c o n s i d e r e d .
T u m o u r s o f External Ear

O f a l l t h e cases o f ear c a r c i n o m a , 8 5 % o c c u r o n t h e p i n n a . 2 . S e b a c e o u s c y s t C o m m o n site is p o s t a u r i c u l a r sulcus

1 0 % i n t h e e x t e r n a l cana! a n d 5%) i n t h e m i d d l e ear. o r b e l o w a n d b e h i n d t h e ear l o b u l e . T r e a t m e n t is t o t a l
T u m o u r s o f t h e e x t e r n a l ear m a y arise f r o m t h e p i n n a o r surgical excision.
e x t e r n a l a u d i t o r y canal (Table 16.1).
3. Dermoid c y s t U s u a l l y p r e s e n t s as a r o u n d e d mass
over the upper part o f mastoid b e h i n d the p i n n a .

TUMOURS OF AURICLE 4. K e l o i d I t o f t e n f o l l o w s t r a u m a s u c h as p i e r c i n g t h e ear

lobule for ornaments o r a surgical i n c i s i o n (Fig. 16.1).
T h e r e is a g e n e t i c s u s c e p t i b i l i t y . B l a c k races are m o r e o f t e n
Benign Tumours
a f f e c t e d . K e l o i d p r e s e n t s as a p e d u n c u l a t e d t u m o u r . T r e a t -
m e n t is s u r g i c a l e x c i s i o n w i t h i n j e c t i o n o f t r i a m c i n o l o n e
I. Preauricular sinus or cyst T h i s results f r o m f a u l t y i n t o t h e s u r g i c a l site o r i m m e d i a t e p o s t - o p e r a t i v e r a d i a t i o n
u n i o n o f h i l l o c k s o f t h e 1st a n d 2 n d b r a n c h i a l arches d u r - of300rads.
i n g t h e d e v e l o p m e n t o f p i n n a . P r e a u r i c u l a r sinus p r e s e n t s
as a s m a l l o p e n i n g i n f r o n t o f t h e crus o f h e l i x . I t has a
b r a n c h i n g tract l i n e d by squamous e p i t h e l i u m w h i c h w h e n
b l o c k e d results i n a r e t e n t i o n cyst. P a t i e n t u s u a l l y p r e s e n t s
w i t h a cyst w h i c h is i n f e c t e d . S u r g e r y is i n d i c a t e d i f t h e r e
is u n s i g h t l y s w e l l i n g o r i n f e c t i o n . C y s t o r sinus t r a c t m u s t
be excised c o m p l e t e l y to a v o i d recurrence.

Table 16.1 T u m o u r s o f external ear

Pinna External ear canal

Benign Benign
• Preauricular cyst or sinus • O s t e o m a

• Sebaceous cyst • Exostosis

• D e r m o i d cyst • C e r u m i n o m a

• Keloid • Sebaceous a d e n o m a

• H a e m a n g i o m a • Papilloma

• Papilloma
Malignant
• C u t a n e o u s horn
• S q u a m o u s cell carcinoma
• K e r a t o a c a n t h o m a
• Basal cell c a r c i n o m a
• N e u r o f i b r o m a
• A d e n o c a r c i n o m a

Malignant • Malignant c e r u m i n o m a

Figure 16.1
• S q u a m o u s cell carcinoma • M e l a n o m a

• Basal cell c a r c i n o m a

• M e l a n o m a Keloid following p i e r c i n g o f ear lobule for an ear ring.

5. H a e m a n g i o m a s T h e y are c o n g e n i t a l t u m o u r s o f t e n
seen i n c h i l d h o o d . O t h e r parts o f face a n d n e c k m a y also
b e i n v o l v e d . T h e y are o f t w o t y p e s :

(a) Capillary haemangioma. I t is a mass o f c a p i l l a r y - s i z e d

b l o o d vessels a n d m a y p r e s e n t as a " p o r t - w i n e s t a i n " .
I t d o e s n o t regress s p o n t a n e o u s l y .
(b) Cavernous haemangioma (also c a l l e d s t r a w b e r r y t u m o u r ) .
I t consists o f e n d o t h e l i a l - l i n e d spaces f i l l e d w i t h b l o o d .
I t increases r a p i d l y d u i i n g t h e f i r s t y e a r b u t regresses
thereafter a n d m a y c o m p l e t e l y disappear b y the f i f t h
year.

6. P a p i l l o m a ( w a r t ) I t m a y p r e s e n t as a t u f t e d g r o w t h o r
f l a t g r e y p l a q u e a n d is r o u g h t o f e e l . I t is v i r a l i n o r i g i n .
T r e a t m e n t is s u r g i c a l e x c i s i o n o r c u r e t t a g e w i t h cauterisa-
t i o n o f its base.

7. C u t a n e o u s horn I t is a f o r m o f p a p i l l o m a w i t h h e a p -
i n g u p o f k e r a t i n a n d presents as h o r n - s h a p e d t u m o u r . I t is
Figure 16.2
o f t e n seen at t h e rim o f h e l i x i n e l d e r l y p e o p l e . T r e a t m e n t
is s u r g i c a l e x c i s i o n . S q u a m o u s cell c a r c i n o m a o f pinna.

8. Keratoacanthoma I t is a b e n i g n t u m o u r c l i n i c a l l y
r e s e m b l i n g a m a l i g n a n t o n e . I t presents as a r a i s e d n o d u l e
w i t h a central crater. I n i t i a l l y , i t g r o w s r a p i d l y b u t s l o w l y
regresses l e a v i n g a scar. T r e a t m e n t is e x c i s i o n b i o p s y .
9. N e u r o f i b r o m a I t presents as a n o n - t e n d e r , f i r m s w e l l -
i n g a n d m a y b e associated w i t h v o n R e c k l i n g h a u s e n ' s
ease. T r e a t m e n t is s u r g i c a l e x c i s i o n , i f t u m o u r o c c l u d e s
c a n a l o r presents a c o s m e t i c p r o b l e m .
Malignant T u m o u r s
1. Squamous cell c a r c i n o m a T h e site o f p r e d i l e c t i o n is
t h e h e l i x ( F i g . 1 6 . 2 ) . I t m a y p r e s e n t as a painless n o d u l e o r
an ulcer w i t h raised e v e r t e d edges a n d i n d u r a t e d base.
Metastases t o r e g i o n a l l y m p h n o d e s o c c u r v e r y l a t e . Disease
is m o r e c o m m o n i n m a l e s i n t h e i r f i f t i e s w h o h a d p r o -
longed exposure to direct sunlight. Fair-complexioned
p e o p l e are m o r e p r o n e .
Treatment. S m a l l lesions w i t h n o n o d a l metastases are
e x c i s e d l o c a l l y w i t h 1 c m o f h e a l t h y area a r o u n d i t . L a r g e r
lesions o f t h e p i n n a o r those c o m i n g w i t h i n 1 c m o f e x t e r -
n a l a u d i t o r y c a n a l a n d lesions w i t h n o d a l metastases, m a y
require total a m p u t a t i o n o f the p i n n a , o f t e n w i t h en b l o c
removal o f parotid gland and cervical l y m p h nodes.
2. Basal cell c a r c i n o m a T h e c o m m o n sites are t h e h e l i x
a n d t h e t r a g u s . I t is m o r e c o m m o n i n m e n b e y o n d 50 years
o f age. I t presents as a n o d u l e w i t h c e n t r a l c r u s t , r e m o v a l
o f w h i c h results i n b l e e d i n g . U l c e r has a r a i s e d o r b e a d e d
edge. L e s i o n o f t e n extends c i r c u m f e r e n t i a l l y i n t o the skin
b u t m a y penetrate deeper, i n v o l v i n g cartilage or bone.
L y m p h n o d e metastases u s u a l l y d o n o t o c c u r .
Treatment. S u p e r f i c i a l lesions, not involving cartilage,
can b e i r r a d i a t e d a n d c o s m e t i c d e f o r m i t y a v o i d e d . L e s i o n s
i n v o l v i n g c a r t i l a g e m a y r e q u i r e s u r g i c a l e x c i s i o n as i n cases
o f squamous cell carcinoma.
dis-
3. M e l a n o m a I t m a y occur a n y w h e r e over the auricle.
ear
I t is m o r e c o m m o n i n m e n o f l i g h t c o m p l e x i o n w h o are
exposed t o s u n . Metastases are seen i n 16—50% o f t h e
cases.
Treatment. S u p e r f i c i a l m e l a n o m a , less t h a n 1 c m i n d i a m -
eter, s i t u a t e d o v e r t h e h e l i x , is m a n a g e d b y w e d g e r e s e c t i o n
and p r i m a r y closure.
Superficial m e l a n o m a , larger than 1 c m , infiltrative m e l -
a n o m a s , m e l a n o m a o f p o s t e r i o r a u r i c u l a r surface o r c o n -
cha a n d all r e c u r r e n t m e l a n o m a s are t r e a t e d b y r e s e c t i o n o f
p i n n a , p a r o t i d e c t o m y and radical neck dissection.
TUMOURS OF EXTERNAL AUDITORY CANAL
Benign T u m o u r s
1. Osteoma I t arises f r o m c a n c e l l o u s b o n e a n d presents
as a s i n g l e , s m o o t h , b o n y , h a r d , p e d u n c u l a t e d t u m o u r , o f t e n
a r i s i n g f r o m t h e p o s t e r i o r w a l l o f t h e osseous m e a t u s , n e a r
its o u t e r e n d . T r e a t m e n t is s u r g i c a l r e m o v a l b y f r a c t u r i n g
t h r o u g h its p e d i c l e o r r e m o v a l w i t h a d r i l l .
2. E x o s t o s e s T h e y are m u l t i p l e a n d b i l a t e r a l , o f t e n p r e -
s e n t i n g as s m o o t h , sessile, b o n y s w e l l i n g s i n t h e deeper
part o f the meatus near the t y m p a n i c m e m b r a n e . They
arise f r o m c o m p a c t b o n e . E x o s t o s i s is o f t e n seen i n persons
 Tumours of External Ear

e x p o s e d t o e n t r y o f c o l d w a t e r i n t h e m e a t u s as i n d i v e r s
Malignant T u m o u r s
a n d s w i m m e r s . M a l e s are a f f e c t e d t h r e e t i m e s m o r e t h a n
females.
1. Squamous cell c a r c i n o m a M o s t o f t e n , i t is s e e n i n
Treatment. W h e n small and asymptomatic, n o treatment
cases o f l o n g - s t a n d i n g ear d i s c h a r g e . I t m a y arise p r i m a r i l y
is necessary. L a r g e r o n e s , w h i c h i m p a i r h e a r i n g o r cause
f r o m the meatus or be a secondary extension from the
r e t e n t i o n o f w a x a n d d e b r i s , m a y be r e m o v e d w i t h high
m i d d l e ear carcinoma.
s p e e d d r i l l t o r e s t o r e n o r m a l sized m e a t u s . E x o s t o s e s m a y
Presenting symptoms are: b l o o d staining o f hitherto
e x t e n d d e e p l y a n d l i e i n close r e l a t i o n t o t h e f a c i a l n e r v e .
m u c o p u r u l e n t o r p u r u l e n t d i s c h a r g e a n d severe e a r a c h e .
T h e r e f o r e , use o f g o u g e a n d h a m m e r s h o u l d b e a v o i d e d .
E x a m i n a t i o n m a y s h o w a n u l c e r a t e d area i n t h e m e a t u s
3. C e r u m i n o m a I t is a t u m o u r o f m o d i f i e d s w e a t glands o r a b l e e d i n g p o l y p o i d mass o r g r a n u l a t i o n s . F a c i a l nerve
w h i c h secrete c e r u m e n . I t presents as a s m o o t h , f i r m , s k i n - m a y be paralysed because o f l o c a l e x t e n s i o n o f disease
covered p o l y p o i d s w e l l i n g i n o u t e r part o f the meatus, g e n - t h r o u g h p o s t e r i o r m e a t a l w a l l o r its spread i n t o t h e m i d d l e
erally attached t o the posterior o r i n f e r i o r w a l l . I t obstructs ear. Regional lymph nodes (preauricular, postauricular,
the meatus l e a d i n g t o r e t e n t i o n o f w a x a n d debris. M a l i g n a n t infra-auricular and u p p e r deep cervical) m a y be i n v o l v e d .
type o u t n u m b e r s the b e n i g n b y 2:1 ratio. T r e a t m e n t is e n b l o c w i d e s u r g i c a l e x c i s i o n w i t h p o s t -
Treatment. T u m o u r has a t e n d e n c y t o r e c u r , therefore operative radiation.
w i d e surgical excision s h o u l d be d o n e a n d patient r e g u -
2. B a s a l cell a n d adenocarcinomas They can rarely
l a r l y f o l l o w e d u p . S o m e o f t h e c e r u m i n o m a s are m a l i g n a n t
arise f r o m t h e m e a t u s . C l i n i c a l p i c t u r e is s i m i l a r to t h a t o f
a n d i f t h e r e is a n y s u s p i c i o n o f m a l i g n a n c y o n h i s t o l o g y ,
s q u a m o u s c e l l v a r i e t y . D i a g n o s i s is m a d e o n l y o n b i o p s y .
p o s t - o p e r a t i v e r a d i o t h e r a p y s h o u l d be g i v e n .
Treatment is w i d e s u r g i c a l e x c i s i o n and post-operative

4. Sebaceous a d e n o m a I t arises from sebaceous g l a n d s radiation.

o f t h e m e a t u s a n d presents as a s m o o t h , s k i n - c o v e r e d s w e l l - 3. M a l i g n a n t ceruminoma M a l i g n a n t t y p e is t w i c e as
i n g i n t h e o u t e r m e a t u s . T r e a t m e n t is s u r g i c a l e x c i s i o n . c o m m o n as b e n i g n .

5. P a p i l l o m a S i m i l a r t o t h e o n e seen o n t h e p i n n a . 4. Malignant m e l a n o m a Rare tumour.

 f u m o u r s o f M i d d l e Ear and M a s t o i d

n o contractile muscle coat, a c c o u n t i n g f o r profuse b l e e d -

CLASSIFICATION
ing f r o m the tumours.
F o r p u r p o s e s o f d i a g n o s i s a n d t r e a t m e n t , t w o t y p e s are

T u m o u r s o f m i d d l e ear a n d m a s t o i d c a n b e d i v i d e d i n t o : differentiated.

1. G l o m u s jugulare T h e y arise f r o m t h e d o m e o f j u g u -
1. Primary Tumours
lar b u l b , i n v a d e the h y p o t y m p a n u m a n d j u g u l a r f o r a m e n ,

Benign: Glomus tumour c a u s i n g n e u r o l o g i c a l signs o f I X t h t o X l l t h c r a n i a l n e r v e

M a l i g n a n t : C a r c i n o m a , sarcoma i n v o l v e m e n t . T h e y may compress j u g u l a r v e i n o r invade

its l u m e n .
2. Secondary Tumours
2. G l o m u s t y m p a n i c u m T h e y arise from t h e p r o m o n -

(a) From adjacent areas, e.g. nasopharynx, external t o r y o f t h e m i d d l e ear a n d cause a u r a l s y m p t o m s , s o m e -

meatus and the parotid. t i m e s w i t h f a c i a l paralysis.

(b) M e t a s t a t i c , e . g . f r o m c a r c i n o m a o f b r o n c h u s , breast,
k i d n e y , t h y r o i d , prostate and gastrointestinal tract. Spread of Glomus Tumour

1. T u m o u r m a y i n i t i a l l y f i l l t h e m i d d l e ear a n d l a t e r p e r -
f o r a t e t h r o u g h t h e t y m p a n i c m e m b r a n e t o p r e s e n t as
GLOMUS TUMOUR a vascular p o l y p .
2. It may invade labyrinth, petrous p y r a m i d and the
mastoid.
I t is t h e m o s t c o m m o n b e n i g n n e o p l a s m o f m i d d l e ear a n d
I t m a y i n v a d e j u g u l a r f o r a m e n a n d t h e base o f s k u l l ,
is s o - n a m e d b e c a u s e o f its o r i g i n f r o m t h e g l o m u s b o d i e s .
causing I X t h to X l l t h cranial nerve palsies.
T h e l a t t e r r e s e m b l e c a r o t i d b o d y i n s t r u c t u r e a n d are f o u n d
B y spread t h r o u g h e u s t a c h i a n t u b e , i t m a y p r e s e n t i n
i n the d o m e o f j u g u l a r b u l b or o n the p r o m o n t o r y along
the nasopharynx.
the course o f tympanic branch of IXth cranial nerve
(Jacobson's n e r v e ) . T h e t u m o u r consists o f p a r a g a n g l i o n i c It m a y spread i n t r a c r a n i a l l y t o t h e p o s t e r i o r a n d m i d -

cells d e r i v e d f r o m t h e n e u r a l crest. d l e c r a n i a l fossae.

M e t a s t a t i c s p r e a d t o l u n g s a n d b o n e s is r a r e , b u t seen
i n 4 % o f cases. M e t a s t a t i c l y m p h node enlargement
c a n also o c c u r .
Jj Aetiology and Pathology

T h e t u m o u r is o f t e n seen i n t h e m i d d l e age ( 4 0 - 5 0 y e a r s ) .
F e m a l e s are a f f e c t e d five t i m e s m o r e . Clinical Features

I t is a b e n i g n , n o n - e n c a p s u l a t e d b u t e x t r e m e l y vascular
n e o p l a s m . Its r a t e o f g r o w t h is v e r y s l o w a n d several years I n 9 0 % o f cases, s y m p t o m s p e r t a i n t o t h e ear.

m a y pass b e f o r e t h e r e is a n y c h a n g e f r o m t h e i n i t i a l s y m p - (a) W h e n t u m o u r is i n t r a t y m p a n i c Earliest s y m p t o m s

t o m s . T u m o u r is l o c a l l y i n v a s i v e . are h e a r i n g loss a n d t i n n i t u s . H e a r i n g loss is c o n d u c t i v e
M i c r o s c o p i c a l l y , i t s h o w s masses o r sheets o f e p i t h e l i a l a n d s l o w l y p r o g r e s s i v e . T i n n i t u s is p u l s a t i l e a n d o f s w i s h i n g
cells w h i c h h a v e l a r g e n u c l e i a n d a g r a n u l a r c y t o p l a s m . c h a r a c t e r , s y n c h r o n o u s w i t h p u l s e , a n d can b e t e m p o r a r i l y
There is a b u n d a n c e o f t h i n - w a l l e d b l o o d sinusoids with s t o p p e d b y c a r o t i d pressure.
 Tumours of Middle Ear and Mastoid

O t o s c o p y shows a red reflex t h r o u g h intact tympanic s p i n e w h i c h is e r o d e d i n t h e l a t t e r . C T scan also h e l p s t o

m e m b r a n e . " R i s i n g s u n " a p p e a r a n c e is seen w h e n t u m o u r differentiate it f r o m the aberrant carotid artery, h i g h or
arises f r o m t h e f l o o r o f m i d d l e ear. S o m e t i m e s , t y m p a n i c dehiscent j u g u l a r b u l b .
m e m b r a n e appears b l u i s h a n d m a y be b u l g i n g .
MRI I t g i v e s s o f t tissue e x t e n t o f t u m o u r . M a g n e t i c r e s o -
" P u l s a t i o n s i g n " ( B r o w n ' s s i g n ) is p o s i t i v e , i . e . w h e n ear
n a n c e a n g i o g r a p h y a n d v e n o g r a p h y f u r t h e r h e l p to d e l i n -
c a n a l pressure is r a i s e d w i t h Siegle's s p e c u l u m , t u m o u r p u l -
eate i n v a s i o n o f j u g u l a r b u l b a n d v e i n o r c o m p r e s s i o n of
sates v i g o r o u s l y a n d t h e n b l a n c h e s ; r e v e r s e h a p p e n s with
the carotid artery.
release o f p r e s s u r e .
CT head and M R I combined together provide an
(b) W h e n t u m o u r p r e s e n t s as a p o l y p I n addition to excellent preoperative guidance i n the differential diagno-
h e a r i n g loss a n d t i n n i t u s , t h e r e is h i s t o r y o f p r o f u s e b l e e d - sis o f p e t r o u s a p e x l e s i o n s .
i n g f r o m t h e ear e i t h e r s p o n t a n e o u s l y or o n attempts to
Four-vessel angiography I t is necessary w h e n C T head
clean i t .
shows i n v o l v e m e n t o fjugular b u l b , carotid artery or intra-
Dizziness o r v e r t i g o a n d f a c i a l paralysis m a y appear.
d u r a l e x t e n s i o n . I t also helps t o d e l i n e a t e a n y o t h e r g l o m u s
E a r a c h e is less c o m m o n t h a n i n c a r c i n o m a o f t h e e x t e r n a l
t u m o u r (as t h e y m a y b e m u l t i p l e ) , f i n d t h e f e e d i n g vessels
a n d m i d d l e ear, a n d h e l p s t o d i f f e r e n t i a t e i t .
or embolization o f t u m o u r i f required.
O t o r r h o e a m a y occur due t o secondary i n f e c t i o n and
Brain perfusion and flow studies T h e y are necessary
the c o n d i t i o n may simulate chronic suppurative otitis media
w h e n t u m o u r is p r e s s i n g o n i n t e r n a l c a r o t i d a r t e r y . I f t h e
w i t h polyp.
case n e e d s s u r g e r y , b r a i n p e r f u s i o n a n d a d e q u a c y o f c o n -
E x a m i n a t i o n reveals a r e d , v a s c u l a r polyp filling the
t r a l a t e r a l i n t e r n a l c a r o t i d a r t e r y a n d c i r c l e o f W i l l i s c a n be
meatus. I t bleeds r e a d i l y a n d p r o f u s e l y o n m a n i p u l a t i o n o r
assessed. I f n e e d e d , x e n o n b l o o d f l o w a n d i s o t o p e studies
at b i o p s y .
are d o n e f o r p r e c i s e b l o o d flow, a n d t h e risk o f s t r o k e a n d
Cranial nerve palsies T h i s is a late f e a t u r e appearing
need for surgical replacement o f internal c a r o t i d artery.
several years after a u r a l s y m p t o m s . I X t h t o X l l t h cranial
Embolization I n large t u m o u r s , e m b o l i z a t i o n o f f e e d -
n e r v e s m a y b e p a r a l y s e d . T h e r e is d y s p h a g i a a n d h o a r s e -
i n g vessels 1 - 2 days b e f o r e o p e r a t i o n h e l p s t o r e d u c e b l o o d
ness w i t h u n i l a t e r a l paralysis o f t h e soft p a l a t e , p h a r y n x a n d
loss.
v o c a l c o r d w i t h weakness o f t h e trapezius a n d sternomas-
t o i d muscles. Biopsy P r e o p e r a t i v e b i o p s y o f t h e t u m o u r f o r d i a g n o s i s is

T u m o u r m a y p r e s e n t as a mass o v e r t h e m a s t o i d o r i n never d o n e . C l i n i c a l a n d r a d i o l o g i c features are v e r y c h a r -

the nasopharynx. a c t e r i s t i c t o m a k e d i a g n o s i s . T u m o u r is v e r y v a s c u l a r a n d

Signs o f i n t r a c r a n i a l i n v o l v e m e n t m a y also o c c u r . b l e e d s p r o f u s e l y . T h e r e is also l i k e l i h o o d o f i n j u r i n g the

h i g h j u g u l a r b u l b o r aberrant internal c a r o t i d artery i f
Audible bruit A t a l l stages, a u s c u l t a t i o n w i t h s t e t h o s c o p e
d i a g n o s i s is m i s t a k e n .
o v e r the m a s t o i d m a y reveal systolic b r u i t .
S o m e g l o m u s t u m o u r s secrete c a t e c h o l a m i n e s a n d p r o -
duce s y m p t o m s like headache, sweating, palpitation, h y p e r -
Treatment
tension and anxiety, and require f u r t h e r investigations.

Rule of 10s R e m e m b e r that 10% o f the t u m o u r s are I t consists o f :

f a m i l i a l , 1 0 % m u l t i c e n t r i c a n d u p to 1 0 % f u n c t i o n a l , i.e.
1. Surgical r e m o v a l .
t h e y secrete catecholamines.
2. Radiation.
3. Embolisation.

4. C o m b i n a t i o n o f the above techniques.

Diagnosis J

Surgical approaches to glomus tumours

I n addition to t h o r o u g h history and physical examination,
1. Transcanal approach Suited for limited glomus
t h e p a t i e n t is c h e c k e d - u p t o f i n d o u t t h e e x t e n t o f t u m o u r ,
t y m p a n i c u m t u m o u r w h e r e entire circumference of
other associated g l o m u s tumours, and serum levels of
t h e t u m o u r is v i s i b l e , o n l y t y m p a n o t o m y w i l l s u f f i c e .
catecholamines or their b r e a k - d o w n products i n urine
2. Hypotympanic a p p r o a c h Suited for tumours l i m -
( v a n i l l y l m a n d e l i c acid, m e t a n e p h r i n e , etc.). Investigations
ited to p r o m o n t o r y w i t h extension to hypotympa-
include:
n u m b u t n o t i n t o t h e m a s t o i d . A s u p e r i o r l y based
C T scan-head U s i n g b o n e w i n d o w , 1 m m t h i n sections
t y m p a n o m e a t a l flap is r a i s e d b y p o s t a u r i c u l a r a p p r o a c h .
are c u t . I t h e l p s t o d i s t i n g u i s h g l o m u s t y m p a n i c u m f r o m t h e
B o n y i n f e r i o r t y m p a n i c r i n g is d r i l l e d a w a y t o see t h e
glomus jugulare t u m o u r b y identification o f caroticojugular
lower limit of tumour.
3. E x t e n d e d facial recess a p p r o a c h Used for glomus
t y m p a n i c u m extending into mastoid but not into the
j u g u l a r b u l b . I f e x t e n s i v e , m o d i f i e d radical o p e r a t i o n is
done.
4. M a s t o i d - n e c k a p p r o a c h Used for glomus jugulare
t u m o u r s n o t e x t e n d i n g to internal carotid artery, pos-
t e r i o r c r a n i a l fossa o r n e c k .
5. I n f r a t e m p o r a l fossa a p p r o a c h o f F i s c h Used for
large g l o m u s j u g u l a r e t u m o u r s .
6. Transcondylar a p p r o a c h Used for tumours extend-
i n g t o w a r d s f o r a m e n m a g n u m . U s u a l l y t h e y are r e c u r -
r e n t g l o m u s j u g u l a r e t u m o u r s . I t gives a p p r o a c h to
cranio-cervical junction with exposure o f occipital
condyle and jugular tubercle.

R a d i a t i o n t r e a t m e n t does n o t cure the t u m o u r b u t m a y

reduce its v a s c u l a r i t y a n d arrest its g r o w t h . R a d i a t i o n is
used f o r i n o p e r a b l e t u m o u r s , residual t u m o u r s , recurrences
after s u r g e r y o r f o r o l d e r i n d i v i d u a l s w h e r e e x t e n s i v e s k u l l Figure 17.1

base s u r g e r y is n o t i n d i c a t e d . S q u a m o u s cell carcinoma o f middle ear and mastoid in a

E m b o l i s a t i o n is u s e d t o r e d u c e t h e v a s c u l a r i t y o f t u m o u r 3-year-old c h i l d . He also had facial paralysis.

before surgery, or is t h e sole t r e a t m e n t in inoperable

patients w h o have received radiation.

p e t r o u s p y r a m i d t o w a r d s its a p e x . D u r a is u s u a l l y r e s i s t a n t .
I t m a y spread t o the p a r o t i d gland, t e m p o r o m a n d i b u l a r

CARCINOMA OF MIDDLE j o i n t , i n f r a t e m p o r a l fossa a n d d o w n t h e e u s t a c h i a n tube

EAR AND MASTOID t o n a s o p h a r y n x . L y m p h n o d e e n l a r g e m e n t o c c u r s late.

I t is a r a r e c o n d i t i o n , t h e r e b e i n g o n e case i n 2 0 , 0 0 0 n e w Clinical Features

p a t i e n t s e x a m i n e d , b u t i t is t h e c o m m o n e s t primary m i d -
d l e ear m a l i g n a n c y . Patient often presents w i t h clinical picture simulating
chronic suppurative otitis media. H o w e v e r , the f o l l o w i n g
features i n age g r o u p o f 4 0 - 6 0 years m a y a r o u s e s u s p i c i o n
| Aetiology J o f malignancy:

(a) Chronic foul-smelling discharge especially when

I t affects age g r o u p o f 40—60 a n d is s l i g h t l y m o r e common
blood-stained.
i n f e m a l e s . M o s t cases ( 7 5 % ) h a v e associated l o n g - s t a n d i n g
(b) P a i n w h i c h is u s u a l l y severe a n d c o m e s at n i g h t .
ear d i s c h a r g e . C h r o n i c i r r i t a t i o n m a y b e t h e c a u s a t i v e f a c -
t o r i n s u c h cases. S o m e cases are seen i n r a d i c a l m a s t o i d (c) Facial palsy.

c a v i t i e s . P r i m a r y c a r c i n o m a o f m a s t o i d air cells is also seen (d) Friable, haemorrhagic granulations or p o l y p .

i n r a d i u m dial painters. (e) A p p e a r a n c e o f o r increase i n h e a r i n g loss o r v e r t i g o .

Pathology
• • Diagnosis

D e f i n i t i v e diagnosis is m a d e o n l y o n b i o p s y . E x t e n t o f disease
T u m o u r m a y arise p r i m a r i l y f r o m m i d d l e ear o r b e an
is j u d g e d b y c l i n i c a l a n d r a d i o l o g i c a l e x a m i n a t i o n . C T scan
extension o f c a r c i n o m a o f the deep meatus. Squamous cell
a n d a n g i o g r a p h y are useful i n t h e assessment o f disease.
v a r i e t y is b y far t h e m o s t c o m m o n ( F i g . 1 7 . 1 ) . A d e n o c a r -
c i n o m a may occasionally be s e e n ; i t arises f r o m t h e g l a n -
d u l a r e l e m e n t s o f m i d d l e ear.
[ Treatment [
Spread of tumour T o begin w i t h , carcinoma destroys
ossicles, f a c i a l c a n a l , i n t e r n a l ear, j u g u l a r b u l b , carotid A c o m b i n a t i o n o f surgery and r a d i o t h e r a p y gives bet-
canal o r deep b o n y meatus a n d m a s t o i d . I t m a y spread i n t e r results. Surgery consists o f r a d i c a l mastoidectomy,
 Tumours of Middle Ear and Mastoid

subtotal or total petrosectomy, d e p e n d i n g o n the extent o f r a d i a t i o n a n d c h e m o t h e r a p y is t h e t r e a t m e n t o f c h o i c e .

of tumour. S u r g e r y is d o n e i n s e l e c t e d l o c a l i s e d l e s i o n s .
R a d i o t h e r a p y a l o n e is g i v e n as a p a l l i a t i v e m e a s u r e w h e n
Other sarcomas Osteosarcoma, lymphoma, fibrosar-
t u m o u r i n v o l v e s c r a n i a l n e r v e s ( I X t h t o X l l t h ) o r spreads
c o m a a n d c h o n d r o s a r c o m a are r a r e . D i s t a n t metastases are
i n t o the cranial cavity or the nasopharynx.
seen i n t h e l u n g s o r b o n e . P r o g n o s i s is p o o r .

SARCOMAS SECONDARY TUMOURS

Rhabdomyosarcoma I t is a r a r e t u m o u r , m o s t l y a f f e c t - T u m o u r s o f external a u d i t o r y meatus, parotid gland or

i n g c h i l d r e n . I t arises f r o m t h e e m b r y o n i c m u s c l e s tissue
o r t h e p l u r i p o t e n t i a l m e s e n c h y m e . I n e a r l y stages, i t m i m -
ics c h r o n i c s u p p u r a t i v e o t i t i s m e d i a w i t h ear discharge,
p o l y p o r g r a n u l a t i o n s . F a c i a l palsy o c c u r s e a r l y . D i a g n o s i s
is m a d e o n l y o n b i o p s y . P r o g n o s i s is p o o r . A c o m b i n a t i o n
n a s o p h a r y n x m a y i n v a d e m i d d l e ear c l e f t e i t h e r t h r o u g h
the p r e f o r m e d pathways or bone erosion.
Sometimes, t e m p o r a l b o n e is t h e site o f d i s t a n t m e t a -
stases i n a d v a n c e d cases o f c a r c i n o m a o f t h e breast, b r o n -
chus, prostate, k i d n e y or gastrointestinal tract.
Acoustic Neuroma

A c o u s t i c n e u r o m a is also k n o w n as v e s t i b u l a r s c h w a n n o m a , I n l a t e r stages, i t causes d i s p l a c e m e n t o f b r a i n s t e m , pressure

n e u r i l e m m o m a or eighth nerve t u m o u r . o n c e r e b e l l u m a n d raised i n t r a c r a n i a l t e n s i o n ( F i g . 1 8 . 2 ) .
T h e g r o w t h o f t h e t u m o u r is e x t r e m e l y s l o w a n d t h e h i s -
t o r y m a y e x t e n d o v e r several years.
[ Incidence [

Acoustic n e u r o m a constitutes 8 0 % o f all cerebellopontine Classification [

a n g l e t u m o u r s a n d 1 0 % o f all t h e b r a i n t u m o u r s .

D e p e n d i n g o n t h e size, t h e t u m o u r is c l a s s i f i e d as:

Pathology (a) I n t r a c a n a l i c u l a r ( w h e n i t is c o n f i n e d t o i n t e r n a l a u d i -
t o r y canal)
It is a benign, encapsulated, extremely slow-growing (b) S m a l l size ( u p t o 1.5 c m )
t u m o u r o f t h e 8 t h n e r v e . M i c r o s c o p i c a l l y , i t consists of (c) M e d i u m size (1.5 t o 4 c m )
e l o n g a t e d s p i n d l e cells w i t h rod-shaped nuclei lying i n (d) L a r g e size ( o v e r 4 c m )
r o w s o r palisades. B i l a t e r a l t u m o u r s are seen i n p a t i e n t s
w i t h neurofibromatosis.
Clinical Features

Origin and G r o w t h of T u m o u r
1 . A g e a n d sex T u m o u r is m o s t l y seen i n age g r o u p o f
4 0 - 6 0 y e a n . B o t h sexes are e q u a l l y a f f e c t e d .
T h e t u m o u r a l m o s t a l w a y s arises f r o m t h e S c h w a n n cells
2. C o c h l e o v e s t i b u l a r symptoms T h e y are t h e earliest
o f the vestibular, b u t rarely f r o m the cochlear division o f
s y m p t o m s w h e n t u m o u r is s t i l l i n t r a c a n a l i c u l a r a n d are
V I H t h nerve w i t h i n the i n t e r n a l a u d i t o r y canal (Fig. 18.1).
caused b y pressure o n c o c h l e a r o r v e s t i b u l a r n e r v e fibres o r
A s i t e x p a n d s , i t causes w i d e n i n g a n d e r o s i o n o f t h e canal
o n the internal auditory artery.
a n d t h e n appears i n t h e c e r e b e l l o p o n t i n e a n g l e . H e r e , i t
P r o g r e s s i v e u n i l a t e r a l s e n s o r i n e u r a l h e a r i n g loss, o f t e n
m a y g r o w anterosuperiorly to involve V t h nerve or infe-
accompanied b y t i n n i t u s , is t h e p r e s e n t i n g s y m p t o m i n
r i o r l y to i n v o l v e the I X t h , X t h a n d X l t h cranial nerves.
m a j o r i t y o f cases. T h e r e is m a r k e d d i f f i c u l t y i n u n d e r -
standing speech, o u t o f p r o p o r t i o n to the p u r e t o n e hear-
i n g loss. T h i s f e a t u r e is c h a r a c t e r i s t i c o f a c o u s t i c n e u r o m a .
Bills' bar
CN VII S o m e p a t i e n t s m a y g e t s u d d e n h e a r i n g loss.
Superior vestibular nerve Vestibular symptoms are i m b a l a n c e o r u n s t e a d i n e s s . True
(to utricle, superior and
lateral canals) v e r t i g o is s e l d o m seen.
Transverse
crest nferior vestibular 3. C r a n i a l nerve involvement (Vth nerve) T h i s is t h e
nerve (to saccule}
Foramen singulare earliest n e r v e t o b e i n v o l v e d . T h e r e is r e d u c e d corneal
(for posterior vestibular s e n s i t i v i t y , n u m b n e s s o r paraesthesia o f face. I n v o l v e m e n t
nerve to posterior canal)
o f t h i s n e r v e i n d i c a t e s t h a t t h e t u m o u r is r o u g h l y 2 . 5 c m i n

Figure 18.1 diameter a n d occupies the cerebellopontine angle.

Vllth nerve. S e n s o r y f i b r e s are a f f e c t e d e a r l y . T h e r e is
Inner aspect o f lateral end o f internal auditory canal with struc-
hypoaesthesia o f posterior meatal w a l l (Hitzelberger's sign),
tures passing through different areas.
loss o f taste (as t e s t e d b y e l e c t r o g u s t o m e t r y ) a n d r e d u c e d
 Acoustic Neuroma

A CN VIII & VII B

Figure 18.2

Acoustic n e u r o m a and its e x p a n s i o n : (A) Intracanalicular. (B) T u m o u r extending into cerebellopontine angle. (C) T u m o u r pressing

on C N V. ( D ) Very large t u m o u r pressing o n C N V, IX, X, X I , a n d brainstem and cerebellum.

l a c r i m a t i o n o n S c h i r m e r ' s test. M o t o r f i b r e s are m o r e resis- p o s s i b l e w h e n a l l cases o f u n i l a t e r a l s e n s o r i n e u r a l h e a r i n g

t a n t a n d are a f f e c t e d l a t e . D e l a y e d b l i n k r e f l e x m a y b e a n loss w i t h t i n n i t u s o r i m b a l a n c e are c a r e f u l l y e v a l u a t e d .
early m a n i f e s t a t i o n . 1 . A u d i o l o g i c a l tests See T a b l e 15.1 f o r d i f f e r e n c e b e t w e e n
IXth and Xth nerves. T h e r e is d y s p h a g i a a n d hoarseness c o c h l e a r a n d r e t r o c o c h l e a r lesions.
d u e t o p a l a t a l , p h a r y n g e a l a n d l a r y n g e a l paralysis.
(a) Pure t o n e a u d i o m e t r y w i l l s h o w sensorineural hear-
Other cranial nerves. X l t h a n d X l l t h , I l l r d , I V t h a n d V l t h
are a f f e c t e d w h e n t u m o u r is v e r y l a r g e . i n g loss, m o r e m a r k e d i n h i g h frequencies.
(b) Speech a u d i o m e t r y shows p o o r speech d i s c r i m i n a t i o n
4. Brainstem involvement There is a t a x i a , weakness
a n d t h i s is d i s p r o p o r t i o n a t e t o p u r e t o n e h e a r i n g loss.
and n u m b n e s s o f t h e a r m s a n d legs w i t h e x a g g e r a t e d ten-
R o l l - o v e r p h e n o m e n o n , i.e. r e d u c t i o n o f d i s c r i m i n a -
don r e f l e x e s . T h e y are seen w h e n l o n g m o t o r a n d s e n s o r y
t i o n s c o r e w h e n l o u d n e s s is i n c r e a s e d b e y o n d a p a r t i -
tracts are i n v o l v e d .
c u l a r l i m i t is m o s t c o m m o n l y o b s e r v e d .
5. Cerebellar involvement Pressure s y m p t o m s o n c e r e - (c) R e c r u i t m e n t p h e n o m e n o n is absent.
bellum are s e e n i n l a r g e t u m o u r s . T h i s is r e v e a l e d by (d) Short Increment Sensitivity I n d e x (SISI) test will
f i n g e r - n o s e test, k n e e - h e e l test, d y s d i a d o c h o k i n e s i a , a t a x i c s h o w a score o f 0 - 2 0 % i n 7 0 - 9 0 % o f cases.
gait, i n a b i l i t y to w a l k a l o n g a straight l i n e w i t h tendency (e) T h r e s h o l d t o n e d e c a y test s h o w s r e t r o c o c h l e a r t y p e o f
t o f a l l t o t h e a f f e c t e d side. lesion.
6. R a i s e d intracranial tension T h i s is also a late f e a t u r e .
2. S t a p e d i a l reflex d e c a y test (see p a g e 3 0 ) .
T h e r e is h e a d a c h e , nausea, v o m i t i n g , d i p l o p i a d u e t o V l t h
nerve i n v o l v e m e n t and papilloedema w i t h blurring o f vision. 3 . V e s t i b u l a r tests C a l o r i c test w i l l s h o w d i m i n i s h e d o r
a b s e n t r e s p o n s e i n 9 6 % o f p a t i e n t s . W h e n t u m o u r is v e r y
s m a l l , c a l o r i c test m a y b e n o r m a l .

J Investigations and D i a g n o s i s J 4. Neurological tests C o m p l e t e e x a m i n a t i o n o f cranial

n e r v e s , c e r e b e l l a r f u n c t i o n s , b r a i n s t e m signs o f p y r a m i d a l
A t t e m p t s s h o u l d b e m a d e t o d i a g n o s e t h e t u m o u r i n its a n d sensory tracts s h o u l d b e d o n e . F u n d u s is e x a m i n e d f o r
o t o l o g i c a l p h a s e w h e n i t is s t i l l i n t r a c a n a l i c u l a r . T h i s is b l u r r i n g o f disc m a r g i n s o r p a p i l l o e d e m a .
5 . R a d i o l o g i c a l tests
Table 18.1 T u m o u r s o f cerebellopontine angle

(a) Plain X-rays (transorbital, Stenver's, T o w n e ' s a n d sub-

Acoustic n e u r o m a
mentovertical views) give positive findings i n 80% of M e n i n g i o m a
p a t i e n t s . H o w e v e r , s m a l l i n t r a c a n a l i c u l a r t u m o u r s are Epidermoid (cholesteatoma)

n o t detected. A r a c h n o i d cyst

(b) CT scan. A t u m o u r t h a t p r o j e c t s e v e n 0.5 c m i n t o t h e S c h w a n n o m a o f other cranial nerves

p o s t e r i o r fossa c a n b e d e t e c t e d b y a C T scan. I f c o m - (e.g. C N V > V I I > I X , X, XI)

b i n e d w i t h i n t r a t h e c a l air, e v e n t h e i n t r a m e a t a l t u m o u r Aneurysm

c a n b e d e t e c t e d . C T scan has r e p l a c e d e a r l i e r m e t h o d s G l o m u s t u m o u r

o f pneumoencephalography and m y o d i l meatography. Metastasis

(c) MRI with gadolinium contrast. I t is s u p e r i o r t o C T scan

a n d is t h e gold standard f o r diagnosis o f acoustic neu-
roma. Intracanalicular t u m o u r , o f even a f e w m i l l i m e -
tres, c a n b e easily d i a g n o s e d b y this m e t h o d .
Treatment
(d) Vertebral angiography. T h i s is h e l p f u l t o d i f f e r e n t i a t e
acoustic neuroma from other tumours o f cerebello-
Surgery
p o n t i n e a n g l e w h e n d o u b t exists.

S u r g i c a l r e m o v a l o f t h e t u m o u r is t h e t r e a t m e n t o f c h o i c e .
6. E v o k e d response audiometry (BERA) I t is v e r y
S u r g i c a l a p p r o a c h w i l l d e p e n d u p o n t h e size o f t u m o u r .
useful i n the diagnosis o f r e t r o c o c h l e a r lesions. I n t h e pres-
T h e various approaches are:
ence o f V I H t h nerve t u m o u r , a delay o f > 0 . 2 m s e c i n
w a v e V b e t w e e n t w o ears is s i g n i f i c a n t (see p a g e 3 1 ) . 1. M i d d l e c r a n i a l fossa a p p r o a c h .

7. CSF examination P r o t e i n l e v e l is r a i s e d . Lumbar 2. Translabyrinthine approach.

p u n c t u r e is u s u a l l y a v o i d e d . I m p o r t a n t tests f o r w o r k - u p 3. Suboccipital (retrosigmoid) approach.

o f a c o u s t i c n e u r o m a are g i v e n b e l o w : 4. C o m b i n e d translabyrinthine-suboccipital approach.

Radiotherapy
Important T e s t s for W o r k - u p of
Conventional radiotherapy b y e x t e r n a l b e a m has n o r o l e i n
Acoustic N e u r o m a 1 the t r e a t m e n t o f acoustic n e u r o m a s d u e to l o w tolerance
o f the central nervous system t o radiation.
Pure tone audiometry
X-knife or Gamma knife surgery. I t is a f o r m o f s t e r e o -
S p e e c h d i s c r i m i n a t i o n score
t a c t i c r a d i o t h e r a p y w h e r e r a d i a t i o n e n e r g y is c o n v e r g e d o n
R o l l - o v e r curve
t h e t u m o u r , t h u s m i n i m i s i n g its e f f e c t o n t h e s u r r o u n d i n g
Stapedial r e f l e x decay
n o r m a l tissue. T h i s causes arrest o f t h e g r o w t h o f t h e t u m o u r
E v o k e d response a u d i o m e t r y
a n d also r e d u c t i o n i n its size. I t c a n b e u s e d i n p a t i e n t s
M R I with contrast
w h o refuse surgery o r have c o n t r a i n d i c a t i o n s t o surgery o r
i n those w i t h a residual t u m o u r .
Differential Diagnosis X - k n i f e s u r g e r y is d o n e t h r o u g h l i n e a r a c c e l e r a t o r a n d
gamma knife through a Cobalt-60 source.
Acoustic neuroma should be differentiated f r o m the Cyber knife: I t is a n i m p r o v e m e n t o v e r t h e a b o v e . It
c o c h l e a r p a t h o l o g y ( i . e . M e n i e r e ' s disease) a n d o t h e r c e r e - is t o t a l l y frameless a n d m o r e accurate. I t uses r e a l - t i m e
b e l l o p o n t i n e angle t u m o u r s , e.g. meningioma, primary image guidance technology t h r o u g h computer controlled
c h o l e s t e a t o m a a n d a r a c h n o i d a l cyst ( T a b l e 18.1). robotics.
The Deaf Child

C h i l d r e n w i t h p r o f o u n d ( > 9 0 d B loss) o r t o t a l deafness f a i l a n d s a c c u l e ; h e n c e also c a l l e d cochleosaccular dysplasia.

t o d e v e l o p s p e e c h a n d h a v e o f t e n b e e n t e r m e d as deaf-mute I t is i n h e r i t e d as a n a u t o s o m a l recessive n o n - s y n d r o m i c
o r deaf and dumb. H o w e v e r , these c h i l d r e n h a v e n o d e f e c t trait.
i n t h e i r s p e e c h p r o d u c i n g a p p a r a t u s . T h e m a i n d e f e c t is (ii) Alexander's dysplasia. I t affects o n l y t h e basal t u r n of
deafness. T h e y h a v e n e v e r h e a r d s p e e c h a n d t h e r e f o r e d o membranous cochlea. Thus only high frequencies
n o t d e v e l o p i t . I n lesser degrees o f h e a r i n g loss, speech are a f f e c t e d . R e s i d u a l h e a r i n g is p r e s e n t i n l o w fre-
does d e v e l o p b u t is d e f e c t i v e . T h e p e r i o d f r o m b i r t h t o 5 quencies and can be e x p l o i t e d b y a m p l i f i c a t i o n w i t h
years o f l i f e is c r i t i c a l f o r t h e d e v e l o p m e n t o f s p e e c h a n d h e a r i n g aids.
l a n g u a g e , t h e r e f o r e , t h e r e is n e e d f o r e a r l y i d e n t i f i c a t i o n ( i i i r Bing-Siebenmann dysplasia. T h e r e is c o m p l e t e absence
a n d assessment o f h e a r i n g loss a n d e a r l y r e h a b i l i t a t i o n i n of membranous labyrinth.
infants a n d c h i l d r e n . I t was o b s e r v e d that c h i l d r e n w h o s e (iv) Michel aplasia. T h e r e is c o m p l e t e absence o f b o n y a n d
h e a r i n g loss w a s o b s e r v e d a n d m a n a g e d b e f o r e 6 m o n t h s m e m b r a n o u s l a b y r i n t h . E v e n t h e p e t r o u s apex is absent
o f age h a d h i g h e r scores o f v o c a b u l a r y , b e t t e r expressive but external and middle ears m a y b e completely
a n d c o m p r e h e n s i v e l a n g u a g e skills t h a n t h o s e diagnosed u n a f f e c t e d . N o h e a r i n g aids o r c o c h l e a r i m p l a n t a t i o n
a n d m a n a g e d a f t e r 6 m o n t h s o f age e m p h a s i s i n g t h e i m p o r - can be used.
tance o f early i d e n t i f i c a t i o n a n d t r e a t m e n t . (v) Mondini's dysplasia. O n l y basal c o i l is p r e s e n t o r c o c h l e a
is 1.5 t u r n s . T h e r e is i n c o m p l e t e p a r t i t i o n b e t w e e n
t h e scalae d u e t o absence o f osseous s p i n a l l a m i n a .
C o n d i t i o n is u n i l a t e r a l o r b i l a t e r a l . T h i s deformity
B Aetiology J
m a y b e seen i n P e n d r e d , W a a r d e n b u r g , B r a n c h i o -
oto-renal, Treacher-Collins and Wildervanch
H e a r i n g loss i n a c h i l d m a y d e v e l o p f r o m causes b e f o r e b i r t h
syndromes.
(prenatal), d u r i n g b i r t h (perinatal) o r thereafter (postnatal).
(vi) Enlarged vestibular aqueduct. Vestibular aqueduct is
e n l a r g e d ( > 2 m m ) , e n d o l y m p h a t i c sac is also e n l a r g e d
A. Prenatal Causes a n d c a n b e seen o n T 2 M R I . I t causes e a r l y o n s e t
sensorineural hearing loss which is progressive.
T h e y m a y pertain to the infant or the m o t h e r .
V e r t i g o m a y be present. P e r i l y m p h a t i c fistula m a y
1 . I n f a n t f a c t o r s A n i n f a n t m a y b e b o r n w i t h i n n e r ear
occur.
a n o m a l i e s d u e t o g e n e t i c o r n o n - g e n e t i c causes. A n o m a l i e s
( v i i ) Semicircular canal malformations. B o t h superior and lat-
m a y a f f e c t i n n e r ear a l o n e ( n o n - s y n d r o m i c ) o r m a y f o r m
e r a l o r o n l y l a t e r a l s e m i c i r c u l a r canal m a l f o r m a t i o n s
part o f a syndrome (syndromic).
m a y be seen. T h e y c a n be i d e n t i f i e d o n i m a g i n g
A n o m a l i e s a f f e c t i n g t h e i n n e r ear m a y i n v o l v e o n l y t h e
techniques.
membranous labyrinth or b o t h the membranous and b o n y
labyrinths. T h e y include: 2. M a t e r n a l factors

(i) Sheibe's dysplasia. I t is t h e m o s t c o m m o n i n n e r ear (a) Infections

a n o m a l y . B o n y l a b y r i n t h is n o r m a l . S u p e r i o r p a r t o f (b) Drugs during pregnancy
membranous labyrinth (utricle and semicircular (c) R a d i a t i o n t o m o t h e r i n the first trimester
d u c t s ) is also n o r m a l . D y s p l a s i a is seen i n t h e c o c h l e a (d) O t h e r factors
 4. Neonatal j a u n d i c e B i l i r u b i n l e v e l greater t h a n 2 0 m g %
damages the cochlear n u c l e i .

5. N e o n a t a l meningitis

6. Sepsis

7. T i m e s p e n t i n n e o n a t a l I C U

8. O t o t o x i c drugs used for neonatal meningitis or

septicaemia.

C Postnatal Causes

1. Genetic T h o u g h deafness is g e n e t i c i t m a n i f e s t s later

i n c h i l d h o o d o r a d u l t l i f e . D e a f n e s s m a y o c c u r a l o n e as i n
familial progressive sensorineural deafness o r i n a s s o c i a t i o n w i t h
c e r t a i n s y n d r o m e s , e . g . A l p o r t ' s , K l i p p e l - F e i l , H u r l e r , etc.

2. N o n - g e n e t i c T h e y are essentially s a m e as i n a d u l t s
and include:

(i) V i r a l i n f e c t i o n s (measles, m u m p s , v a r i c e l l a , i n f l u e n z a ) ,
m e n i n g i t i s and encephalitis.
Figure 19.1 (ii) Secretory otitis media.

Waardenburg's syndrome. Note white forelock, heterochromia (iii) O t o t o x i c drugs.

iridis a n d depigmentation o f skin. (iv) T r a u m a , e . g . f r a c t u r e s o f t e m p o r a l b o n e , m i d d l e ear

surgery o r p e r i l y m p h leak.

Syndromes c o m m o n l y associated w i t h h e a r i n g loss are (v) N o i s e - i n d u c e d deafness.

given i n Table 19.1.

(a) Infections. I n f e c t i o n s w h i c h affect t h e d e v e l o p i n g f o e - EVALUATION O F A DEAF CHILD

tus are toxoplasmosis, rubella, cytomegaloviruses,
herpes type 1 and 2 and syphilis. R e m e m b e r mne-
monic, TORCHES. Finding the C a u s e

(b) Drugs during pregnancy. Streptomycin, gentamicin,

tobramycin, amikacin, quinine or chloroquine, w h e n This m a y require a detailed history o f prenatal, perinatal or

g i v e n t o t h e p r e g n a n t m o t h e r , cross t h e p l a c e n t a l b a r - p o s t n a t a l causes, f a m i l y h i s t o r y , p h y s i c a l e x a m i n a t i o n a n d

rier and damage the cochlea. T h a l i d o m i d e n o t o n l y c e r t a i n i n v e s t i g a t i o n s d e p e n d i n g o n t h e cause s u s p e c t e d .

affects ear b u t also causes a b n o r m a l i t i e s o f l i m b s , h e a r t , Suspicion of hearing loss H e a r i n g loss is s u s p e c t e d i f

face, l i p a n d palate. (i) t h e c h i l d sleeps t h r o u g h l o u d noises u n p e r t u r b e d o r fails
(c) Radiation to mother in the first trimester. t o startle t o l o u d s o u n d , ( i i ) fails t o d e v e l o p s p e e c h at 1-2
(d) Otherfactors. N u t r i t i o n a l d e f i c i e n c y , diabetes, toxaemia years. A p a r t i a l l y h e a r i n g c h i l d m a y h a v e a d e f e c t i v e s p e e c h
a n d t h y r o i d d e f i c i e n c y . M a t e r n a l a l c o h o l i s m is also and p e r f o r m p o o r l y i n school and be labelled m e n t a l l y
teratogenic to the d e v e l o p i n g a u d i t o r y system. r e t a r d e d . I t is essential t h a t all c h i l d r e n at risk f o r h e a r i n g
loss s h o u l d b e s c r e e n e d a n d f o l l o w e d .
B. Perinatal Causes
R i s k factors for h e a r i n g loss i n c h i l d r e n (Recommen-
They r e l a t e t o causes d u r i n g b i r t h o r i n e a r l y neonatal dations o f J o i n t C o m m i t t e e o n I n f a n t H e a r i n g - — u p d a t e d
p e r i o d . T h e y are:
to 1994).
1. Anoxia I t d a m a g e s t h e c o c h l e a r n u c l e i a n d causes h a e -
(i) F a m i l y h i s t o r y o f h e a r i n g loss.
m o r r h a g e i n t o t h e ear. P l a c e n t a p r a e v i a , p r o l o n g e d l a b o u r ,
(ii) Prenatal infections (TORCHES).
c o r d r o u n d t h e n e c k a n d p r o l a p s e d c o r d c a n a l l cause f o e t a l
(iii) Craniofacial anomalies i n c l u d i n g those o f p i n n a a n d
anoxia.
ear c a n a l .
2. Prematurity and low birth weight Born before
(iv) B i r t h w e i g h t less t h a n 1 5 0 0 g (3.3 l b s ) .
t e r m o r w i t h b i r t h w e i g h t less t h a n 1 5 0 0 g.
(v) H y p e r b i l i r u b i n a e m i a r e q u i r i n g exchange transfusion.
3. B i r t h injuries, e . g . f o r c e p s d e l i v e r y . T h e y m a y cause (vi) O t o t o x i c medications included but not limited to
intracranial haemorrhage w i t h extravasation o f b l o o d i n t o a m i n o g l y c o s i d e s used i n m u l t i p l e courses o r i n c o m -
t h e i n n e r ear. bination w i t h loop diuretics.
 T h e D e a f Child

8
c

01 o
a: Q G D
< <
< <

c
41
M
c

E
&0 <u
bd
c c c
o o O o
O D U U
• U U

4-1

mi
M c
C 15 it. O
at o 0 *4->
» n)
-c "5 > >
4-4
> X
u=
u
3
U U
_l _J 0)

I I I T3
C
T5 "D EL
rt)
C C
p u
z z z O O O on
0
1/1 on U U

bo

Q. E

c
o
CL
a) rd >
5 E *
o
u _c
E
•n m c
o
i/i UJ
rS N
4-4 — ^ 1_ o
r9 -a
-Q -c c U

II
41
res:

>-.
_C -
_D_ 5 n) «
ra aj c
44
r3
c
x u 41
ca
E CL E c = K O >
aj in O .2 o o E rt o Q_ O i_
E £ p i_
Q_ 4-1 -o °
c in
4- >. >. l/l O D_ E ^ J- rt rt > •a 44 rt
o "D
itar

u 0—
"5 •£ 2 M t/l 4) 4 ) ft! 44 - Q _Q
44
4)
U
1Q 0
S O E ~o ftj
"rt
c b Ol
rd
C
41
rt
0 o a.
41 • — 4-1
4-1 ~ 1/1 O fc
T3
C
41 c
ft) 1o.
JS E E
«• QL fc 1 E
i-i ~a
0 V)
4)
c
on
V-

1 > D a: z la I
o | |
u_ I o_ nJ 41 _c D, 4-1
U 00 u_
T3
<

4) 10
C O
E u
E
me

E E E S 0
e
41
i-
E XI
2 e
C 2? = ^5
o o
- E £
— >-
in
u ~ ul CD T3
in C
in 4)
"E as >- Li.

E O
o o "ftj
CL

s Q_ = 1 CL
CL

•a u a. <

ON
Diseases o f Ear

u u
c u
l/l
•c 41
v
VI
3
-C
c rt
U
C

1 c
!-

•<
c
-C
X < i3 2 « 5 5 u
IE
in
'5!
0
D-
O
1/1
c 0
M
O
c 4-1
o V)
"D
rt
OJ
bo bC bo _E
c c u
o o o 1c
O Q U U u S
.d
j=
1-)

rt
c

S e
.o
M
1
aj
c
rt o &
0) U
u
i_
o rt
E
0 3
f t t.
~o "D 0
E c c
O O o * o o ^3

u U U E o u rt
rt
E
a.
aj
DO
C
t/l

rt
£
0
i£
0- 41
u
o E rt
c
4J
3
0 T3 O-
4)
£ c c
o o
'&0 "O
1_
~Q
•
4)
C
c in E
o >-
o ° g 0 1 "rt
E rt
1
5
n* ">
T3 E
L
4_j
8 b
rt
•il <u Si
trt
'ui : =
o ui rt «
5 rt
v 0.
O. rt
0-
7;
rt
4-i
0
c
£ rt E —; E E bO ' - U O in
T3 "5 . E
n
c
c
aj rt rt
i->
4>
rt
3
0-
rt
-g
l_
rt uai c rt
V
C IJ
- o Q_
E O
M= Ti- -c ' 5 « rt -D "O rt
rt rd
s 1 '&
rt 5 JS J- 1
*J H ™ -2 E
_E 4-1 "rt
^ -—
3
0- rt c _Q
rt rt rt 2 J5 nj w u
rt
-O P •S 'y A E
rt
. 2
U O — - °- "5_ &o u O ui - si .a o
Q.
c jo . E g 4)
^ > r

rt « 0 ,rt O v rt | E rt O c 3
rt rt E -Si ^ rt .ii O flj
oJ Q. O rt
Lo U er: on U S U O cfl I O U O LL U l I LJJ U 2 2 CL
UJ
£
on X
:;= 4J
<
u
4)
-D
u
E
0
•a
c
•A
E id
4-1
rt 0
-a E 3 B
c
cr U
c
s O
c u
3
0 CT
i 4> o 41
I E
oi tfl
rt
•a
rj
"rt
u 4>
4-1
<n rt
u
rt
CL
*
(vii) Bacterial meningitis. (b) B e h a v i o u r observation audiometry A u d i t o r y sig-
(viii) *Apgar score of 0-4 at 1 minute or 0-6 at nal presented to an i n f a n t produces a change i n b e h a v i o u r ,
5 minutes. e.g. a l e r t i n g , c e s s a t i o n o f a n a c t i v i t y , w i d e n i n g o f eyes o r
(ix) M e c h a n i c a l v e n t i l a t i o n f o r 5 days o r l o n g e r . f a c i a l g r i m a c i n g . Moro's reflex is o n e o f t h e m a n d consists o f
(x) Stigmata o r o t h e r f i n d i n g s associated w i t h a s y n - sudden movement o f limbs and extension o f head in
d r o m e k n o w n to include sensorineural and/or c o n - r e s p o n s e t o s o u n d o f 80—90 d B . I n cochleopalpebrai reflex,
d u c t i v e h e a r i n g loss. the c h i l d responds b y a b l i n k to a l o u d s o u n d . I n cessation
reflex, a n i n f a n t stops a c t i v i t y o r starts c r y i n g i n r e s p o n s e t o
a sound of90dB.
y Assessment o f H e a r i n g in I n f a n t s a n d C h i l d r e n |
(c) Distraction t e c h n i q u e s are used i n c h i l d r e n 6-7
m o n t h s o l d . T h e c h i l d at t h i s age t u r n s his h e a d t o l o c a t e
Assessment o f a u d i t o r y f u n c t i o n i n neonates, infants a n d
t h e s o u r c e o f s o u n d . I n t h i s test, t h e c h i l d is seated i n his
children demands special t e c h n i q u e s . They are grouped
m o t h e r ' s l a p , a n assistant distracts t h e c h i l d ' s a t t e n t i o n w h i l e
u n d e r t h e f o l l o w i n g heads { T a b l e 1 9 . 2 ) :
the examiner produces a sound f r o m b e h i n d or f r o m one
(a) Screening procedures T h e y are e m p l o y e d t o test
side t o see i f t h e c h i l d tries t o l o c a t e i t . S o u n d s u s e d are
h e a r i n g i n " h i g h r i s k " i n f a n t s a n d are b a s e d o n infant's
h i g h f r e q u e n c y r a t t l e (8 k H z ) , l o w f r e q u e n c y h u m , w h i s -
b e h a v i o u r a l response t o the s o u n d signal.
p e r e d s o u n d as "S, S, S", x y l o p h o n e , w a r b l e d tones or
Arousal test. A h i g h f r e q u e n c y n a r r o w b a n d n o i s e is p r e -
n a r r o w b a n d noise ( 5 0 0 - 4 0 0 0 H z ) .
s e n t e d f o r 2 s e c o n d s t o t h e i n f a n t w h e n h e is i n l i g h t sleep.
(d) C o n d i t i o n i n g techniques
A n o r m a l h e a r i n g i n f a n t can be aroused t w i c e w h e n three
Visual reinforcement audiometry (VRA). I t is a c o n d i t i o n -
s u c h s t i m u l i are p r e s e n t e d t o h i m .
i n g t e c h n i q u e i n w h i c h c h i l d is t r a i n e d t o l o o k f o r an a u d i -
Auditory response cradle is a s c r e e n i n g device for new-
tory stimulus by turning his head. This behaviour is
b o r n s , w h e r e b a b y is p l a c e d i n a c r a d l e a n d his b e h a v i o u r
r e i n f o r c e d b y a f l a s h i n g l i g h t o r a n a n i m a t e d t o y . T h i s test
( t r u n k a n d l i m b m o v e m e n t , head j e r k and respiration) i n
helps to d e t e r m i n e the h e a r i n g t h r e s h o l d u s i n g standard
r e s p o n s e t o a u d i t o r y s t i m u l a t i o n are m o n i t o r e d b y t r a n s -
a u d i o m e t r i c t e c h n i q u e s . T h e a u d i t o r y s t i m u l u s is d e l i v e r e d
d u c e r s . I t c a n s c r e e n b a b i e s w i t h m o d e r a t e , severe o r p r o -
b y h e a d p h o n e s o r b e t t e r s t i l l b y i n s e r t e a r p h o n e s w h i c h are
f o u n d h e a r i n g loss.
a c c e p t e d b e t t e r a n d are also l i g h t w e i g h t . T e s t is w e l l s u i t e d
b e t w e e n t h e d e v e l o p m e n t a l age o f 5 m o n t h s t o 2 years.
Play audiometry. T h e c h i l d is c o n d i t i o n e d t o p e r f o r m a n
I M e t h o d s o f h e a r i n g a s s e s s m e n t in infants act s u c h as p l a c i n g a m a r b l e i n a b o x , p u t t i n g a r i n g o n a
I and children p o s t o r p u t t i n g a plastic b l o c k i n a b u c k e t e a c h t i m e h e

A. Neonatal screening procedures hears a s o u n d s i g n a l . E a c h c o r r e c t p e r f o r m a n c e o f t h e act

• Arousal test is r e i n f o r c e d w i t h praise, e n c o u r a g e m e n t o r r e w a r d . Ear

• A u d i t o r y response cradle specific thresholds can be d e t e r m i n e d b y standard a u d i o -
• A B R / O A E ' s metric techniques. T h i s test c a n b e u s e d i n c h i l d r e n w i t h

B. Behaviour observation a u d i o m e t r y d e v e l o p m e n t a l age o f 2—4 o r 5 years.

• M o r o ' s reflex Speech audiometry. T h e c h i l d is a s k e d t o r e p e a t t h e n a m e s
• Cochleopalpebrai reflex o f certain objects o r t o p o i n t t h e m o u t o n the pictures. T h e
• Cessation reflex v o i c e can be gradually l o w e r e d . I n this w a y , h e a r i n g level
C. Distraction techniques a n d s p e e c h d i s c r i m i n a t i o n c a n b e t e s t e d . T h e test c a n also

D. C o n d i t i o n i n g techniques b e used t o e x a m i n e the child's expressive a b i l i t y w h e n he

• Visual reinforcement audiometry is a s k e d t o n a m e t h e t o y s l i k e h o r s e , d u c k o r o b j e c t s l i k e
• Play a u d i o m e t r y c u p , p l a t e , etc.

E. Objective tests
(e) O b j e c t i v e tests
• A B R
(i) Evoked response audiometry.
• Otoacoustic emissions
Electrocochleography. I t can measure a u d i t o r y sensitivity
• Impedance a u d i o m e t r y
t o w i t h i n 2 0 d B . B u t i t is a n i n v a s i v e p r o c e d u r e .
Auditory brainstem response. I t is n o t a d i r e c t test o f h e a r -
i n g b u t correlates h i g h l y w i t h the p u r e - t o n e thresholds.
*Developed by Virginia Apgar, an anaesthesiologist. It takes note of
Identifiable waveforms in A B R are generally present
five items: heart rate, respiratory effort, muscle tone, reflex irritability
and colour; noted at 1 and 5 minutes after birth. Low score is 0 and 10—20 d B a b o v e b e h a v i o u r a l t h r e s h o l d . A B R p r o v i d e s a n

highest 10, i.e. 2 marks for each item. ear s p e c i f i c i n f o r m a t i o n as s o u n d s t i m u l u s c a n b e presented

t o e a c h ear s e p a r a t e l y b y h e a d p h o n e s o r ear inserts. I t is a n
o b j e c t i v e test a n d c a n b e d o n e u n d e r s e d a t i o n as t h e l a t t e r
has n o e f f e c t o n A B R . A B R is u s e d b o t h as a s c r e e n i n g test
a n d as a d e f i n i t i v e h e a r i n g assessment test i n c h i l d r e n . I n a
s c r e e n i n g test, a r e s p o n s e t o a c l i c k s t i m u l u s o f 4 0 n H L o r
less is t h e c r i t e r i o n o f p a s s i n g t h e test. T o find hearing
threshold i n an infant, A B R t r a c i n g is o b t a i n e d f i r s t at
h i g h e r s o u n d stimulus and then gradually l o w e r e d till w a v e
V is j u s t i d e n t i f i a b l e b u t r e p e a t a b l e .
(ii) Otoacoustic emissions (see p a g e 3 2 ) . T r a n s i e n t evoked
e m i s s i o n s ( T E O A E ' s ) are a b s e n t i n ears w h e r e h e a r i n g loss
exceeds 3 0 d B . D i s t o r t i o n p r o d u c t emissions (DPOAE's)
are a b s e n t w h e n h e a r i n g loss e x c e e d s 5 0 d B .
( i i i ) Impedance audiometry. N o r m a l l y , stapedius muscle
c o n t r a c t s r e f l e x l y i n r e s p o n s e t o a s o u n d o f 70—100 d B H L
a n d this reflex can be r e c o r d e d . A b s e n c e o f acoustic reflex
i n d i c a t e s m i d d l e ear d i s o r d e r , r e t r o c o c h l e a r h e a r i n g loss o r
severe t o p r o f o u n d S N H L . U s e d w i t h b e h a v i o u r a u d i o m -
e t r y , a c o u s t i c r e f l e x e s are u s e f u l c o m p o n e n t t o c r o s s - c h e c k .
Absence o f acoustic reflex, b u t a n o r m a l t y m p a n o m e t r y
w i t h p a r e n t a l c o n c e r n f o r h e a r i n g loss suggests p o s s i b i l i t y
o f S N H L o f severe t o p r o f o u n d d e g r e e . A b s e n c e o f a c o u s -
tic reflex b u t an a b n o r m a l t y m p a n o g r a m generally indi-
cates c o n d u c t i v e loss. S i n c e A B R a n d O A E s p r o v i d e m o r e
i n f o r m a t i o n , use o f a c o u s t i c r e f l e x e s i n assessment o f p a e -
d i a t r i c t e s t i n g has d e c l i n e d .
O A E s and A B R have been used b o t h i n screening p r o -
grammes and i n h e a r i n g e v a l u a t i o n i n infants a n d c h i l d r e n .
Management
I t is essential t o k n o w t h e d e g r e e a n d t y p e o f h e a r i n g loss,
a n d o t h e r associated h a n d i c a p s s u c h as b l i n d n e s s o r m e n t a l
r e t a r d a t i o n a n d w h e t h e r h e a r i n g loss is p r e - l i n g u a l ( b e f o r e
development o f speech) or post-lingual. Aetiology
h e a r i n g loss r e m a i n s o b s c u r e i n a b o u t h a l f t h e cases.
A i m s o f h a b i l i t a t i o n o f a n y h e a r i n g - i m p a i r e d c h i l d are
d e v e l o p m e n t o f speech and language, adjustment i n soci-
ety and useful e m p l o y m e n t i n a v o c a t i o n .
1. Parental guidance I t is a g r e a t e m o t i o n a l s h o c k f o r
p a r e n t s t o l e a r n t h a t t h e i r c h i l d is d e a f . T h e y s h o u l d be
d e a l t w i t h s y m p a t h e t i c a l l y , so as t o a c c e p t t h e c h i l d . T h e y
s h o u l d b e t o l d o f c h i l d ' s d i s a b i l i t y a n d h o w t o care f o r i t .
H a b i l i t a t i o n o f the deaf demands a l o t f r o m parents: care
and periodic replacement o f hearing aid, change o f ear-
m o u l d s as c h i l d g r o w s , f o l l o w u p v i s i t s f o r r e e v a l u a t i o n ,
e d u c a t i o n at h o m e a n d t h e s e l e c t i o n o f v o c a t i o n .
2. H e a r i n g aids M o s t deaf c h i l d r e n have a small b u t useful
portion o f residual h e a r i n g w h i c h can be exploited by
a m p l i f i c a t i o n o f s o u n d . H e a r i n g aids s h o u l d b e p r e s c r i b e d as
e a r l y as possible. I f necessary, b i n a u r a l aids, o n e f o r e a c h ear,
c a n b e u s e d . H e a r i n g aids h e l p t o d e v e l o p l i p - r e a d i n g also.
3. D e v e l o p m e n t of speech and language Communi-
c a t i o n is a t w o w a y process, d e p e n d i n g o n t h e receptive
a n d expressive skills. R e c e p t i o n o f i n f o r m a t i o n is t h r o u g h
v i s u a l , a u d i t o r y o r t a c t i l e faculties w h i l e e x p r e s s i o n is t h r o u g h
oral o r w r i t t e n speech o r the m a n u a l sign language. I n the
h e a r i n g - i m p a i r e d , a u d i t o r y f a c u l t y is p o o r o r t o t a l l y absent
( F i g . 1 9 . 2 ) . T h u s , f o r p r o p e r c o m m u n i c a t i o n , t h e r e is n e e d
either to i m p r o v e hearing t h r o u g h a m p l i f i c a t i o n o f the
r e s i d u a l h e a r i n g o r c o c h l e a r i m p l a n t s ; a n d i n t h e absence
o f the feasibility o f d e v e l o p i n g the a u d i t o r y faculty, one
has t o d e v e l o p v i s u a l o r t a c t i l e m e a n s o f c o m m u n i c a t i o n .
(a) Auditory-oral communication. T h i s is t h e m e t h o d u s e d b y
a n o r m a l p e r s o n a n d is t h e best w a y o f c o m m u n i c a t i o n . I n
t h e deaf, i t can b e u s e d i n those w i t h m o d e r a t e t o severe
h e a r i n g loss o r t h o s e w h o are p o s t - k n g u a l l y deaf. H e a r i n g
aids are p r o v i d e d t o a u g m e n t a u d i t o r y r e c e p t i o n . A t t h e same
t i m e , t r a i n i n g is also i m p a r t e d i n speech r e a d i n g , i.e. t o r e a d
of movements o f l i p s , face, a n d n a t u r a l gestures o f h a n d a n d
b o d y . E x p r e s s i v e s k i l l is e n c o u r a g e d t h r o u g h o r a l speech.

Receptive skills Expressive skills

Written language
Lip reading Visual
Oral speech
Sign language faculty

Hearing aid
Auditory Sign language or
Cochlear implant faculty Finger spelling
Sound signal

Vibrotactile aid Written communication

(letters, electronic media, etc.

Figure 19.2

The faculties o f a hearing-impaired person which can be utilised for receptive and expressive skills in c o m m u n i c a t i o n .
 (b) Manual communication. I t m a k e s use o f t h e sign lan- 4. E d u c a t i o n o f t h e d e a f T h e r e are r e s i d e n t i a l a n d d a y
guage o r finger-spelling method b u t has t h e d i s a d v a n t a g e that s c h o o l s f o r t h e deaf. S o m e d e a f c h i l d r e n w i t h moderate
abstract ideas are d i f f i c u l t t o express a n d g e n e r a l public h e a r i n g loss c a n b e i n t e g r a t e d i n t o s c h o o l s f o r t h e n o r m a l
does n o t u n d e r s t a n d i t . c h i l d r e n w i t h p r e f e r e n t i a l s e a t i n g i n t h e class.
(c) Total communication. I t uses a l l m o d a l i t i e s o f s e n s o r y R a d i o h e a r i n g aids h a v e r e v o l u t i o n i s e d e d u c a t i o n o f t h e
i n p u t , i.e. a u d i t o r y , visual, tactile a n d kinaesthetic. Such deaf. I n t h i s d e v i c e , the m i c r o p h o n e and transmitter are
c h i l d r e n are t a u g h t t o d e v e l o p o r a l s p e e c h , l i p - r e a d i n g a n d w o r n b y the teacher and the receiver and a m p l i f i e r b y the
s i g n l a n g u a g e . A l l c h i l d r e n w i t h p r e - l i n g u a l severe t o p r o - c h i l d . W i t h this system, the c h i l d can hear the teacher's
f o u n d deafness, s h o u l d u n d e r g o t r a i n i n g i n this f o r m of voice better, w i t h o u t being disturbed by environmental
communication. Vibrotactile aids are u s e f u l f o r t h o s e w h o noises.
are t o t a l l y d e a f a n d also b l i n d . T h e s e aids are a t t a c h e d t o 5. V o c a t i o n a l g u i d a n c e T h e d e a f are s i n c e r e a n d g o o d
the child's h a n d o r s t e r n u m and the vibrations o f speech w o r k e r s . G i v e n the o p p o r t u n i t y , commensurate w i t h their
are p e r c e i v e d t h r o u g h t a c t i l e s e n s a t i o n . a b i l i t y , t h e y can b e u s e f u l l y e m p l o y e d i n several v o c a t i o n s .
R e h a b i l i t a t i o n o f the
Hearing-Impaired

A l l h e a r i n g - i m p a i r e d i n d i v i d u a l s n e e d s o m e sort o f aural u s e f u l i n persons w i t h a c t i v e l y d r a i n i n g ears, o t i t i s e x t e r n a

r e h a b i l i t a t i o n f o r c o m m u n i c a t i o n . T h e various means a v a i l - o r atresia o f t h e ear c a n a l w h e n ear-inserts c a n n o t be w o r n .
a b l e t o t h e m are: M o s t o f t h e aids are air c o n d u c t i o n t y p e . T h e y c a n b e :
I. I n s t r u m e n t a l devices
1. B o d y - w o r n types M o s t c o m m o n type (Fig. 20.1 A ) ;
A. H e a r i n g aids
m i c r o p h o n e a n d a m p l i f i e r a l o n g w i t h t h e b a t t e r y are i n o n e
(i) C o n v e n t i o n a l h e a r i n g aids
case w o r n at t h e chest l e v e l w h i l e r e c e i v e r is s i t u a t e d at t h e
(ii) B o n e a n c h o r e d h e a r i n g aids ( B A H A )
ear l e v e l . T h i s t y p e o f a i d a l l o w s h i g h d e g r e e o f a m p l i f i c a -
(iii) I m p l a n t a b l e h e a r i n g aids ( v i b r a n t s o u n d b r i d g e )
t i o n w i t h m i n i m a l f e e d b a c k . I t is u s e f u l i n s e v e r e l y d e a f p e r -
B. Implants
sons o r c h i l d r e n w i t h c o n g e n i t a l deafness.
(i) Cochlear implants
(ii) A u d i t o r y brainstem implants 2. Behind-the-ear (BTE) types Here microphone,

C. Assistive devices f o r t h e d e a f a m p l i f i e r , r e c e i v e r a n d b a t t e r y are a l l i n o n e u n i t w h i c h is

II. Training w o r n b e h i n d t h e ear. I t is c o u p l e d t o t h e ear c a n a l w i t h a

A. Speech (lip) r e a d i n g t u b i n g a n d a n e a r m o u l d . I t is u s e f u l f o r s l i g h t t o m o d e r a t e

B. Auditory training cases o f h e a r i n g loss p a r t i c u l a r l y t h e h i g h f r e q u e n c y ones.

C. Speech conservation 3 . S p e c t a c l e t y p e s I t is a m o d i f i c a t i o n o f t h e "Behind-

t h e - e a r " t y p e a n d t h e u n i t is h o u s e d i n t h e a u r i c u l a r p a r t
o f t h e s p e c t a c l e f r a m e . I t is u s e f u l t o p e r s o n s w h o need
I. INSTRUMENTAL DEVICES b o t h eye glasses f o r v i s i o n a n d a h e a r i n g a i d . I t is n o t v e r y
popular n o w .

4 . I n - t h e - e a r ( I T E ) t y p e s T h e e n t i r e h e a r i n g a i d is h o u s e d

| A. Hearing Aids J i n a n e a r m o u l d w h i c h c a n b e w o r n i n t h e ear. I t is u s e f u l f o r

m i l d to moderate h e a r i n g losses w i t h flat c o n f i g u r a t i o n .
Conventional Hearing Aids
T h e y are v e r y p o p u l a r because o f t h e i r c o s m e t i c appeal.
A h e a r i n g a i d is a d e v i c e t o a m p l i f y s o u n d s r e a c h i n g the
5 . C a n a l t y p e s ( I T C & C I C ) T h e h e a r i n g a i d is so s m a l l
ear. E s s e n t i a l l y , i t consists o f t h r e e p a r t s : (a) a microphone,
t h a t t h e e n t i r e a i d c a n b e w o r n i n t h e ear c a n a l without
w h i c h picks u p sounds a n d converts t h e m i n t o electrical
p r o j e c t i n g i n t o t h e c o n c h a . F o r u s i n g this a i d , i t is r e q u i r e d
i m p u l s e s , (b) a n amplifier, w h i c h magnifies electrical i m p u l -
t h a t t h e ear c a n a l s h o u l d be l a r g e a n d w i d e , a n d p a t i e n t
ses, a n d (c) a receiver, which converts electrical impulses
should have the dexterity t o manipulate the m i n u t e c o n -
b a c k t o s o u n d . This a m p l i f i e d s o u n d is t h e n c a r r i e d t h r o u g h
t r o l s i n t h e a i d . I t is u s e f u l f o r m i l d t o m o d e r a t e cases o f
the e a r m o u l d t o the t y m p a n i c membrane.
h e a r i n g loss o f h i g h f r e q u e n c y (1 t o 4 k H z ) .
T w o types are available; i n t h e canal ( I T C ) a n d another
Types of Hearing Aids
still smaller and invisible type, completely i n the canal
Air conduction hearing aid In this, the amplified (CIC).
s o u n d is t r a n s m i t t e d v i a t h e ear canal to the tympanic
membrane. Indications for Hearing Aid

Bone conduction hearing a i d Instead o f a receiver, it A n y i n d i v i d u a l w h o has a h e a r i n g p r o b l e m t h a t c a n n o t be

has a b o n e v i b r a t o r w h i c h s n u g l y f i t s o n t h e m a s t o i d a n d h e l p e d b y m e d i c a l o r s u r g i c a l m e a n s is a c a n d i d a t e for
d i r e c t l y s t i m u l a t e s t h e c o c h l e a . T h i s t y p e o f a i d is specially hearing aid.
 Rehabilitation of the Hearing-Impaired

1. Sensorineural hearing loss w h i c h interferes with (b) C o n f i g u r a t i o n o f h e a r i n g loss ( t y p e o f f r e q u e n c i e s

day to day activities o f a person. H e a r i n g a i d m a y n o t suit affected),
all s u c h persons because o f the i n t o l e r a b l e d i s t o r t i o n o f (c) T y p e o f h e a r i n g loss ( c o n d u c t i v e o r s e n s o r i n e u r a l ) ,
s o u n d i n some, particularly i n those w i t h r e c r u i t m e n t . (d) Presence o f r e c r u i t m e n t ,

2. D e a f children s h o u l d b e f i t t e d w i t h h e a r i n g a i d as (e) U n c o m f o r t a b l e loudness level,

e a r l y as p o s s i b l e f o r d e v e l o p m e n t o f s p e e c h a n d l e a r n i n g . (£) A g e and dexterity o f patient,

I n s e v e r e l y d e a f c h i l d r e n , b i n a u r a l aids ( o n e f o r e a c h ear (g) C o n d i t i o n o f t h e o u t e r a n d m i d d l e ear,

a n d i n d i v i d u a l l y f i t t e d ) are m o r e u s e f u l . T r a i n i n g i n l i p - (h) C o s m e t i c acceptance o f the aid,

r e a d i n g is g i v e n s i m u l t a n e o u s l y . (i) Type o f earmould,

(j) T h e t y p e o f f i t t i n g , w h e t h e r i t is m o n o a u r a l , ( o n e a i d
3. Conductive d e a f n e s s M o s t o f such persons can be
o n l y ) , b i n a u r a l ( o n e a i d f o r e a c h ear), b i n a u r a l w i t h
h e l p e d b y s u r g e r y b u t h e a r i n g a i d is p r e s c r i b e d w h e n s u r -
y - c o n n e c t i o n (one aid b u t t w o receivers, one f o r each
g e r y is r e f u s e d o r n o t feasible o r has f a i l e d .
ear) o r t h e C R O S t y p e .
Fitting a Hearing Aid
C R O S (contralateral routing o f signals) I n this t y p e ,
W h i l e f i t t i n g a h e a r i n g a i d , c o n s i d e r a t i o n is g i v e n t o :
m i c r o p h o n e is f i t t e d o n t h e s i d e o f t h e d e a f ear a n d t h e
(a) D e g r e e o f h e a r i n g loss, s o u n d t h u s p i c k e d u p is p a s s e d t o t h e r e c e i v e r p l a c e d i n
Diseases o f Ear

t h e b e t t e r ear. T h i s is u s e f u l f o r p e r s o n s w i t h o n e ear (ii) C h i l d r e n w i t h m a l f o r m e d o r a b s e n t o u t e r ear a n d ear

severely i m p a i r e d a n d helps i n s o u n d l o c a l i s a t i o n com- canals as i n m i c r o t i a o r c a n a l atresia.
i n g f r o m t h e side o f t h e d e a f ear. N o w bone-anchored (iii) S i n g l e - s i d e d deafness (see T a b l e 20.1)
h e a r i n g aids ( B A H A ) (see i n f r a ) are b e i n g p r e f e r r e d f o r
I n t h e past, t h e c o n t r a l a t e r a l r o u t i n g o f s i g n a l ( C R O S )
single-sided deafness and have replaced the use of
h e a r i n g a i d was the o n l y o p t i o n available f o r r e h a b i l i t a -
CROS aids.
t i o n o f p a t i e n t s w i t h s i n g l e - s i d e d deafness. P o o r p e r f o r -
m a n c e a n d aesthetic considerations l i m i t e d t h e use of
Bone-anchored Hearing Aid ( B A H A )
C R O S aids. T h e B A H A d e v i c e c a n n o w b e i m p l a n t e d o n
Bone-anchored h e a r i n g a i d is a t y p e o f h e a r i n g a i d w h i c h t h e side o f t h e d e a f ear, a n d i t t r a n s m i t s t h e s o u n d b y
is b a s e d o n t h e p r i n c i p l e o f b o n e c o n d u c t i o n . I t is p r i m a r i l y means o f b o n e c o n d u c t i o n t o the contralateral cochlea.
s u i t e d t o p e o p l e w h o h a v e c o n d u c t i v e h e a r i n g loss, u n i l a t - T h e B A H A is f i x e d o n t h e d e a f side a n d c o l l e c t s s o u n d
e r a l h e a r i n g loss a n d t h o s e w i t h m i x e d h e a r i n g loss w h o waves to transmit to healthy cochlea o f the other side.
cannot otherwise wear " i n the ear" o r " b e h i n d the ear" T h i s process e l i m i n a t e s t h e h e a d - s h a d o w effect a n d a l l o w s
h e a r i n g aids. f o r h e a r i n g f r o m b o t h sides o f t h e h e a d . T h e B A H A sub-
Bone-anchored h e a r i n g aids use a s u r g i c a l l y i m p l a n t e d stantially i m p r o v e s speech r e c o g n i t i o n i n q u i e t a n d i n
abutment to transmit sound by direct c o n d u c t i o n t h r o u g h n o i s e c o m p a r e d w i t h t h e C R O S aids.
b o n e t o the cochlea, bypassing t h e e x t e r n a l a u d i t o r y canal
Surgery The s u r g e r y is t y p i c a l l y p e r f o r m e d i n a s i n g l e
a n d m i d d l e ear ( F i g . 2 0 . 2 ) .
stage i n a d u l t s . A b o u t 3 m o n t h s are a l l o w e d f o r o s s e o i n t e -
B A H A has t h r e e c o m p o n e n t s : (a) t i t a n i u m f i x t u r e (b) tita-
gration before the s o u n d processor can be attached. A
n i u m a b u t m e n t a n d (c) s o u n d p r o c e s s o r ( F i g . 2 0 . 3 ) . T h e tita-
t w o - s t a g e p r o c e d u r e is r e c o m m e n d e d i n c h i l d r e n i n w h o m
n i u m f i x t u r e is surgically e m b e d d e d i n t h e s k u l l b o n e w i t h
t h e f i x t u r e is p l a c e d i n t o t h e b o n e i n t h e f i r s t stage. A f t e r
a b u t m e n t exposed outside the skin. T h e titanium fixture
about 6 m o n t h s to a l l o w for osseointegration, a second-
b o n d s w i t h t h e s u r r o u n d i n g tissue i n a process c a l l e d osseointe-
stage o p e r a t i o n is d o n e t o c o n n e c t t h e a b u t m e n t t h r o u g h
gration. The s o u n d processor is a t t a c h e d t o t h e abutment
the skin to the fixture.
o n c e o s s e o i n t e g r a t i o n is c o m p l e t e w h i c h u s u a l l y takes 2 t o
6 m o n t h s after i m p l a n t a t i o n . T h e B A H A d e v i c e transmits
v i b r a t i o n s t o t h e e x t e r n a l a b u t m e n t w h i c h f u r t h e r vibrates
the skull and cochleae. Sound
processor
Candidacy profile Bone-anchored h e a r i n g aids c a n be
used i n : Titanium
abutment
(i) People w h o have chro nic i n f l a m m a t i o n or i n f e c t i o n
o f t h e ear c a n a l a n d c a n n o t w e a r s t a n d a r d " i n t h e
e a r " a i r - c o n d u c t i o n h e a r i n g aids.

Titanium
fixture

Bone-anchorec hearing aid ( B A H A ) .

Table 20.1 Indications f o r B A H A

1 . W h e n a i r - c o n d u c t i o n ( A C ) h e a r i n g aid c a n n o t be used:
• C a n a l atresia, c o n g e n i t a l o r a c q u i r e d , n o t a m e n a b l e
to treatment.
• C h r o n i c ear d i s c h a r g e , n o t a m e n a b l e t o t r e a t m e n t .
• Excessive f e e d b a c k a n d d i s c o m f o r t f r o m
a i r - c o n d u c t i o n hearing a i d .
2. C o n d u c t i v e o r m i x e d h e a r i n g loss, e.g. o t o s c l e r o s i s a n d
Figure 20.2
t y m p a n o s c l e r o s i s w h e r e surgery is c o n t r a i n d i c a t e d .
A p p e a r a n c e s w h e n s o u n d processor is a t t a c h e d t o a b u t m e n t . 3 . Single-sided h e a r i n g loss.
 Rehabilitation o f the Hearing-Impaired

C o m p l i c a t i o n s o f B A H A are f e w a n d m a y i n c l u d e o c c a - t h r e e parts t h e r e c e i v e r , F M T ( f l o a t i n g mass t r a n s d u c e r )

sional failure t o osseointegrate the i m p l a n t a n d local i n f e c - a n d a c o n d u c t o r l i n k b e t w e e n t h e t w o . F M T is c o n n e c t e d
t i o n s a n d i n f l a m m a t i o n at t h e i m p l a n t site. t o t h e i n c u s (Figs 2 0 . 4 a n d 2 0 . 5 ) .
T h e e x t e r n a l c o m p o n e n t is c a l l e d t h e a u d i o p r o c e s s o r
Implantable Hearing Aids
w h i c h is w o r n b e h i n d t h e ear. T h e a u d i o p r o c e s s o r c o n -
I m p l a n t a b l e m i d d l e ear h e a r i n g aids represent a n e w c a t e g o r y tains a m i c r o p h o n e t h a t p i c k s u p s o u n d f r o m t h e e n v i r o n -
o f h e a r i n g devices that w o r k o n a d i r e c t d r i v e p r i n c i p l e . m e n t a n d t r a n s m i t s i t across t h e s k i n b y r a d i o f r e q u e n c y
R a t h e r t h a n d e l i v e r i n g acoustic energy i n t o t h e e x t e r n a l waves to the internal receiver.
a u d i t o r y c a n a l (as w i t h t r a d i t i o n a l h e a r i n g a i d systems),
Candidacy profile Appropriate candidates for direct
d i r e c t d r i v e m i d d l e ear i m p l a n t systems use mechanical
drive middle ear h e a r i n g devices i n c l u d e adults aged
v i b r a t i o n s d e l i v e r e d d i r e c t l y t o t h e ossicular c h a i n , w h i l e
18 years a n d o l d e r w i t h m o d e r a t e - t o - s e v e r e s e n s o r i n e u r a l
l e a v i n g t h e ear c a n a l c o m p l e t e l y o p e n .
h e a r i n g loss. C a n d i d a t e s s h o u l d h a v e e x p e r i e n c e o f u s i n g
I m p l a n t a b l e m i d d l e ear d e v i c e s are g e n e r a l l y a v a i l a b l e i n
t r a d i t i o n a l h e a r i n g aids a n d s h o u l d h a v e a d e s i r e f o r a n
t w o types:
alternative h e a r i n g system.

Piezoelectric devices Piezoelectric devices operate

b y passing an electric current into a piezoceramic
c r y s t a l , w h i c h c h a n g e s its v o l u m e a n d t h e r e b y p r o - EXTERNAL PART ' IMPLANTED PART

duce a v i b r a t o r y signal. T h i s piezoelectric transducer

i n t u r n is c o u p l e d t o t h e ossicles a n d d r i v e s t h e o s s i c u -
lar c h a i n b y v i b r a t i o n .
E x a m p l e s o f s u c h devices are: E n v o y , M E T ( m i d d l e -
ear t r a n s d u c e r ( o r also c a l l e d O t o l o g i c s d e v i c e ) , R i o n
and T I C A (totally integrated cochlear amplifier).
2. Electromagnetic hearing devices Electromagnetic
h e a r i n g devices f u n c t i o n b y passing an electric c u r r e n t
i n t o a c o i l , w h i c h creates a m a g n e t i c f l u x t h a t d r i v e s
a n a d j a c e n t m a g n e t . T h e s m a l l m a g n e t is a t t a c h e d t o
o n e o f t h e ossicles o f t h e m i d d l e ear t o c o n v e y v i b r a -
tions t o the cochlea.
A n e x a m p l e o f s u c h a d e v i c e is t h e v i b r a n t s o u n d -
b r i d g e d e v i c e ( p r e v i o u s l y k n o w n as t h e S y m p h o n i x
device; n o w b e i n g manufactured b y M E D - E L ) .

Vibrant soundbridge device T h e vibrant soundbridge

is a s e m i - i m p l a n t a b l e d e v i c e m a d e o f t w o c o m p o n e n t s : a n Figure 20.4
internal and an external. T h e internal component is c a l l e d
Vibrant s o u n d b r i d g e m i d d l e ear implant.
VORP ( v i b r a t i n g o s s i c u l a r p r o s t h e s i s ) a n d is m a d e u p o f

Figure 20.S

C o m p o n e n t s o f the vibrating ossicular prosthesis (VORP).

 Components and Functioning of a Cochlear Implant (Fig. 20.9)
I Disadvantages o f c o n v e n t i o n a l h e a r i n g aids
A c o c h l e a r i m p l a n t has a n e x t e r n a l a n d i n t e r n a l c o m p o n e n t .
• C o s m e t i c a l l y u n a c c e p t a b l e d u e t o visibility
• Acoustic feedback E x t e r n a l c o m p o n e n t I t consists o f a n e x t e r n a l speech
• Spectral d i s t o r t i o n processor and a transmitter. T h e speech processor m a y
• O c c l u s i o n o f external a u d i t o r y canal be b o d y w o r n o r b e h i n d t h e ear t y p e ; t h e l a t t e r b e i n g
• C o l l e c t i o n o f w a x in the canal a n d b l o c k a g e o f insert
preferred.
• Sensitivity o f c a n a l skin t o e a r m o u l d s
2. Internal c o m p o n e n t I t is s u r g i c a l l y i m p l a n t e d a n d
• P r o b l e m t o use in d i s c h a r g i n g ears
c o m p r i s e s t h e receiver/stimulator package w i t h an electrode
array.
Often, patients w h o are i n t e r e s t e d i n seeking direct
d r i v e m i d d l e ear h e a r i n g d e v i c e s h a v e e x p e r i e n c e d dissat- S o u n d is p i c k e d u p b y t h e m i c r o p h o n e i n t h e s p e e c h p r o -

isfaction regarding the sound quality o f their current hear- cessor. T h e s p e e c h p r o c e s s o r analyses a n d c o d e s sounds

i n g aids. O t h e r p r o b l e m s these p a t i e n t s f e e l w i t h these aids i n t o e l e c t r i c a l pulses. T h e p r o c e s s o r uses a v a r i e t y o f c o d -

are: d i s c o m f o r t d u e t o t h e o c c l u s i o n e f f e c t o f t h e canal, ing strategies t o deliver m e a n i n g f u l speech parameters

w a x o c c l u d i n g hearing aid m o u l d and w a x i m p a c t i o n o f f r o m the acoustic stimulus t o the nerve. Examples o f such

t h e e x t e r n a l a u d i t o r y canal, i n a b i l i t y t o w e a r t r a d i t i o n a l strategies are S A S (simultaneous analogue strategy), CIS

h e a r i n g aids d u e t o s e n s i t i v e ear c a n a l s k i n , a n d t h e i n a b i l - ( c o n t i n u o u s i n t e r l e a v e d s a m p l i n g ) , S P E A K (spectral p e a k )

i t y t o o v e r c o m e a c o u s t i c f e e d b a c k issues, (see T a b l e 20.2 and A C E (advanced c o m b i n a t i o n encoder).

f o r d i s a d v a n t a g e s o f c o n v e n t i o n a l h e a r i n g aids).

Procedure The i n t e r n a l d e v i c e is s u r g i c a l l y i m p l a n t e d . A B
The procedure is c o n d u c t e d u n d e r general anaesthesia.
T h e r e c e i v e r o f t h e i m p l a n t is p o s i t i o n e d u n d e r t h e s k i n
over the m a s t o i d b o n e via a standard cortical mastoidec-
t o m y a n d posterior t y m p a n o t o m y approach; the ossicular
c h a i n is v i s u a l i s e d a n d t h e F M T is a t t a c h e d t o t h e l o n g
process o f t h e i n c u s . T h e m i d d l e ear s t r u c t u r e s are not
m o d i f i e d . T h e r e f o r e , t h e r e is n o s i g n i f i c a n t i m p a c t o n t h e
residual h e a r i n g o f the patient.
S i x t o e i g h t w e e k s after t h e p r o c e d u r e , t h e p a t i e n t is f i t t e d
w i t h t h e e x t e r n a l a u d i o processor t h a t attaches m a g n e t i c a l l y
t o t h e b a c k o f t h e ear. T h e processor is t h e n p r o g r a m m e d .

A d v a n t a g e s A direct d r i v e system provides mechanical

e n e r g y d i r e c t l y t o t h e ossicles, b y p a s s i n g t h e ear c a n a l a n d Figure 20.6

the tympanic membrane. This eliminates many of the

M E D - E L cochlear implants: (A) M E D - E L C - 4 0 + . (B) Sonata
i n h e r e n t issues o f c o n v e n t i o n a l h e a r i n g aids s u c h as o c c l u - model w i t h ear level s p e e c h processor.

sion, feedback, d i s c o m f o r t and w a x related problems. One

m a j o r advantage o f d i r e c t d r i v e d e v i c e s is t h e a b i l i t y t o
p r o v i d e i m p r o v e d s o u n d quality t o the h e a r i n g - i m p a i r e d
subjects p a r t i c u l a r l y i n n o i s y e n v i r o n m e n t s .

J B. Implants J

Cochlear Implants

A c o c h l e a r i m p l a n t is an e l e c t r o n i c d e v i c e t h a t c a n p r o v i d e
useful h e a r i n g and i m p r o v e d c o m m u n i c a t i o n abilities f o r
p e r s o n s w h o h a v e severe t o p r o f o u n d s e n s o r i n e u r a l h e a r -
i n g loss a n d w h o c a n n o t b e n e f i t f r o m h e a r i n g aids.
A cochlear i m p l a n t w o r k s b y p r o d u c i n g m e a n i n g f u l elec-
trical s t i m u l a t i o n o f the a u d i t o r y nerve w h e r e degeneration o f Figure 20.7
t h e hair cells i n t h e c o c h l e a has progressed t o a p o i n t s u c h t h a t
Nucleus cochlear implant (Cochlear Corporation) with ear
a m p l i f i c a t i o n p r o v i d e d b y h e a r i n g aids is n o l o n g e r e f f e c t i v e .
level s p e e c h processor.
V a r i o u s c o c h l e a r i m p l a n t s are s h o w n i n Figs 2 0 . 6 t o 2 0 . 8 .
 Rehabilitation of the Hearing-Impaired

T h e e l e c t r i c a l i m p u l s e s are s e n t f r o m t h e p r o c e s s o r t o • N o medical contraindication for surgery.

t h e t r a n s m i t t i n g c o i l w h i c h i n t u r n sends t h e s i g n a l t o t h e
surgically i m p l a n t e d receiver/stimulator via radiofrequency.
T h e r e c e i v e r / s t i m u l a t o r d e c o d e s t h e signal a n d t r a n s m i t s i t
t o t h e e l e c t r o d e a r r a y . C u r r e n t d a y i m p l a n t s are m u l t i c h a n -
nel processors w i t h the electrode h a v i n g a l i n e a r array o f
electrode contacts used t o d e l i v e r m u l t i p l e channels of
c u r r e n t t o d i f f e r e n t places a l o n g t h e basilar m e m b r a n e . T h e
e l e c t r o d e a r r a y w h i c h has b e e n p l a c e d i n t h e scala t y m p a n i
o f t h e c o c h l e a s t i m u l a t e s t h e s p i r a l g a n g l i o n cells. T h e a u d i -
t o r y n e r v e is t h u s s t i m u l a t e d a n d sends these electrical
pulses t o t h e b r a i n w h i c h are f i n a l l y i n t e r p r e t e d as s o u n d .
Candidacy profile C o c h l e a r i m p l a n t s m a y be used b o t h
in c h i l d r e n and adults. T h e f o l l o w i n g criteria help define
candidacy for cochlear i m p l a n t a t i o n :
Realistic expectation.
• G o o d f a m i l y a n d social s u p p o r t t o w a r d h a b i l i t a t i o n .
• A d e q u a t e c o g n i t i v e f u n c t i o n t o be able t o use t h e d e v i c e .
C a n d i d a t e s w i t h such h e a r i n g i m p a i r m e n t m a y be d e f i n e d
as p r e - l i n g u a l o r p o s t - l i n g u a l d e p e n d i n g o n w h e t h e r t h e y
w e r e d e a f e n e d b e f o r e o r after t h e a c q u i s i t i o n o f s p e e c h
and language.
I n c h i l d r e n w h o h a v e h e a r i n g i m p a i r m e n t at b i r t h or
e a r l y i n c h i l d h o o d , early i n t e r v e n t i o n w i t h h e a r i n g aids o r
a c o c h l e a r i m p l a n t is v i t a l f o r a u d i t o r y s t i m u l u s . A u d i t o r y
d e p r i v a t i o n , i.e. lack o f a u d i t o r y s t i m u l u s i n the early d e v e l -
o p m e n t a l p e r i o d causes d e g e n e r a t i o n i n t h e c e n t r a l a u d i -
t o r y p a t h w a y s . T h i s w i l l l i m i t the b e n e f i t i n terms o f speech
a n d language acquisition f o l l o w i n g cochlear i m p l a n t a t i o n .

* B i l a t e r a l severe t o p r o f o u n d s e n s o r i n e u r a l h e a r i n g loss. Outcomes of Cochlear Implantation

s
L i t t l e o r n o b e n e f i t f r o m h e a r i n g aids.
F a c t o r s t h a t p r e d i c t a successful c l i n i c a l o u t c o m e are:

• Previous auditory experience (post-lingual patients or

p r i o r use o f h e a r i n g aids).
• Y o u n g e r age at i m p l a n t a t i o n ( e s p e c i a l l y f o r p r e - l i n g u a l
children).
S h o r t e r d u r a t i o n o f deafness.
• N e u r a l plasticity w i t h i n the a u d i t o r y system.

M u l t i c h a n n e l i m p l a n t s are t h e s t a n d a r d t o d a y a n d p e r f o r m
m u c h better t h a n single-channel devices. P o s t - l i n g u a l c h i l -
d r e n or adults achieve v e r y g o o d benefit. T h e y d e v e l o p the
a b i l i t y t o r e c o g n i z e speech w i t h n o o r m i n i m a l l i p r e a d i n g
o r v i s u a l cues. T h e y e v e n t u a l l y c a n also use t h e t e l e p h o n e .
P r e - l i n g u a l l y d e a f e n e d c h i l d r e n also d e v e l o p g o o d speech
u n d e r s t a n d i n g a n d language a c q u i s i t i o n o v e r a p e r i o d o f t i m e .
Figure 20.8 T h i s can take a c o u p l e o f years a n d requires c o n s t a n t a u d i t o -
r y - v e r b a l t r a i n i n g . E a r l y age at i m p l a n t a t i o n ensures b e t t e r
Advanced bionics cochlear implant system.
results a n d c h i l d r e n can be i m p l a n t e d at 12 m o n t h s o f age.

Transmitter
1. External speech processor captures s o u n d
and c o n v e r t s it t o d i g i t a l signals
2. Processor sends digital signals
to internal implant

3. Internal implant turns signals

into electrical energy, sending
it t o a n array inside the cochlea
4. Electrodes stimulate hearing
nerve, bypassing d a m a g e d hair
cells, a n d the brain perceives
signals; you hear sound

Figure 20.9

P r i n c i p l e of cochlear implant.
 P r e - I i n g u a l l y deafened adults w i t h n o o r little p r i o r a u d i - a l l o w s t h e e l e c t r o d e s t o be i n close p r o x i m i t y t o t h e spiral
tory experience obtain very l i m i t e d benefit f r o m cochlear g a n g l i o n cells a n d t h e i r d e n d r i t e s (that l i e i n t h e m o d i o l u s
i m p l a n t a t i o n . T h e y w i l l h o w e v e r o b t a i n s o u n d awareness. a n d osseous spiral l a m i n a o f t h e c o c h l e a , r e s p e c t i v e l y ) .
Surgery is c a r r i e d o u t u n d e r g e n e r a l anaesthesia a n d is
Evaluation s i m i l a r t o m a s t o i d s u r g e r y . O n c e t h e p a t i e n t is p o s i t i o n e d ,
p r e p p e d a n d d r a p e d , t h e p o s i t i o n o f t h e d e v i c e is m a r k e d a n d
T h o r o u g h e v a l u a t i o n o f t h e p a t i e n t is v e r y c r i t i c a l i n t h e
t h e i n c i s i o n p l a n n e d . Flaps are e l e v a t e d c a r e f u l l y so as n o t t o
selection o f candidates for a cochlear implant. T h e main
d i s r u p t t h e b l o o d s u p p l y . U s u a l l y , a t w o - l a y e r e d a p p r o a c h is
purpose is t o d e t e r m i n e i f t h e p a t i e n t is m e d i c a l l y and
c h o s e n u t i l i s i n g a f l a p o f s k i n a n d s u b c u t a n e o u s tissue, f o l -
a u d i o l o g i c a l l y s u i t a b l e f o r a n i m p l a n t . I t also h e l p s t h e c l i -
l o w e d b y a s e c o n d l a y e r o f m u s c u l o p e r i o s t e a l flap. A p o c k e t
nicians to predict and counsel the f a m i l y regarding the
is c r e a t e d u n d e r t h e s e c o n d flap a n d a w e l l o r recess is d r i l l e d
expected outcomes f o l l o w i n g the procedure.
i n the b o n e to house the receiver/stimulator.
M e d i c a l evaluation t h r o u g h detailed history and physical
e x a m i n a t i o n is necessary t o c o n f i r m fitness f o r a general T h e r e are b r o a d l y t w o s u r g i c a l t e c h n i q u e s t o a p p r o a c h

anaesthetic. T h e necessary preanaestheric tests w i l l be r e q u i r e d t h e c o c h l e a f o r i m p l a n t a t i o n , (i) T h e f a c i a l recess a p p r o a c h

to b e c a r r i e d o u t . A l l candidates m u s t be f u l l y vaccinated where a simple cortical mastoidectomy is d o n e f i r s t a n d

against m e n i n g i t i s ( p a r t i c u l a r l y Haemophilus Influenzae type t h e s h o r t process o f t h e i n c u s a n d t h e l a t e r a l semicircular

B , Pneumococcus a n d i n s o m e areas Meningococcus). c a n a l are i d e n t i f i e d . T h e f a c i a l recess is o p e n e d b y per-

f o r m i n g a posterior t y m p a n o t o m y . T h e stapes, p r o m o n -
I m a g i n g o f the temporal bone, cochlea, auditory nerve
t o r y a n d r o u n d w i n d o w n i c h e are i d e n t i f i e d . C o c h l e o s t o m y
a n d b r a i n is c a r r i e d o u t u s i n g C T a n d M R I . T h i s is r e q u i r e d
is t h e n p e r f o r m e d a n t e r o - i n f e r i o r t o t h e r o u n d w i n d o w
to p r o v i d e an image o f the structure o f the cochlea a n d
m e m b r a n e t o a d i a m e t e r o f 1.0 t o 1.6 m m d e p e n d i n g o n
help i d e n t i f y any anomalies or p a t h o l o g y that may c o m p l i -
the electrode to be used, (ii) T h e pericanal techniques
cate t h e i m p l a n t a t i o n p r o c e s s .
w h e r e a t y m p a n o m e a t a l flap is e l e v a t e d t o p e r f o r m a c o c h -
A u d i o l o g i c a l e v a l u a t i o n m a y i n c l u d e s o m e o r all o f t h e
leostomy either b y endaural or postaural approach. I n the
f o l l o w i n g d e p e n d i n g o n t h e age o f t h e p a t i e n t :
pericanal techniques a b o n y t u n n e l is d r i l l e d a l o n g the
• Pure tone audiogram
e x t e r n a l c a n a l t o w a r d s t h e m i d d l e ear. T h e examples of
• S p e e c h d i s c r i m i n a t i o n tests
p e r i c a n a l t e c h n i q u e s i n c l u d e t h e Veria and suprameatal recess
• Tympanometry
approach.
• Otoacoustic emissions ( O A E )
T h e d e v i c e is p l a c e d i n t h e " w e l l " c r e a t e d a n d is s e c u r e d
9
A u d i t o r y b r a i n s t e m responses ( A B R ) and
w i t h ties. T h e e l e c t r o d e a r r a y is g e n t i y a n d g r a d u a l l y i n s e r -
• A u d i t o r y s t e a d y state responses ( A S S R ) .
ted t h r o u g h the cochleostomy till c o m p l e t e i n s e r t i o n has

A h e a r i n g a i d t r i a l a n d e v a l u a t i o n is m a n d a t o r y i n d e t e r - b e e n a c h i e v e d . E l e c t r o p h y s i o l o g i c a l t e s t i n g is c a r r i e d o u t

m i n i n g the candidacy for cochlear implantation. This may to check that the electrode impedances and telemetry

i n c l u d e a i d e d f r e e - f i e l d s o u n d d e t e c t i o n t h r e s h o l d s , as w e l l responses are satisfactory.

as a i d e d s p e e c h p e r c e p t i o n a n d d i s c r i m i n a t i o n scores. T h e w o u n d is c l o s e d i n layers a n d a m a s t o i d b a n d a g e
S p e e c h a n d l a n g u a g e e v a l u a t i o n is r e q u i r e d t o assess t h e applied.
c h i l d ' s c o m m u n i c a t i v e status a n d t o d e t e r m i n e a n y d e v e l -
Postoperative Mapping (Programming) of Device and
o p m e n t a l l a n g u a g e o r a r t i c u l a t i o n d i s o r d e r s . T h i s w i l l also
Habilitation
f o r m a baseline f o r f u r t h e r evaluations p o s t - i m p l a n t a t i o n
t o h e l p assess p r o g r e s s a n d i d e n t i f y areas o f d e f i c i t i n s p e e c h Activation o f the i m p l a n t is d o n e 3 to 4 weeks after
perception. T h i s i n t u r n w o u l d aid i n the p r o g r a m m i n g o f i m p l a n t a t i o n . F o l l o w i n g this t h e i m p l a n t is " p r o g r a m m e d "
the patient's device. o r " m a p p e d " . M a p p i n g is d o n e o n a r e g u l a r basis d u r i n g
P s y c h o l o g i c a l e v a l u a t i o n is p e r f o r m e d w h e r e t h e r e m a y postoperative rehabilitation t o f m e t u n e the processor and
b e c o n c e r n s r e g a r d i n g t h e c o g n i t i v e status o r m e n t a l f u n c - get t h e b e s t p e r f o m i a n c e as t h e p a t i e n t gets u s e d t o h e a r i n g
t i o n o f t h e p a t i e n t . T h i s is also i m p o r t a n t t o i d e n t i f y c h i l - w i t h the implant.
d r e n w h o m a y h a v e d i s a b i l i t i e s o t h e r t h a n h e a r i n g loss. (Re) H a b i l i t a t i o n is a n essential p a r t f o r t h o s e who
This may p r o v i d e i n f o r m a t i o n t h a t is i m p o r t a n t when have u n d e r g o n e cochlear i m p l a n t a t i o n . A l l patients need
c o u n s e l l i n g parents a b o u t expectations f o l l o w i n g cochlear auditory-verbal therapy. I n auditory-verbal therapy, the
implantation. e m p h a s i s is l a i d o n m a k i n g t h e c h i l d l i s t e n a n d s p e a k l i k e a
n o r m a l p e r s o n r a t h e r t h a n use l i p r e a d i n g a n d v i s u a l cues.
Surgery
L e a r n i n g t o l i s t e n takes t i m e a n d r e q u i r e s c o n c e r t e d efforts
The p r i n c i p l e o f c o c h l e a r i m p l a n t s u r g e r y is t o p l a c e t h e f r o m the patient, the family a n d the person providing
e l e c t r o d e array w i t h i n t h e scala t y m p a n i o f t h e c o c h l e a . T h i s h a b i l i t a t i o n services.
 Rehabilitation of the Hearing-Impaired

theatres. T h e y m a y be used b y t h e p e r s o n i n d i v i d u a l l y o r
Table 20.3 Complications o f cochlear implant surgery
are m e a n t f o r a g r o u p .
Early complications Late complications A c c o r d i n g t o t h e t e c h n o l o g y u s e d , t h e y are g r o u p e d as

• Facial paralysis • Exposure o f device and extrusion h a r d - w i r e d system, i n d u c t i o n loops, A M ( a m p l i t u d e m o d -

• W o u n d infection • Pain at the site o f implant u l a t i o n ) , F M ( f r e q u e n c y m o d u l a t i o n ) o r i n f r a - r e d signals.

• W o u n d dehiscence • Migration/displacement o f

• Flap necrosis device 2. Alerting Devices

• Electrode migration • Late device failure

• Device failure • Otitis media

A h e a r i n g - i m p a i r e d person may n o t hear a telephone or a

• CSF leak d o o r b e l l , a baby c r y i n g i n another r o o m , an alarm c l o c k o r

• Meningitis t h e n o i s e o f a s m o k e d e t e c t o r . A l e r t i n g d e v i c e s are u s e f u l i n
• Post-operative such situations. T h e y p r o d u c e an extra l o u d s o u n d signal o r
dizziness/ vertigo r e l a y t h e s i g n a l t o a n area close t o t h e i n d i v i d u a l . A " h e a r -
i n g d o g " is o n e s u c h s i m p l e d e v i c e . T h e d o g is t r a i n e d t o
b a r k l o u d l y at t h e s o u n d o f a d o o r b e l l , c r y o f a b a b y , etc.
F o r p e o p l e w i t h severe t o p r o f o u n d o r t o t a l deafness,
Table 20.3 summarises the complications o f cochlear
e v e n these d e v i c e s w h i c h p r o d u c e e x t r a - l o u d s o u n d m a y
i m p l a n t surgery.
n o t b e u s e f u l . T h e y n e e d assistive s i g n a l l i n g d e v i c e s w h e r e

Auditory Brainstem Implant (ABI) t h e s o u n d (as o f d o o r b e l l , t e l e p h o n e , alarm clock, baby

c r y i n g ) is c h a n g e d i n t o a l i g h t s i g n a l o r v i b r a t i o n s . A l a r m
T h i s i m p l a n t is d e s i g n e d t o s t i m u l a t e t h e c o c h l e a r n u c l e a r
c l o c k w i t h flashing lights o r those devices w h i c h p r o d u c e
c o m p l e x i n the brainstem directly b y placing the i m p l a n t
s t r o n g v i b r a t i o n s to a w a k e n the i n d i v i d u a l o r e v e n shake
i n t h e l a t e r a l recess o f t h e f o u r t h v e n t r i c l e . S u c h a n i m p l a n t
h i s b e d are also a v a i l a b l e .
is n e e d e d w h e n C N V I I I has b e e n s e v e r e d i n s u r g e r y of
v e s t i b u l a r s c h w a n n o m a . I n t h e s e cases, cochlear i m p l a n t s are
3. Telecommunication Devices
o b v i o u s l y o f n o use. I n u n i l a t e r a l a c o u s t i c n e u r o m a , A B I
is n o t necessary as h e a r i n g is p o s s i b l e f r o m t h e c o n t r a l a t e r a l A t e l e p h o n e a m p l i f i e r c a n b e a t t a c h e d t o t h e h a n d set of
side b u t i n b i l a t e r a l a c o u s t i c n e u r o m a s as N F 1 5 rehabilita- a telephone, residential or public, to a m p l i f y the s o u n d . A
t i o n is r e q u i r e d b y A B I . t e l e p h o n e c o u p l e r is a d e v i c e t h a t c a n b e c o n n e c t e d t o t h e
B r a i n s t e m i m p l a n t is s i m i l a r t o " N u c l e u s " m u l t i c h a n n e l telephone a n d t h e s i g n a l p r o d u c e d is p i c k e d u p b y the
c o c h l e a r i m p l a n t e x c e p t t h a t t h e m u l t i e l e c t r o d e a r r a y is hearing aid.
a t t a c h e d t o a d e c r o n m e s h w h i c h is p l a c e d o n t h e b r a i n - For the p r o f o u n d l y or totally deaf individuals, Tele-
s t e m . R e c e i v e r / s t i m u l a t o r has a r e m o v a b l e m a g n e t so t h a t c o m m u n i c a t i o n D e v i c e s f o r the D e a f ( T D D s ) can be used.
M R I c a n b e safely p e r f o r m e d i n s u c h cases i f n e e d arises. T h e y c o n v e r t t y p e d message i n t o s o u n d s t h a t c a n b e t r a n s -
A B I s h e l p i n c o i m n u n i c a t i o n , awareness a n d r e c o g n i - m i t t e d o v e r t h e s t a n d a r d t e l e p h o n e l i n e s , a n d at t h e o t h e r
t i o n o f e n v i r o n m e n t a l s o u n d s ; h o w e v e r t h e y are n o t as e f f i - e n d a n o t h e r T D D c o n v e r t s these s o u n d signals b a c k i n t o
cient as m u l t i c h a n n e l cochlear implants. Only limited t y p e w r i t t e n messages.
n u m b e r o f such implants have b e e n p e r f o r m e d i n the w o r l d Closed-caption television decoder can be attached to
a n d are u n d e r c o n s t a n t t e c h n o l o g i c a l developments. t e l e v i s i o n sets t o p r o v i d e t h e m cues t o e n j o y n e w s , m o v i e s
and other programmes.

C. Assistive Devices

H e a r i n g - i m p a i r e d persons s h o u l d enjoy l i f e as n o r m a l l y
II. TRAINING

h e a r i n g p e r s o n s d o . F o r t h i s , d e v i c e s are n e e d e d t o h e l p h i m
t o l i s t e n i n special d i f f i c u l t s i t u a t i o n s , w a r n h i m o f d a n g e r
A. Speech Reading
signals a n d h e l p h i m t o t e l e c o m m u n i c a t e w i t h his f a m i l y
a n d f r i e n d s w h o are f a r a w a y f r o m h i m . T h e s e d e v i c e s c a n
E a r l i e r c a l l e d l i p - r e a d i n g , i t is an i n t e g r a t e d process t o u n d e r -
thus be d i v i d e d i n t o three groups:
stand speech b y s t u d y i n g m o v e m e n t s o f Hps, facial expres-
s i o n , gestures a n d t h e p r o b a b l e c o n t e x t o f c o n v e r s a t i o n . T h e
1. Assistive Listening Devices and Systems
s k i l l o f speech r e a d i n g is n o t o n l y useful f o r t h e t o t a l l y d e a f
They are n o t h e a r i n g aids b u t d e v i c e s w h i c h help the b u t also u s e f u l f o r those h e a r i n g - i m p a i r e d i n d i v i d u a l s w h o
h e a r i n g i m p a i r e d to listen efficiently i n the presence of h a v e h i g h f r e q u e n c y loss a n d d i f f i c u l t y i n h e a r i n g i n n o i s y
b a c k g r o u n d noise, o v e r t h e telephone, i n a u d i t o r i u m s o r surroundings.
 B. Auditory Training
1 • C. Speech Conservation

I t e n h a n c e s l i s t e n i n g s k i l l a n d is u s e d w i t h s p e e c h r e a d i n g . I n s u d d e n , severe o r p r o f o u n d h e a r i n g loss, t h e person

T h e p a t i e n t is e x p o s e d t o v a r i o u s l i s t e n i n g s i t u a t i o n s w i t h loses t h e a b i l i t y t o m o n i t o r his o w n s p e e c h p r o d u c t i o n . A s
d i f f e r e n t degrees o f d i f f i c u l t y a n d taught selectively to a r e s u l t , d e f e c t s arise i n a r t i c u l a t i o n , r e s o n a n c e , p i t c h a n d
c o n c e n t r a t e o n speech sounds. the v o l u m e o f v o i c e . Speech conservation aims t o educate
A u d i t o r y t r a i n i n g is u s e f u l f o r t h o s e u s i n g h e a r i n g aids s u c h a p e r s o n t o use his t a c t i l e a n d p r o p r i o c e p t i v e f e e d -
and cochlear implants. b a c k systems t o m o n i t o r his s p e e c h p r o d u c t i o n .
O t a l g i a (Earache)

P a i n i n t h e ear c a n b e d u e t o causes o c c u r r i n g l o c a l l y i n
B. Referred Causes
t h e ear o r r e f e r r e d t o i t f r o m r e m o t e areas.

As ear r e c e i v e s n e r v e s u p p l y f r o m V t h ( a u r i c u l o t e m p o -
ral b r . ) , I X t h (tympanic br.) and X t h (auricular br.) cranial
A. Local C a u s e s n e r v e s ; a n d f r o m C (lesser o c c i p i t a l ) a n d C a n d C
2 2 3 (greater
a u r i c u l a r ) , p a i n m a y b e r e f e r r e d f r o m these r e m o t e areas
1. External e a r Furuncle, i m p a c t e d w a x , otitis externa, (Fig. 21.1).
otomycosis, m y r i n g i t i s b u l l o s a , h e r p e s zoster, a n d m a l i g - 1. Via V t h cranial nerve
nant neoplasms.
(a) Dental. C a r i e s t o o t h , a p i c a l abscess, i m p a c t e d m o l a r ,
2. M i d d l e e a r A c u t e otitis m e d i a , eustachian tube obs- malocclusion.
t r u c t i o n , m a s t o i d i t i s , e x t r a d u r a l abscess, a e r o - o t i t i s m e d i a , (b) Oral cavity. B e n i g n o r m a l i g n a n t u l c e r a t i v e lesions o f
a n d c a r c i n o m a m i d d l e ear. oral cavity o r tongue.

c2r

F i g u r e 21.1

Referred causes o f otalgia. Pain is r e f e r r e d v i a C N V ( t e e t h , o r a l c a v i t y , T M j o i n t , anterior t w o thirds o ftongue), C 2 3 (cervical spine),

C N IX (tonsil, base o f tongue, elongated styloid process) a n d C N X (vallecula, pyriform fossa o r larynx).
 (c) Temporomandibular joint disorders. B r u x i s m , osteoar- 4. V i a C 2 and C 3 spinal nerves Cervical spondylosis
thritis, recurrent dislocation, i l l - f i t t i n g denture. i n j u r i e s o f c e r v i c a l s p i n e , caries s p i n e .
(d) Sphenopalatine neuralgia.

2. V i a I X t h cranial nerve
(a) Oropharynx. Acute t o n s i l l i t i s , p e r i t o n s i l l a r abscess,
J C . Psychogenic Causes
t o n s i l l e c t o m y . B e n i g n o r m a l i g n a n t u l c e r s o f soft palate,
t o n s i l a n d its p i l l a r s . W h e n n o cause has b e e n d i s c o v e r e d , p a i n m a y be func-
(b) Base of tongue. T u b e r c u l o s i s o r m a l i g n a n c y . tional i n o r i g i n b u t the patient s h o u l d be kept u n d e r obser-
(c) Elongated styloid process. vation w i t h periodic re-evaluation.
3 . V i a X t h c r a n i a l n e r v e M a l i g n a n c y o r u l c e r a t i v e lesion of: O t a l g i a is a symptom. I t is essential t o f i n d its cause befor>
vallecula, epiglottis, l a r y n x o r l a r y n g o p h a r y n x , oesophagus. specific t r e a t m e n t can be i n s t i t u t e d .
 "innitus

T i n n i t u s is ringing s o u n d o r n o i s e i n t h e ear. T h e c h a r a c - m u s c l e s o f soft palate a n d c a n b e easily d i a g n o s e d . Clonic

t e r i s t i c f e a t u r e is t h a t t h e o r i g i n o f t h i s s o u n d is within the
p a t i e n t . U s u a l l y , i t is u n i l a t e r a l b u t m a y also a f f e c t b o t h
ears. I t m a y v a r y i n p i t c h a n d l o u d n e s s a n d has b e e n v a r i -
o u s l y d e s c r i b e d b y t h e p a t i e n t as r o a r i n g , h i s s i n g , s w i s h -
i n g , r u s t l i n g o r c l i c k i n g t y p e o f n o i s e . T i n n i t u s is m o r e
annoying i n q u i e t s u r r o u n d i n g s , p a r t i c u l a r l y at n i g h t ,
w h e n the m a s k i n g effect o f a m b i e n t noise f r o m the e n v i -
r o n m e n t is l o s t .
c o n t r a c t i o n o f m u s c l e s o f m i d d l e ear (stapedius a n d t e n s o r
t y m p a n i ) m a y cause t i n n i t u s w h i c h is o f t e n d i f f i c u l t to
diagnose.
S o m e t i m e s , t i n n i t u s is p s y c h o g e n i c a n d n o cause can b e
f o u n d i n t h e ear o r c e n t r a l n e r v o u s s y s t e m .
T i n n i t u s s h o u l d b e d i f f e r e n t i a t e d from a u d i t o r y h a l l u c i -
n a t i o n s i n w h i c h a p e r s o n hears v o i c e s o r o t h e r o r g a n i s e d
s o u n d s l i k e t h a t o f m u s i c . I t is seen i n p s y c h i a t r i c d i s o r d e r s .

Treatment
Types of Tinnitus

T i n n i t u s is a s y m p t o m a n d n o t a disease. W h e r e possible,
T w o t y p e s o f t i n n i t u s are d e s c r i b e d :
its cause s h o u l d b e d i s c o v e r e d a n d t r e a t e d . Sometimes,
(a) Subjective, w h i c h can o n l y be heard b y the patient.
(b) O b j e c t i v e , w h i c h c a n even be h e a r d b y t h e examiner
Table 22.1 Causes o f tinnitus
w i t h t h e use o f a s t e t h o s c o p e .

A. Subjective
I. Otologic if Non-otologic

| Causes of Tinnitus (Table 22.1) | • Impacted wax • Diseases o f CNS

• Fluid in the middle ear • A n a e m i a

• Acute and chronic otitis • Arteriosclerosis

Subjective tinnitus m a y h a v e its o r i g i n i n t h e e x t e r n a l ear,
media • Hypertension
m i d d l e ear, i n n e r ear, V I H t h n e r v e o r t h e c e n t r a l n e r v o u s
• Abnormally patent • Hypotension
system. Systemic disorders l i k e anaemia, arteriosclerosis,
eustachian tube • Hypoglycaemia
h y p e r t e n s i o n a n d c e r t a i n d r u g s m a y act t h r o u g h t h e i n n e r
• Meniere's disease • Epilepsy
ear o r c e n t r a l a u d i t o r y p a t h w a y s . I n t h e p r e s e n c e o f c o n - • Otosclerosis • Migraine
d u c t i v e deafness, t h e p a t i e n t m a y h e a r a b n o r m a l noises i n • Presbyacusis • Drugs

the head d u r i n g eating, speaking or even respiration. • Noise t r a u m a

Objective tinnitus is s e e n less f r e q u e n t . V a s c u l a r lesions, • Ototoxic drugs

e.g. glomus t u m o u r or carotid artery aneurysm cause • T u m o u r s o f Vlllth nerve

s w i s h i n g t i n n i t u s s y n c h r o n o u s w i t h pulse. I t can be t e m -
B. Objective
p o r a r i l y a b o l i s h e d b y pressure on the c o m m o n carotid
• Vascular t u m o u r s o f middle
a r t e r y . V e n o u s h u m can s o m e t i m e s be s t o p p e d b y pressure ear (glomus t u m o u r )
o n the neck veins. • Aneurysm o f carotid artery

T i n n i t u s synchronous w i t h respiration m a y occur due • Palatal m y o c l o n u s

t o a b n o r m a l l y patent eustachian t u b e . Palatal myoclonus

C. Psychogenic
produces c l i c k i n g s o u n d due to clonic c o n t r a c t i o n o f the
even the treatment o f cause m a y n o t a l l e v i a t e t i n n i t u s . l o u d l y c l i c k i n g clock or a similar device m a y mask t h e
W h e n n o cause is f o u n d , m a n a g e m e n t o f t i n n i t u s i n c l u d e s : t i n n i t u s a n d h e l p t h e p a t i e n t t o g o t o sleep. U s e o f a
h e a r i n g a i d , i n persons w i t h h e a r i n g loss, n o t o n l y
1. Reassurance and psychotherapy. M a n y times the patient
i m p r o v e s h e a r i n g b u t also p r o v i d e s a m a s k i n g e f f e c t .
has t o l e a r n t o l i v e w i t h t i n n i t u s .
2. Techniques of relaxation and biofeedback. T i n n i t u s maskers c a n b e used i n patients w h o have n o
3. Sedation and tranquillizers. T h e y m a y be needed i n i n i - h e a r i n g loss. T h e y are w o r n l i k e a h e a r i n g a i d . U s e o f t i n -
t i a l stages t i l l p a t i e n t has a d j u s t e d t o t h e s y m p t o m . nitus masker f o r a short t i m e m a y p r o v i d e , i n some i n d i -
4. Masking of tinnitus. T i n n i t u s is m o r e a n n o y i n g at b e d viduals, a s y m p t o m - f r e e p e r i o d f o r several h o u r s d u e t o t h e
t i m e w h e n t h e s u r r o u n d i n g s are q u i t e . U s e o f a f a n , p h e n o m e n o n o f residual inhibition.
P a r a n a s a l Sinuses
23. Anatomy o f Nose
24. Physiology o f Nose
25. Diseases o f External Nose and Nasal Vestibule 158
26. Nasal Septum and Its Diseases 162
27. Acute and Chronic Rhinitis
28. Granulomatous Diseases o f Nose 172
29. Miscellaneous Disorders o f Nasal Cavity 176
30. Allergic Rhinitis
31. Vasomotor and Other Forms o f Non-allergic Rhinitis
32. Nasal Polypi 185
33. Epistaxis
34. Trauma to the Face
35. Anatomy and Physiology o f Paranasal Sinuses
36. Acute Sinusitis
Chronic Sinusitis
38. Complications o f Sinusitis
39. Neoplasms o f Nasal Cavity
40. Neoplasms o f Paranasal Sinuses
A n a t o m y o f Nose

Cartilaginous Part
EXTERNAL NOSE
I t consists o f :

I t is p y r a m i d a l i n shape w i t h its r o o t u p a n d t h e base Upper lateral cartilages. T h e y extend f r o m the undersur-

d i r e c t e d d o w n w a r d s . V a r i o u s t e r m s u s e d i n its d e s c r i p t i o n face o f t h e nasal b o n e s a b o v e , t o t h e alar c a r t i l a g e s

are s h o w n i n F i g . 2 3 . 1 . N a s a l p y r a m i d consists o f o s t e o c a r - b e l o w . T h e y fuse w i t h e a c h o t h e r a n d w i t h t h e u p p e r

tilaginous f r a m e w o r k c o v e r e d b y muscles a n d skin. b o r d e r o f t h e septal c a r t i l a g e i n t h e m i d l i n e a n t e r i o r l y .

T h e l o w e r f r e e e d g e o f u p p e r l a t e r a l c a r t i l a g e is seen
i n t r a n a s a l l y as limen vestibuli o r nasal valve on each
g| Osteocartilaginous Framework
side.
Lower lateral cartilages (alar cartilages). E a c h alar c a r t i l a g e
Bony Part
is U - s h a p e d . I t has a l a t e r a l c r u s w h i c h f o r m s t h e ala
U p p e r o n e - t h i r d o f t h e e x t e r n a l n o s e is b o n y w h i l e l o w e r and a m e d i a l crus w h i c h runs i n t h e c o l u m e l l a . L a t e r a l
t w o - t h i r d s are c a r t i l a g i n o u s . T h e b o n y p a r t consists o f t w o crus overlaps l o w e r edge o f u p p e r lateral cartilage o n
nasal b o n e s w h i c h m e e t i n t h e m i d l i n e a n d rest o n t h e each side.
u p p e r p a r t o f t h e nasal process o f t h e f r o n t a l b o n e s a n d Lesser alar (or sesamoid) cartilages. T w o or more i n n u m -
are t h e m s e l v e s h e l d b e t w e e n t h e f r o n t a l processes o f t h e b e r . T h e y l i e a b o v e a n d l a t e r a l t o alar c a r t i l a g e s . T h e
maxillae (Fig. 23.2). v a r i o u s cartilages are c o n n e c t e d w i t h o n e a n o t h e r a n d
Diseases o f N o ^ e a n

with the a d j o i n i n g bones by perichondrium and t h r o u g h naris o r n o s t r i l a n d w i t h t h e n a s o p h a r y n x t h r o u g h

periosteum. Most o f the free m a r g i n o f n o s t r i l is p o s t e r i o r nasal a p e r t u r e o r t h e choana. E a c h nasal c a v i t y
f o r m e d o f f i b r o f a t t y tissue a n d n o t t h e alar c a r t i l a g e . consists o f a skin-lined p o r t i o n — t h e vestibule, and a
Septal cartilage. Its a n t e r o s u p e r i o r b o r d e r runs from m u c o s a - l i n e d p o r t i o n , t h e nasal c a v i t y p r o p e r .
u n d e r t h e nasal b o n e s t o t h e nasal t i p . I t s u p p o r t s t h e
d o r s u m o f t h e c a r t i l a g i n o u s p a r t o f t h e n o s e . I n septal
abscess o r a f t e r excessive r e m o v a l o f septal c a r t i l a g e as Vestibule o f N o s e

i n S M R (submucosal resection) o p e r a t i o n , support o f

nasal d o r s u m is l o s t a n d a s u p r a t i p d e p r e s s i o n r e s u l t s . A n t e r i o r a n d i n f e r i o r p a r t o f nasal c a v i t y is c a l l e d t h e v e s -
t i b u l e . I t is l i n e d b y s k i n a n d c o n t a i n s s e b a c e o u s g l a n d s ,

I
Nasal Musculature
O s t e o c a r t i l a g i n o u s f r a m e w o r k o f n o s e is c o v e r e d b y m u s -
cles w h i c h b r i n g a b o u t m o v e m e n t s o f t h e nasal t i p , ala a n d
t h e o v e r l y i n g s k i n . T h e y a r e t h e p r o c e r u s , nasalis ( t r a n s -
v e r s e a n d alar p a r t s ) , l e v a t o r l a b i i s u p e r i o r i s a l a e q u e nasi,
a n t e r i o r a n d p o s t e r i o r d i l a t o r nares a n d d e p r e s s o r s e p t i .
h a i r f o l l i c l e s a n d t h e h a i r c a l l e d vibrissae. Its u p p e r l i m i t o n
t h e l a t e r a l w a l l is m a r k e d b y l i m e n nasi (nasal v a l v e ) w h i c h
is f o r m e d b y t h e c a u d a l m a r g i n o f u p p e r l a t e r a l c a r t i l a g e .
Its m e d i a l w a l l is f o r m e d b y t h e c o l u m e l l a a n d l o w e r p a r t
o f t h e nasal s e p t u m u p t o its m u c o c u t a n e o u s j u n c t i o n .
Nasal Cavity Proper

E a c h nasal c a v i t y has a l a t e r a l w a l l , a m e d i a l w a l l , a r o o f a n d
Nasal Skin
a floor.

L a t e r a l n a s a l w a l l T h r e e and occasionally f o u r turbinates

T h e s k i n o v e r t h e nasal b o n e s a n d u p p e r l a t e r a l cartilages is
t h i n a n d f r e e l y m o b i l e w h i l e t h a t c o v e r i n g t h e alar c a r t i -
lages is t h i c k a n d a d h e r e n t , a n d c o n t a i n s m a n y s e b a c e o u s
glands. I t is t h e h y p e r t r o p h y o f t h e s e sebaceous glands
w h i c h g i v e s rise t o a l o b u l a t e d t u m o u r c a l l e d r h i n o p h y m a
(see p a g e 1 6 0 ) .
INTERNAL NOSE
I t is d i v i d e d i n t o right a n d l e f t nasal c a v i t i e s b y nasal s e p -
t u m . E a c h nasal c a v i t y c o m m u n i c a t e s w i t h the exterior
o r c o n c h a e m a r k t h e lateral w a l l o f nose. C o n c h a e o r t u r -
b i n a t e s are s c r o l l - l i k e b o n y p r o j e c t i o n s c o v e r e d b y m u c o u s
membrane. T h e spaces b e l o w t h e t u r b i n a t e s are c a l l e d
m e a t u s e s (Figs 2 3 . 3 a n d 2 3 . 4 ) .
Inferior turbinate is a separate b o n e a n d b e l o w i t , i n t o t h e
i n f e r i o r m e a t u s , o p e n s t h e n a s o l a c r i m a l d u c t g u a r d e d at its
t e r m i n a l e n d b y a mucosal valve called Hasner's valve.
Middle turbinate is a n e t h m o t u r b i n a l — a p a r t o f e t h m o i d
b o n e . I t is a t t a c h e d t o t h e lateral w a l l b y a b o n y l a m e l l a
c a l l e d ground or basal lamella. Its a t t a c h m e n t is n o t s t r a i g h t b u t
i n a n S - s h a p e d m a n n e r . I n t h e a n t e r i o r t h i r d , i t lies i n sagittal
 Sup. turbinate and meatus

Middle turbinate
and meatus

Vestibule

Figure 23.3

Structures on lateral wall o f nose.

Hiatus semilunaris
Sphenoethmoid recess with
Uncinate process opening of sphenoid sinus

Opening of frontal sinus

Opening of max. sinus

Opening of middle
ethmoidal sinuses

Opening of
nasolacrimal duct

Figure 23.4

Lateral wall o f nose w i t h turbinates removed showing openings o f various sinuses.

p l a n e a n d is a t t a c h e d t o lateral e d g e o f c r i b r i f o r m p l a t e . I n Uncinate process is a h o o k - l i k e s t r u c t u r e r u n n i n g i n f r o m

t h e m i d d l e t h i r d , i t lies i n f r o n t a l p l a n e a n d is a t t a c h e d t o a n t e r o s u p e r i o r t o p o s t e r o i n f e r i o r d i r e c t i o n . Its p o s t e r o s u -
l a m i n a p a p y r a c e a w h i l e i n its p o s t e r i o r t h i r d , i t r u n s h o r i - p e r i o r b o r d e r is s h a r p a n d r u n s p a r a l l e l t o a n t e r i o r b o r d e r
z o n t a l l y a n d f o r m s r o o f o f t h e m i d d l e m e a t u s a n d is a t t a c h e d o f b u l l a e t h m o i d a l i s ; t h e gap b e t w e e n t h e t w o is c a l l e d
t o l a m i n a papyracea a n d m e d i a l w a l l o f m a x i l l a r y sinus. hiatus semilunaris ( i n f e r i o r ) . I t is a t w o - d i m e n s i o n a l space o f
The ostia o f v a r i o u s sinuses d r a i n i n g a n t e r i o r t o basal 1—2 m m w i d t h .
lamella form anterior group of paranasal sinuses while those T h e a n t e r o i n f e r i o r b o r d e r o f u n c i n a t e p r o c e s s is a t t a c h e d
w h i c h o p e n posterior a n d superior to it f o r m the posterior t o the lateral w a l l . P o s t e r o i n f e r i o r e n d o f u n c i n a t e process
group. is a t t a c h e d t o i n f e r i o r t u r b i n a t e d i v i d i n g t h e membranous
Middle meatus s h o w s several i m p o r t a n t structures w h i c h part o f l o w e r m i d d l e meatus i n t o anterior a n d posterior
are important in endoscopic surgery of the sinuses f o n t a n e l l e . T h e f o n t a n e l area is d e v o i d o f b o n e a n d c o n -
(Fig. 23.5). sists o f m e m b r a n e o n l y a n d leads i n t o m a x i l l a r y s i n u s w h e n
Diseases of Nose and Paranasal Sinuses

p e r f o r a t e d . U p p e r a t t a c h m e n t o f u n c i n a t e process shows
g r e a t v a r i a t i o n a n d m a y b e i n s e r t e d i n t o t h e l a t e r a l nasal
w a l l , u p w a r d s i n t o t h e base o f s k u l l o r m e d i a l l y i n t o t h e
middle turbinate (Fig. 23.6). This also accounts for
v a r i a t i o n s i n drainage o f f r o n t a l sinus.
T h e space l i m i t e d m e d i a l l y b y t h e u n c i n a t e process a n d
frontal process o f m a x i l l a a n d s o m e t i m e s l a c r i m a l b o n e , a n d
l a t e r a l l y b y t h e l a m i n a p a p y r a c e a is c a l l e d infundibulum.
N a t u r a l o s t i u m o f t h e m a x i l l a r y s i n u s is s i t u a t e d i n t h e
l o w e r p a r t o f i n f u n d i b u l u m . A c c e s s o r y o s t i u m o r ostia o f
m a x i l l a r y sinus are s o m e t i m e s seen i n t h e a n t e r i o r o r p o s -
terior fontanel (Fig. 23.7).

Bulla ethmoidafis I t is a n e t h m o i d a l c e l l s i t u a t e d b e h i n d
t h e u n c i n a t e p r o c e s s . A n t e r i o r surface o f t h e b u l l a f o r m s

Figure 23.5 the posterior b o u n d a r y o f hiatus semilunaris. D e p e n d i n g

o n p e n u m a t i s a t i o n bulla m a y be a p n e u m a t i s e d cell o r a
Lateral wall o f nose. Middle turbinate is r e f l e c t e d upwards to
solid b o n y p r o m i n e n c e . I t m a y extend superiorly to the
s h o w structures o f the middle meatus.
s k u l l base a n d p o s t e r i o r l y t o fuse w i t h g r o u n d lamella.

Figure 23.6

U p p e r a t t a c h m e n t o f uncinate process: ( A ) into l a m i n a papyracea, (B) into skull base, (C) into middle turbinate thus affecting drain-

age o f frontal sinus.

Middle
turbinate

Figure 23.7

(A) Coronal section through middle meatus. Uncinate process forms the medial wall and floor o f the infundibulum. (B) Coronal

section showing relationships o f uncinate process, bulla ethmoidalis, middle turbinate, maxillary sinus, orbit and cribriform plate.
 Superior turbinate is also a n e t h m o t u r b i n a l a n d is s i t u a t e d
p o s t e r i o r a n d s u p e r i o r t o m i d d l e t u r b i n a t e . I t m a y also g e t
p n e u m a t i s e d b y o n e o r m o r e cells.

Superior meatus is a space b e l o w t h e s u p e r i o r t u r b i n a t e .

P o s t e r i o r e t h m o i d cells o p e n i n t o i t . N u m b e r o f p o s t e r i o r
e t h m o i d cells varies f r o m 1 t o 5 . O n i d i c e l l is a p o s t e r i o r
e t h m o i d a l c e l l w h i c h m a y g r o w p o s t e r i o r l y b y t h e side o f
s p h e n o i d sinus o r s u p e r i o r t o i t f o r as m u c h a d i s t a n c e as
1.5 c m f r o m t h e a n t e r i o r s u r f a c e o f s p h e n o i d . O n i d i c e l l is
s u r g i c a l l y i m p o r t a n t as t h e o p t i c n e r v e m a y be r e l a t e d t o its
lateral w a l l .

Sphenoethmoidal recess is situated above the superior

t u r b i n a t e . S p h e n o i d sinus o p e n s i n t o i t .

Supreme turbinate is s o m e t i m e s present above the supe-

r i o r t u r b i n a t e a n d has a n a r r o w m e a t u s b e n e a t h i t .
T h e o s t i u m o f s p h e n o i d sinus is s i t u a t e d i n t h e s p h e n o e t h -
m o i d a l recess m e d i a l t o t h e s u p e r i o r o r s u p r e m e t u r b i n a t e .
I t can b e l o c a t e d e n d o s c o p i c a l l y a b o u t 1 c m a b o v e t h e u p p e r
m a r g i n o f p o s t e r i o r c h o a n a close t o t h e p o s t e r i o r b o r d e r o f
the septum.

M e d i a l w a l l N a s a l s e p t u m f o r m s t h e m e d i a l w a l l a n d is
Axial view s h o w i n g m i d d l e meatus a n d its s t r u c t u r e . N o t e also
described o n page 162.
the r e t r o b u l l a r recess.
Roof A n t e r i o r s l o p i n g p a r t o f t h e r o o f is f o r m e d b y nasal
b o n e s ; p o s t e r i o r s l o p i n g p a r t is f o r m e d b y t h e b o d y of
W h e n t h e r e is a space a b o u t o r b e h i n d t h e b u l l a , i t is c a l l e d
s p h e n o i d b o n e ; a n d t h e m i d d l e h o r i z o n t a l p a r t is f o r m e d
s u p r a b u l l a r o r r e t r o b u l l a r recesses, r e s p e c t i v e l y ( F i g . 2 3 . 8 ) .
by the cribriform plate o f e t h m o i d t h r o u g h w h i c h the
T h e s u p r a b u l l a r a n d r e t r o b u l l a r recesses t o g e t h e r f o r m t h e
o l f a c t o r y n e r v e s e n t e r t h e nasal c a v i t y .
lateral sinus (sinus lateralis o f G r u n w a l d ) . T h e l a t e r a l sinus
is t h u s b o u n d e d s u p e r i o r l y b y t h e s k u l l base, l a t e r a l l y b y Floor I t is f o r m e d b y p a l a t i n e p r o c e s s o f t h e m a x i l l a i n its
lamina papyracea, m e d i a l l y b y m i d d l e t u r b i n a t e a n d i n f e r i - anterior t h r e e - f o u r t h s a n d h o r i z o n t a l part o f the palatine
o r l y b y t h e b u l l a e t h m o i d a l i s . P o s t e r i o r l y t h e sinus lateralis b o n e i n its p o s t e r i o r o n e - f o u r t h .
m a y e x t e n d u p t o basal l a m e l l a o f m i d d l e t u r b i n a t e . The
c l e f t ~ H k e c o m m u n i c a t i o n b e t w e e n t h e b u l l a a n d s k u l l base
a n d o p e n i n g i n t o m i d d l e m e a t u s is also c a l l e d hiatus semilu- Lining M e m b r a n e o f Internal Nose
naris superior in contrast to hiatus semilunaris inferior
referred to before. Vestibule I t is l i n e d b y s k i n c o n t a i n i n g h a i r , h a i r f o l l i c l e s
a n d sebaceous g l a n d s .
Atrium o f t h e m i d d l e m e a t u s is a s h a l l o w d e p r e s s i o n l y i n g
i n f r o n t o f m i d d l e t u r b i n a t e a n d a b o v e t h e nasal v e s t i b u l e . Olfactory region U p p e r o n e - t h i r d o f lateral w a l l ( u p t o
superior concha), c o r r e s p o n d i n g p a r t o f t h e nasal s e p t u m
Agger nasi is a n e l e v a t i o n j u s t a n t e r i o r t o t h e attachment
a n d t h e r o o f o f nasal cavity f o r m the olfactory region.
o f middle turbinate. W h e n pneumatised i t contains air
H e r e , m u c o u s m e m b r a n e is p a l e r i n c o l o u r .
cells, t h e a g g e r nasi cells, w h i c h c o m m u n i c a t e with the
f r o n t a l recess. A n e n l a r g e d a g g e r nasi c e l l m a y e n c r o a c h o n Respiratory region L o w e r t w o - t h i r d s o f t h e nasal cav-
f r o n t a l recess area, c o n s t r i c t i n g i t a n d c a u s i n g mechanical ity f o r m the respiratory region. H e r e mucous membrane
o b s t r u c t i o n t o f r o n t a l sinus d r a i n a g e . s h o w s v a r i a b l e t h i c k n e s s b e i n g t h i c k e s t o v e r nasal c o n c h a e
P n e u m a t i s a t i o n o f m i d d l e t u r b i n a t e leads t o a n e n l a r g e d e s p e c i a l l y at t h e i r ends, q u i t e t h i c k o v e r t h e nasal s e p t u m
ballooned o u t m i d d l e t u r b i n a t e c a l l e d concha bullosa. It b u t v e r y t h i n i n t h e meatuses a n d f l o o r o f t h e n o s e . I t is
d r a i n s i n t o f r o n t a l recess d i r e c t l y o r t h r o u g h a g g e r nasi h i g h l y v a s c u l a r a n d also c o n t a i n s e r e c t i l e tissue. Its s u r f a c e
cells. Halier cells are a i r cells s i t u a t e d i n t h e r o o f o f m a x i l l a r y is l i n e d b y p s e u d o s t r a t i f i e d c i l i a t e d c o l u m n a r e p i t h e l i u m
sinus. T h e y are p n e u m a t i s e d f r o m a n t e r i o r o r posterior w h i c h c o n t a i n s p l e n t y o f g o b l e t cells. I n t h e submucous
e t h m o i d cells. E n l a r g e m e n t o f 1 taller cells e n c r o a c h e s o n l a y e r o f m u c o u s m e m b r a n e , are s i t u a t e d serous, m u c o u s ,
ethmoid infundibulum, impeding draining o f maxillary both serous a n d m u c o u s secreting glands, the ducts of
sinus. w h i c h o p e n o n t h e surface o f mucosa.
Diseases o f Nose and Paranasal Sinuses

A Olfactory nerves
Olfactory bulb
Olfactory nerves

Anf. ethmoida
Ant. ethmoidal
nerve

Nasopalatine
Branches of nerve
sphenopalatine
ganglion
Greater palatine
nerve

Fig. 23.9

Nerve supply o f nose. (A) Lateral wall. Sphenopalatine ganglion situated at the posterior end o f middle turbinate supplies m o s t o f

posterior two-thirds o f nose. (B) Nerves on the medial wall.

n e r v e o f p t e r y g o i d c a n a l (vidian nerve) a n d r e a c h t h e s p h e -
Nerve Supply
n o p a l a t i n e g a n g l i o n w h e r e t h e y relay b e f o r e r e a c h i n g the
( a ) O l f a c t o r y n e r v e s T h e y c a r r y sense o f s m e l l a n d s u p - nasal c a v i t y . T h e y also s u p p l y t h e b l o o d vessels o f n o s e a n d
p l y o l f a c t o r y r e g i o n o f n o s e . T h e y are t h e c e n t r a l f i l a m e n t s cause v a s o d i l a t i o n .
o f t h e o l f a c t o r y cells a n d are a r r a n g e d i n t o 12—20 n e r v e s Sympathetic nerve fibres c o m e f r o m u p p e r t w o t h o -
w h i c h pass t h r o u g h t h e c r i b r i f o r m p l a t e a n d e n d i n t h e r a c i c s e g m e n t s o f s p i n a l c o r d , pass t h r o u g h s u p e r i o r c e r v i -
o l f a c t o r y b u l b . These nerves c a n c a r r y sheaths o f d u r a , cal g a n g l i o n , travel i n deep petrosal n e r v e a n d j o i n the
a r a c h n o i d a n d p i a w i t h t h e m i n t o t h e n o s e . I n j u r y t o these parasympathetic fibres o f greater petrosal n e r v e t o form
n e r v e s c a n o p e n C S F space l e a d i n g t o C S F r h i n o r r h o e a o r t h e n e r v e o f p t e r y g o i d c a n a l (vidian nerve). T h e y reach the
meningitis (Fig. 23.9). nasal c a v i t y w i t h o u t r e l a y i n t h e s p h e n o p a l a t i n e g a n g l i o n .

(b) N e r v e s o f c o m m o n sensation T h e y are: T h e i r s t i m u l a t i o n causes v a s o c o n s t r i c t i o n . E x c e s s i v e r h i n -

o r r h o e a i n cases o f v a s o m o t o r a n d a l l e r g i c r h i n i t i s c a n be
Anterior ethmoidal nerve.
controlled by section o f the vidian nerve.
Branches o f sphenopalatine ganglion.
Branches o f infra-orbital nerve. T h e y supply vesti-
b u l e o f nose b o t h o n its m e d i a l a n d l a t e r a l side. Blood Supply

M o s t o f t h e p o s t e r i o r t w o - t h i r d s o f nasal c a v i t y ( b o t h
B o t h t h e i n t e r n a l a n d e x t e r n a l c a r o t i d systems s u p p l y t h e
s e p t u m a n d l a t e r a l w a l l ) is s u p p l i e d b y b r a n c h e s o f s p h e n o -
n o s e . D e t a i l s o f b l o o d s u p p l y are g i v e n o n page 189.
p a l a t i n e g a n g l i o n w h i c h c a n be b l o c k e d b y p l a c i n g a p l e d g e t
o f c o t t o n soaked i n anaesthetic s o l u t i o n near the spheno-
p a l a t i n e f o r a m e n s i t u a t e d at t h e p o s t e r i o r e x t r e m i t y o f m i d -
Lymphatic Drainage
dle turbinate. A n t e r i o r e t h m o i d a l nerve which supplies
a n t e r i o r a n d s u p e r i o r p a r t o f t h e nasal c a v i t y (lateral w a l l
L y m p h a t i c s f r o m t h e e x t e r n a l nose a n d a n t e r i o r p a r t of
a n d septum) can be b l o c k e d b y p l a c i n g the pledget h i g h u p
nasal c a v i t y d r a i n i n t o s u b m a n d i b u l a r l y m p h n o d e s w h i l e
o n t h e i n s i d e o f nasal b o n e s w h e r e t h e n e r v e enters.
t h o s e f r o m t h e rest o f nasal c a v i t y d r a i n i n t o u p p e r j u g u l a r
(c) Autonomic nerves Parasympathetic nerve fibres nodes either directly o r t h r o u g h the retropharyngeal nodes.
s u p p l y t h e nasal g l a n d s a n d c o n t r o l nasal s e c r e t i o n . They L y m p h a t i c s o f t h e u p p e r p a r t o f nasal c a v i t y c o m m u n i c a t e
c o m e f r o m greater superficial petrosal n e r v e , t r a v e l i n the w i t h s u b a r a c h n o i d space a l o n g t h e o l f a c t o r y n e r v e s .
Physiology o f Nose

F u n c t i o n s o f t h e n o s e are classified as: nasal s e p t u m . V e r y l i t t l e air passes t h r o u g h i n f e r i o r m e a t u s

or olfactory r e g i o n o f nose (Fig. 24.1). T h e r e f o r e , weak
Respiration.
o d o r o u s substances h a v e t o b e s n i f f e d b e f o r e t h e y c a n r e a c h
A i r c o n d i t i o n i n g o f i n s p i r e d air.
t h e o l f a c t o r y area.
Protection o f l o w e r airway.
V o c a l resonance. D u r i n g expiration a i r c u r r e n t f o l l o w s t h e same c o u r s e

Nasal reflex functions. as d u r i n g inspiration, but the entire air c u r r e n t is not

6. Olfaction. e x p e l l e d d i r e c t l y t h r o u g h t h e nares. F r i c t i o n o f f e r e d at
l i m e n nasi c o n v e r t s i t i n t o e d d i e s u n d e r c o v e r o f i n f e r i o r
and middle turbinates and this ventilates the sinuses
Respiration t h r o u g h the ostia.
A n t e r i o r end o f inferior turbinate undergoes swelling
N o s e is t h e n a t u r a l p a t h w a y f o r b r e a t h i n g . M o u t h b r e a t h - a n d shrinkage thus r e g u l a t i n g i n f l o w o f air.
i n g is a n a c q u i r e d act t h r o u g h l e a r n i n g . So n a t u r a l is t h e
Nasal cycle Nasal mucosa undergoes r h y t h m i c cyclical
i n s t i n c t t o b r e a t h t h r o u g h the nose that a n e w b o r n i n f a n t
congestion and decongestion, thus c o n t r o l l i n g the air
with choanal atresia m a y asphyxiate to death i f urgent
f l o w t h r o u g h nasal c h a m b e r s . W h e n o n e nasal c h a m b e r is
m e a s u r e s are n o t t a k e n t o r e l i e v e i t . T h e n o s e also p e r m i t s
working, t o t a l nasal respiration, equal to that o f b o t h
b r e a t h i n g and eating to go o n simultaneously.
nasal c h a m b e r s , is c a r r i e d o u t b y i t . N a s a l c y c l e varies
During quiet respiration i n s p i r a t o r y air c u r r e n t passes every 2%—4 hours and may be characteristic of an
t h r o u g h m i d d l e p a r t o f nose b e t w e e n the turbinates and individual.

Figure 24.1

Physiology o f nasal airflow: (A) Inspiration. (B) Expiration.

 s e c r e t i o n f o r m s a c o n t i n u o u s sheet c a l l e d mucous blan-
Air-conditioning of Inspired Air
ket spread o v e r t h e n o r m a l m u c o s a . M u c o u s b l a n k e t
consists o f a s u p e r f i c i a l m u c u s layer and a deeper
N o s e is a p t l y c a l l e d t h e " a i r - c o n d i t i o n e r " for l u n g s . I t f i l t e r s
serous l a y e r , floating o n the t o p o f cilia w h i c h are
a n d p u r i f i e s t h e i n s p i r e d a i r a n d adjusts its t e m p e r a t u r e a n d
constandy beating to carry it like a " c o n v e y e r belt"
h u m i d i t y b e f o r e t h e a i r passes t o t h e l u n g s .
t o w a r d s t h e n a s o p h a r y n x { F i g . 2 4 . 2 ) . I t m o v e s at a
Filtration and purification. N a s a l v i b r i s s a e at t h e e n t r a n c e s p e e d o f 5 - 1 0 m m p e r m i n u t e a n d t h e c o m p l e t e sheet
o f n o s e act as f d t e r s t o sift l a r g e r p a r t i c l e s l i k e fluffs of o f m u c u s is c l e a r e d i n t o t h e p h a r y n x e v e r y 10 t o 2 0
c o t t o n . F i n e r particles like dust, p o l l e n a n d bacteria m i n u t e s . T h e i n s p i r e d bacteria, viruses a n d dust p a r -
a d h e r e t o t h e m u c u s w h i c h is s p r e a d l i k e a sheet a l l ticles are e n t r a p p e d o n t h e v i s c o u s m u c o u s blanket
o v e r t h e surface o f t h e m u c o u s m e m b r a n e . T h e f r o n t and t h e n carried to the nasopharynx to be s w a l l o w e d .
o f t h e n o s e c a n f i l t e r p a r t i c l e s u p t o 3 p m , w h i l e nasal P r e s e n c e o f t u r b i n a t e s a l m o s t d o u b l e s t h e surface area
m u c u s traps p a r t i c l e s as f i n e as 0 . 5 - 3 . 0 p - m . P a r t i c l e s t o p e r f o r m t h i s f u n c t i o n . A b o u t 600—700 m l o f nasal
s m a l l e r t h a n 0.5 p m s e e m t o pass t h r o u g h t h e n o s e i n t o s e c r e t i o n s are p r o d u c e d i n 2 4 h o u r s .
l o w e r airways w i t h o u t difficulty. I n m a m m a l s , cilia beat 1 0 - 2 0 times p e r s e c o n d at
Temperature control o f t h e i n s p i r e d a i r is r e g u l a t e d b y r o o m temperature. T h e y have a rapid "effective s t r o k e "
l a r g e surface o f nasal m u c o s a which is s t r u c t u r a l l y and a slow " r e c o v e r y stroke". I n the former, the extended
a d a p t e d t o p e r f o r m this f u n c t i o n . T h i s m u c o u s m e m - cilia reach m u c u s layer w h i l e i n t h e r e c o v e r y s t r o k e , t h e y
brane, particularly i n the r e g i o n o f m i d d l e and i n f e r i o r b e n d a n d t r a v e l s l o w l y i n t h e reverse d i r e c t i o n i n t h e
t u r b i n a t e s a n d a d j a c e n t parts o f t h e s e p t u m is h i g h l y t h i n serous layer, thus m o v i n g t h e m u c o u s b l a n k e t i n
vascular w i t h cavernous v e n o u s spaces o r sinusoids o n l y o n e d i r e c t i o n . I n i m m o t i l e cilia s y n d r o m e , cilia are
w h i c h c o n t r o l t h e b l o o d f l o w , a n d t h i s increases o r d e f e c t i v e a n d c a n n o t beat e f f e c t i v e l y , l e a d i n g t o stagna-
decreases t h e size o f t u r b i n a t e s . T h i s also m a k e s an e f f i - tion o f m u c u s i n t h e nose a n d sinuses a n d b r o n c h i caus-
c i e n t " r a d i a t o r " m e c h a n i s m t o w a r m u p t h e c o l d air. i n g c h r o n i c r h i n o s i n u s i t i s a n d bronchiectasis. M o v e m e n t s
I n s p i r e d a i r w h i c h m a y b e at 2 0 ° C o r 0 ° C o r e v e n at o f cilia are affected b y d r y i n g , d r u g s (adrenaline), exces-
s u b z e r o t e m p e r a t u r e is h e a t e d t o n e a r b o d y t e m p e r a - sive heat o r c o l d , s m o k i n g , i n f e c t i o n s a n d n o x i o u s f u m e s
t u r e ( 3 7 ° C ) i n o n e - f o u r t h o f s e c o n d t h a t t h e a i r takes like sulphur d i o x i d e and carbon dioxide.
t o pass f r o m t h e n o s t r i l t o t h e n a s o p h a r y n x . S i m i l a r l y , Enzymes and immunoglobulins. Nasal secretions also
h o t a i r is c o o l e d t o t h e l e v e l o f b o d y t e m p e r a t u r e . contain an enzyme called muramidase (lysozyme)
Humidification. This f u n c t i o n goes o n simultaneously w h i c h kills bacteria a n d viruses. I m m u n o g l o b u l i n s I g A
w i t h t h e t e m p e r a t u r e c o n t r o l o f i n s p i r e d air. R e l a t i v e a n d I g E , a n d i n t e r f e r o n are also p r e s e n t i n nasal secre-
h u m i d i t y o f a t m o s p h e r i c air varies d e p e n d i n g o n c l i - tions a n d p r o v i d e i m m u n i t y against u p p e r r e s p i r a t o r y
m a t i c c o n d i t i o n s . A i r is d r y i n w i n t e r a n d saturated w i t h tract i n f e c t i o n s .
moisture i n s u m m e r m o n t h s . Nasal m u c o u s membrane Sneezing. I t is a p r o t e c t i v e r e f l e x . F o r e i g n particles
adjusts t h e relative h u m i d i t y o f t h e i n s p i r e d air t o 7 5 % o r w h i c h i r r i t a t e nasal m u c o s a are e x p e l l e d b y s n e e z i n g .
m o r e . W a t e r , t o saturate t h e i n s p i r e d air, is p r o v i d e d b y t h e C o p i o u s flow o f nasal s e c r e t i o n s t h a t f o l l o w s i r r i t a t i o n
nasal m u c o u s m e m b r a n e w h i c h is r i c h i n m u c o u s a n d b y n o x i o u s substance helps t o w a s h t h e m o u t .
serous s e c r e t i n g glands. A b o u t 1000 m l o f w a t e r is e v a p -
T h e p H o f nasal s e c r e t i o n is n e a r l y c o n s t a n t at 7. The
o r a t e d f r o m t h e surface o f nasal m u c o s a i n 2 4 h o u r s .
c i l i a a n d t h e l y s o z y m e act best at t h i s p H . A l t e r a t i o n i n
M o i s t u r e is essential for integrity and f u n c t i o n o f the
ciliary e p i t h e l i u m . A t 5 0 % relative h u m i d i t y , ciliary f u n c -
t i o n stops i n 8 - 1 0 m i n u t e s . T h u s , d r y air predisposes to
i n f e c t i o n s o f t h e r e s p i r a t o r y t r a c t . H u m i d i f i c a t i o n also has
a s i g n i f i c a n t e f f e c t o n gas e x c h a n g e i n t h e l o w e r a i r w a y s . I n
nasal o b s t r u c t i o n , gaseous e x c h a n g e is a f f e c t e d i n t h e l u n g s ,
l e a d i n g t o rise i n p C O , , causing apnoeic spells during
sleep; i t also decreases p O , .

Protection of Lower Airway

"Conveyor belt" mechanism o f mucus blanket to entrap and

Mucociliary mechanism. N a s a l m u c o s a is r i c h i n g o b l e t
carry organisms and dust particles.
cells, s e c r e t o r y g l a n d s b o t h m u c o u s a n d s e r o u s . Their
nasal p H , d u e t o i n f e c t i o n s o r nasal d r o p s , s e r i o u s l y i m p a i r
the f u n c t i o n s o f cilia a n d l y s o z y m e .
So e f f i c i e n t are t h e f u n c t i o n s o f n o s e t h a t 5 0 0 c u b i c f e e t
o f air, t h a t w e b r e a t h e e v e r y 2 4 h o u r s , is f i l t e r e d , h u m i d i -
f i e d , adjusted t o p r o p e r t e m p e r a t u r e a n d cleared o f all the
dust, bacteria a n d viruses b e f o r e r e a c h i n g t h e l u n g s .
a n d f o r e n j o y i n g t h e taste o f f o o d . W h e n n o s e is b l o c k e d ,
f o o d tastes b l a n d a n d u n p a l a t a b l e . V a p o u r s o f a m m o n i a are
n e v e r u s e d t o test t h e sense o f s m e l l as t h e y s t i m u l a t e f i b r e s
o f t h e t r i g e m i n a l n e r v e a n d cause i r r i t a t i o n i n t h e n o s e
rather than stimulate the olfactory receptors.
O l f a c t o r y p a t h w a y s S m e l l is p e r c e i v e d i n t h e olfactory
r e g i o n o f nose w h i c h is s i t u a t e d h i g h u p i n t h e nasal c a v i t y .

Vocal Resonance This area contains millions o f olfactory, receptor cells.

P e r i p h e r a l process o f each o l f a c t o r y c e l l reaches t h e m u c o s a l

N o s e forms a resonating chamber for certain consonants surface a n d is e x p a n d e d i n t o a v e n t r i c l e w i t h several cilia o n

i n s p e e c h . I n p h o n a t i n g nasal c o n s o n a n t s ( M / N / N G ) , i t . T h i s acts as a sensory r e c e p t o r t o r e c e i v e o d o r o u s sub-

s o u n d passes t h r o u g h t h e n a s o p h a r y n g e a l i s t h m u s a n d is stances. C e n t r a l processes o f t h e o l f a c t o r y cells are g r o u p e d

e m i t t e d t h r o u g h the nose. " W h e n nose (or nasopharynx) i n t o o l f a c t o r y nerves w h i c h pass t h r o u g h t h e c r i b n f o i m plate

is b l o c k e d , s p e e c h b e c o m e s d e n a s a l , i.e. M / N / N G are o f e t h m o i d a n d e n d i n t h e m i t r a l cells o f t h e o l f a c t o r y b u l b .

u t t e r e d as B / D / G respectively. I t is t o b e remembered A x o n s o f m i t r a l cells f o r m o l f a c t o r y t r a c t a n d c a r r y s m e l l t o

that in Hindi alphabets, last letter of a "varga" the p r e p i r i f o r m cortex and the a m y g d a l o i d nucleus w h e r e it

facpf : IS, 1 , *f, S ; : ?T %

r % EI, *f; w f : *T, *T, IS reaches consciousness. O l f a c t o r y s y s t e m is also associated

s u b s t i t u t e d b y its t h i r d l e t t e r . T h u s , a n a f f e c t e d person w i t h a u t o n o m i c system at t h e h y p o t h a l a m i c l e v e l .

u t t e r s "^TCT f o r ^THT a n d tTRT f o r Tffl. R e v e r s e is t r u e i n Disorders of smell I t is essential f o r t h e p e r c e p t i o n of

velopharyngeal insufficiency where *THT is substituted smell t h a t the o d o r o u s substance be v o l a t i l e a n d that i t
f o r ^T?T. s h o u l d r e a c h t h e o l f a c t o r y area u n i m p e d e d . A l s o necessary
are t h e h e a l t h y state o f o l f a c t o r y m u c o s a a n d t h e i n t e g r i t y
o f n e u r a l pathways, i.e. olfactory nerves, olfactory bulb
Nasal Reflexes
a n d tract and the cortical centre o f o l f a c t i o n .
Anosmia is t o t a l loss o f sense o f s m e l l w h i l e hyposmia is
S e v e r a l r e f l e x e s are i n i t i a t e d i n t h e nasal m u c o s a . S m e l l of
p a r t i a l loss. T h e y c a n r e s u l t f r o m nasal o b s t r u c t i o n d u e t o
a p a l a t a b l e f o o d cause r e f l e x s e c r e t i o n o f saliva a n d gastric
nasal p o l y p i , e n l a r g e d turbinates or oedema o f mucous
juice. Irritation o f nasal m u c o s a causes s n e e z i n g . Nasal
m e m b r a n e as i n c o m m o n c o l d , a l l e r g i c o r v a s o m o t o r r h i n -
f u n c t i o n is c l o s e l y r e l a t e d t o p u l m o n a r y f u n c t i o n s t h r o u g h
i t i s . A n o s m i a is also seen i n a t r o p h i c r h i n i t i s , a d e g e n e r a -
nasobronchial and nasopulmonary reflexes. I t has been
t i v e d i s o r d e r o r nasal m u c o s a ; p e r i p h e r a l n e u r i t i s ( t o x i c o r
o b s e r v e d t h a t nasal o b s t r u c t i o n leads t o i n c r e a s e d p u l m o -
influenzal); i n j u r y to o l f a c t o r y nerves o r o l f a c t o r y b u l b i n
n a r y resistance a n d is r e v e r s e d w h e n nasal o b s t r u c t i o n is
f r a c t u r e s o f a n t e r i o r c r a n i a l fossa; a n d i n t r a c r a n i a l l e s i o n s
s u r g i c a l l y t r e a t e d . N a s a l p a c k i n g i n cases o f epistaxis or
l i k e abscess, t u m o u r o r m e n i n g i t i s w h i c h cause pressure o n
a f t e r nasal s u r g e r y leads t o l o w e r i n g o f p O . , w h i c h r e t u r n s
o l f a c t o r y tracts.
t o n o r m a l after r e m o v a l o f the pack. P u l m o n a r y h y p e r t e n -
Parosmia is p e r v e r s i o n o f s m e l l ; t h e p e r s o n i n t e r p r e t s t h e
s i o n o r cor p u l m o n a l e can d e v e l o p i n c h i l d r e n w i t h l o n g -
o d o u r s i n c o r r e c t l y . O f t e n these p e r s o n s c o m p l a i n o f d i s -
standing nasal obstruction due to tonsil and adenoid
g u s t i n g o d o u r s . I t is s e e n i n t h e r e c o v e r y p h a s e o f p o s t i n -
h y p e r t r o p h y a n d can be reversed after r e m o v a l o f t h e t o n -
f l u e n z a l a n o s m i a a n d t h e p r o b a b l e e x p l a n a t i o n is m i s d i r e c t e d
sils a n d a d e n o i d s .
r e g e n e r a t i o n o f nerve fibres. Intracranial t u m o u r s h o u l d be
e x c l u d e d i n a l l cases o f p a r o s m i a .
Olfaction Sense o f s m e l l c a n b e t e s t e d b y a s k i n g t h e p a t i e n t t o
s m e l l c o m m o n o d o u r s s u c h as l e m o n , p e p p e r m i n t , r o s e ,
Sense o f s m e l l is w e l l d e v e l o p e d i n l o w e r a n i m a l s t o g i v e g a r l i c o r c l o v e s f r o m e a c h side o f t h e n o s e separately, with
w a r n i n g o f t h e e n v i r o n m e n t a l d a n g e r s b u t i t is compara- eyes c l o s e d . Q u a n t i t a t i v e e s t i m a t i o n ( q u a n t i t a t i v e o l f a c t o -
t i v e l y less i m p o r t a n t i n m a n . S t i l l i t is i m p o r t a n t f o r p l e a s u r e m e t r y ' ) r e q u i r e s special equipment.
Diseases o f External Nose a n d
Nasal Vestibule

corrected by augmentation rhinoplasty b y f i l l i n g the d o r -

DISEASES OF EXTERNAL NOSE
s u m w i t h cartilage, b o n e or a synthetic i m p l a n t . I f depres-
s i o n is o n l y c a r t i l a g i n o u s , c a r t i l a g e is t a k e n f r o m t h e nasal
s e p t u m o r a u r i c l e a n d l a i d i n a s i n g l e o r m u l t i p l e layers. I f
Cellulitis
d e f o r m i t y i n v o l v e s b o t h cartilage and bone, cancellous
b o n e f r o m t h e i l i a c crest is t h e best. A u t o g r a f t s ( t a k e n f r o m
T h e nasal s k i n m a y b e i n v a d e d b y s t r e p t o c o c c i o r s t a p h y -
t h e same i n d i v i d u a l ) are p r e f e r r e d t o a l l o g r a f t s ( t a k e n f r o m
l o c o c c i l e a d i n g to a r e d , s w o l l e n a n d t e n d e r nose. S o m e -
o t h e r i n d i v i d u a l s o r cadavers). S a d d l e d e f o r m i t y c a n also
t i m e s , i t is a n e x t e n s i o n o f i n f e c t i o n f r o m t h e nasal v e s t i b u l e .
be corrected b y synthetic implants o f silicone o r t e f l o n b u t
T r e a t m e n t is s y s t e m i c a n t i b a c t e r i a l s , h o t f o m e n t a t i o n a n d
t h e y are l i k e l y t o b e e x t r u d e d .
analgesics.

Hump Nose

Nasal Deformities T h i s m a y also i n v o l v e t h e b o n e o r c a r t i l a g e o r b o t h b o n e

and cartilage. I t can be c o r r e c t e d b y r e d u c t i o n rhinoplasty
Saddle Nose
w h i c h consists o f e x p o s u r e o f nasal f r a m e w o r k b y c a r e f u l

D e p r e s s e d nasal d o r s u m m a y i n v o l v e b o n y , c a r t i l a g i n o u s r a i s i n g o f t h e nasal s k i n b y a v e s t i b u l a r i n c i s i o n , r e m o v a l o f

o r b o t h b o n y a n d c a r t i l a g i n o u s c o m p o n e n t s o f nasal d o r - h u m p and n a r r o w i n g o f the lateral walls b y osteotomies to

s u m ( F i g . 2 5 . 1 ) . N a s a l t r a u m a c a u s i n g d e p r e s s e d f r a c t u r e s is reduce the w i d e n i n g left b y h u m p r e m o v a l .

t h e m o s t c o m m o n a e t i o l o g y . I t c a n also r e s u l t f r o m e x c e s -
Crooked or a Deviated Nose
sive r e m o v a l o f s e p t u m i n s u b m u c o u s resection, destruc-
t i o n o f septal c a r t i l a g e b y h a e m a t o m a o r abscess, s o m e t i m e s I n c r o o k e d nose, the m i d l i n e o f d o r s u m f r o m frontonasal
b y l e p r o s y , t u b e r c u l o s i s o r s y p h i l i s . T h e d e f o r m i t y c a n be a n g l e t o t h e t i p , is c u r v e d i n a C o r S shaped manner.

Norma Saddle Supralip Humped Crooked nose Deviated nose

nose depression nose

Figure 25.1
Nasal bridge is S-shaped in c r o o k e d nose. It is straight b u t
D e f o r m i t i e s o f nose. deviated t o o n e side in deviated nose.
 Diseases o f External N o s e a n d N a s a l Vestibule

I n a d e v i a t e d n o s e , t h e m i d l i n e is s t r a i g h t b u t d e v i a t e d t o Encephalocele o r m e n i n g o e n c e p h a l o c e l e I t is a h e r n i a -
o n e side ( F i g . 2 5 . 2 ) . t i o n o f b r a i n tissue w i t h m e n i n g e s t h r o u g h a c o n g e n i t a l b o n y
Usually, these deformities are traumatic in origin. defect. A n extranasal m e n i n g o e n c e p h a l o c e l e presents as a
Injuries sustained d u r i n g b i r t h , neonatal p e r i o d or c h i l d - s u b c u t a n e o u s pulsatile s w e l l i n g i n t h e m i d l i n e at t h e r o o t o f
h o o d , b u t n o t i m m e d i a t e l y r e c o g n i s e d , w i l l also d e v e l o p nose (nasofrontal variety), side o f nose (nasoethmoid variety) or
i n t o these d e f o r m i t i e s w i t h t h e g r o w t h o f n o s e . T h e d e v i - o n t h e a n t e r o m e d i a l aspect o f t h e o r b i t (naso-orbital variety).
a t e d o r c r o o k e d nose c a n b e c o r r e c t e d b y r h i n o p l a s t y o r Swellings s h o w c o u g h impulse and m a y be reducible.
s e p t o r h i n o p l a s t y . A i m o f t h e s e o p e r a t i o n s is t o c o r r e c t n o t T r e a t m e n t is n e u r o s u r g i c a l ; s e v e r i n g t h e t u m o u r s t a l k f r o m
o n l y t h e o u t e r a p p e a r a n c e o f nose b u t also its f u n c t i o n . the b r a i n and repairing the b o n y defect through which
h e r n i a t i o n has t a k e n p l a c e .

Glioma I t is a n i p p e d o f f p o r t i o n o f e n c e p h a l o c e l e d u r -
Tumours
ing embryonic development. Most of them (60%) are
extranasal a n d p r e s e n t as f i r m s u b c u t a n e o u s swellings o n
T h e y m a y be congenital, b e n i g n or malignant.
t h e b r i d g e , side o f nose o r n e a r t h e i n n e r c a n t h u s . S o m e o f

1. Congenital Tumours t h e m are p u r e l y i n t r a n a s a l ( 3 0 % ) w h i l e 1 0 % are b o t h i n t r a

a n d e x t r a n a s a l . E x t r a n a s a l g l i o m a s are e n c a p s u l a t e d a n d c a n
D e r m o i d cyst (Fig. 25.3) I t is o f t w o t y p e s :
b e easily r e m o v e d b y e x t e r n a l nasal a p p r o a c h .
(a) Simple dermoid. I t o c c u r s as a m i d l i n e s w e l l i n g u n d e r
t h e s k i n b u t i n f r o n t o f t h e nasal b o n e s . I t does n o t h a v e
any external o p e n i n g .
(b) Tliat associated with a sinus. I t is seen i n i n f a n t s a n d
c h i l d r e n a n d is r e p r e s e n t e d b y a p i t o r a s i n u s i n t h e m i d -
l i n e o f t h e d o r s u m o f n o s e . H a i r m a y be seen p r o t r u d i n g
t h r o u g h t h e sinus o p e n i n g . I n these cases, t h e sinus t r a c k
m a y l e a d t o a d e r m o i d cyst u n d e r t h e nasal b o n e i n f r o n t
o f u p p e r p a r t o f nasal s e p t u m o r m a y h a v e a n i n t r a c r a n i a l
dural connection. I n those w i t h intracranial extension,
sinus t r a c t passes t h r o u g h t h e c r i b r i f o r m p l a t e o r f o r a m e n
c a e c u m a n d is a t t a c h e d t o d u r a o r has o t h e r i n t r a c r a n i a l
connection. M e n i n g i t i s o c c u r s i f i n f e c t i o n travels a l o n g
t h i s p a t h . T r e a t m e n t o f s u c h cysts m a y necessitate s p l i t t i n g
o f t h e nasal b o n e s t o r e m o v e a n y e x t e n s i o n i n t h e u p p e r
part of the nasal septum. A combined neurosurgical
o t o l a r y n g o l o g i c a p p r o a c h is r e q u i r e d i n t h o s e e x t e n d i n g Figure 25.4
i n t r a c r a n i a l l y so as t o close s i m u l t a n e o u s l y a n y b o n y d e f e c t
Rhinophyma.
t h r o u g h w h i c h t h e f i s t u l o u s t r a c t passes ( F i g . 2 5 . 4 ) .

Duro

Figure 25.3

Types o f dermoids. (A) Simple dermoid beneath the skin. (B) D e r m o i d with an external pit or sinus but in front o f septum. Its tract

extends under the nasal bones but in front o f septum. (C) Dermoid with an intracranial connection to dura.
2. Benign Tumours

T h e y arise f r o m t h e nasal s k i n a n d i n c l u d e papilloma (skin

w a r t ) , haemangioma, pigmented naevus, seborrhoeic keratosis,
neurofibroma or tumour of sweat glands.
Rhinophyma or potato t u m o u r is a s l o w - g r o w i n g
b e n i g n t u m o u r d u e t o h y p e r t r o p h y o f t h e sebaceous g l a n d s
o f t h e t i p o f n o s e o f t e n seen i n cases o f l o n g - s t a n d i n g a c n e
rosacea. I t presents as a p i n k , l o b u l a t e d mass o v e r t h e n o s e
w i t h s u p e r f i c i a l vascular d i l a t i o n ; m o s t l y affects m e n past
m i d d l e age ( F i g . 2 5 . 4 ) . P a t i e n t seeks a d v i c e because o f t h e
unsightly appearance o f the t u m o u r , or obstruction i n
b r e a t h i n g a n d v i s i o n d u e t o t h e l a r g e size o f t h e t u m o u r .
Treatment consists o f p a r i n g d o w n the b u l k o f t u m o u r
with sharp knife or carbon d i o x i d e laser a n d t h e area
a l l o w e d to re-epithelialise. S o m e t i m e s , t u m o u r is com-
p l e t e l y e x c i s e d a n d t h e r a w area s k i n - g r a f t e d .

3. Malignant Tumours
Carcinoma nose.
(a) Basal cell carcinoma (rodent ulcer) (Fig. 25.5)
T h i s is t h e m o s t c o m m o n malignant t u m o u r involving
s k i n o f nose ( 8 7 % ) , e q u a l l y a f f e c t i n g males a n d females i n
e q u a l l y a f f e c t i n g b o t h sexes i n 4 0 - 6 0 age g r o u p . I t o c c u r s
t h e age g r o u p o f 4 0 - 6 0 . C o m m o n sites o n t h e nose are t h e
as a n i n f i l t r a t i n g n o d u l e o r a n u l c e r w i t h r o l l e d o u t edges
t i p a n d t h e ala. I t m a y p r e s e n t as a cyst o r papulo-pearly nod-
a f f e c t i n g side o f nose o r c o l u m e l l a (Fig. 25.6). Nodal
ule o r a n ulcer with rolled edges. I t is v e r y s l o w - g r o w i n g a n d
metastases are seen i n 2 0 % o f cases.
remains c o n f i n e d t o the skin for a l o n g t i m e . U n d e r l y i n g
Early lesions r e s p o n d t o r a d i o t h e r a p y ; m o r e advanced
c a r t i l a g e o r b o n e m a y get i n v a d e d . N o d a l metastases are
lesions o r t h o s e w i t h e x p o s u r e o f b o n e o r c a r t i l a g e r e q u i r e
e x t r e m e l y rare. T r e a t m e n t d e p e n d s o n t h e size, l o c a t i o n
w i d e s u r g i c a l e x c i s i o n a n d plastic r e p a i r o f t h e d e f e c t . E n l a r -
and d e p t h o f the t u m o u r . E a r l y lesion can be c u r e d b y
ged regional l y m p h nodes w i l l require b l o c k dissection.
c r y o s u r g e r y , i r r a d i a t i o n o r s u r g i c a l e x c i s i o n w i t h 3—5 m m
o f skin a r o u n d the palpable borders o f the t u m o u r . (c) M e l a n o m a T h i s is t h e least c o m m o n v a r i e t y . C l i n i -

L e s i o n s w h i c h are r e c u r r e n t , e x t e n s i v e o r w i t h i n v o l v e - c a l l y , i t is s u p e r f i c i a l l y - s p r e a d i n g t y p e ( s l o w - g r o w i n g ) o r

ment o f cartilage o r b o n e are excised and the surgical n o d u l a r i n v a s i v e t y p e . T r e a t m e n t is s u r g i c a l e x c i s i o n .

d e f e c t c l o s e d b y l o c a l o r d i s t a n t flaps o r a p r o s t h e s i s .

(b) S q u a m o u s c e l l c a r c i n o m a ( e p i t h e l i o m a ) T h i s is
the second most common malignant tumour (ll%i),
DISEASES OF NASAL VESTIBULE

Furuncle o r B o i l ( F i g . 25.7)

I t is a n a c u t e i n f e c t i o n o f t h e h a i r f o l l i c l e b y Staphylococcus
aureus. T r a u m a f r o m p i c k i n g o f the nose o r p l u c k i n g the
nasal v i b r i s s a e , is t h e u s u a l p r e d i s p o s i n g f a c t o r .
T h e l e s i o n is s m a l l b u t e x q u i s i t e l y p a i n f u l a n d tender.
I n f l a m m a t i o n m a y spread t o t h e s k i n o f nasal t i p a n d d o r -
sum w h i c h become red and swollen. T h e furuncle may
r u p t u r e s p o n t a n e o u s l y i n t h e nasal v e s t i b u l e .
Treatment o f f u r u n c l e consists o f w a r m compresses,
analgesics t o r e l i e v e p a i n , a n d t o p i c a l a n d s y s t e m i c a n t i b i -
o t i c s d i r e c t e d against staphylococcus. I f a f l u c t u a n t area
appears, i n c i s i o n a n d d r a i n a g e can b e d o n e . I n no case
s h o u l d t h e f u r u n c l e be s q u e e z e d o r p r e m a t u r e l y incised
because o f t h e danger o f spread o f i n f e c t i o n t o cavernous
B a s a l cell carcinoma o f the nose.
sinus t h r o u g h v e n o u s t h r o m b o p h l e b i t i s .
 peroxide and application o f antibiotic-steroid ointment.
T h e l a t t e r s h o u l d a l w a y s b e c o n t i n u e d f o r a f e w m o r e days,
e v e n a f t e r t h e a p p a r e n t c u r e , as t h e c o n d i t i o n is l i k e l y t o
relapse. A c h r o n i c fissure can be c a u t e r i s e d w i t h s i l v e r n i t r a t e .
A t t e n t i o n s h o u l d be p a i d t o t h e cause o f nasal discharge.

Stenosis and Atresia o f the Nares

A c c i d e n t a l o r s u r g i c a l t r a u m a t o t h e nasal t i p o r v e s t i b u l e
c a n l e a d t o w e b f o r m a t i o n a n d stenosis o f a n t e r i o r nares. I n
Y o u n g ' s o p e r a t i o n , v e s t i b u l a r s k i n flaps are r a i s e d t o c r e a t e
deliberate closure o f nares i n t h e t r e a t m e n t o f a t r o p h i c
r h i n i t i s (sec page 1 7 0 ) . D e s t r u c t i v e i n f l a m m a t o r y lesions o f
n o s e also cause stenosis. E a r l i e r , several cases o f v e s t i b u l a r
stenosis r e s u l t e d f r o m s m a l l p o x ( F i g . 2 5 . 9 ) .
Furuncle right nasal vestibule. Congenital atresia o f a n t e r i o r nares d u e t o noncanalisa-
t i o n o f e p i t h e l i a l p l u g is a rare c o n d i t i o n .
A f u r u n c l e o f nose m a y c o m p l i c a t e i n t o cellulitis o f t h e S t e n o s i s o f nares c a n b e corrected by reconstructive
u p p e r l i p o r septal abscess. plastic p r o c e d u r e s .

Vestibulitis
H I Tumours

I t is d i f f u s e d e r m a t i t i s o f nasal v e s t i b u l e . N a s a l discharge, Nasoalveolar cyst presents a s m o o t h b u l g e i n t h e l a t e r a l

d u e t o a n y cause s u c h as r h i n i t i s , s i n u s i t i s o r nasal a l l e r g y , wall a n d f l o o r o f nasal v e s t i b u l e . T h e cyst can be
c o u p l e d w i t h t r a u m a o f h a n d k e r c h i e f , is t h e u s u a l p r e d i s - excised b y sublabial approach preserving the i n t e g r i t y
p o s i n g factor. The causative organism is Staph, aureus. o f vestibular skin.
Vestibulitis m a y be acute or c h r o n i c . Papilloma or wart m a y b e s i n g l e o r m u l t i p l e , p e d u n c u -
I n acute form, v e s t i b u l a r s k i n is r e d , s w o l l e n a n d t e n d e r ; l a t e d o r sessile. T r e a t m e n t is s u r g i c a l e x c i s i o n under
crusts a n d scales c o v e r a n area o f s k i n e r o s i o n o r e x c o r i a - l o c a l anaesthesia.
t i o n . T h e u p p e r l i p m a y also b e i n v o l v e d ( F i g . 2 5 . 8 ) . Squamous cell carcinoma arises f r o m t h e l a t e r a l w a l l of
I n chronic form, t h e r e is i n d u r a t i o n o f v e s t i b u l a r s k i n t h e v e s t i b u l e a n d m a y e x t e n d i n t o nasal floor, colu-
w i t h p a i n f u l fissures a n d c r u s t i n g . m e l l a a n d u p p e r l i p . I t can metastasise t o t h e p a r o t i d
T r e a t m e n t consists o f c l e a n i n g t h e nasal v e s t i b u l e o f all a n d s u b m a n d i b u l a r n o d e s . T r e a t m e n t is s u r g i c a l e x c i -
crusts a n d scales w i t h c o t t o n a p p l i c a t o r s o a k e d i n h y d r o g e n sion or irradiation.

A c u t e vestibulitis (left side). S t e n o s i s left naris following smallpox.

 Nasal S e p t u m and Its Diseases

s p h e n o i d , crest o f p a l a t i n e b o n e s a n d t h e crest m a x -
Anatomy
i l l a , a n d t h e a n t e r i o r nasal s p i n e o f m a x i l l a .

N a s a l s e p t u m consists o f t h r e e parts: Septal cartilage n o t o n l y f o r m s a p a r t i t i o n b e t w e e n the

1. Columellar septum I t is f o r m e d o f c o l u m e l l a c o n - r i g h t a n d l e f t nasal c a v i t i e s b u t also p r o v i d e s s u p p o r t t o t h e

t a i n i n g t h e m e d i a l c r u r a o f alar cartilages u n i t e d t o g e t h e r t i p a n d d o r s u m o f c a r t i l a g i n o u s p a r t o f n o s e . Its d e s t r u c -

b y f i b r o u s tissue a n d c o v e r e d o n e i t h e r side b y s k i n . t i o n , e . g . i n septal abscess, i n j u r i e s , t u b e r c u l o s i s o r excessive

r e m o v a l d u r i n g septal s u r g e r y , leads t o d e p r e s s i o n o f l o w e r
2. M e m b r a n o u s septum I t consists o f d o u b l e l a y e r o f
p a r t o f n o s e a n d d r o o p i n g o f t h e nasal t i p .
s k i n w i t h n o b o n y o r c a r t i l a g i n o u s s u p p o r t . I t lies b e t w e e n
S e p t a l c a r t i l a g e lies i n a g r o o v e i n t h e a n t e r i o r e d g e of
t h e c o l u m e l l a a n d t h e c a u d a l b o r d e r o f septal c a r t i l a g e .
v o m e r a n d rests a n t e r i o r l y o n a n t e r i o r nasal s p i n e . D u r i n g
B o t h c o l u m e l l a r a n d m e m b r a n o u s parts are f r e e l y m o v a b l e
t r a u m a , i t m a y g e t d i s l o c a t e d f r o m a n t e r i o r nasal s p i n e o r
f r o m side t o s i d e .
v o m e r i n e g r o o v e c a u s i n g c a u d a l septal d e v i a t i o n o r septal
3. S e p t u m proper I t consists o f o s t e o c a r t i l a g i n o u s f r a m e -
s p u r r e s p e c t i v e l y . T h i s c o m p r o m i s e s t h e nasal a i r w a y . Septal
w o r k , c o v e r e d w i t h nasal m u c o u s m e m b r a n e .
c a r t i l a g e is also i n t i m a t e l y r e l a t e d t o t h e u p p e r l a t e r a l c a r -
Its p r i n c i p a l c o n s t i t u e n t s are ( F i g . 2 6 . 1 ) :
tilages o f n o s e a n d is i n fact f u s e d w i t h t h e m i n t h e u p p e r

t h e p e r p e n d i c u l a r plate o f e t h m o i d t h i r d . F o r t h i s r e a s o n septal d e v i a t i o n m a y b e associated

the v o m e r , and w i t h d e v i a t i o n o f cartilaginous part o f external nose.

a l a r g e septal ( q u a d r i l a t e r a l ) c a r t i l a g e w e d g e d b e t w e e n Blood Vessels of Nasal Septum (see C h a p t e r 3 3 ) .

the above t w o bones anteriorly. O t h e r bones w h i c h Nerve Supply of Nasal Septum (see C h a p t e r 2 3 ) .

m a k e m i n o r c o n t r i b u t i o n s at t h e p e r i p h e r y are: crest Little's area or Kiesselbach's plexus T h i s is t h e vascular

o f nasal b o n e s , nasal s p i n e o f f r o n t a l b o n e , r o s t r u m o f area i n t h e a n t e r o - i n f e r i o r p a r t o f nasal s e p t u m j u s t a b o v e t h e
vestibule. A n t e r i o r e t h m o i d a l , sphenopalatine, greater pala-
t i n e a n d septal b r a n c h o f s u p e r i o r labia! arteries a n d t h e i r

Nasal spine of c o r r e s p o n d i n g veins f o r m an anastomosis h e r e . T h i s is t h e

frontal bone c o m m o n e s t site f o r epistaxis. T h i s is also t h e site f o r o r i g i n o f
t h e " b l e e d i n g p o l y p u s " ( h a e m a n g i o m a ) o f nasal s e p t u m .
Cresl of nasa
bone elhmoid

Membranous
septum Fractures of Nasal Septum
Vomer Rostrum of
sphenoid
Columellar
Aetiopathogenesis
septum
T r a u m a i n f l i c t e d o n t h e n o s e f r o m t h e f r o n t , side o r b e l o w
Ant. nasal spine
of maxilla Crest of maxilla c a n r e s u l t i n i n j u r i e s t o t h e nasal s e p t u m . T h e s e p t u m m a y
buckle on itself, f r a c t u r e v e r t i c a l l y , h o r i z o n t a l l y o r be
Crest of palatine bone
c r u s h e d t o p i e c e s as i n a s m a s h e d n o s e . T h e f r a c t u r e d pieces
o f s e p t u m m a y o v e r l a p each o t h e r o r p r o j e c t i n t o t h e nasal
c a v i t y t h r o u g h m u c o s a l tears. F r a c t u r e o f t h e septal c a r t i l a g e
A n a t o m y o f nasal septum.
or its d i s l o c a t i o n f r o m t h e v o m e r i n e g r o o v e , can r e s u l t

ft
 N a s a l S e p t u m a n d Its D i s e a s e s

f r o m t r a u m a t o t h e l o w e r n o s e w i t h o u t associated f r a c t u r e s Complications
o f nasal b o n e s . S e p t a l i n j u r i e s w i t h m u c o s a l tears cause
S e p t u m is i m p o r t a n t i n s u p p o r t i n g t h e l o w e r p a r t o f t h e
p r o f u s e epistaxis w h i l e t h o s e w i t h i n t a c t m u c o s a r e s u l t i n
e x t e r n a l n o s e . I f its i n j u r i e s are i g n o r e d , t h e y w o u l d r e s u l t
septal h a e m a t o m a w h i c h , i f n o t d r a i n e d e a r l y , w i l l cause
i n d e v i a t i o n o f t h e cartilaginous nose, o r a s y m m e t r y of
a b s o r p t i o n o f t h e septal cartilage a n d saddle nose d e f o r m i t y .
nasal t i p , c o l u m e l l a o r t h e n o s t r i l .
"Jarjaway" f r a c t u r e o f nasal s e p t u m results f r o m b l o w s
f r o m t h e f r o n t ; i t starts j u s t a b o v e t h e a n t e r i o r nasal s p i n e
and runs horizontally backwards just above the j u n c t i o n o f DEVIATED NASAL SEPTUM (DNS)
septal c a r t i l a g e w i t h t h e v o m e r ( F i g . 2 6 . 2 A ) .
" C h e v a l l e t " f r a c t u r e o f septal c a r t i l a g e results f r o m b l o w s T h i s is a n i m p o r t a n t cause o f nasal o b s t r u c t i o n .
f r o m b e l o w ; i t r u n s v e r t i c a l l y f r o m t h e a n t e r i o r nasal s p i n e
upwards to the j u n c t i o n o f b o n y and cartilaginous d o r s u m Aetiology
o f nose (Fig. 2 6 . 2 B ) .
T r a u m a a n d errors o f d e v e l o p m e n t f o r m the t w o i m p o r -
tant factors i n t h e causation o f d e v i a t e d s e p t u m .
Treatment
1. Trauma A l a t e r a l b l o w o n t h e n o s e m a y cause d i s -
E a r l y r e c o g n i t i o n a n d t r e a t m e n t o f septal i n j u r i e s is essen-
placement o f septal cartilage f r o m the v o m e r i n e groove
tial. H a e m a t o m a s s h o u l d be d r a i n e d . Dislocated o r frac-
a n d m a x i l l a r y crest, w h i l e a c r u s h i n g b l o w f r o m t h e f r o n t
t u r e d septal f r a g m e n t s s h o u l d b e r e p o s i t i o n e d a n d s u p p o r t e d
m a y cause b u c k l i n g , t w i s t i n g , fractures and duplication o f
between m u c o p e r i c h o n d r i a l flaps w i t h mattress sutures
nasal s e p t u m w i t h t e l e s c o p i n g o f its f r a g m e n t s . I n j u r i e s t o
a n d nasal p a c k i n g . F r a c t u r e s o f nasal p y r a m i d are often
t h e nose c o m m o n l y occur i n c h i l d h o o d b u t are often
c o m p l i c a t e d w i t h fractures o f the s e p t u m and b o t h s h o u l d
o v e r l o o k e d . E v e n the h i s t o r y m a y n o t be f o r t h c o m i n g .
be treated c o n c o m i t a n t l y .
Trauma may also b e i n f l i c t e d at b i r t h during difficult
l a b o u r w h e n n o s e is p r e s s e d d u r i n g its passage t h r o u g h
the birth canal. Birth injuries should be immediately
a t t e n d e d t o as t h e y r e s u l t i n s e p t a l d e v i a t i o n l a t e r i n l i f e .

2. Developmental error N a s a l s e p t u m is f o r m e d b y
the tectoseptal process w h i c h descends t o m e e t the t w o
halves o f t h e d e v e l o p i n g palate i n the m i d l i n e . During
the p r i m a r y and secondary dentition, further develop-
m e n t takes place i n t h e palate, w h i c h descends a n d w i d -
ens t o a c c o m m o d a t e the teeth.
Unequal g r o w t h between t h e palate a n d t h e base of
s k u l l m a y cause b u c k l i n g o f t h e nasal s e p t u m . I n m o u t h
breathers, as i n a d e n o i d h y p e r t r o p h y , t h e p a l a t e is o f t e n
highly arched and the septum is d e v i a t e d (Fig. 26.3).

Figure 26.2

Septal fracture showing: (A)Jarjaway type. (B) Chevallet type. D N S associated with high-arched palate.
S i m i l a r l y , D N S m a y b e seen i n cases o f c l e f t l i p a n d palate 2. C - s h a p e d d e f o r m i t y S e p t u m is d e v i a t e d i n a s i m p l e
and i n those w i t h dental abnormalities. c u r v e t o o n e side. N a s a l c h a m b e r o n t h e c o n c a v e side o f

3. Racial factors C a u c a s i a n s are affected more than t h e nasal s e p t u m w i l l b e w i d e r a n d m a y s h o w compensa-

Negroes. t o r y h y p e r t r o p h y o f turbinates.

4. Hereditary factors Several members o f the same 3. S - s h a p e d deformity S e p t u m may s h o w a S-shaped

f a m i l y m a y h a v e d e v i a t e d nasal s e p t u m . curve either in vertical or anteroposterior plane. Such a

d e f o r m i t y m a y cause b i l a t e r a l nasal o b s t r u c t i o n .

Types of DNS ( F i g . 26.4) 4 . S p u r s A s p u r is a s h e l f - l i k e p r o j e c t i o n o f t e n f o u n d at

t h e j u n c t i o n o f b o n e a n d c a r t i l a g e . A s p u r m a y press o n t h e
D e v i a t i o n m a y i n v o l v e o n l y the cartilage, b o n e o r b o t h the
l a t e r a l w a l l a n d g i v e s rise t o h e a d a c h e . I t m a y also p r e d i s -
cartilage and b o n e .
pose t o r e p e a t e d epistaxis f r o m t h e vessels s t r e t c h e d o n its
1. Anterior dislocation Septal cartilage m a y be dislo-
c o n v e x surface.
c a t e d i n t o o n e o f t h e nasal c h a m b e r s . T h i s is b e t t e r a p p r e -
5. T h i c k e n i n g I t m a y be due to organised h a e m a t o m a o r
c i a t e d b y l o o k i n g at t h e base o f n o s e w h e n p a t i e n t ' s h e a d
o v e r - r i d i n g o f d i s l o c a t e d septal f r a g m e n t s .
is t i l t e d b a c k w a r d s ( F i g . 2 6 . 5 ) .

Clinical Features

D N S c a n i n v o l v e a n y age a n d sex. M a l e s are a f f e c t e d m o r e

t h a n females.

1. Nasal obstruction D e p e n d i n g o n t h e t y p e o f septal

Anterior dislocation C-shaped deflection
Nasal spur impinging
on turbinate
Types o f deviated nasal septum.
S-shaped deflection
Thickening of nasal
septum
deformity, obstruction may be unilateral or bilateral.
R e s p i r a t o r y c u r r e n t s pass t h r o u g h u p p e r p a r t o f nasal c a v -
i t y , t h e r e f o r e , h i g h septal d e v i a t i o n cause nasal o b s t r u c t i o n
m o r e t h a n l o w e r ones.
When e x a m i n i n g a case o f nasal obstruction, one
s h o u l d ascertain t h e site o f o b s t r u c t i o n i n t h e n o s e . I t
c o u l d b e (1) vestibular ( c a u d a l septal d i s l o c a t i o n , s y n e c h i a e
o r s t e n o s i s ) , (2) at t h e nasal valve ( s y n e c h i a e , u s u a l l y p o s t -
r h i n o p l a s t y ) , (3) attic ( a l o n g t h e u p p e r p a r t o f nasal s e p -
t u m d u e t o h i g h s e p t a l d e v i a t i o n ; (4) turbinal (hypertrophic
turbinates or concha b u l l o s a ) ; a n d (5) choanal (choanal
atresia o r a c h o a n a l p o l y p . ) u n i l a t e r a l c h o a n a l atresia m a y
be missed i n i n f a n c y and c h i l d h o o d . C h o a n a l p o l y p m a y
be m i s s e d o n t h e a n t e r i o r r h i n o s c o p y unless posterior
r h i n o s c o p y o r nasal e n d o s c o p y is d o n e .
Cottle test. I t is u s e d i n nasal o b s t r u c t i o n d u e t o a b n o r -
m a l i t y o f t h e nasal v a l v e . I n t h i s test, c h e e k is d r a w n l a t e r -
a l l y w h i l e t h e p a t i e n t b r e a t h e s q u i e t l y . I f t h e nasal a i r w a y
i m p r o v e s o n t h e test side, t h e test is p o s i t i v e , a n d i n d i c a t e s
a b n o r m a l i t y o f t h e v e s t i b u l a r c o m p o n e n t o f nasal valve
(Fig. 26.6).

2. Headache D e v i a t e d s e p t u m , especially a spur, may

press o n t h e l a t e r a l w a l l o f nose g i v i n g rise t o pressure
headache.

3. S i n u s i t i s D e v i a t e d s e p t u m m a y o b s t r u c t sinus ostia
r e s u l t i n g i n p o o r v e n t i l a t i o n o f t h e sinuses. T h e r e f o r e , i t
f o r m s a n i m p o r t a n t cause t o p r e d i s p o s e o r p e r p e t u a t e sinus
infections.

Figure 26.5 4. Epistaxis M u c o s a o v e r t h e d e v i a t e d p a r t o f s e p t u m is

e x p o s e d t o t h e d r y i n g effects o f air currents l e a d i n g to
Anterior dislocation. Caudal border o f septal cartilage projects
f o m i a t i o n o f crusts w h i c h w h e n r e m o v e d , cause b l e e d i n g .
into right naris.
B l e e d i n g m a y also o c c u r f r o m vessels o v e r a septal s p u r .
 Nasal Septum and its Diseases

o f t h e septal f r a m e w o r k is c o r r e c t e d a n d r e p o s i t i o n e d b y
plastic m e a n s . M u c o p e r i c h o n d r i a l / p e r i o s t e a l flap is g e n e r -
a l l y raised o n l y o n o n e side o f t h e s e p t u m , r e t a i n i n g t h e
attachment a n d b l o o d s u p p l y o n the o t h e r . Septoplasty has
n o w almost replaced S M R o p e r a t i o n (see C h a p t e r 85).
S e p t a l s u r g e r y is u s u a l l y d o n e a f t e r t h e age o f 17 so as
n o t t o i n t e r f e r e w i t h t h e g r o w t h o f nasal s k e l e t o n . H o w e v e r ,
i f a c h i l d has severe septal d e v i a t i o n c a u s i n g m a r k e d nasal
obstruction, conservative septal s u r g e r y (septoplasty) can
be p e r f o r m e d to p r o v i d e a g o o d a i r w a y .

SEPTAL HAEMATOMA

Aetiology

It is c o l l e c t i o n o f blood under the perichondrium or

p e r i o s t e u m o f t h e nasal s e p t u m ( F i g . 2 6 . 7 ) . I t o f t e n results
f r o m nasal t r a u m a o r septal s u r g e r y . I n b l e e d i n g d i s o r d e r s ,
it may occur spontaneously.
Figure 26.6
Clinical Features
C o t t l e test: O n p u l l i n g the cheek a w a y f r o m the m i d l i n e , the
nasal valve opens, increasing the a i r f l o w f r o m t h a t side o f the B i l a t e r a l nasal o b s t r u c t i o n is t h e c o m m o n e s t presenting
nasal cavity. s y m p t o m . T h i s m a y b e associated w i t h f r o n t a l h e a d a c h e
a n d a sense o f pressure o v e r t h e nasal b r i d g e .
E x a m i n a t i o n reveals s m o o t h r o u n d e d s w e l l i n g o f t h e
5. A n o s m i a Failure o f t h e i n s p i r e d air t o reach t h e olfac-
s e p t u m i n b o t h t h e nasal fossae. P a l p a t i o n m a y s h o w t h e
t o r y r e g i o n m a y r e s u l t i n t o t a l o r p a r t i a l loss o f sense o f
mass t o b e soft a n d fluctuant.
smell.

6. E x t e r n a l d e f o r m i t y Septal d e f o r m i t i e s m a y be associ- Treatment

ated w i t h d e v i a t i o n o f the cartilaginous o r b o t h the b o n y
Small h a e m a t o m a s can be aspirated w i t h a w i d e b o r e ster-
a n d c a r t i l a g i n o u s d o r s u m o f n o s e , d e f o r m i t i e s o f t h e nasal
i l e n e e d l e . L a r g e r h a e m a t o m a s are i n c i s e d a n d d r a i n e d b y a
tip or columella.
s m a l l a n t e r o - p o s t e r i o r i n c i s i o n p a r a l l e l t o t h e nasal f l o o r .
7. M i d d l e ear i n f e c t i o n D N S also p r e d i s p o s e s t o m i d d l e E x c i s i o n o f a small piece o f m u c o s a f r o m t h e edge o f i n c i -
ear i n f e c t i o n . s i o n gives b e t t e r drainage. F o l l o w i n g drainage, n o s e is
p a c k e d o n b o t h sides t o p r e v e n t r e a c c u m u l a t i o n . S y s t e m i c
Treatment
a n t i b i o t i c s s h o u l d b e g i v e n , t o p r e v e n t septal abscess.

M i n o r degrees o f septal d e v i a t i o n w i t h n o s y m p t o m s are

c o m m o n l y seen i n p a t i e n t s a n d r e q u i r e n o t r e a t m e n t . I t is
only when deviated septum produces mechanical nasal
o b s t r u c t i o n o r the s y m p t o m s g i v e n above, that an opera-
t i o n is i n d i c a t e d .

Submucous resection ( S M R ) operation I t is g e n e r -

a l l y d o n e i n a d u l t s u n d e r l o c a l anaesthesia. I t consists o f
e l e v a t i n g t h e m u c o p e r i c h o n d r i a l a n d m u c o p e r i o s t e a l flaps
o n e i t h e r side o f t h e septal f r a m e w o r k b y a s i n g l e i n c i s i o n
m a d e o n o n e side o f t h e s e p t u m , r e m o v i n g t h e deflected
parts o f the b o n y a n d cartilaginous s e p t u m , a n d t h e n r e p o -
sitioning the flaps (see section o n O p e r a t i v e Surgery for
details).

Septoplasty I t is a c o n s e r v a t i v e a p p r o a c h t o septal s u r -
g e r y . I n t h i s o p e r a t i o n , m u c h o f t h e s e p t a l f r a m e w o r k is
Septal h a e m a t o m a .
r e t a i n e d . O n l y t h e m o s t d e v i a t e d parts are r e m o v e d . R e s t
Complications s t a r t e d as s o o n as d i a g n o s i s has b e e n m a d e a n d c o n t i n u e d
at least f o r a p e r i o d o f 10 days.
Septal haematoma, if not drained, may organise into
f i b r o u s tissue l e a d i n g t o a p e r m a n e n t l y t h i c k e n e d s e p t u m . Complications
I f s e c o n d a i y i n f e c t i o n s u p e r v e n e s , i t results i n septal abscess
N e c r o s i s o f septal c a r t i l a g e o f t e n results i n d e p r e s s i o n o f t h e
w i t h n e c r o s i s o f c a r t i l a g e a n d d e p r e s s i o n o f nasal d o r s u m .
c a r t i l a g i n o u s d o r s u m i n t h e s u p r a t i p area a n d m a y r e q u i r e
a u g m e n t a t i o n r h i n o p l a s t y , 2 t o 3 m o n t h s later. N e c r o s i s of

SEPTAL ABSCESS septal flaps m a y l e a d t o septal p e r f o r a t i o n . M e n i n g i t i s a n d

c a v e r n o u s sinus t h r o m b o s i s f o l l o w i n g septal abscess, t h o u g h
rare these days, c a n b e a serious c o m p l i c a t i o n .
Aetiology

M o s t l y , i t results f r o m s e c o n d a r y i n f e c t i o n o f septal h a e m a -
PERFORATION O F NASAL SEPTUM
t o m a . Occasionally, i t f o l l o w s f u r u n c l e o f the nose o r u p p e r
(Fig- 26.9)
l i p . I t m a y also f o l l o w a c u t e i n f e c t i o n s u c h as t y p h o i d o r
measles.
Aetiology

Clinical Features
1. Traumatic perforations T r a u m a is t h e m o s t com-

There is s e v e r e b i l a t e r a l nasal o b s t r u c t i o n w i t h p a i n a n d mon cause. I n j u r y t o m u c o s a l flaps d u r i n g S M R , caute-

t e n d e r n e s s o v e r t h e b r i d g e o f n o s e . P a t i e n t m a y also c o m - rization o f septum w i t h chemicals or galvanocautery for

plain o f fever w i t h chills a n d f r o n t a l headache. S k i n over epistaxis a n d h a b i t u a l n o s e - p i c k i n g are t h e c o m m o n f o r m s

the nose m a y be r e d a n d s w o l l e n . I n t e r n a l e x a m i n a t i o n o f o f t r a u m a . O c c a s i o n a l l y , s e p t u m is d e l i b e r a t e l y p e r f o r a t e d

n o s e reveals s m o o t h b i l a t e r a l s w e l l i n g o f t h e nasal s e p t u m to p u t ornaments.

(Fig. 2 6 . 8 ) . F l u c t u a t i o n can be e l i c i t e d i n this s w e l l i n g . 2. P a t h o l o g i c a l perforations T h e y c a n be c a u s e d b y :

S e p t a l m u c o s a is o f t e n c o n g e s t e d . Submandibular lymph
n o d e s m a y also b e e n l a r g e d a n d t e n d e r .
(b> N a s a l m y i a s i s .
Treatment
Abscess s h o u l d b e d r a i n e d as e a r l y as p o s s i b l e . I n c i s i o n is
m a d e i n t h e m o s t d e p e n d e n t p a r t o f t h e abscess a n d a p i e c e
o f septal m u c o s a e x c i s e d . Pus a n d n e c r o s e d pieces o f c a r t i -
l a g e are r e m o v e d b y s u c t i o n . I n c i s i o n m a y r e q u i r e t o b e
r e o p e n e d d a i l y f o r 2 - 3 days t o d r a i n a n y p u s o r t o r e m o v e
a n y n e c r o s e d p i e c e s o f c a r t i l a g e . S y s t e m i c a n t i b i o t i c s are
S e p t a l abscess.
R h i n o l i t h o r neglected f o r e i g n b o d y causing pressure
necrosis.
C h r o n i c granulomatous conditions like lupus, tuber-
c u l o s i s a n d l e p r o s y cause p e r f o r a t i o n i n t h e cartila-
ginous part w h i l e syphilis involves the b o n y part. I n
these cases, e v i d e n c e o f t h e c a u s a t i v e disease, m a y also
b e seen i n o t h e r systems o f t h e b o d y .
W e g e n e r ' s g r a n u l o m a is a m i d l i n e d e s t r u c t i v e l e s i o n
w h i c h m a y cause t o t a l septal d e s t r u c t i o n .

Septal abscess. Septal p e r f o r a t i o n .

 N a s a l S e p t u m a n d Its D i s e a s e s

3. D r u g s and chemicals

P r o l o n g e d use o f s t e r o i d sprays i n nasal a l l e r g y .

C o c a i n e addicts.
W o r k e r s i n c e r t a i n o c c u p a t i o n s e.g. c h r o m i u m p l a t i n g ,
d i c h r o m a t e o r soda ash { s o d i u m c a r b o n a t e ) m a n u f a c -
t u r e o r t h o s e e x p o s e d t o arsenic o r its c o m p o u n d s .

4. Idiopathic I n m a n y cases, t h e r e is n o h i s t o r y o f t r a u m a
o r p r e v i o u s disease a n d t h e p a t i e n t m a y e v e n be unaware
o f the existence o f a perforation.

Clinical Features

S m a l l a n t e r i o r p e r f o r a t i o n s cause w h i s t l i n g s o u n d d u r i n g
i n s p i r a t i o n o r e x p i r a t i o n . L a r g e r p e r f o r a t i o n s d e v e l o p crusts
w h i c h o b s t r u c t t h e n o s e o r cause severe epistaxis when Figure 26.10
removed.
Septal button for closure o f perforation.

Treatment
A n a t t e m p t s h o u l d a l w a y s b e m a d e t o f i n d o u t t h e cause
before treatment o f perforation. This may require biopsy
f r o m the g r a n u l a t i o n o r the edge o f the p e i f o r a t i o n . Inactive
s m a l l p e r f o r a t i o n s c a n b e s u r g i c a l l y c l o s e d b y plastic
L a r g e r p e r f o r a t i o n s are d i f f i c u l t t o close. T h e i r t r e a t m e n t is
a i m e d t o k e e p t h e nose c r u s t - f r e e b y a l k a l i n e nasal douches
and application o f a bland ointment. Sometimes, a thin
silastic b u t t o n can b e w o r n t o g e t r e l i e f f r o m t h e s y m p t o m s
flaps. (Fig. 26.10.)
A c u t e and C h r o n i c Rhinitis

3. Rhinitis associated with exanthemas Measles,

Acute Rhinitis
rubella, chickenpox are often associated with rhinitis
w h i c h p r e c e d e s e x a n t h e m a s b y 2 - 3 days. S e c o n d a r y i n f e c -
A c u t e r h i n i t i s c a n b e viral, bacterial o r irritative type.
t i o n a n d c o m p l i c a t i o n s are m o r e f r e q u e n t a n d s e v e r e .

VIRAL RHINITIS BACTERIAL RHINITIS

1. C o m m o n cold (coryza) Non-specific i n f e c t i o n s I t m a y be p r i m a r y o r secondary.

P r i m a r y b a c t e r i a l r h i n i t i s is seen i n c h i l d r e n a n d is u s u a l l y the
Aetiology. I t is c a u s e d b y a v i r u s . T h e i n f e c t i o n is u s u a l l y
result o f i n f e c t i o n w i t h pneumococcus, streptococcus o r staphylo-
contracted through airborne droplets. Several viruses
coccus. A g r e y i s h w h i t e t e n a c i o u s m e m b r a n e m a y f o r m i n t h e
( a d e n o v i r u s , p i c o r n a v i r u s a n d its s u b - g r o u p s s u c h as r h i -
nose, w h i c h w i t h a t t e m p t e d r e m o v a l , causes b l e e d i n g .
n o v i r u s , c o x s a c k i e , a n d E C H O ) are r e s p o n s i b l e . I n c u b a t i o n
Secondary bacterial r h i n i t i s is t h e result of bacterial
p e r i o d is 1 - 4 days a n d illness lasts f o r 2 - 3 weeks.
i n f e c t i o n s u p e r v e n i n g acute viral rhinitis.
Clinical features. T o b e g i n w i t h , t h e r e is b u r n i n g sensa-
t i o n at t h e b a c k o f n o s e s o o n f o l l o w e d b y nasal s t u f f i n e s s , Diphtheritic rhinitis D i p h t h e r i a o f n o s e is r a r e these

r h i n o r r h o e a a n d s n e e z i n g . P a t i e n t feels c h i l l y a n d t h e r e is days. I t m a y b e p r i m a r y , o r s e c o n d a r y t o f a u c i a l d i p h t h e r i a

low g r a d e f e v e r . I n i t i a l l y , nasal d i s c h a r g e is w a t e r y and and m a y o c c u r i n acute or chronic f o n n . A greyish m e m -

profuse b u t m a y b e c o m e m u c o p u r u l e n t due t o secondary b r a n e is seen c o v e r i n g t h e i n f e r i o r t u r b i n a t e a n d t h e floor

b a c t e r i a l i n v a s i o n . S e c o n d a r y i n v a d e r s i n c l u d e Strept. hae- o f nose; m e m b r a n e is t e n a c i o u s a n d its r e m o v a l causes

molyticus, pneumococcus, staphylococcus, H. influenzae, Klcb. b l e e d i n g . E x c o r i a t i o n o f a n t e r i o r nares a n d u p p e r l i p m a y

pneumoniae a n d M. catarrhalis. b e s e e n . T r e a t m e n t is i s o l a t i o n o f t h e p a t i e n t , s y s t e m i c p e n -

Treatment. B e d rest is essential t o c u t d o w n t h e c o u r s e o f icillin and diphtheria antitoxin.

illness. P l e n t y o f f l u i d s are e n c o u r a g e d . S y m p t o m s c a n b e
easily c o n t r o l l e d w i t h a n t i h i s t a m i n i c s a n d nasal d e c o n g e s -
tants. A n a l g e s i c s are u s e f u l t o r e l i e v e h e a d a c h e , f e v e r a n d IRRITATIVE RHINITIS
m y a l g i a . N o n - a s p i r i n c o n t a i n i n g analgesics are preferable
as a s p i r i n causes i n c r e a s e d s h e d d i n g o f v i r u s . A n t i b i o t i c s
T h i s f o n n o f a c u t e r h i n i t i s is c a u s e d b y e x p o s u r e t o dust,
are r e q u i r e d w h e n s e c o n d a r y i n f e c t i o n s u p e r v e n e s .
s m o k e o r i r r i t a t i n g gases s u c h as a m m o n i a , f o r m a l i n e , a c i d
Complications. The disease is u s u a l l y s e l f - l i m i t i n g a n d
f u m e s , etc. o r i t m a y r e s u l t f r o m t r a u m a i n f l i c t e d o n t h e
resolves s p o n t a n e o u s l y after 2 t o 3 w e e k s , b u t o c c a s i o n -
nasal m u c o s a d u r i n g i n t r a n a s a l m a n i p u l a t i o n , e . g . r e m o v a l
a l l y , c o m p l i c a t i o n s s u c h as s i n u s i t i s , p h a r y n g i t i s , t o n s i l l i t i s ,
o f a f o r e i g n b o d y . T h e r e is a n i m m e d i a t e c a t a r r h a l r e a c t i o n
b r o n c h i t i s , p n e u m o n i a and otitis m e d i a m a y result.
with sneezing, rhinorrhoea and nasal c o n g e s t i o n . The
2. I n f l u e n z a l rhinitis I n f l u e n z a viruses A , B or C are s y m p t o m s m a y pass o f f r a p i d l y w i t h r e m o v a l o f t h e o f f e n d -
responsible. Symptoms a n d signs are s i m i l a r t o t h o s e of i n g a g e n t o r m a y persist f o r s o m e days i f nasal e p i t h e l i u m
c o m m o n c o l d . C o m p l i c a t i o n s d u e t o b a c t e r i a l i n v a s i o n are has b e e n d a m a g e d . R e c o v e r y w i l l d e p e n d o n t h e a m o u n t
common. o f epithelial damage and the i n f e c t i o n that supervenes.
 Acute and Chronic Rhinitis

Treatment
Chronic Rhinitis
I T r e a t t h e cause w i t h p a r t i c u l a r a t t e n t i o n t o sinuses,
C h r o n i c n o n - s p e c i f i c i n f l a m m a t i o n s o f nose i n c l u d e : tonsils, adenoids, allergy, personal habits ( s m o k i n g o r
alcohol indulgence), e n v i r o n m e n t or w o r k situation
C h r o n i c simple rhinitis.
(smoky or dusty surroundings).
Hypertrophic rhinitis.
Nasal irrigations w i t h alkaline s o l u t i o n help t o keep
A t r o p h i c rhinitis.
t h e n o s e f r e e f r o m v i s c i d s e c r e t i o n s a n d also r e m o v e
R h i n i t i s sicca.
superficial infection.
R h i n i t i s caseosa.
N a s a l d e c o n g e s t a n t s h e l p t o r e l i e v e nasal o b s t r u c t i o n
a n d i m p r o v e sinus v e n t i l a t i o n . E x c e s s i v e use o f nasal
d r o p s a n d sprays s h o u l d be a v o i d e d because i t m a y l e a d
C H R O N I C SIMPLE RHINITIS to rhinitis medicamentosa. A short course o f systemic
steroids helps t o w e a n the patients already a d d i c t e d to

Aetiology excessive use o f d e c o n g e s t a n t d r o p s o r sprays.

A n t i b i o t i c s h e l p t o clear nasal i n f e c t i o n a n d c o n c o m i -
R e c u r r e n t attacks o f acute r h i n i t i s i n the presence o f p r e -
tant sinusitis.
disposing factors leads t o chronicity. The predisposing
f a c t o r s are:

P e r s i s t e n c e o f nasal i n f e c t i o n d u e t o s i n u s i t i s , t o n s i l l i - H Y P E R T R O P H I C RHINITIS
tis, a n d a d e n o i d s .
C h r o n i c i r r i t a t i o n f r o m dust, s m o k e , cigarette smok- I t is c h a r a c t e r i s e d b y t h i c k e n i n g o f m u c o s a , submucosa,
i n g , s n u f f , etc. seromucinous g l a n d s , p e r i o s t e u m a n d b o n e . C h a n g e s are
Nasal o b s t r u c t i o n due t o D N S , synechia leading t o m o r e m a r k e d o n the turbinates.
persistence o f discharge i n t h e nose.
Aetiology
Vasomotor rhinitis.
E n d o c r i n a l o r m e t a b o l i c f a c t o r s , e.g. h y p o t h y r o i d i s m , Common causes are r e c u r r e n t nasal i n f e c t i o n s , chronic
excessive i n t a k e o f c a r b o h y d r a t e s , l a c k o f e x e r c i s e . s i n u s i t i s , c h r o n i c i r r i t a t i o n o f nasal m u c o s a d u e t o smok-
i n g , i n d u s t r i a l i r r i t a n t s , p r o l o n g e d use o f nasal d r o p s a n d
Pathology
v a s o m o t o r a n d allergic r h i n i t i s .

S i m p l e c h r o n i c r h i n i t i s is a n e a r l y stage o f h y p e r t r o p h i c
Symptoms
rhinitis. There is hyperaemia and oedema of mucous
membrane w i t h hypertrophy o f seromucinous glands a n d N a s a l o b s t r u c t i o n is t h e p r e d o m i n a n t s y m p t o m . N a s a l d i s -

i n c r e a s e i n g o b l e t cells. B l o o d s i n u s o i d s p a r t i c u l a r l y t h o s e c h a r g e is t h i c k a n d s t i c k y . S o m e c o m p l a i n o f h e a d a c h e ,

o v e r t h e t u r b i n a t e s are d i s t e n d e d . heaviness o f h e a d o r transient anosmia.

Signs
Clinical Features
E x a m i n a t i o n shows h y p e r t r o p h y o f turbinates. Turbinal
Nasal obstruction. U s u a l l y w o r s e o n l y i n g a n d affects
m u c o s a is t h i c k a n d does n o t p i t o n p r e s s u r e . I t s h o w s l i t t l e
t h e d e p e n d e n t side o f n o s e .
shrinkage w i t h vasoconstrictor drugs due to presence of
Nasal discharge. I t may be m u c o i d or m u c o p u r u l e n t ,
u n d e r l y i n g fibrosis.
t h i c k a n d v i s c i d a n d o f t e n t r i c k l e s i n t o t h e t h r o a t as
M a x i m u m c h a n g e s are seen i n t h e i n f e r i o r t u r b i n a t e . I t
p o s t - n a s a l d r i p . P a t i e n t has a c o n s t a n t desire t o b l o w
m a y b e h y p e r t r o p h i e d i n its e n t i r e t y o r o n l y at t h e a n t e r i o r
t h e n o s e o r clear t h e t h r o a t .
end, posterior end or along the inferior border giving it a
Headache. I t is d u e t o s w o l l e n t u r b i n a t e s i m p i n g i n g o n
m u l b e r r y appearance.
t h e nasal s e p t u m .
Swollen turbinates. N a s a l m u c o s a is d u l l r e d i n c o l o u r . Treatment
Turbinates are swollen; they pit on pressure and
A t t e m p t s h o u l d b e m a d e t o d i s c o v e r t h e cause a n d r e m o v e
s h r i n k w i t h a p p l i c a t i o n o f v a s o c o n s t r i c t o r d r o p s (this
i t . N a s a l o b s t r u c t i o n can b e r e l i e v e d b y r e d u c t i o n i n size
differentiates the c o n d i t i o n f r o m h y p e r t r o p h i c r h i n i -
o f turbinates. T h e various methods are:
t i s ) . M i d d l e t u r b i n a t e m a y also b e s w o l l e n a n d i m p i n g e
o n the septum. Linear cauterisation.
Post-nasal discharge. M u c o i d or mucopurulent dis- Submucosal diathermy.
c h a r g e is seen o n t h e p o s t e r i o r p h a r y n g e a l w a l l . Cryosurgery o f turbinates.
Diseases o f Nose and Paranasal Sinuses

Partial or total t u r b i n e c t o m y . H y p e r t r o p h i e d i n f e r i o r Infective. V a r i o u s organisms have been c u l t u r e d f r o m

t u r b i n a t e c a n b e p a r t i a l l y r e m o v e d at its a n t e r i o r e n d , cases o f a t r o p h i c r h i n i t i s s u c h as Klebsiella ozaenae, (Perez
inferior border or posterior end. M i d d l e turbinate, i f b a c i l l u s ) , diphtheroids, P. vulgaris, Esch. coli, Staphylococci
h y p e r t r o p h i e d , c a n also b e r e m o v e d p a r t i a l l y o r t o t a l l y . a n d Streptococci b u t t h e y are all c o n s i d e r e d t o b e s e c o n d -
E x c e s s i v e r e m o v a l o f t u r b i n a t e s s h o u l d b e a v o i d e d as ary invaders responsible f o r f o u l smell rather t h a n the
i t leads t o p e r s i s t e n t c r u s t i n g . p r i m a r y causative o r g a n i s m s o f t h e disease,
Submucous resection o f turbinate bone. This removes i Autoimmune process. T h e b o d y reacts b y a d e s t r u c t i v e
b o n y o b s t r u c t i o n b u t p r e s e r v e s t u r b i n a l m u c o s a f o r its process t o t h e a n t i g e n s released f r o m t h e nasal m u c o s a .
function. V i r a l i n f e c t i o n o r s o m e o t h e r u n s p e c i f i e d agents m a y
Lasers have also b e e n used to reduce t h e size of t r i g g e r a n t i g e n i c i t y o f nasal m u c o s a .
turbinates.
Pathology

C o m p e n s a t o r y Hypertrophic Rhinitis
T h i s is seen i n cases o f m a r k e d d e v i a t i o n o f s e p t u m t o o n e
side. T h e r o o m i e r side o f t h e nose s h o w s h y p e r t r o p h y o f
i n f e r i o r a n d m i d d l e t u r b i n a t e s . T h i s is an a t t e m p t o n t h e p a r t
o f n a t u r e t o r e d u c e t h e w i d e space t o o v e r c o m e t h e i l l -
effects o f d r y i n g a n d c r u s t i n g t h a t a l w a y s a t t e n d w i d e r nasal
space. H y p e r t r o p h i c changes i n these cases are n o t r e v e r s -
i b l e w i t h t h e c o r r e c t i o n o f nasal s e p t u m a n d o f t e n r e q u i r e
r e d u c t i o n o f t u r b i n a t e s at t h e t i m e o f septal s u r g e r y .
C i l i a t e d c o l u m n a r e p i t h e l i u m is l o s t a n d is r e p l a c e d b y
s t r a t i f i e d s q u a m o u s t y p e . T h e r e is a t r o p h y o f s e r o m u c i -
n o u s glands, v e n o u s b l o o d sinusoids a n d n e r v e elements.
Arteries i n the mucosa, periosteum and b o n e s h o w o b l i t -
erative endarteritis. T h e bone o f turbinates undergoes
r e s o r p t i o n c a u s i n g w i d e n i n g o f nasal c h a m b e r s . Paranasal
sinuses are s m a l l d u e t o t h e i r a r r e s t e d d e v e l o p m e n t .
Clinical Features
Disease is c o m m o n l y seen i n f e m a l e s a n d starts around
p u b e r t y . T h e r e is f o u l s m e l l f r o m t h e n o s e m a k i n g t h e
p a t i e n t a s o c i a l o u t c a s t t h o u g h p a t i e n t h i m s e l f is u n a w a r e

ATROPHIC RHINITIS (OZAENA) o f the smell due t o m a r k e d anosmia (merciful anosmia)

which accompanies these degenerative changes. Patient
m a y c o m p l a i n o f nasal o b s t r u c t i o n i n s p i t e o f u n d u l y w i d e
I t is a c h r o n i c i n f l a m m a t i o n o f n o s e c h a r a c t e r i s e d b y a t r o -
nasal c h a m b e r s . T h i s is d u e t o l a r g e crusts f i l l i n g t h e n o s e .
p h y o f nasal m u c o s a a n d t u r b i n a t e b o n e s . T h e nasal c a v i -
E p i s t a x i s m a y o c c u r w h e n t h e crusts are r e m o v e d .
ties are r o o m y a n d f u l l o f f o u l - s m e l l i n g crusts. A t r o p h i c
E x a m i n a t i o n s h o w s nasal c a v i t y t o b e f u l l o f g r e e n i s h o r
r h i n i t i s is o f t w o t y p e s : p r i m a r y a n d s e c o n d a r y .
g r e y i s h b l a c k d r y crusts c o v e r i n g t h e t u r b i n a t e s a n d sep-
t u m . A t t e m p t s t o r e m o v e t h e m m a y cause b l e e d i n g . W h e n

Primary Atrophic Rhinitis t h e crusts h a v e b e e n r e m o v e d , nasal c a v i t i e s a p p e a r r o o m y

w i t h a t r o p h y o f t u r b i n a t e s so m u c h so t h a t t h e p o s t e r i o r

Aetiology (Remember Mnemonic HERNIA) w a l l o f n a s o p h a r y n x c a n b e easily seen. N a s a l t u r b i n a t e s

m a y be r e d u c e d to mere ridges. Nasal mucosa appears
T h e e x a c t cause is n o t k n o w n . V a r i o u s t h e o r i e s a d v a n c e d
p a l e . S e p t a l p e r f o r a t i o n a n d d e r m a t i t i s o f nasal v e s t i b u l e
r e g a r d i n g its c a u s a t i o n are:
m a y b e p r e s e n t . N o s e m a y s h o w a saddle d e f o r m i t y .
Hereditary factors. Disease is k n o w n t o i n v o l v e m o r e A t r o p h i c changes m a y also b e seen i n t h e p h a r y n g e a l
t h a n o n e m e m b e r i n the same f a m i l y . mucosa w h i c h m a y appear d r y a n d glazed w i t h crusts
Endocrinal disturbance. Disease u s u a l l y starts at p u b e r t y , ( a t r o p h i c p h a r y n g i t i s , page 2 7 0 ) .
involves females m o r e t h a n males, the c r u s t i n g a n d S i m i l a r changes m a y o c c u r i n t h e l a r y n x w i t h cough
f o e t o r associated with disease t e n d s t o cease after a n d hoarseness o f v o i c e ( a t r o p h i c l a r y n g i t i s ) .
m e n o p a u s e ; these f a c t o r s h a v e r a i s e d t h e p o s s i b i l i t y o f H e a r i n g - i m p a i r m e n t m a y b e n o t i c e d because o f o b s t r u c -
disease b e i n g a n e n d o c r i n a l d i s o r d e r . t i o n t o e u s t a c h i a n t u b e a n d m i d d l e ear e f f u s i o n .
Racial factors. W h i t e a n d y e l l o w races are m o r e s u s c e p - Paranasal sinuses are u s u a l l y s m a l l a n d u n d e r d e v e l o p e d
tible t h a n natives o f equatorial Africa. w i t h t h i c k walls. T h e y appear o p a q u e o n X - r a y . A n t r a l
Nutritional deficiency. Disease m a y b e due to defi- wash is d i f f i c u l t to perform due to t h i c k walls o f the
ciency o f v i t a m i n A , D or i r o n o r some other dietary sinuses.
f a c t o r s . T h e f a c t t h a t i n c i d e n c e o f disease is d e c r e a s -
Prognosis
i n g i n w e s t e r n c o u n t r i e s a n d is r a r e l y s e e n i n w e l l -
t o - d o f a m i l i e s raises t h e p o s s i b i l i t y o f s o m e n u t r i t i o n a l T h e disease persists f o r years b u t t h e r e is a t e n d e n c y t o
deficiency. r e c o v e r s p o n t a n e o u s l y i n m i d d l e age.
Treatment nasal a i r w a y h e l p s t o r e l i e v e t h e s y m p t o m s . Among
t h e t e c h n i q u e s f o l l o w e d , s o m e are:
I t m a y be m e d i c a l o r surgical.
(i) S u b m u c o s a l i n j e c t i o n o f t e f l o n paste.
1. Medical C o m p l e t e c u r e o f t h e disease is n o t y e t p o s -
( i i ) I n s e r t i o n o f fat, c a r t i l a g e , b o n e o r t e f l o n strips
sible. Treatment aims at m a i n t a i n i n g nasal h y g i e n e by
u n d e r t h e m u c o p e r i o s t e u m o f t h e floor a n d l a t e r a l
r e m o v a l o f crusts a n d t h e associated p u t r e f y i n g s m e l l , a n d
w a l l o f nose and the m u c o p e r i c h o n d r i u m o f the
t o f u r t h e r check crust f o r m a t i o n .
septum.
Nasal irrigation and removal of crusts. Warm normal (iii) S e c t i o n a n d m e d i a l displacement o f lateral w a l l o f
saline o r an alkaline s o l u t i o n m a d e b y dissolving a nose.
t e a s p o o n f u l o f p o w d e r c o n t a i n i n g soda bicarbonate
1 part, Sodium biborate 1 part, S o d i u m chloride
Secondary Atrophic Rhinitis
2 parts i n 2 8 0 m l o f w a t e r , is u s e d t o i r r i g a t e t h e nasal
c a v i t i e s . T h e s o l u t i o n is r u n t h r o u g h o n e n o s t r i l a n d
Specific infections l i k e syphilis, lupus, leprosy a n d r h i n o -
c o m e s o u t f r o m t h e o t h e r . I t l o o s e n s t h e crusts a n d
scleroma m a y cause d e s t r u c t i o n o f the nasal structures
r e m o v e s t h i c k tenacious discharge. Care s h o u l d be
l e a d i n g t o a t r o p h i c changes. A t r o p h i c r h i n i t i s can also result
taken to avoid pushing the fluid i n t o t h e sinuses a n d
f r o m l o n g - s t a n d i n g p u r u l e n t s i n u s i t i s , r a d i o t h e r a p y t o nose
e u s t a c h i a n t u b e . I n i t i a l l y , i r r i g a t i o n s are d o n e 2 o r 3
o r excessive s u r g i c a l r e m o v a l o f t u r b i n a t e s .
t i m e s a d a y b u t l a t e r o n c e e v e r y 2 o r 3 days is s u f f i -
c i e n t . H a r d crusts m a y b e d i f f i c u l t t o r e m o v e b y i r r i - Unilateral atrophic rhinitis E x t r e m e d e v i a t i o n o f nasal
g a t i o n . T h e y are f i r s t l o o s e n e d a n d t h e n m e c h a n i c a l l y septum m a y be a c c o m p a n i e d b y atrophic rhinitis o n the
r e m o v e d w i t h forceps or suction. w i d e r side.
25%glucose in glycerine. A f t e r crusts are r e m o v e d , n o s e
is p a i n t e d w i t h 2 5 % g l u c o s e i n g l y c e r i n e . T h i s i n h i b i t s
t h e g r o w t h o f p r o t e o l y t i c o r g a n i s m s w h i c h are r e s p o n - RHINITIS SICCA
sible f o r f o u l smell.
Local antibiotics. S p r a y i n g or p a i n t i n g the nose with
I t is also a c r u s t - f o r m i n g disease seen i n p a t i e n t s w h o w o r k
appropriate antibiotics help to eliminate secondary
i n h o t , d r y a n d d u s t y s u r r o u n d i n g s , e.g. b a k e r s , i r o n - a n d
infection. Kemicetine™ antiozaena s o l u t i o n contains
g o l d s m i t h s . C o n d i t i o n is c o n f i n e d t o t h e a n t e r i o r t h i r d o f
C h l o r o m y c e t i n , oestradiol and v i t a m i n D , and m a y be
n o s e p a r t i c u l a r l y o f t h e nasal s e p t u m . H e r e , t h e c i l i a t e d
f o u n d useful.
c o l u m n a r e p i t h e l i u m undergoes squamous metaplasia w i t h
Oestradiol spray. H e l p s t o i n c r e a s e v a s c u l a r i t y o f nasal
a t r o p h y o f s e r o m u c i n o u s glands. Crusts f o r m o n t h e a n t e -
mucosa and regeneration o f seromucinous glands.
r i o r p a r t o f s e p t u m a n d t h e i r r e m o v a l causes u l c e r a t i o n a n d
Placental extract i n j e c t e d s u b m u c o s a l l y i n t h e n o s e m a y
epistaxis, a n d m a y l e a d t o septal p e r f o r a t i o n .
p r o v i d e some relief.
Treatment consists o f c o r r e c t i o n o f the occupational
Systemic use of streptomycin. 1 g / d a y f o r 10 days has
surroundings and application o f bland ointment or one
g i v e n g o o d results i n r e d u c i n g c r u s t i n g a n d o d o u r . I t
w i t h an antibiotic and steroid, t o the affected part. N o s e
is e f f e c t i v e against Klebsiella organisms.
p r i c k i n g a n d f o r c i b l e r e m o v a l o f crusts s h o u l d b e a v o i d e d .
Potassium iodide g i v e n b y t h e m o u t h p r o m o t e s a n d l i q -
N a s a l d o u c h e , l i k e t h e o n e u s e d i n cases o f a t r o p h i c r h i n i -
u e f i e s nasal s e c r e t i o n .
tis, is u s e f u l .
2. Surgical It includes:

Young's operation. B o t h t h e n o s t r i l s are c l o s e d com-

RHINITIS C A S E O S A
p l e t e l y j u s t w i t h i n t h e nasal v e s t i b u l e b y r a i s i n g flaps.
They are opened after 6 m o n t h s o r l a t e r . I n these
cases, m u c o s a may revert to n o r m a l and crusting I t is a n u n c o m m o n c o n d i t i o n , u s u a l l y u n i l a t e r a l a n d m o s t l y
reduced. affecting males.
Modified Young's operation. T o a v o i d the discom- N o s e is f i l l e d w i t h o f f e n s i v e p u r u l e n t discharge a n d cheesy
f o r t o f b i l a t e r a l nasal o b s t r u c t i o n , m o d i f i e d Y o u n g ' s m a t e r i a l . T h e disease p o s s i b l y arises f r o m c h r o n i c sinusitis
o p e r a t i o n a i m s t o p a r t i a l l y close t h e n o s t r i l s . I t is also w i t h c o l l e c t i o n o f inspissated c h e e s y m a t e r i a l . S i n u s m u c o s a
c l a i m e d t o g i v e t h e same b e n e f i t as Y o u n g ' s . becomes granulomatous. Bony walls o f sinus may be
Narrowing the nasal cavities. N a s a l c h a m b e r s are very destroyed, r e q u i r i n g differentiation f r o m malignancy. Treat-
w i d e i n a t r o p h i c r h i n i t i s a n d air currents d r y u p secre- m e n t is r e m o v a l o f d e b r i s a n d g r a n u l a t i o n tissue a n d f r e e
t i o n s l e a d i n g t o c r u s t i n g . N a r r o w i n g t h e size o f t h e d r a i n a g e o f t h e a f f e c t e d sinus. P r o g n o s i s is g o o d .
G r a n u l o m a t o u s Diseases o f Nose

V a r i o u s g r a n u l o m a t o u s l e s i o n s i n v o l v i n g t h e n o s e are l i s t e d Granulomatous stage. G r a n u l o m a t o u s n o d u l e s f o r m i n

in Table 2 8 . 1 . T h e y are t h e result o f bacterial o r f u n g a l nasal m u c o s a . T h e r e is also s u b d e r m a l i n f i l t r a t i o n o f
i n f e c t i o n s o r d u e t o causes n o t y e t clear. M a n y o f these lesions l o w e r p a r t o f e x t e r n a l nose a n d u p p e r l i p g i v i n g a
m a y be manifestations o f systemic diseases, w h i c h s h o u l d 'woody' feel (Fig. 28.1). N o d u l e s are painless a n d
always b e l o o k e d f o r w h i l e m a k i n g t h e diagnosis. B i o p s y o f non-ulcerative.
t h e l e s i o n is also essential, n o t o n l y t o establish t h e c o r r e c t Cicatricial stage. T h i s causes stenosis o f nares, d i s t o r t i o n
diagnosis o f g r a n u l o m a t o u s disease b u t also t o e x c l u d e a n e o - o f u p p e r l i p , adhesions i n t h e nose, n a s o p h a r y n x a n d
p l a s m , w h i c h m a n y o f these diseases m a y c l i n i c a l l y s i m u l a t e . oropharynx. There m a y b e s u b g l o t t i c stenosis w i t h
r e s p i r a t o r y distress.

Diagnosis Biopsy shows infiltration o f submucosa with

BACTERIAL INFECTIONS
p l a s m a cells, l y m p h o c y t e s , e o s i n o p h i l s , M i k u l i c z cells a n d
R u s s e l l b o d i e s . T h e l a t t e r t w o are d i a g n o s t i c f e a t u r e s o f t h e

Rhinoscleroma disease. M i k u l i c z cells are large f o a m cells w i t h a c e n t r a l

nucleus and vacuolated cytoplasm containing causative
b a c i l l i . R u s s e l l b o d i e s are h o m o g e n o u s e o s i n o p h i l i c i n c l u -
I t is a c h r o n i c g r a n u l o m a t o u s disease caused b y G r a m - n e g a t i v e
s i o n b o d i e s f o u n d i n t h e p l a s m a cells. T h e y o c c u r d u e t o
b a c i l l u s called Klebsiella rhinoscleromatis o r Frisch bacillus. T h e
a c c u m u l a t i o n o f i m m u n o g l o b u l i n s secreted b y t h e plasma
disease is e n d e m i c i n several parts o f t h e w o r l d . I n I n d i a , i t is
cells. T h e c a u s a t i v e organisms can b e c u l t u r e d f r o m t h e
seen m o r e o f t e n i n t h e n o r t h e r n t h a n i n t h e s o u t h e r n parts.
biopsy material.
Pathology T h e disease starts i n t h e n o s e a n d e x t e n d s t o
nasopharynx, oropharynx, larynx (mostly subglottic
region), trachea and bronchi. Mode o f infection is
u n k n o w n . B o t h sexes o f a n y age m a y b e a f f e c t e d .

C l i n i c a l features T h e disease r u n s t h r o u g h t h e f o l l o w i n g
stages:

Atrophic stage. I t resembles atrophic rhinitis a n d is

c h a r a c t e r i s e d b y f o u l s m e l l i n g p u r u l e n t nasal d i s c h a r g e
and crusting.

T a b l e 28.1 G r a n u l o m a t o u s disease o f nose

Bacterial Fungal Unspecified cause

Rhinoscleroma Rhinosporidiosis Wegener's
granulomatosis
Syphilis Aspergillosis Non-healing midline

Tuberculosis Mucormycosis Granuloma

Lupus Candidiasis 11 Sarcoidosis

Leprosy Histoplasmosis. f Rare

R h i n o s c l e r o m a nose.
Blastomycosis J1
 Granulomatous Diseases of Nose

Treatment B o t h streptomycin ( l g / d a y ) and tetracycline Complications S y p h i l i s c a n l e a d t o v e s t i b u l a r stenosis,

(2 g/day) are g i v e n t o g e t h e r f o r a m i n i m u m p e r i o d o f 4—6
w e e k s a n d r e p e a t e d , i f necessary, a f t e r 1 m o n t h . T r e a t m e n t
is s t o p p e d o n l y w h e n t w o c o n s e c u t i v e cultures f r o m
b i o p s y m a t e r i a l are n e g a t i v e . S t e r o i d s c a n b e c o m b i n e d t o
reduce fibrosis.
S u r g i c a l t r e a t m e n t m a y b e r e q u i r e d t o establish t h e a i r -
w a y a n d c o r r e c t nasal d e f o r m i t y .
Syphilis
N a s a l s y p h i l i s is o f t w o t y p e s : a c q u i r e d a n d c o n g e n i t a l .
p e r f o r a t i o n s o f nasal s e p t u m a n d h a r d palate, secondary
a t r o p h i c r h i n i t i s a n d saddle n o s e d e f o r m i t y .
the
Tuberculosis
P r i m a r y t u b e r c u l o s i s o f n o s e is r a r e . M o r e o f t e n i t is sec-
o n d a r y t o l u n g t u b e r c u l o s i s . A n t e r i o r p a r t o f nasal s e p t u m
a n d a n t e r i o r e n d o f i n f e r i o r t u r b i n a t e are t h e sites c o m -
m o n l y i n v o l v e d . First, there is n o d u l a r i n f i l t r a t i o n fol-
l o w e d l a t e r b y u l c e r a t i o n a n d p e r f o r a t i o n o f nasal s e p t u m
i n its c a r t i l a g i n o u s p a r t .
D i a g n o s i s c a n be m a d e o n b i o p s y a n d special s t a i n i n g o f

1. Acquired I t o c c u r s as: s e c t i o n s f o r a c i d fast b a c i l l i , c u l t u r e o f o r g a n i s m s a n d a n i -

mal inoculation.
Primary. I t m a n i f e s t s as p r i m a r y c h a n c r e o f t h e v e s t i -
T r e a t m e n t is a n t i t u b e r c u l a r d r u g s .
b u l e o f n o s e . I t is r a r e ,
t Secondary. Rarely recognised. I t manifests as s i m p l e
r h i n i t i s w i t h c r u s t i n g a n d A s s u r i n g i n t h e nasal v e s t i - Lupus Vulgaris
b u l e . D i a g n o s i s is s u g g e s t e d b y t h e p r e s e n c e o f m u c o u s
p a t c h e s i n t h e p h a r y n x , s k i n rash, f e v e r a n d g e n e r a - I t is a l o w - g r a d e t u b e r c u l o u s i n f e c t i o n c o m m o n l y a f f e c t -
lised lymphadenitis. i n g nasal v e s t i b u l e o r t h e s k i n o f n o s e a n d face. T h e s k i n
Tertiary. T h i s is t h e stage i n w h i c h n o s e is c o m m o n l y lesions manifest characteristically as brown, gelatinous
i n v o l v e d . T y p i c a l m a n i f e s t a t i o n is t h e f o r m a t i o n o f a nodules called " a p p l e - j e l l y " nodules. I n the vestibule, i t
gumma o n t h e nasal septum. Later, the septum is p r e s e n t s as c h r o n i c v e s t i b u l i t i s . P e r f o r a t i o n m a y o c c u r i n
d e s t r o y e d b o t h i n its b o n y and cartilaginous parts. t h e c a r t i l a g i n o u s p a r t o f nasal s e p t u m .
P e r f o r a t i o n m a y also appear i n t h e h a r d p a l a t e . There I t is d i f f i c u l t t o i s o l a t e t u b e r c l e b a c i l l i b y c u l t u r e o r a n i -
is o f f e n s i v e nasal d i s c h a r g e w i t h crusts. B o n y o r c a r t i - m a l i n o c u l a t i o n , h o w e v e r , b i o p s y o f t h e l e s i o n is u s e f u l t o
l a g i n o u s sequestra m a y b e s e e n . B r i d g e o f t h e n o s e m a k e t h e diagnosis.
collapses c a u s i n g a saddle n o s e d e f o r m i t y . T r e a t m e n t is t h e s a m e as f o r t u b e r c u l o s i s o f n o s e .

2. C o n g e n i t a l I t occurs i n t w o f o r m s : early a n d late.

Early form. I t is seen i n t h e f i r s t 3 m o n t h s o f l i f e a n d Leprosy

m a n i f e s t s as " s n u f f l e s " . S o o n t h e nasal d i s c h a r g e becomes
p u r u l e n t . T h i s is associated w i t h f i s s u r i n g a n d e x c o r i a t i o n L e p r o s y is v e r y c o m m o n i n t h e t r o p i c s a n d is w i d e l y p r e v a -
o f t h e nasal v e s t i b u l e a n d o f t h e u p p e r l i p . l e n t i n o u r c o u n t r y . I t is c a u s e d b y Mycobacterium leprae.
Late form. U s u a l l y manifests around puberty. Clini- T h e n o s e is i n v o l v e d as a p a r t o f s y s t e m i c disease, m o r e
cal p i c t u r e is s i m i l a r t o that seen i n t e r t i a r y stage of often i n the lepromatous than tuberculoid or d i m o r p h o u s
acquired syphilis. Gummatous lesions destroy the f o r m s o f disease.
nasal s t r u c t u r e s . O t h e r s t i g m a t a o f s y p h i l i s s u c h as cor- I n f e c t i o n starts i n t h e a n t e r i o r p a r t o f nasal s e p t u m a n d
neal opacities, deafness a n d H u t c h i n s o n ' s t e e t h are also a n t e r i o r e n d o f i n f e r i o r t u r b i n a t e . I n i t i a l l y , t h e r e is e x c e s -
present. sive nasal d i s c h a r g e w i t h r e d a n d s w o l l e n m u c o s a . Later,
c r u s t i n g a n d b l e e d i n g s u p e r v e n e . N o d u l a r lesions o n t h e
Diagnosis I t is m a d e o n s e r o l o g i c a l tests ( V D R L ) and
s e p t u m m a y u l c e r a t e a n d cause p e r f o r a t i o n . L a t e sequelae
biopsy o f the tissue with special stains to demonstrate
o f disease are a t r o p h i c r h i n i t i s , d e p r e s s i o n o f bridge of
Trep. pallidum.
n o s e , d e s t r u c t i o n o f a n t e r i o r nasal s p i n e w i t h r e t r u s i o n o f
Treatment Penicillin is the drug of choice: benza- the columella (Fig. 28.2).
thine penicillin 2.4 million units i . m . every week for Diagnosis can be made from the scrapings of nasal
3 weeks with a t o t a l dose o f 7.2 million units. Nasal m u c o s a a n d b i o p s y . A c i d - f a s t l e p r a b a c i l l i c a n b e seen i n
crusts are r e m o v e d b y i r r i g a t i o n w i t h alkaline solution. t h e f o a m y a p p e a r i n g h i s t i o c y t e s c a l l e d l e p r a cells.
B o n y a n d c a r t i l a g i n o u s sequestra s h o u l d also b e r e m o v e d . Treatment is with dapsone, rifampin and isoniazid.
Cosmetic d e f o r m i t y is c o r r e c t e d a f t e r disease becomes Reconstruction procedures are r e q u i r e d w h e n disease is
inactive. inactive.
 a n d a t t a c h e d t o nasal s e p t u m o r l a t e r a l w a l l . S o m e t i m e s , i t
extends i n t o the nasopharynx a n d m a y h a n g b e h i n d the
soft p a l a t e . T h e mass is v e r y v a s c u l a r a n d bleeds easily o n
t o u c h . Its s u r f a c e is s t u d d e d w i t h w h i t e d o t s r e p r e s e n t i n g
the sporangia o f fungus.
I n early stages, t h e p a t i e n t m a y c o m p l a i n o f nasal discharge
w h i c h is o f t e n b l o o d - t i n g e d , o r nasal stuffiness. S o m e t i m e s ,
frank epistaxis is t h e o n l y p r e s e n t i n g c o m p l a i n t .
Diagnosis is m a d e o n b i o p s y . I t s h o w s several s p o r a n g i a ,
o v a l o r r o u n d i n shape a n d f i l l e d w i t h spores w h i c h m a y b e
seen b u r s t i n g t h r o u g h its c h i t i n o u s w a l l . I t has n o t b e e n
p o s s i b l e t o c u l t u r e t h e o r g a n i s m o r t r a n s f e r t h e disease t o
e x p e r i m e n t a l animals.
Treatment is c o m p l e t e e x c i s i o n o f t h e mass w i t h d i a t h e r m y

Leprosy nose.
k n i f e a n d c a u t e r i s a t i o n o f its base. R e c u r r e n c e m a y occur
a f t e r s u r g i c a l e x c i s i o n . N o t m a n y d r u g s are e f f e c t i v e against
t h e disease. D a p s o n e has b e e n t r i e d w i t h s o m e success.

FUNGAL INFECTIONS
Aspergillosis

Rhinosporidiosis ( F i g . 2 8 . 3 ) The usual causative organisms are Aspergillus niger,

A. fumigatus o r A. flavus. T h e y i n v a d e nasal tissues w h e n
I t is a f u n g a l g r a n u l o m a caused b y Rhinosporidium secberi. I t host's defence mechanisms are compromised due to
is seen i n I n d i a , P a k i s t a n a n d S r i L a n k a . I n I n d i a , m o s t o f immunosuppressive drugs.
t h e cases are seen i n s o u t h e r n states t h o u g h several cases Clinical features are t h o s e o f a c u t e o r s u b a c u t e r h i n i t i s o r
h a v e also b e e n r e p o r t e d f r o m o t h e r parts o f t h e c o u n t r y . s i n u s i t i s . A b l a c k o r g r e y i s h m e m b r a n e is seen i n t h e nasal
Clinical features. The disease m o s t l y affects n o s e and m u c o s a . E x p l o r a t i o n o f m a x i l l a r y sinus reveals a f u n g u s ball
nasopharynx; o t h e r sites s u c h as l i p , p a l a t e , conjunctiva, containing semisolid cheesy-white or blackish material.
epiglottis, l a r y n x , trachea, b r o n c h i , s k i n , v u l v a , vagina m a y T h e o r g a n i s m s c a n b e seen o n special s t a i n i n g .
also b e a f f e c t e d . Treatment is s u r g i c a l d e b r i d e m e n t o f t h e i n v o l v e d tissues
T h e disease is a c q u i r e d t h r o u g h c o n t a m i n a t e d w a t e r o f a n d a n t i f u n g a l d r u g s , e.g. A m p h o t e r i c i n — B . R e p e a t e d i r r i -
p o n d s also f r e q u e n t e d b y a n i m a l s . I n t h e n o s e , t h e disease g a t i o n o f t h e i n v o l v e d area w i t h a p p l i c a t i o n o f 1 % s o l u t i o n
presents as a l e a f y , p o l y p o i d a l mass, p i n k t o p u r p l e i n c o l o u r o f g e n t i a n v i o l e t is also u s e f u l .

R h i n o s p o r i d i o s i s p r e s e n t i n g as (A) a polypoidal mass protruding through the naris, (B) m u l t i p l e s i t e s o f i n v o l v e m e n t , viz. nose, con-

junctiva and tongue.

 S o o n e r o r l a t e r , k i d n e y s are also i n v o l v e d . U r i n e e x a m i -
Mucormycosis
n a t i o n w i l l s h o w r e d cells, casts a n d a l b u m i n . S e r u m c r e a -
t i n i n e l e v e l is r a i s e d . R e n a l f a i l u r e is t h e u s u a l cause of
I t is f u n g a l i n f e c t i o n o f nose a n d paranasal sinuses w h i c h
d e a t h i n these p a t i e n t s .
m a y p r o v e r a p i d l y f a t a l . I t is seen i n u n c o n t r o l l e d d i a b e t i c s
o r i n those t a k i n g immunosuppressive drugs. F r o m the
Diagnosis
n o s e a n d sinuses, i n f e c t i o n can spread t o o r b i t , c r i b r i f o n n
p l a t e , m e n i n g e s a n d b r a i n . T h e r a p i d d e s t r u c t i o n associated B i o p s y f r o m t h e nose is d i a g n o s t i c . I t s h o w s necrosis a n d
w i t h t h e disease is d u e t o a f f i n i t y o f t h e f u n g u s t o i n v a d e ulceration o f mucosa, epithelioid granuloma and necrotising
t h e arteries a n d cause e n d o t h e l i a l d a m a g e a n d t h r o m b o s i s . vasculitis i n v o l v i n g s m a l l arteries o r v e i n s . E S R is raised.
T y p i c a l f i n d i n g is t h e p r e s e n c e o f a b l a c k n e c r o t i c mass f r i l -
i n g t h e nasal c a v i t y a n d e r o d i n g t h e s e p t u m a n d h a r d p a l a t e . Treatment

S p e c i a l stains h e l p t o i d e n t i f y t h e f u n g u s i n tissue s e c t i o n s .
I t consists o f s y s t e m i c s t e r o i d s a n d c y t o t o x i c d r u g s . C y c l o -
T r e a t m e n t is b y a m p h o t e r i c i n — B a n d s u r g i c a l d e b r i d e -
p h o s p h a m i d e a n d a z a t h i o p r i n e , b o t h are f o u n d e f f e c t i v e .
m e n t o f t h e a f f e c t e d tissues a n d c o n t r o l o f u n d e r l y i n g p r e -
d i s p o s i n g cause.

T-cell Lymphoma

O t h e r Fungal Infections
Earlier terms used to describe this lesion w e r e m i d l i n e
malignant lesion and p o l y m o r p h i c reticulosis.
O t h e r f u n g a l i n f e c t i o n s o f n o s e s u c h as candidiasis, histoplas-
I t is a d e s t r u c t i v e l e s i o n u s u a l l y s t a r t i n g o n o n e side o f nose
mosis, blastomycosis, etc. are rare.
i n v o l v i n g the upper l i p , oral cavity maxilla a n d sometimes
even extending to orbit. Histologically polymorphic l y m -
p h o i d tissue w i t h a n g i o c e n t r i c a n d a n g i o i n v a s i v e features is
GRANULOMAS OF UNSPECIFIED
seen. T h e r e is n o v a s c u l i t i s — a f e a t u r e t y p i c a l o f W e g e n e r ' s
AETIOLOGY
g r a n u l o m a t o s i s . U n l i k e W e g e n e r ' s g r a n u l o m a t o s i s , i t is r a p -
i d l y d e s t r u c t i v e a n d u s u a l l y d e v o i d o f systemic i n v o l v e m e n t ;

Wegener's Granulomatosis there is absence of involvement of lung and kidneys.

I m m u n o h i s t o c h e m i c a l s t u d i e s o f b i o p s y m a t e r i a l are n e c -
Aetiology essary t o establish d i a g n o s i s o f T - c e l l l y m p h o m a . L o c a l i s e d
T - c e l l l y m p h o m a is t r e a t e d b y r a d i a t i o n w h i l e a d i s s e m i -
I t is a s y s t e m i c d i s o r d e r o f u n k n o w n a e t i o l o g y i n v o l v i n g
n a t e d disease r e q u i r e s chemotherapy.
m a i n l y the u p p e r airways, lungs, kidneys and the skin. It
s h o u l d be differentiated f r o m n o n - h e a l i n g m i d l i n e g r a n u -
l o m a b e c a u s e t h e t r e a t m e n t o f t h e t w o is q u i t e d i f f e r e n t .
[ Sarcoidosis

Clinical Features
I t is g r a n u l o m a t o u s disease o f u n k n o w n a e t i o l o g y resem-
E a r l y s y m p t o m s o f W e g e n e r ' s granulomatosis i n c l u d e clear b l i n g t u b e r c u l o s i s o n h i s t o r y b u t w i t h t h e absence o f case-
or blood-stained nasal discharge which later becomes a t i o n . I t is a s y s t e m i c d i s o r d e r a n d t h e s y m p t o m s m a y r e f e r
p u r u l e n t . T h e patient often complains o f "persistent c o l d " t o i n v o l v e m e n t o f l u n g s , l y m p h n o d e s , eyes o r s k i n .
o r " s i n u s " . Nasal findings i n c l u d e crusting, granulations, I n t h e n o s e , i t presents w i t h s u b m u c o s a l n o d u l e s i n v o l v -
septal p e r f o r a t i o n a n d a saddle n o s e . D e s t r u c t i o n m a y also i n g s e p t u m o r t h e i n f e r i o r t u r b i n a t e w i t h nasal obstruc-
i n v o l v e eyes, o r b i t , p a l a t e , o r a l c a v i t y o r o r o p h a r y n x . M i d d l e t i o n , nasal p a i n a n d s o m e t i m e s epistaxis. N o d u l e s m a y also
ear c a n also b e i n v o l v e d . f o r m i n t h e nasal v e s t i b u l e o r s k i n o f face.
General systemic s y m p t o m s i n c l u d e anaemia, fatigue, X - r a y chest s h o w s d i f f u s e p u l m o n a r y i n f i l t r a t e w i t h h i l a r
n i g h t sweats a n d m i g r a t o r y a r t h r a l g i a s . a d e n o p a t h y . S e r u m a n d u r i n a r y c a l c i u m levels are raised.
I n v o l v e m e n t o f l u n g is m a n i f e s t e d b y c o u g h a n d s o m e - B i o p s y o f t h e lesions h e l p s t o establish t h e d i a g n o s i s .
t i m e s h a e m o p t y s i s . X - r a y chest m a y s h o w a s i n g l e o r m u l - Treatment is w i t h s y s t e m i c s t e r o i d s . F o r nasal symp-
tiple c a v i t y lesions. t o m s , s t e r o i d s c a n b e u s e d l o c a l l y as nasal spray.
Miscellaneous D i s o r d e r s o f
Nasal Cavity

FOREIGN BODIES RHINOLITH

Aetiology T h e y are m o s t l y seen i n c h i l d r e n a n d m a y b e Aetiology I t is s t o n e f o r m a t i o n i n t h e nasal c a v i t y . A r h i -

o r g a n i c o r i n o r g a n i c . Pieces o f p a p e r , c h a l k , b u t t o n , p e b - n o l i t h usually f o r m s a r o u n d the nucleus o f a small e x o g e -
bles a n d seeds are t h e c o m m o n o b j e c t s . P l e d g e t s o f c o t t o n n o u s f o r e i g n b o d y , b l o o d c l o t o r inspissated s e c r e t i o n by
o r swabs m a y b e a c c i d e n t a l l y l e f t i n t h e n o s e . s l o w d e p o s i t i o n o f c a l c i u m a n d m a g n e s i u m salts. O v e r a
p e r i o d o f t i m e , i t g r o w s i n t o a l a r g e , i r r e g u l a r mass w h i c h
C l i n i c a l f e a t u r e s Patient m a y present i m m e d i a t e l y i f t h e
fills t h e nasal c a v i t y a n d t h e n m a y cause p r e s s u r e n e c r o s i s
h i s t o r y o f f o r e i g n b o d y is k n o w n . I f o v e r l o o k e d , t h e c h i l d
o f t h e s e p t u m a n d / o r lateral w a l l o f nose.
presents w i t h u n i l a t e r a l nasal d i s c h a r g e w h i c h is often
f o u l - s m e l l i n g and occasionally b l o o d - s t a i n e d . I t is a d i c - C l i n i c a l f e a t u r e s R h i n o l i t h s are m o r e c o m m o n i n adults.
t u m t h a t " I f a child presents with unilateral, foul-smelling nasal Its c o m m o n p r e s e n t a t i o n is u n i l a t e r a l nasal o b s t r u c t i o n a n d
discharge, foreign body must be excluded." Occasionally, a f o u l - s m e l l i n g d i s c h a r g e w h i c h is v e r y o f t e n b l o o d - s t a i n e d .
r a d i o g r a p h o f t h e n o s e is u s e f u l t o c o n f i r m a n d l o c a l i s e a F r a n k epistaxis a n d n e u r a l g i c p a i n m a y r e s u l t f r o m ulcer-
f o r e i g n b o d y i f i t is r a d i o - o p a q u e . I n addition to over- ation o f the s u r r o u n d i n g mucosa.
l o o k e d f o r e i g n b o d y i n t h e n o s e , o t h e r i m p o r t a n t causes O n e x a m i n a t i o n , a grey b r o w n or greenish-black mass
f o r u n i l a t e r a l b l o o d s t a i n e d d i s c h a r g e i n a c h i l d are r h i n o - w i t h i r r e g u l a r surface a n d s t o n y h a r d feel is seen i n t h e
l i t h , nasal d i p h t h e r i a , nasal m y i a s i s a n d a c u t e o r chronic nasal c a v i t y b e t w e e n t h e s e p t u m a n d t u r b i n a t e s . I t is o f t e n
unilateral sinusitis. brittle and a p o r t i o n o f it may break o f f w h i l e m a n i p u l a t -
i n g . S o m e t i m e s i t is s u r r o u n d e d b y g r a n u l a t i o n s .
Treatment Pieces o f p a p e r o r c o t t o n swabs can be easily
r e m o v e d w i t h a pair o f forceps. R o u n d e d f o r e i g n bodies Treatment T h e y are r e m o v e d u n d e r g e n e r a l anaesthesia.

can be r e m o v e d b y passing a b l u n t h o o k (a eustachian Most o f t h e m can be removed t h r o u g h anterior nares.

c a t h e t e r is a g o o d i n s t r u m e n t ) past t h e f o r e i g n b o d y a n d L a r g e o n e s n e e d t o b e b r o k e n i n t o pieces b e f o r e r e m o v a l .

gently dragging it f o r w a r d along the floor. I n babies a n d S o m e p a r t i c u l a r l y h a r d a n d i r r e g u l a r ones, r e q u i r e lateral

uncooperative c h i l d r e n , general anaesthesia w i t h cuffed rhino tomy.

e n d o t r a c h e a l t u b e is u s e d . P a t i e n t is p l a c e d i n R o s e ' s p o s i -
t i o n , a p a c k is i n s e r t e d i n t o t h e n a s o p h a r y n x a n d t h e f o r -
eign b o d y r e t r i e v e d w i t h a forceps o r a h o o k . Foreign N A S A L M Y I A S I S ( M A G G O T S IN NOSE)
bodies l o d g e d far b e h i n d i n the nose m a y need to be
pushed into the nasopharynx before removal.
M a g g o t s are l a r v a l f o r m s o f flies. T h e y are seen t o i n f e s t
Complications A foreign body left i n the nose may n o s e , n a s o p h a r y n x a n d paranasal sinuses c a u s i n g e x t e n s i v e
result i n : d e s t r u c t i o n (Figs 2 9 . 1 A , B , C a n d 2 9 . 2 ) . Flies, p a r t i c u l a r l y
nasal i n f e c t i o n a n d s i n u s i t i s . o f t h e g e n u s Chrysomyia, are a t t r a c t e d b y t h e f o u l s m e l l i n g
rhinolith formation. d i s c h a r g e e m a n a t i n g f r o m cases o f a t r o p h i c r h i n i t i s , s y p h i -
inhalation i n t o the tracheobronchial tree. lis, l e p r o s y o r i n f e c t e d w o u n d s a n d lay eggs, a b o u t 2 0 0 at
 Miscellaneous Disorders o f Nasal Cavity

Figure 29.1

Maggots nose. ( A ) Swelling o f nose and puffy eyelids w i t h s e r o s a n g u i n o u s nasal discharge. (B) M a g g o t s have practically destroyed

the cheek and eye in this o l d a n d neglected lady. ( C ) Perforation o f palate (arrow).

Figure 29.2

(A) The maggot. (B) The fly r e s p o n s i b l e f o r maggots.

a t i m e , w h i c h w i t h i n 24 hours hatch i n t o larvae. I n o u r e p i s t a x i s . I t is o n l y o n t h e 3 r d o r 4 t h d a y t h a t t h e m a g g o t s

c o u n t r y , t h e y are m o s t l y seen f r o m t h e m o n t h o f A u g u s t t o m a y c r a w l o u t o f t h e n o s e . P a t i e n t has f o u l s m e l l s u r r o u n d -
October. i n g h i m . M a g g o t s cause e x t e n s i v e destruction to nose,

C l i n i c a l features I n t h e f i r s t 3 o r 4 days m a g g o t s pro- sinuses, s o f t tissue o f face, p a l a t e a n d t h e e y e b a l l . F i s t u l a e

duce intense irritation, sneezing, l a c r i m a t i o n and headache. m a y f o n n i n t h e palate o r a r o u n d t h e nose. D e a t h m a y

T h i n b l o o d - s t a i n e d discharge oozes f r o m the nostrils. T h e occur from meningitis.

e y e l i d s a n d lips b e c o m e p u f f y . T i l l t h i s t i m e p a t i e n t is n o t Treatment A l l visible maggots s h o u l d be p i c k e d u p w i t h

a w a r e o f m a g g o t s . H e m a y p r e s e n t s i m p l y as a case of forceps. M a n y o f t h e m t r y t o retreat i n t o d a r k e r cavities
w h e n l i g h t falls o n t h e m . I n s t i l l a t i o n o f c h l o r o f o r m w a t e r B i l a t e r a l atresia presents w i t h r e s p i r a t o r y o b s t r u c t i o n as t h e
a n d o i l k i l l s t h e m . N a s a l d o u c h e w i t h w a r m saline is u s e d n e w b o r n , b e i n g a n a t u r a l nose-breather, does n o t breathe
t o r e m o v e s l o u g h , crusts a n d d e a d m a g g o t s . A p a t i e n t w i t h f r o m m o u t h . D i a g n o s i s o f c h o a n a l atresia c a n b e m a d e b y
m a g g o t s s h o u l d be i s o l a t e d w i t h a m o s q u i t o n e t t o a v o i d (i) p r e s e n c e o f m u c o i d d i s c h a r g e i n t h e n o s e , ( i i ) absence o f
contact with flies which can perpetuate this cycle. A l l air b u b b l e s i n t h e nasal d i s c h a r g e , ( i i i ) f a i l u r e t o pass a c a t h -
p a t i e n t s s h o u l d r e c e i v e i n s t r u c t i o n f o r nasal h y g i e n e b e f o r e e t e r f r o m nose t o p h a r y n x , ( i v ) p u t t i n g a f e w d r o p s o f a d y e
leaving the hospital. ( m e t h y l e n e - b l u e ) i n t o t h e nose a n d s e e i n g its passage i n t o
t h e p h a r y n x , o r (v) i n s t a l l i n g r a d i o - o p a q u e d y e i n t o t h e
nose a n d t a k i n g a lateral f i l m .

NASAL SYNECHIA Emergency management m a y be r e q u i r e d i n bilateral

c h o a n a l atresia t o p r o v i d e a n a i r w a y . A f e e d i n g n i p p l e w i t h
a large h o l e p r o v i d e s a g o o d o r a l a i r w a y ( M c G o v e r n ' s t e c h -
A d h e s i o n f o r m a t i o n b e t w e e n t h e nasal s e p t u m a n d t u r b i -
n i q u e ) and obviates the need for tracheostomy. D e f i n i t i v e
nates b y scar tissue is o f t e n t h e r e s u l t o f i n j u r y t o o p p o s i n g
t r e a t m e n t consists o f c o r r e c t i o n o f atresia b y transnasal o r
surfaces o f nasal m u c o s a . I t c a n r e s u l t f r o m i n t r a n a s a l o p e r -
t r a n s p a l a t a l a p p r o a c h . T h e l a t t e r is u s u a l l y d o n e at o n e a n d
a t i o n s s u c h as septal s u r g e r y , p o l y p e c t o m y , r e m o v a l o f f o r -
a h a l f years. C h o a n a l atresia c a n b e c o r r e c t e d b y u s i n g nasal
e i g n b o d i e s , r e d u c t i o n o f nasal f r a c t u r e s o r e v e n i n t r a n a s a l
endoscopes and drill.
p a c k i n g . S e v e r e i n f e c t i o n s w h i c h cause u l c e r a t i v e l e s i o n s i n
t h e n o s e c a n also l e a d t o s y n e c h i a f o r m a t i o n .
N a s a l s y n e c h i a ( F i g . 2 9 . 3 ) o f t e n cause nasal o b s t r u c t i o n
CSF RHINORRHOEA
o r m a y i m p e d e d r a i n a g e f r o m t h e sinuses r e s u l t i n g i n s i n u s -
i t i s , h e a d a c h e a n d nasal d i s c h a r g e .
T r e a t m e n t is r e m o v a l o f s y n e c h i a a n d p r e v e n t i o n o f t h e CSF r h i n o r r h o e a presents as flow o f clear fluid f r o m the

o p p o s i n g r a w surfaces t o c o m e i n t o c o n t a c t w i t h e a c h o t h e r nose.

b y p l a c i n g a t h i n silastic o r a c e l l o p h a n e sheet b e t w e e n Aetiology

t h e m . T h i s is c h a n g e d e v e r y t w o o r t h r e e days t i l l h e a l i n g is
Traumatic: H e a d injuries, surgery o f frontal, e t h m o i d
complete.
o r s p h e n o i d sinus o r h y p o p h y s c c t o m y . I t m a y f o l l o w
as a c o m p l i c a t i o n o f e n d o s c o p i c sinus s u r g e r y . I t m a y

CHOANAL ATRESIA be i m m e d i a t e o r delayed i n onset.

Tumours: Large osteomas o f f r o n t o e t h m o i d r e g i o n ,
tumours o f the pituitary or the olfactory bulb.
I t is d u e t o p e r s i s t e n c e o f b u c c o n a s a l m e m b r a n e , a n d m a y
Congenital defects i n s k u l l associated w i t h encephalocele.
be unilateral o r bilateral, c o m p l e t e o r i n c o m p l e t e , b o n y
Spontaneous type.
(90%) or membranous ( 1 0 % ) . U n i l a t e r a l atresia is m o r e
common and may remain undiagnosed until adult life. Sites o f leakage C S F f r o m a n t e r i o r c r a n i a l fossa reaches
t h e n o s e b y w a y o f c r i b r i f o r m p l a t e , e t h m o i d air cells o r
f r o n t a l sinus. C S F f r o m m i d d l e c r a n i a l fossa reaches t h e nose
v i a s p h e n o i d sinus. S o m e t i m e s , i n j u r i e s o f t e m p o r a l b o n e
result i n leakage o f C S F i n t o t h e m i d d l e ear a n d t h e n c e v i a
t h e e u s t a c h i a n t u b e i n t o t h e nose ( o t o r h i n o r r h o e a ) .

Diagnosis There is h i s t o r y o f d r i b b l i n g o f clear fluid

f r o m the nose o n b e n d i n g o r s t r a i n i n g . C S F r h i n o r r h o e a
s h o u l d be d i f f e r e n t i a t e d f r o m nasal d i s c h a r g e o f a l l e r g i c o r
v a s o m o t o r r h i n i t i s . D i s c h a r g e i n C S F r h i n o r r h o e a is clear
a n d w a t e r y , appears s u d d e n l y i n a g u s h o f d r o p s w h e n
b e n d i n g f o r w a r d o r s t r a i n i n g , is u n c o n t r o l l a b l e a n d c a n n o t
be s n i f f e d b a c k . T h e r e is n o associated s n e e z i n g , nasal c o n -
gestion or lacrimation. W h e n collected into a test-tube and
a l l o w e d t o s t a n d , i t r e m a i n s clear i n c o n t r a d i s t i n c t i o n t o
nasal d i s c h a r g e t h a t leaves a s e d i m e n t b e c a u s e o f m u c u s
a n d o t h e r p r o t e i n s . T h i s is also t h e reason t h a t a nasal d i s -
charge stiffens t h e h a n d k e r c h i e f . CSF contains glucose
Nasal synechia left.
w h i c h can be d e m o n s t r a t e d b y oxidase-peroxidase paper
 Differences between CSF and nasal secretions

Features C S F fluid Nasal secretion

History Nasal or sinus surgery, head injury or intracranial Sneezing, nasal stuffiness, itching in the

t u m o u r nose or lacrimation

Flow o f discharge A few drops or a stream o f fluid gushes d o w n w h e n Continuous, N o effect o f bending

bending forward or straining; c a n n o t be sniffed back forward or straining. Can be sniffed back

Character o f discharge Thin, watery and clear Slimy (mucus) or clear (tears)

Taste Sweet Salty

Sugar content M o r e than 30 m g / d l { C o m p a r e with s u g a r in C S F after Less t h a n 10 m g / d l

l u m b a r p u n c t u r e as s u g a r is l e s s i n C S F in meningitis)

P r e s e n c e o f fi 2 transferrin Always present. I t is s p e c i f i c f o r CSF Always absent

s t r i p o r b i o c h e m i c a l tests. p 2 t r a n s f e r r i n is s p e c i f i c f o r C S F . scan is c o m b i n e d w i t h i n j e c t i o n o f a c o n t r a s t m a t e r i a l i n t o
I t is a b s e n t i n nasal s e c r e t i o n s o r tears. Its p r e s e n c e c o n - i n t r a t h e c a l space v i a cisterna m a g n a . T h e s e days, a n o n i n v a -
f i r m s t h e d i a g n o s i s o f C S F l e a k , (see T a b l e 2 9 . 1 f o r d i f f e r - sive, n o n - i o n i s i n g t e c h n i q u e of M R I with T^-weighted
ences b e t w e e n C S F r h i n o r r h o e a a n d nasal d i s c h a r g e ) . i m a g e s o r M R I c i s t e r n o g r a p h y is m o r e u s e f u l .
Localisation o f C S F leak I t is d o n e b y i n t r a t h e c a l i n j e c - I n s u s p e c t e d cases o f o t o r h i n o r r h o e a , a l w a y s e x a m i n e t h e
tion o f a dye (fluorescein 5%, 1 ml) or a radioisotope and ear f o r t h e p r e s e n c e o f f l u i d a n d c o n d u c t i v e h e a r i n g loss.
p l a c i n g pledgets o f c o t t o n i n the o l f a c t o r y slit, m i d d l e I n t r a u m a t i c C S F l e a k , w h e n C S F a n d b l o o d are m i x e d ,
m e a t u s , s p h e n o e t h m o i d a l recess a n d n e a r t h e eustachian double ring sign ( o r t a r g e t s i g n ) is h e l p f u l . I n t h i s s i g n , d i s -
tube and e x a m i n i n g the pledgets f o r dye o r radioactivity. charge collected o n a piece o f filter paper shows a central
s p o t o f b l o o d w h i l e C S F spreads o u t l i k e a h a l o a r o u n d i t .
O l f a c t o r y slit —> C r i b r i f o r m plate
T r e a t m e n t Early cases o f p o s t - t r a u m a t i c CSF rhinor-
M i d d l e meatus —> F r o n t a l o r e t h m o i d sinuses
r h o e a are m a n a g e d c o n s e r v a t i v e l y b y p l a c i n g t h e p a t i e n t i n
S p h e n o e t h m o i d a l recess —> S p h e n o i d sinus
the s e m i - s i t t i n g p o s i t i o n , a v o i d i n g b l o w i n g o f nose, sneez-
I n f e r i o r meatus near the —> Temporal bone
i n g a n d s t r a i n i n g . P r o p h y l a c t i c a n t i b i o t i c s are also a d m i n -
eustachian tube
istered t o p r e v e n t m e n i n g i t i s .
Site o f l e a k can b e d e t e m i i n e d b y h i g h r e s o l u t i o n , t h i n P e r s i s t e n t cases o f C S F r h i n o r r h o e a are t r e a t e d s u r g i -
s e c t i o n c o r o n a l cuts w i t h b o n e w i n d o w . I t can s h o w t h e c a l l y b y nasal e n d o s c o p i c or intracranial approach. Nasal
area o f b o n y d e f e c t . H o w e v e r , i f this fails t o localise the endoscopic a p p r o a c h is u s e f u l f o r leaks f r o m t h e f r o n t a l
d e f e c t , a C T c i s t e r n o g r a m is a d v i s e d . I n this p r o c e d u r e , CT sinus, c r i b r i f o r m p l a t e , e t h m o i d o r s p h e n o i d sinuses.
Allergic Rhinitis

It is a n I g E - m e d i a t e d i m m u n o l o g i c response of nasal
Pathogenesis
mucosa to a i r - b o r n e allergens a n d is c h a r a c t e r i s e d by
w a t e r y nasal d i s c h a r g e , nasal o b s t r u c t i o n , s n e e z i n g and
I n h a l e d allergens p r o d u c e specific I g E a n t i b o d y i n t h e g e n e t -
i t c h i n g i n t h e n o s e . T h i s m a y also b e associated w i t h s y m p -
ically predisposed individuals. T h i s a n t i b o d y becomes f i x e d
t o m s o f i t c h i n g i n t h e eyes, p a l a t e a n d p h a r y n x . T w o c l i n i -
t o t h e b l o o d basophils o r tissue mast cells b y its Fc e n d ( F i g .
cal t y p e s h a v e b e e n r e c o g n i s e d :
30.1). O n subsequent exposure, antigen combines w i t h IgE

Seasonal S y m p t o m s appear i n o r a r o u n d a particular a n t i b o d y at its Fab e n d . T h i s r e a c t i o n p r o d u c e s d e g r a n u l a -

season w h e n t h e p o l l e n s o f p a r t i c u l a r p l a n t , t o w h i c h t i o n o f t h e mast cells w i t h release o f several c h e m i c a l m e d i a -

t h e p a t i e n t is s e n s i t i v e , are p r e s e n t i n t h e a i r . t o r s , s o m e o f w h i c h already exist i n p r e f o r m e d state w h i l e

Perennial Symptoms are present throughout the o t h e r s are synthesised afresh. T h e s e m e d i a t o r s ( F i g . 3 0 . 2 ) are

year. responsible f o r s y m p t o m a t o l o g y o f allergic disease. D e p e n d i n g

o n t h e tissues i n v o l v e d , t h e r e m a y be v a s o d i l a t i o n , m u c o s a l
oedema, infiltration w i t h e o s i n o p h i l s , excessive secretion
Aetiology
from nasal glands o r s m o o t h m u s c l e c o n t r a c t i o n . A " p r i m i n g
a f f e c t " has also b e e n d e s c r i b e d , i.e. m u c o s a earlier sensitised
Inhalant allergens are o f t e n t h e cause. P o l l e n f r o m t h e trees
t o a n a l l e r g e n w i l l react t o smaller doses o f s u b s e q u e n t spe-
a n d grasses, m o u l d spores, h o u s e d u s t , d e b r i s f r o m insects
c i f i c a l l e r g e n . I t also gets " p r i m e d " t o o t h e r n o n - s p e c i f i c
o r h o u s e m i t e are c o m m o n o f f e n d e r s . F o o d a l l e r g y is r a r e l y
antigens to w h i c h patient was n o t exposed (Fig. 30.3).
a n i m p o r t a n t cause.
C l i n i c a l l y , a l l e r g i c response o c c u r s i n 2 phases:
Genetic predisposition plays a n i m p o r t a n t p a r t . C h a n c e s o f
c h i l d r e n d e v e l o p i n g a l l e r g y are 2 0 % a n d 47%) r e s p e c t i v e l y , A c u t e or early phase It occurs i m m e d i a t e l y w i t h i n
i f o n e o r b o t h parents suffer f r o m allergic diathesis. 5-30 m i n , after e x p o s u r e t o t h e specific allergen a n d

B
Fab end Heavy chain Antigen

Antibody
• Light chain

0 _ —
Mast cell
s s

Mediator release

Tail Newly synthesised mediators

Preformed
mediators

Fc end

(A) Structure o f IgE antibody. Fc end is attached to the mast cell or blood basophil while Fab end is t h e antigen binding site.

(B) Release o f m e d i a t o r substances f r o m m a s t cell p r o d u c i n g s y m p t o m s o f nasal allergy.

 Specific allergic stimulus Non-specific stimuli
Sensitised
Antigen (igE-mediated] • Weather changes
mast cell
(Temp-humidity)
• Emotional stimuli
Release of mediators • Salicylates
1
• Viral infections
• Air pollution
Preformed Newly synthesised
• Histamine • Prostaglandins, i_
• ECF-A e.g. PGD 2 Mast cell or blood basophi
• NCF-A • Leukotrienes,
• Heparin e.g. 5RS-A
• Others • PAF Drop in cAMP/cGMP ratio
• Thromboxane A
• TNFa
Histamine Vasodilatation, bronchospasm Release of preformed and
ECF-A Eosinophil chemotactic factor of anaphylaxis— newly-formed mediators
attracts eosinophils to the site of reaction.
NCF-A Neutrophil chemotactic factor—attracts
neutrophils
J I I
Increased vascular Change in smooth Hyperactivity
Heparin Enhances phagocytosis permeability and muscle tone of glands
Prostaglandins Vasoactive and bronchospastic vasodilatation

Leukotriene Vasoactive and bronchospastic 1

PAF Platelet aggregating factor. Histamine and Tissue oedema Increased secretion
serotonin are released from platelets. Causes
chemotaxis of neutrophils and eosinophils.
I
Nasal blockage Bronchospasm Rhinorrhoea
Thromboxane A Spasmogenic

TNFa Tumour necrosis factor. Helps transmigration

of neutrophils and eosinophils and attracts Both allergic and non-specific stimuli act on m a s t cells o r blood
them to the site of reaction.
b a s o p h i l s releasing several m e d i a t o r s u b s t a n c e s responsible for

s y m p t o m a t o l o g y o f allergy.

Release o f m e d i a t o r s f r o m m a s t cell w h e n c h a l l e n g e d by allergic

or non-specific stimuli.

Symptoms of perennial allergy are n o t so severe as t h a t o f

t h e seasonal t y p e . T h e y i n c l u d e f r e q u e n t c o l d s , p e r s i s t e n t l y
consists o f s n e e z i n g , r h i n o r r h o e a nasal b l o c k a g e a n d /
s t u f f y n o s e , loss o f sense o f s m e l l d u e t o m u c o s a l o e d e m a ,
o r b r o n c h o s p a s m . I t is d u e t o release o f v a s o a c t i v e
postnasal d r i p , c h r o n i c c o u g h a n d h e a r i n g i m p a i r m e n t d u e
amines like histamine.
t o e u s t a c h i a n t u b e b l o c k a g e o r fluid i n t h e m i d d l e ear.
Late or delayed phase It occurs 2 - 8 h o u r s after
Signs o f a l l e r g y m a y b e seen i n t h e n o s e , eyes, ears,
e x p o s u r e t o a l l e r g e n w i t h o u t a d d i t i o n a l e x p o s u r e . I t is
pharynx or larynx.
due to infiltration o f i n f l a m m a t o r y cells-eosinophils,
Nasal signs i n c l u d e transverse nasal c r e a s e — a b l a c k l i n e
neutrophils, basophil, monocytes and C D 4 + T cells
across t h e middle o f d o r s u m o f nose d u e t o constant
at t h e site o f a n t i g e n d e p o s i t i o n c a u s i n g s w e l l i n g , c o n -
u p w a r d r u b b i n g o f n o s e s i m u l a t i n g a salute ( a l l e r g i c s a l u t e ) ,
gestion, t h i c k secretion. I n the event o f repeated or
p a l e a n d o e d e m a t o u s nasal m u c o s a w h i c h m a y a p p e a r b l u -
c o n t i n u o u s e x p o s u r e t o a l l e r g e n , a c u t e phase s y m p -
i s h . T u r b i n a t e s are s w o l l e n . T h i n , w a t e r y o r m u c o i d d i s -
t o m a t o l o g y o v e r l a p s t h e late p has e.
c h a r g e is u s u a l l y p r e s e n t .
Ocular signs i n c l u d e o e d e m a o f l i d s , c o n g e s t i o n a n d c o b -
Clinical Features b l e - s t o n e a p p e a r a n c e o f t h e c o n j u n c t i v a , d a r k circles u n d e r
t h e eyes ( a l l e r g i c s h i n e r s ) .
T h e r e is n o age o r sex p r e d i l e c t i o n . I t m a y start i n i n f a n t s Otologic signs include retracted tympanic membrane
as y o u n g as 6 m o n t h s o r o l d e r p e o p l e . U s u a l l y t h e o n s e t is or serous otitis media as a result o f eustachian tube
at 12—16 years o f age. blockage.
The c a r d i n a l symptoms of seasonal nasal allergy include Pharyngeal signs include granular pharyngitis due to
paroxysmal sneezing, 10—20 sneezes at a time, nasal h y p e r p l a s i a o f s u b m u c o s a l l y m p h o i d tissue. A c h i l d w i t h
o b s t r u c t i o n , w a t e r y nasal d i s c h a r g e a n d i t c h i n g i n t h e n o s e . p e r e n n i a l a l l e r g i c r h i n i t i s m a y s h o w all t h e f e a t u r e s o f p r o -
I t c h i n g m a y also i n v o l v e eyes, p a l a t e o r p h a r y n x . S o m e l o n g e d m o u t h b r e a t h i n g as seen i n a d e n o i d h y p e r p l a s i a .
may get bronchospasm. The duration a n d severity of Laryngeal signs i n c l u d e hoarseness o f v o i c e a n d o e d e m a
s y m p t o m s m a y v a r y w i t h t h e season. o f the vocal cords.
 al Sinuses

be r e q u i r e d . A p a r t i c u l a r f o o d article t o w h i c h t h e patient
Diagnosis
is f o u n d a l l e r g i c c a n b e e l i m i n a t e d f r o m t h e d i e t .

A d e t a i l e d h i s t o r y a n d p h y s i c a l e x a m i n a t i o n is h e l p f u l , a n d 2. T r e a t m e n t w i t h drugs
also g i v e s c l u e s t o t h e p o s s i b l e a l l e r g e n . O t h e r causes o f
(a) Antihistamines. They control rhinorrhoea, sneezing
nasal stuffiness s h o u l d b e e x c l u d e d .
and pruritis. A l l antihistaminics have the side effect of
d r o w s i n e s s ; s o m e m o r e t h a n t h e o t h e r . T h e dose a n d t y p e
o f t h e a n t i h i s t a m i n i c has t o be i n d i v i d u a l i s e d . I f o n e a n t i h i s -
Investigations
t a m i n i c is n o t e f f e c t i v e , a n o t h e r m a y b e t r i e d from a d i f f e r -
e n t class.
Total and differential count. P e r i p h e r a l e o s i n o p h i l i a m a y
(b) Sympathomimetic drugs (oral or topical). Alpha-
b e s e e n b u t is a n i n c o n s i s t e n t finding.
adrenergic d r u g s c o n s t r i c t b l o o d vessels a n d r e d u c e nasal
Nasal smear shows large number o f eosinophils in
c o n g e s t i o n a n d o e d e m a . T h e y also cause C N S s t i m u l a t i o n
a l l e r g i c r h i n i t i s . N a s a l s m e a r s h o u l d b e t a k e n at t h e
a n d are o f t e n g i v e n i n c o m b i n a t i o n w i t h a n t i h i s t a m i n i c s t o
t i m e o f c l i n i c a l l y a c t i v e disease o r after nasal c h a l l e n g e
counteract drowsiness. Pseudoephedrine and p h e n y l p r o -
test. N a s a l e o s i n o p h i l i a is also seen i n c e r t a i n n o n - a l -
p a n o l a m i n e are o f t e n c o m b i n e d w i t h a n t i h i s t a m i n i c s for
l e r g i c r h i n i t i s , e.g. N A P J E S ( n o n - a l l e r g i c r h i n i t i s w i t h
oral administration.
eosinophilia syndrome).
T o p i c a l use o f s y m p a t h o m i m e t i c d r u g s cause nasal d e c o n -
Skin tests h e l p t o i d e n t i f y s p e c i f i c a l l e r g e n . T h e y are
gestion. Phenylephrine, oxymetazoline and xylometazoline
p r i c k , s c r a t c h a n d i n t r a d e r m a l tests.
are o f t e n u s e d t o r e l i e v e nasal o b s t r u c t i o n , b u t are n o t o r i o u s
Radioallergosorbent test (RAST) is a n i n v i t r o test a n d
t o cause severe r e b o u n d c o n g e s t i o n . P a t i e n t resorts t o u s i n g
measures specific I g E a n t i b o d y c o n c e n t r a t i o n i n the
m o r e a n d m o r e o f t h e m t o r e l i e v e nasal o b s t r u c t i o n . T h i s
patient's serum.
v i c i o u s c y c l e leads t o r h i n i t i s m e d i c a m e n t o s a .
Nasal provocation test. A c r u d e m e t h o d is t o challenge the
(c) Corticosteroids. O r a l c o r t i c o s t e r o i d s are v e r y e f f e c t i v e
nasal m u c o s a w i t h a small a m o u n t o f allergen placed at the
i n c o n t r o l l i n g the s y m p t o m s o f allergic r h i n i t i s b u t their
e n d o f a t o o t h p i c k a n d asking t h e p a t i e n t t o s n i f f i n t o each
use s h o u l d b e l i m i t e d t o a c u t e e p i s o d e s w h i c h h a v e n o t
nostril a n d t o observe i f allergic s y m p t o m s are r e p r o d u c e d .
b e e n c o n t r o l l e d b y o t h e r m e a s u r e s . T h e y h a v e s e v e r a l sys-
M o r e sophisticated t e c h n i q u e s are available n o w .
t e m i c side effects.
T o p i c a l s t e r o i d s s u c h as b e c l o m e t h a s o n e d i p r o p i o n a t e ,

Complications budesonide, flunisolide acetate, fluticasone and mometa-

s o n e i n h i b i t r e c r u i t m e n t o f i n f l a m m a t o r y cells i n t o the

N a s a l a l l e r g y m a y cause: nasal m u c o s a a n d suppress l a t e - p h a s e a l l e r g i c r e a c t i o n , are

u s e d as aerosols a n d are v e r y e f f e c t i v e i n t h e c o n t r o l of
R e c u r r e n t sinusitis b e c a u s e o f o b s t r u c t i o n t o t h e sinus
s y m p t o m s . T h e y h a v e also b e e n u s e d i n r h i n i t i s m e d i c a -
ostia.
m e n t o s a w h i l e w i t h d r a w i n g t o p i c a l use o f d e c o n g e s t a n t
Nasal p o l y p i .
nasal d r o p s . T o p i c a l steroids have fewer systemic side
Serous otitis media.
effects b u t t h e i r c o n t i n u o u s use m a y cause m u c o s a l atro-
Orthodontic problems and other ill-effects of pro- p h y a n d e v e n septal p e r f o r a t i o n . I t is w i s e t o b r e a k their
l o n g e d m o u t h b r e a t h i n g especially i n c h i l d r e n . use f o r 1—2 w e e k s e v e r y 2—3 m o n t h s . T h e y m a y also p r o -
B r o n c h i a l a s t h m a . P a t i e n t s o f nasal a l l e r g y h a v e f o u r m o t e g r o w t h o f fungus.
times m o r e risk o f d e v e l o p i n g b r o n c h i a l a s t h m a .
(d) Sodium cromoglycatc. I t stabilises t h e m a s t cells a n d
prevents t h e m f r o m d e g r a n u l a t i o n despite t h e f o r m a t i o n
o f I g E - a n t i g e n c o m p l e x . I t is u s e d as 2 % s o l u t i o n f o r nasal
Treatment d r o p s o r s p r a y o r as a n a e r o s o l p o w d e r . I t is u s e f u l b o t h i n
seasonal a n d p e r e n n i a l a l l e r g i c r h i n i t i s .

T r e a t m e n t can b e d i v i d e d i n t o : 3. I m m u n o t h e r a p y Immunotherapy or hyposensitisation

is used w h e n d m g t r e a t m e n t fails t o c o n t r o l s y m p t o m s or
A v o i d a n c e o f allergen
p r o d u c e s i n t o l e r a b l e side effects. A l l e r g e n is g i v e n i n g r a d u a l l y
T r e a t m e n t w i t h drugs
increasing doses till the maintenance dose is reached.
Immunotherapy
I m m u n o t h e r a p y suppresses t h e f o r m a t i o n o f I g E . I t also raises
1. Avoidance of allergen T h i s is m o s t successful i f t h e t h e titre o f specific I g G a n t i b o d y . I m m u n o t h e r a p y has t o be
antigen i n v o l v e d is s i n g l e . Removal o f a pet from the g i v e n f o r a y e a r o r so b e f o r e significant i m p r o v e m e n t of
h o u s e , e n c a s i n g t h e p i l l o w o r m a t t r e s s w i t h plastic sheet, s y m p t o m s c a n b e n o t i c e d . I t is d i s c o n t i n u e d i f u n i n t e r r u p t e d
c h a n g e o f place o f w o r k o r s o m e t i m e s change o f j o b may t r e a m i e n t f o r 3 years s h o w s n o c l i n i c a l i m p r o v e m e n t .
V a s o m o t o r a n d O t h e r Forms o f
Non-allergic Rhinitis

S i g n s N a s a l m u c o s a o v e r t h e t u r b i n a t e s is g e n e r a l l y c o n -
V a s o m o t o r Rhinitis (VMR)
gested a n d h y p e r t r o p h i c . I n s o m e , i t m a y b e n o r m a l .

I t is n o n - a l l e r g i c r h i n i t i s b u t c l i n i c a l l y s i m u l a t i n g nasal Complications L o n g - s t a n d i n g cases o r V M R develop

a l l e r g y w i t h s y m p t o m s o f nasal o b s t r u c t i o n , r h i n o r r h o e a nasal p o l y p i , h y p e r t r o p h i c r h i n i t i s a n d s i n u s i t i s .

and sneezing. O n e o r t h e o t h e r o f these s y m p t o m s may

Treatment
predominate. T h e c o n d i t i o n u s u a l l y persists t h r o u g h o u t
t h e y e a r a n d a l l t h e tests o f nasal a l l e r g y are n e g a t i v e . Medical

Pathogenesis A v o i d a n c e o f physical factors w h i c h p r o v o k e s y m p -

t o m s , e.g. s u d d e n change i n t e m p e r a t u r e , h u m i d i t y ,
N a s a l m u c o s a has r i c h b l o o d s u p p l y . Its v a s c u l a t u r e is s i m i -
blasts o f a i r o r d u s t .
lar t o t h e e r e c t i l e tissue i n h a v i n g v e n o u s sinusoids or
A n t i h i s t a m i n i c s a n d o r a l nasal d e c o n g e s t a n t s are h e l p f u l
" l a k e s " w h i c h are s u r r o u n d e d b y f i b r e s o f s m o o t h m u s c l e
i n r e l i e v i n g nasal o b s t r u c t i o n , s n e e z i n g a n d r h i n o r r h o e a .
w h i c h act as s p h i n c t e r s a n d c o n t r o l t h e f i l l i n g o r e m p t y i n g
T o p i c a l steroids (e.g. b e c l o m e t h a s o n e dipropionate,
o f t h e s e s i n u s o i d s . S y m p a t h e t i c s t i m u l a t i o n causes v a s o -
b u d e s o n i d e o r f l u t i c a s o n e ) , u s e d as spray o r a e r o s o l ,
constriction a n d shrinkage o f mucosa, w h i l e parasympa-
are u s e f u l t o c o n t r o l s y m p t o m s .
t h e t i c s t i m u l a t i o n causes v a s o d i l a t i o n a n d engorgement.
S y s t e m i c s t e r o i d s c a n be g i v e n f o r a s h o r t t i m e i n v e r y
O v e r a c t i v i t y o f p a r a s y m p a t h e t i c s y s t e m also causes e x c e s -
severe cases.
s i v e s e c r e t i o n f r o m t h e nasal g l a n d s .
Psychologicalfactorsshouldberemoved. Tranquillizers
A u t o n o m i c n e r v o u s system is u n d e r t h e c o n t r o l o f h y p o -
m a y be needed i n some patients.
t h a l a m u s a n d t h e r e f o r e e m o t i o n s p l a y a great r o l e i n v a s o m o -
t o r r h i n i t i s . A u t o n o m i c system is unstable i n cases o f v a s o m o t o r Surgical
r h i n i t i s . N a s a l m u c o s a is also h y p e r r e a c t i v e a n d responds t o
N a s a l o b s t r u c t i o n c a n b e r e l i e v e d b y measures w h i c h
several non-specific stimuli, e.g. change in temperature,
r e d u c e t h e size o f nasal t u r b i n a t e s (see h y p e r t r o p h i c
h u m i d i t y , blasts o f air, s m a l l a m o u n t s o f dust o r s m o k e .
r h i n i t i s ) . O t h e r associated causes o f nasal o b s t r u c t i o n ,
Symptoms e.g. polyp, d e v i a t e d nasal septum, s h o u l d also be
corrected.
Paroxysmal sneezing Bouts o f sneezing start j u s t Excessive rhinorrhoea, not corrected by medical
after g e t t i n g o u t o f t h e b e d i n t h e m o r n i n g . therapy a n d b o t h e r s o m e to the patient, can be relieved
Excessive rhinorrhoea T h i s accompanies sneezing b y s e c t i o n i n g t h e parasympathetic secretomotor fibres
o r t h i s m a y be t h e o n l y p r e d o m i n a n t s y m p t o m . I t is t o nose ( v i d i a n n e u r e c t o m y ) .
p r o f u s e a n d w a t e r y a n d m a y e v e n w e t several h a n d -
k e r c h i e f s . T h e n o s e m a y d r i p w h e n t h e p a t i e n t leans
f o r w a r d , a n d this m a y n e e d to be d i f f e r e n t i a t e d f r o m O t h e r F o r m s of Non-allergic Rhinitis
C S F r h i n o r r h o e a (seepage 1 7 8 ) .
Nasal obstruction T h i s alternates from side t o side. N a s a l m u c o s a r e s p o n d s t o several d i f f e r e n t s t i m u l i p r o d u c -
U s u a l l y m o r e m a r k e d at n i g h t . I t is t h e d e p e n d e n t side o f i n g s y m p t o m s o f r h i n i t i s . S o m e o f these c o n d i t i o n s h a v e
nose w h i c h is o f t e n b l o c k e d w h e n l y i n g o n o n e side. a c q u i r e d specific eponyms. S o m e a u t h o r i t i e s categorise
Postnasal drip. t h e m under the catch-all t e r m o f vasomotor rhinitis.
1 . D r u g - i n d u c e d rhinitis Several a n t i h y p e r t e n s i v e drugs h o s t i l i t y , h u m i l i a t i o n , r e s e n t m e n t a n d g r i e f are all k n o w n
s u c h as r e s e r p i n e , g u a n e t h i d i n e , m e t h y l d o p a a n d p r o p r a - t o cause r h i n i t i s . T r e a t m e n t is p r o p e r c o u n s e l l i n g f o r p s y -
nolol are sympathetic b l o c k i n g agents a n d cause nasal c h o l o g i c a l a d j u s t m e n t . I m i p r a m i n e , w h i c h has b o t h a n t i -
stuffiness. S o m e a n t i c h o l i n e s t e r a s e d r u g s , e.g. n e o s t i g m i n e , depressant and anticholinergic effects has been found
used i n the t r e a t m e n t o f m y a s t h e n i a gravis, have acetyl- useful.
c h o l i n e l i k e a c t i o n a n d cause nasal o b s t r u c t i o n . C o n t r a c e p -
6. R h i n i t i s d u e to hypothyroidism Hypothyroidism
t i v e pills also cause nasal o b s t r u c t i o n because o f o e s t r o g e n s .
leads t o h y p o a c t i v i t y o f t h e s y m p a t h e t i c s y s t e m w i t h p r e -
2. R h i n i t i s m e d i c a m e n t o s a T o p i c a l d e c o n g e s t a n t nasal d o m i n a n c e o f p a r a s y m p a t h e t i c a c t i v i t y c a u s i n g nasal s t u f f i -
d r o p s are n o t o r i o u s t o cause r e b o u n d p h e n o m e n o n . T h e i r ness a n d ' c o l d s ' . R e p l a c e m e n t o f t h y r o i d h o r m o n e r e l i e v e s
excessive use causes r h i n i t i s . I t is t r e a t e d b y w i t h d r a w a l o f the c o n d i t i o n .
nasal d r o p s , s h o r t c o u r s e o f s y s t e m i c s t e r o i d t h e r a p y a n d i n
7. Gustatory rhinitis Spicy and pungent f o o d may i n
s o m e cases, s u r g i c a l r e d u c t i o n o f t u r b i n a t e s , i f t h e y have
s o m e p e o p l e p r o d u c e r h i n o r r h o e a , nasal stuffiness, l a c r i -
become hypertrophied.
m a t i o n , s w e a t i n g a n d e v e n f l u s h i n g o f face. T h i s is a c h o -
3. R h i n i t i s o f p r e g n a n c y Pregnant w o m e n m a y develop linergic response t o s t i m u l a t i o n o f sensory receptors on
persistent r h i n i t i s d u e t o h o r m o n a l changes. N a s a l mucosa the palate. S p i c y f o o d , p a r t i c u l a r l y the r e d pepper, contains
becomes oedematous and blocks the airway. Some may capsaicin w h i c h is k n o w n t o s t i m u l a t e s e n s o r y n e r v e s . I t
develop secondary i n f e c t i o n a n d even sinusitis. I n such c a n b e r e l i e v e d b y i p r a t r o p i u m b r o m i d e nasal spray (an
cases, care should be taken while prescribing drugs. anticholinergic), a f e w minutes before meals.
G e n e r a l l y , l o c a l measures s u c h as l i m i t e d use o f nasal d r o p s ,
8. N o n air-flow rhinitis I t is seen i n p a t i e n t s o f l a r y n -
t o p i c a l steroids a n d l i m i t e d surgery ( c r y o s u r g e r y ) t o t u r -
gectomy and tracheostomy. Nose is n o t used for air
b i n a t e s are s u f f i c i e n t t o r e l i e v e t h e s y m p t o m s . Safety o f t h e
flow a n d t h e t u r b i n a t e s b e c o m e s w o l l e n d u e t o loss of
d e v e l o p i n g fetus is n o t established f o r n e w e r a n t i h i s t a m i n i c s
vasomotor control. Similar changes are also seen in
a n d t h e y s h o u l d be a v o i d e d .
n a s o p h a r y n g e a l o b s t r u c t i o n d u e t o c h o a n a l atresia o r a d e -
4. Honeymoon rhinitis This usually f o l l o w s sexual noidal hyperplasia, the latter h a v i n g the additional factor
e x c i t e m e n t l e a d i n g t o nasal s t u f f i n e s s . o f i n f e c t i o n due to stagnation o f discharge i n the nasal
5. E m o t i o n a l rhinitis N o s e m a y r e a c t t o several emo- cavity which should otherwise drain freely into the
tional stimuli. Psychological states l i k e a n x i e t y , tension, nasopharynx.
Nasal Polypi

N a s a l P o l y p i are n o n - n e o p l a s t i c masses o f oedematous Pathogenesis Nasal mucosa, particularly i n the r e g i o n o f

nasal o r sinus m u c o s a . m i d d l e meatus and turbinate becomes oedematous due to
T h e y are d i v i d e d i n t o t w o m a i n v a r i e t i e s : c o l l e c t i o n o f extracellular f l u i d causing p o l y p o i d a l change.
P o l y p i w h i c h are sessile i n t h e b e g i n n i n g b e c o m e p e d u n -
Bilateral ethmoidal p o l y p i .
c u l a t e d d u e t o g r a v i t y a n d t h e excessive s n e e z i n g .
Antrochoanal polyp.
Pathology I n e a r l y stages, surface o f nasal p o l y p i is c o v -
ered b y ciliated c o l u m n a r e p i t h e l i u m like that o f n o r m a l
Bilateral Ethmoidal Polypi
nasal m u c o s a b u t l a t e r i t u n d e r g o e s a m e t a p l a s t i c c h a n g e t o
transitional and squamous type o n exposure to atmospheric
Aetiology A e t i o l o g y o f nasal p o l y p i is v e r y c o m p l e x a n d
i r r i t a t i o n . S u b m u c o s a s h o w s l a r g e i n t e r c e l l u l a r spaces f i l l e d
not well-understood. They may arise i n i n f l a m m a t o r y
w i t h serous f l u i d . T h e r e is also i n f i l t r a t i o n w i t h eosino-
c o n d i t i o n s o f nasal m u c o s a (rhinosinusitis), disorders of
p h i l s a n d r o u n d cells.
c i l i a r y m o t i l i t y o r a b n o r m a l c o m p o s i t i o n o f nasal mucus
(cystic f i b r o s i s ) . V a r i o u s diseases associated w i t h t h e f o r - Site of origin M u l t i p l e nasal p o l y p i a l w a y s arise from

m a t i o n o f nasal p o l y p i are: t h e lateral w a l l o f nose, usually f r o m the m i d d l e meatus.

Common sites are u n c i n a t e process, b u l l a e t h m o i d a l i s ,
Chronic rhinosinusitis. P o l y p i are seen i n c h r o n i c r h i - ostia o f sinuses, m e d i a l surface a n d e d g e o f m i d d l e t u r -
nosinusitis o f b o t h allergic and n o n - a l l e r g i c origin. b i n a t e . A l l e r g i c nasal p o l y p i a l m o s t n e v e r arise f r o m the
Non-allergic rhinitis with eosinophilia syndrome s e p t u m or the f l o o r o f nose.
(NARES) is a f o r m o f chronic rhinitis associated
Symptoms
with polypi.
Asthma. 7 % o f the patients w i t h asthma o f atopic or M u l t i p l e p o l y p i c a n o c c u r at a n y age b u t are m o s t l y
n o n - a t o p i c o r i g i n s h o w nasal p o l y p i . seen i n a d u l t s .
Aspirin intolerance. 36% o f the patients w i t h aspirin N a s a l stuffiness l e a d i n g t o t o t a l nasal o b s t r u c t i o n m a y
i n t o l e r a n c e m a y s h o w p o l y p i . S a m p t e r ' s t r i a d consists be the presenting s y m p t o m .
o f nasal p o l y p i , a s t h m a a n d a s p i r i n i n t o l e r a n c e . P a r t i a l o r t o t a l loss o f sense o f s m e l l .
Cystic fibrosis. 20% o f patients w i t h cystic fibrosis H e a d a c h e d u e t o associated s i n u s i t i s .
f o r m p o l y p i . I t is d u e t o a b n o r m a l m u c u s . S n e e z i n g a n d w a t e r y nasal d i s c h a r g e d u e t o associated
Allergic fungal sinusitis. A l m o s t a l l cases o f fungal allergy.
s i n u s i t i s f o r m nasal p o l y p i . Mass p r o t r u d i n g f r o m the n o s t r i l .
Kartagener's syndrome. T h i s consists o f bronchiectasis
sinusitis, situs i n v e r s u s a n d c i l i a r y d y s k i n e s i s . Signs O n a n t e r i o r r h i n o s c o p y , p o l y p i a p p e a r as s m o o t h ,
Young's syndrome. I t consists o f s i n o p u l m o n a r y d i s - g l i s t e n i n g , g r a p e - l i k e masses o f t e n p a l e i n c o l o u r . They
ease a n d a z o o s p e r m i a . m a y b e sessile o r p e d u n c u l a t e d , i n s e n s i t i v e t o p r o b i n g a n d
Churg-Strauss syndrome. Consists o f asthma, fever, d o n o t b l e e d o n t o u c h . O f t e n t h e y are m u l t i p l e a n d b i l a t -
eosinophilia, vasculitis a n d g r a n u l o m a . e r a l . L o n g - s t a n d i n g cases p r e s e n t w i t h b r o a d e n i n g o f nose
Nasal mastocytosis. I t is a f o r m o f c h r o n i c r h i n i t i s i n and increased i n t e r c a n t h a l distance. A p o l y p m a y p r o t r u d e
w h i c h nasal m u c o s a is i n f i l t r a t e d w i t h m a s t cells b u t f r o m the n o s t r i l a n d appear p i n k a n d vascular s i m u l a t i n g
f e w e o s i n o p h i l s . S k i n tests f o r a l l e r g y a n d I g E l e v e l s neoplasm (Fig. 32.1). Nasal cavity m a y s h o w p u r u l e n t dis-
are n o r m a l . c h a r g e d u e t o associated s i n u s i t i s .
 A p p r o a c h is t h r o u g h t h e m e d i a l w a i l o f t h e o r b i t b y
an external incision, m e d i a l to m e d i a l can thus.
Transantral ethmoidectomy. This is indicated when
i n f e c t i o n a n d p o l y p o i d a l c h a n g e s are also seen i n t h e
m a x i l l a r y a n t r u m . I n t h i s case, a n t r u m is o p e n e d by
Caldwell-Luc approach and the ethmoid air cell
approached t h r o u g h the medial wall o f the a n t r u m .
T h i s p r o c e d u r e is also s u p e r c e d e d b y e n d o s c o p i c sinus
surgery.
Endoscopic sinus surgery. T h e s e days, e t h m o i d a l p o l y p i
are r e m o v e d b y e n d o s c o p i c sinus s u r g e r y m o r e p o p u -
l a r l y c a l l e d F E S S ( f u n c t i o n a l e n d o s c o p i c sinus s u r g e r y ) .
I t is d o n e w i t h v a r i o u s e n d o s c o p e s o f 0 ° , 3 0 ° a n d 7 0 °
A polyp protruding from the left nostril in a patient with bilat- a n g u l a t i o n . P o l y p i c a n be r e m o v e d m o r e accurately
eral e t h m o i d a l polypi. w h e n e t h m o i d cells are r e m o v e d , a n d d r a i n a g e and
v e n t i l a t i o n p r o v i d e d t o t h e o t h e r i n v o l v e d sinuses s u c h
as m a x i l l a r y , s p h e n o i d a l o r f r o n t a l .
P r o b i n g o f a s o l i t a r y e t h m o i d a l p o l y p m a y b e necessary
to differentiate i t f r o m h y p e r t r o p h y o f the turbinate o r cys-
tic m i d d l e t u r b i n a t e . Antrochoanal Polyp

Diagnosis D i a g n o s i s c a n b e easily m a d e o n c l i n i c a l e x a m -
T h i s p o l y p arises f r o m t h e m u c o s a o f m a x i l l a r y a n t r u m
i n a t i o n . C T scan o f paranasal sinuses is essential t o e x c l u d e
n e a r its accessory o s t i u m , c o m e s o u t o f i t a n d g r o w s i n t h e
the b o n y erosion and expansion suggestive of neoplasia.
c h o a n a a n d nasal c a v i t y . T h u s i t has t h r e e parts.
Simple nasal p o l y p i may sometimes be associated with
m a l i g n a n c y u n d e r n e a t h , especially i n p e o p l e a b o v e 4 0 years Antral: w h i c h is a t h i n stalk.
a n d this m u s t be e x c l u d e d b y h i s t o l o g i c a l e x a m i n a t i o n of Choanal: w h i c h is r o u n d a n d g l o b u l a r .
t h e s u s p e c t e d tissue. C T scan also h e l p s t o p l a n s u r g e r y . Nasal: w h i c h is f l a t f r o m side t o s i d e .

Treatment Aetiology E x a c t cause is u n k n o w n . N a s a l a l l e r g y cou-

Conservative p l e d w i t h sinus i n f e c t i o n is i n c r i m i n a t e d . A n t r o c h o a n a l
p o l y p i are seen i n c h i l d r e n a n d y o u n g a d u l t s . U s u a l l y t h e y
Early p o l y p o i d a l changes w i t h o e d e m a t o u s mucosa are s i n g l e a n d u n i l a t e r a l .
m a y revert to n o r m a l w i t h antihistaminics and c o n t r o l
Symptoms U n i l a t e r a l nasal o b s t r u c t i o n is t h e p r e s e n t i n g
o f allergy.
s y m p t o m . O b s t r u c t i o n may b e c o m e bilateral w h e n p o l y p
A s h o r t c o u r s e o f s t e r o i d s m a y p r o v e u s e f u l i n case o f
grows i n t o the nasopharynx a n d starts o b s t r u c t i n g the
people w h o cannot tolerate antihistaminics and/or i n
opposite choana (Tables 32.2 a n d 32.3). V o i c e may b e c o m e
t h o s e w i t h a s t h m a a n d p o l y p o i d a l nasal m u c o s a . T h e y
t h i c k a n d d u l l due to hyponasality. Nasal discharge, m o s t l y
m a y also b e u s e d t o p r e v e n t r e c u r r e n c e after s u r g e r y .
m u c o i d , m a y b e seen o n o n e o r b o t h sides.
Contraindications t o use o f s t e r o i d s , e.g. hyperten-
Signs As the antrochoanal p o l y p g r o w s posteriorly, i t m a y
sion, p e p t i c ulcer, diabetes, pregnancy a n d t u b e r c u l o -
be m i s s e d o n a n t e r i o r r h i n o s c o p y . W h e n l a r g e , a s m o o t h
sis s h o u l d b e excluded.
g r e y i s h mass c o v e r e d w i t h nasal d i s c h a r g e m a y b e seen. I t

Surgical is soft a n d c a n b e m o v e d u p a n d d o w n w i t h a p r o b e . A
large p o l y p m a y p r o t r u d e f r o m the n o s t r i l and s h o w a p i n k
Polypectomy. O n e o r t w o p o l y p s w h i c h are p e d u n c u - c o n g e s t e d l o o k o n its e x p o s e d p a r t ( F i g . 3 2 . 2 ) .
l a t e d c a n b e r e m o v e d w i t h snare. M u l t i p l e a n d sessile
P o s t e r i o r r h i n o s c o p y m a y r e v e a l a g l o b u l a r mass f i l l i n g
p o l y p i r e q u i r e special forceps.
t h e c h o a n a o r t h e n a s o p h a r y n x . A large p o l y p m a y h a n g
Intranasal ethmoidectomy. When polypi are multiple
d o w n b e h i n d t h e soft p a l a t e a n d p r e s e n t i n t h e o r o p h a r y n x
a n d sessile t h e y r e q u i r e u n c a p p i n g o f t h e e t h m o i d a l
(Fig. 32.3 A,F3). (see Table 32.1 f o r differences between
a i r cells b y i n t r a n a s a l r o u t e , a p r o c e d u r e c a l l e d i n t r a -
antrochoanal and ethmoidal polypi.)
nasal e t h m o i d e c t o m y .
Differential diagnosis
Extranasal ethmoidectomy. This is indicated when
p o l y p i r e c u r after i n t r a n a s a l p r o c e d u r e s and surgical A blob o f mucus often looks like a polypi but it w o u l d
landmarks are ill-defined due to previous surgery. disappear o n b l o w i n g the nose.
 Nasal Polypi

H y p e r t r o p h i e d m i d d l e t u r b i n a t e is d i f f e r e n t i a t e d b y
its p i n k a p p e a r a n c e a n d h a r d f e e l o f b o n e o n p r o b e
testing.
A n g i o f i b r o m a has h i s t o r y o f p r o f u s e r e c u r r e n t epistaxis.
I t is firm i n c o n s i s t e n c y a n d easily b l e e d s o n p r o b i n g .
O t h e r neoplasms m a y be differentiated b y their fleshy
p i n k appearance, friable nature a n d their t e n d e n c y t o
bleed.

X - r a y s o f paranasal sinuses m a y s h o w o p a c i t y o f t h e

Figure 32.2 i n v o l v e d a n t r u m . X - r a y , ( l a t e r a l v i e w ) s o f t tissue n a s o p h a r -

y n x , reveals a g l o b u l a r s w e l l i n g i n t h e p o s t n a s a l space. I t is
Antrochonal polyp projecting through the left nostril in a
differentiated f r o m a n g i o f i b r o m a b y t h e presence o f a c o l -
14-year-old patient.
u m n o f air b e h i n d t h e p o l y p .

(A) Antrochoanal p o l y p seen h a n g i n g in the o r o p h a r y n x from behind the soft palate o n the right side o f uvula. ( B ) Polyp after removal.

Table 32. Differences between antrochoanal and ethmoidal polypi

Antrochoanal polypi Ethmoidal polypi

Age C o m m o n in children C o m m o n in adults

Aetiology Infection Allergy or multifactorial

N u m b e r Solitary Multiple

Laterality Unilateral Bilateral

Origin Max. sinus near the ostium Ethmoidal sinuses, uncinate process, middle

turbinate and middle meatus

G r o w t h G r o w s backwards to the choana; m a y hang d o w n Mostly g r o w anteriorly and m a y present at the nares

behind the soft palate

Size & shape Trilobed with antral, nasal a n d choanal parts. Choanal Usually small and grape-like masses

part m a y protrude through the c h o a n a & fill the

nasopharynx obstructing both sides

Recurrence U n c o m m o n , if removed completely C o m m o n

Treatment Polypectomy; endoscopic removal or Caldwell-Luc Polypectomy

operation if recurrent Endoscopic surgery or e t h m o i d e c t o m y (which may

be intranasal, extranasal or transantral)

©e.
 C o m m o n causes o f unilateral nasal o b s t r u c t i o n C o m m o n causes o f bilateral nasal o b s t r u c t i o n

Vestibule Vestibule
Furuncle Bilateral v e s t i b u l i t i s
Vestibulitis C o l l a p s i n g nasal aiae
Stenosis o f nares Stenosis o f nares
Atresia C o n g e n i t a l atresia o f nares
N a s o a l v e o l a r cyst
Nasal cavity
Papilloma
Acute rhinitis (viral, bacterial)
S q u a m o u s cell carcinoma
C h r o n i c r h i n i t i s & sinusitis
Nasal cavity Rhinitis medicamentosa
Foreign b o d y Allergic r h i n i t i s
DNS Hypertrophic turbinates
Hypertrophic turbinates DNS
C o n c h a bullosa Nasal polypi
Antrochoanal polyp Atrophic rhinitis
Synechia R h i n i t i s sicca
Rhinolith Septal h a e m a t o m a
Bleeding polypus o f septum Septal abscess
Benign a n d m a l i g n a n t t u m o u r s o f nose a n d p a r a n a s a l Bilateral c h o a n a l atresia
sinuses Nasopharynx
Sinusitis, u n i l a t e r a l A d e n o i d hyperplasia
Nasopharynx Large c h o a n a l p o l y p
U n i l a t e r a l c h o a n a l atresia T h o r n w a l d t ' s cyst
Adhesions between soft palate and posterior pharyngeal
wall
Treatment A n a n t r o c h o a n a l p o l y p is easily r e m o v e d by
Large b e n i g n a n d m a l i g n a n t t u m o u r s
a v u l s i o n e i t h e r t h r o u g h t h e nasal o r o r a l r o u t e . Recur-
rence is u n c o m m o n after complete removal. In cases
w h i c h d o recur, C a l d w e l l - L u c o p e r a t i o n m a y be r e q u i r e d Simple nasal p o l y p m a y masquerade a malignancy
t o r e m o v e t h e p o l y p c o m p l e t e l y f r o m t h e site o f its o r i g i n u n d e r n e a t h . H e n c e all p o l y p i s h o u l d b e s u b j e c t e d t o
and to deal w i t h c o - e x i s t e n t m a x i l l a r y sinusitis. These histology.
days, e n d o s c o p i c sinus s u r g e r y has s u p e r c e d e d o t h e r m o d e s A simple p o l y p i n a c h i l d m a y be a g l i o m a , an e n c e p h -
o f p o l y p r e m o v a l . C a l d w e l l - L u c o p e r a t i o n is a v o i d e d . alocele o r a m e n i n g o e n c e p h a l o c e l e . I t s h o u l d always
be aspirated and fluid examined for CSF. Careless
r e m o v a l o f such p o l y p w o u l d result i n C S F rhinor-
S o m e I m p o r t a n t Points to R e m e m b e r in
rhoea and meningitis.
a C a s e of Nasal Polypi
M u l t i p l e nasal p o l y p i i n c h i l d r e n m a y b e associated
with mucoviscidosis.

I f a p o l y p u s is r e d a n d f l e s h y , f r i a b l e a n d has g r a n u - Epistaxis and orbital symptoms associated w i t h a

lar surface, especially i n older patients, think of polyp should always arouse the suspicion of

malignancy. malignancy.
Epistaxis

Bleeding from inside t h e n o s e is c a l l e d e p i s t a x i s . I t is f a i r l y

Nasal Septum
c o m m o n a n d is seen i n a l l age g r o u p s - — c h i l d r e n , a d u l t s
and older people. I t o f t e n presents as a n emergency.
Internal Carotid System
E p i s t a x i s is a s i g n a n d n o t a disease p e r se a n d a n a t t e m p t
s h o u l d always be made t o f i n d any local or c o n s t i t u t i o n a l A n t e r i o r e t h m o i d a l artery 1 Branches o f o p h t h a l m i c

cause. Posterior e t h m o i d a l artery J artery

External Carotid System

B L O O D SUPPLY O F NOSE
S p h e n o p a l a t i n e a r t e r y ( b r a n c h o f m a x i l l a r y a r t e r y ) gives
(Figs 33.1 a n d 33.2)
n a s o p a l a t i n e a n d p o s t e r i o r m e d i a l nasal b r a n c h e s .
Septal b r a n c h o f greater palatine artery (Br. o f m a x i l -
N o s e is r i c h l y s u p p l i e d b y b o t h t h e e x t e r n a l a n d i n t e r n a l lary artery).
c a r o t i d systems, b o t h o n t h e s e p t u m a n d t h e l a t e r a l w a l l s . Septal b r a n c h o f superior labial artery (Br. o f facial artery).

Internal carotid artery Internal carotid artery

Ophthalmic artery Ophthalmic artery

Anterior Posterior Anterior Posterior

ethmoidal artery ethmoidal artery ethmoidal artery ethmoidal artery

Branches of
sphenopalatine
Branches of artery
hes of
sphenopalatine
facial artery t ,
Sphenopalatine
Greater artery
Lesser palatine
oalatine
artery
artery
Maxillary artery Facial artery 1 • Maxillary artery
External carotid
artery
External carotid
artery t

Blood supply o f nasal septum. Blood supply o f lateral wall o f nose.

 base of skull, hard-blowing of nose, violent
Lateral W a l l
sneeze.
Infections.
Internal Carotid System
A c u t e : V i r a l r h i n i t i s , nasal d i p h t h e r i a , a c u t e s i n u s i t i s .
Anterior ethmoidal Branches o f Chronic: A l l c r u s t - f o r m i n g diseases, e.g. atrophic
Posterior ethmoidal o p h t h a l m i c artery r h i n i t i s , r h i n i t i s sicca, t u b e r c u l o s i s , s y p h i l i s s e p t a l p e r -
foration, granulomatous lesion of the nose, e.g.
External Carotid System
rhinosporidiosis.
P o s t e r i o r l a t e r a l nasal —» From sphenopalatine Foreign bodies.
branches artery N o n - l i v i n g : A n y neglected foreign b o d y , r h i n o l i t h .
Greater palatine artery —> F r o m maxillary artery L i v i n g : M a g g o t s , leeches.

Nasal b r a n c h o f anterior —» F r o m infraorbital Neoplasms of nose and paranasal sinuses.

superior dental branch o f maxillary Benign: Haemangioma, papilloma.

artery M a l i g n a n t : C a r c i n o m a or sarcoma.

Branches o f facial artery Atmospheric changes. High altitudes, sudden decom-

t o nasal v e s t i b u l e p r e s s i o n ( C a i s s o n ' s disease).

Deviated nasal septum.

Little's A r e a
Nasopharynx

I t is situated i n t h e a n t e r i o r i n f e r i o r p a r t o f nasal s e p t u m , j u s t
Adenoiditis
a b o v e t h e v e s t i b u l e . F o u r arteries-—anterior e t h m o i d a l , septal
Juvenile angiofibroma
b r a n c h o f s u p e r i o r l a b i a l , septal b r a n c h o f s p h e n o p a l a t i n e a n d
Malignant tumours
t h e greater palatine, anastomose h e r e t o f o r m a vascular plexus
c a l l e d "Kiesselbach'splexus". T h i s area is e x p o s e d t o t h e d r y i n g
effect o f i n s p i r a t o r y c u r r e n t a n d t o f i n g e r n a i l t r a u m a , a n d is
B. G e n e r a l Causes
t h e usual site f o r epistaxis i n c h i l d r e n a n d y o u n g adults.

R e t r o c o l u m e l l a r v e i n T h i s v e i n runs vertically d o w n -
Cardiovascular system. Hypertension, arteriosclerosis,
w a r d s j u s t b e h i n d t h e c o l u m e l l a , crosses t h e f l o o r o f n o s e
mitral stenosis, pregnancy (hypertension and
a n d j o i n s v e n o u s p l e x u s o n t h e l a t e r a l nasal w a l l . T h i s is a
hormonal).
c o m m o n site o f v e n o u s b l e e d i n g i n y o u n g p e o p l e .
Disorders of blood and blood vessels. Aplastic anaemia,
l e u k a e m i a , t h r o m b o c y t o p e n i c a n d vascular p u r p u r a ,
Woodruff's Area haemophilia, Christmas disease, s c u r v y , v i t a m i n K
deficiency, hereditary haemorrhagic telangectasia.
T h i s v a s c u l a r area is s i t u a t e d u n d e r t h e p o s t e r i o r e n d of Liver disease. H e p a t i c c i r r h o s i s ( d e f i c i e n c y o f f a c t o r I I ,
i n f e r i o r turbinate w h e r e sphenopalatine artery anastomo- VII, L X & X ) .
ses w i t h p o s t e r i o r p h a r y n g e a l a r t e r y . P o s t e r i o r epistaxis Kidney disease. Chronic nephritis.
m a y o c c u r i n this area. Drugs. E x c e s s i v e use o f salicylates a n d o t h e r analgesics
(as f o r j o i n t p a i n s o r h e a d a c h e s ) , a n t i c o a g u l a n t t h e r a p y
( f o r h e a r t disease).
CAUSES OF EPISTAXIS
Mediastinal compression. Tumours of mediastinum
(raised v e n o u s pressure i n t h e n o s e ) .
T h e y m a y be d i v i d e d i n t o : Acute general infection. I n f l u e n z a , measles, c h i c k e n p o x ,
w h o o p i n g c o u g h , rheumatic fever, infectious m o n o -
L o c a l , i n the nose o r nasopharynx.
nucleosis, typhoid, pneumonia, malaria, dengue
General.
fever.
Idiopathic.
Vicarious menstruation (epistaxis o c c u r r i n g at t h e t i m e
o f menstruation).
A. Local Causes

Nose
C. Idiopathic
Trauma. F i n g e r nail t r a u m a , injuries o f nose, i n t r a -
nasal s u r g e r y , f r a c t u r e s o f m i d d l e t h i r d o f f a c e a n d M a n y t i m e s t h e cause o f epistaxis is n o t c l e a r .
 a n t e r i o r and
SITES O F EPISTAXIS Differences between posterior

epistaxis

Anterior epistaxis Posterior epistaxis

Little's area. I n 9 0 % cases o f epistaxis, b l e e d i n g o c c u r s
Incidence M o r e c o m m o n Less c o m m o n
f r o m t h i s site.
Site Mostly from Little's Mostly from
Above the level of middle turbinate. Bleeding f r o m above
area or anterior part posterosuperior part o f
t h e m i d d l e t u r b i n a t e a n d c o r r e s p o n d i n g area o n the
o f lateral wall nasal cavity; often
s e p t u m is o f t e n from the anterior and posterior eth-
difficult to localise the
m o i d a l vessels ( i n t e r n a l c a r o t i d s y s t e m ) .
bleeding point
Below the level of middle turbinate. H e r e b l e e d i n g is f r o m
Age Mostly occurs in After 40 years o f age
the branches o f sphenopalatine artery. I t m a y be h i d -
children or y o u n g
d e n , l y i n g lateral to m i d d l e o r i n f e r i o r t u r b i n a t e a n d
adults
may require infrastructure of these turbinates for
Cause Mostly t r a u m a Spontaneous; often due
localisation o f the bleeding site a n d placement of
to hypertension or
packing to control it.
arteriosclerosis
Posterior part of nasal cavity. Here b l o o d flows direcdy
Bleeding Usually mild, can be B l e e d i n g is severe,
into the pharynx.
easily c o n t r o l l e d by requires hospitalisation;
Diffuse. B o t h f r o m s e p t u m a n d l a t e r a l nasal w a l l . T h i s
local pressure or postnasal pack often
is o f t e n seen i n g e n e r a l s y s t e m i c d i s o r d e r s a n d b l o o d anterior pack required
dyscrasias.
Nasopharynx.

First Aid
CLASSIFICATION OF EPISTAXIS
M o s t o f t h e t i m e , b l e e d i n g o c c u r s f r o m t h e L i t t l e ' s area a n d
can b e easily c o n t r o l l e d b y p i n c h i n g t h e n o s e w i t h t h u m b

Anterior Epistaxis and i n d e x f i n g e r f o r a b o u t 5 m i n u t e s . T h i s compresses the

vessels o f t h e L i t t l e ' s area. I n T r o t t e r ' s m e t h o d p a t i e n t is

W h e n b l o o d flows out f r o m the front o f nose w i t h the m a d e t o sit, l e a n i n g a l i t t l e f o r w a r d o v e r a b a s i n t o s p i t a n y

patient i n sitting position. b l o o d , and breathe quietly f r o m the m o u t h . C o l d com-

presses s h o u l d b e applied to the nose t o cause reflex
Posterior Epistaxis vasoconstriction.

M a i n l y the b l o o d flows back i n t o the throat. Patient m a y

Cauterisation
s w a l l o w i t a n d later h a v e a " c o f f e e - c o l o u r e d " v o m i t u s . T h i s
m a y e r r o n e o u s l y b e d i a g n o s e d as h a e m a t e m e s i s . T h i s is u s e f u l i n a n t e r i o r epistaxis w h e n b l e e d i n g p o i n t has

T h e d i f f e r e n c e s b e t w e e n t h e t w o t y p e s o f epistaxis are b e e n l o c a t e d . T h e area is f i r s t a n a e s t h e t i s e d a n d t h e b l e e d -

tabulated h e r e w i t h (Table 33.1). i n g p o i n t cauterised w i t h a bead o f silver nitrate o r c o a g u -

lated w i t h electrocautery.

Management Anterior Nasal Packing

I n cases o f a c t i v e a n t e r i o r epistaxis, n o s e is c l e a r e d o f b l o o d
I n a n y case o f epistaxis, i t is i m p o r t a n t t o k n o w :
c l o t s b y s u c t i o n a n d a t t e m p t is m a d e t o l o c a l i s e t h e b l e e d -
M o d e o f onset. Spontaneous o r f i n g e r n a i l t r a u m a . i n g site. I n m i n o r b l e e d s , f r o m t h e accessible sites, c a u t e r i -
Duration and frequency o f bleeding. s a t i o n o f t h e b l e e d i n g area c a n b e d o n e . I f b l e e d i n g is
A m o u n t o f b l o o d loss. p r o f u s e a n d / o r t h e site o f b l e e d i n g is d i f f i c u l t t o localise,
S i d e o f n o s e f r o m w h e r e b l e e d i n g is o c c u r r i n g . a n t e r i o r p a c k i n g s h o u l d b e d o n e . F o r t h i s , use a ribbon
W h e t h e r b l e e d i n g is o f a n t e r i o r o r p o s t e r i o r t y p e . gauze soaked w i t h l i q u i d paraffin. A b o u t 1 m e t r e gauze
A n y k n o w n bleeding tendency i n the patient or family. (2.5 c m w i d e i n a d u l t s a n d 12 m m i n c h i l d r e n ) is r e q u i r e d
History o f k n o w n medical ailment (hypertension, f o r e a c h nasal c a v i t y . F i r s t , f e w c e n t i m e t r e s o f g a u z e are
l e u k a e m i a s , m i t r a l v a l v e disease, c i r r h o s i s , n e p h r i t i s ) . f o l d e d u p o n itself a n d inserted a l o n g the f l o o r , a n d t h e n
History of drug intake (analgesics, anticoagulants, t h e w h o l e nasal c a v i t y is p a c k e d t i g h t l y b y l a y e r i n g t h e
etc.). g a u z e f r o m f l o o r t o t h e r o o f a n d from b e f o r e backwards.
P a c k i n g c a n also b e d o n e i n v e r t i c a l layers f r o m b a c k t o t h e
f r o n t ( F i g . 3 3 . 3 ) . O n e o r b o t h cavities m a y n e e d to be
p a c k e d . P a c k can b e r e m o v e d a f t e r 2 4 h o u r s i f b l e e d i n g
has s t o p p e d . S o m e t i m e s , i t has t o b e k e p t f o r 2 t o 3 days;
i n t h a t case, s y s t e m i c a n t i b i o t i c s s h o u l d b e g i v e n t o p r e -
v e n t sinus i n f e c t i o n a n d t o x i c s h o c k s y n d r o m e .
Posterior Nasal Packing
I t is r e q u i r e d f o r p a t i e n t s b l e e d i n g p o s t e r i o r l y i n t o the
t h r o a t . A p o s t n a s a l p a c k is f i r s t p r e p a r e d b y t y i n g t h r e e
s i l k ties t o a p i e c e o f g a u z e r o l l e d i n t o t h e s h a p e o f a c o n e .
A r u b b e r c a t h e t e r is passed t h r o u g h t h e n o s e a n d its e n d
b r o u g h t o u t f r o m the m o u t h (Fig. 33.4). Ends o f the silk
t h r e a d s are t i e d t o i t a n d c a t h e t e r w i t h d r a w n f r o m n o s e .
M e t h o d s o f anterior nasal p a c k i n g . ( A ) P a c k i n g in vertical layers. ( B )
Technique o f postnasal pack.
P a c k , w h i c h f o l l o w s t h e s i l k t h r e a d , is n o w g u i d e d i n t o
the nasopharynx w i t h the index finger. A n t e r i o r nasal
c a v i t y is n o w p a c k e d a n d s i l k t h r e a d s t i e d o v e r a d e n t a l
r o l l . T h e t h i r d s i l k t h r e a d is c u t s h o r t a n d a l l o w e d t o h a n g
i n t h e o r o p h a r y n x . I t h e l p s i n easy r e m o v a l o f t h e p a c k
later. Patients r e q u i r i n g postnasal pack s h o u l d always be
hospitalised. Instead o f postnasal pack, a Foley's catheter
size 1 2 - 1 4 F c a n also b e u s e d . A f t e r i n s e r t i o n b a l l o o n is
i n f l a t e d w i t h 5 - 1 0 m l o f s a l i n e . T h e b u l b is i n f l a t e d w i t h
s a l i n e a n d p u l l e d f o r w a r d so t h a t c h o a n a is b l o c k e d a n d
t h e n a n a n t e r i o r nasal p a c k is k e p t i n t h e u s u a l m a n n e r .
T h e s e days nasal b a l l o o n s are also a v a i l a b l e ( F i g . 3 3 . 5 ) .
A nasal b a l l o o n has t w o b u l b s , o n e f o r t h e p o s t n a s a l space
a n d t h e o t h e r f o r nasal c a v i t y .
Packing in horizontal layers.
 a v o i d e d these days i n f a v o u r o f e m b o l i s a t i o n o r l i g a -
t i o n o f m o r e peripheral branches.
Maxillary artery. L i g a t i o n o f t h i s a r t e r y is d o n e in
uncontrollable posterior epistaxis. A p p r o a c h is v i a
C a l d w e l l - L u c operation. Posterior w a l l o f maxillary
sinus is removed and the m a x i l l a r y artery or its
b r a n c h e s are b l o c k e d b y a p p l y i n g c l i p s .
E n d o s c o p i c l i g a t i o n o f t h e m a x i l l a r y a r t e r y c a n also
be d o n e t h r o u g h n o s e .
Ethmoidal arteries. I n anterosuperior bleeding above
the middle turbinate, not controlled by packing,
a n t e r i o r a n d p o s t e r i o r e t h m o i d a l arteries w h i c h s u p -
p l y t h i s area, c a n b e l i g a t e d . T h e vessels are exposed
in the medial wall o f the orbit by an external eth-
m o i d incision.

Epistaxis balloon for posterior epistaxis. Posterior balloon

(A) is inflated with 10 ml and anterior balloon (B) w i t h

G e n e r a l M e a s u r e s in E p i s t a x i s
30 ml. Catheter provides nasal airway.

M a k e t h e p a t i e n t sit u p w i t h a b a c k rest a n d r e c o r d a n y
b l o o d loss t a k i n g p l a c e t h r o u g h s p i t t i n g o r v o m i t i n g .
Endoscopic Cautery
Reassure the patient. M i l d sedation s h o u l d be g i v e n .

P o s t e r i o r b l e e d i n g p o i n t can s o m e t i m e s b e b e t t e r located K e e p c h e c k o n pulse, B P a n d respiration.

w i t h an endoscope. I t can be coagulated w i t h suction c a u - M a i n t a i n h a e m o d y n a m i c s . B l o o d t r a n s f u s i o n m a y be

t e r y . L o c a l anaesthesia w i t h s e d a t i o n m a y b e r e q u i r e d . required.
A n t i b i o t i c s m a y b e g i v e n t o p r e v e n t s i n u s i t i s , i f p a c k is
Elevation of Mucoperichondrial Flap and SMR Operation t o be k e p t b e y o n d 24 hours.
I n t e r m i t t e n t o x y g e n m a y be r e q u i r e d i n patients w i t h
I n case o f p e r s i s t e n t o r r e c u r r e n t b l e e d s f r o m t h e s e p t u m ,
b i l a t e r a l p a c k s b e c a u s e o f i n c r e a s e d p u l m o n a r y resis-
j u s t e l e v a t i o n o f m u c o p e r i c h o n d r i a l flap a n d t h e n r e p o s i -
tance f r o m n a s o p u h n o n a r y reflex.
t i o n i n g i t b a c k h e l p s t o cause f i b r o s i s a n d c o n s t r i c t b l o o d
Investigate a n d treat the patient f o r any u n d e r l y i n g
vessels. S M R o p e r a t i o n c a n b e d o n e t o a c h i e v e t h e same
l o c a l o r g e n e r a l cause.
r e s u l t o r r e m o v e a n y septal s p u r w h i c h is s o m e t i m e s the
cause o f e p i s t a x i s . Hereditary h a e m o r r h a g i c telangectasia I t occurs o n
t h e a n t e r i o r p a r t o f nasal s e p t u m a n d is t h e cause o f r e c u r -
Ligation of Vessels r e n t b l e e d i n g . I t can be treated b y using A r g o n , K T P or
N d : Y A G laser. T h e p r o c e d u r e m a y r e q u i r e t o b e r e p e a t e d
External carotid. W h e n b l e e d i n g is f r o m t h e external several t i m e s i n a y e a r as t e l a n g e c t a s i a r e c u r s i n t h e s u r -
c a r o t i d system and the conservative measures have r o u n d i n g mucosa. S o m e cases r e q u i r e scptodermoplasty
failed, ligation o f external carotid artery above the w h e r e a n t e r i o r p a r t o f septal m u c o s a is e x c i s e d a n d r e p l a c e d
o r i g i n o f s u p e r i o r t h y r o i d a r t e r y s h o u l d b e d o n e . I t is b y a split s k i n graft.
T r a u m a t o t h e Face

I n j u r i e s o f face m a y i n v o l v e soft tissues, b o n e s o r b o t h . identified and sutured over a polyethylene tube, w i t h fine
The m a j o r i t y o f f a c i a l i n j u r i e s are c a u s e d b y automobile s u t u r e . T h e t u b e is l e f t f o r 3 days t o 2 w e e k s .
accidents. Others r e s u l t f r o m sports, p e r s o n a l accidents,
assaults a n d f i g h t s . T h e m a n a g e m e n t o f facial t r a u m a can
Facial Nerve
be d i v i d e d i n t o :

General management. I f s e v e r e d , t h e f a c i a l n e r v e is e x p o s e d b y s u p e r f i c i a l p a r o t i -
S o f t tissue i n j u r i e s a n d t h e i r m a n a g e m e n t . d e c t o m y a n d c u t ends are a p p r o x i m a t e d w i t h 8—0 o r 10—0
B o n e injuries and their management. silk u n d e r m a g n i f i c a t i o n .

GENERAL MANAGEMENT
B O N E INJURIES AND THEIR MANAGEMENT

Airway Maintenance o f airway should receive the

T h e face c a n b e d i v i d e d i n t o t h r e e regions:
h i g h e s t p r i o r i t y . A i r w a y is o b s t r u c t e d b y loss o f s k e l -
etal s u p p o r t , a s p i r a t i o n o f f o r e i g n b o d i e s , blood or U p p e r third: A b o v e the level o f supraorbital ridge.
gastric contents or swelling of tissues. Airway is M i d d l e t h i r d : B e t w e e n the supraorbital ridge and the
secured b y i n t u b a t i o n or the tracheostomy. upper teeth.
Haemorrhage I n j u r i e s o f face m a y b l e e d p r o f u s e l y . L o w e r t h i r d : M a n d i b l e and the l o w e r teeth.
B l e e d i n g s h o u l d b e s t o p p e d b y pressure o r l i g a t i o n o f
T h e various fractures e n c o u n t e r e d i n these r e g i o n s are
vessels.
listed i n T a b l e 3 4 . 1 .
Associated injuries Facial i n j u r i e s m a y be associated
w i t h i n j u r i e s o f h e a d , chest, a b d o m e n , neck, larynx,
cervical spine o r limbs and s h o u l d be attended t o .
A. FRACTURES OF UPPER THIRD OF FACE

S O F T T I S S U E INJURIES AND THEIR

1. Frontal Sinus
MANAGEMENT

F r o n t a l sinus f r a c t u r e s m a y i n v o l v e a n t e r i o r w a l l , p o s t e r i o r
Facial Lacerations wall or the nasofrontal duct.

Anterior wall fractures m a y b e d e p r e s s e d o r c o m m i n u t e d .

W o u n d is t h o r o u g h l y c l e a n e d o f a n y d i r t , grease o r f o r e i g n
D e f e c t is m a i n l y c o s m e t i c . S i n u s is a p p r o a c h e d t h r o u g h
m a t t e r . T h e l a c e r a t i o n s are c l o s e d b y a c c u r a t e a p p r o x i m a -
a w o u n d i n t h e s k i n i f t h a t is p r e s e n t , o r t h r o u g h a
t i o n o f each layer.
b r o w i n c i s i o n . T h e b o n e f r a g m e n t s are e l e v a t e d , t a k i n g
care n o t t o s t r i p t h e m f r o m t h e p e r i o s t e u m . T h e i n t e -
Parotid Gland and Duct rior o f t h e sinus is a l w a y s i n s p e c t e d t o r u l e o u t f r a c -
ture o f the posterior wall.
P a r o t i d tissue, i f e x p o s e d , is r e p a i r e d b y s u t u r i n g . I n j u r i e s Posterior wall fractures m a y b e a c c o m p a n i e d by dural
o f p a r o t i d d u c t are m o r e s e r i o u s . B o t h ends o f t h e d u c t are tears, b r a i n i n j u r y a n d C S F rhinorrhoea. They may
 T r a u m a t o t h e Face

Fractures o f t h e face

Upper third Middle third Lower third

F r o n t a l sinuses Nasal b o n e s a n d s e p t u m A l v e o l a r process

S u p r a o r b i t a l ridge N a s o - o r b i t a ! area Symphysis

Frontal bone Zygoma Body

Zygomatic arch Angle
Orbital floor Ascending ramus
Maxilla Condyle
- Le F o r t I (transverse) Temporomandibular joint
- Le F o r t II ( p y r a m i d a l )
- Le F o r t Hi ( c r a n i o f a c i a l d y s j u n c t i o n )

r e q u i r e n e u r o s u r g i c a l c o n s u l t a t i o n . D u r a l tears c a n b e Types of Nasal Fractures (Fig. 34.1)

c o v e r e d b y t e m p o r a l i s fascia. S m a l l sinuses c a n be
Depressed T h e y are d u e t o frontal b l o w . L o w e r part o f
o b l i t e r a t e d w i t h fat.
nasal b o n e s w h i c h is t h i n n e r , easily g i v e s w a y . A severe
Injury to nasofrontal duct cause o b s t r u c t i o n t o sinus
frontal b l o w w i l l cause " o p e n - b o o k f r a c t u r e " i n w h i c h
d r a i n a g e a n d m a y l a t e r be c o m p l i c a t e d b y a m u c o c e l e .
nasal s e p t u m is c o l l a p s e d a n d nasal b o n e s s p l a y e d o u t . S t i l l ,
I n s u c h cases, m a k e a l a r g e c o m m u n i c a t i o n b e t w e e n
g r e a t e r f o r c e s w i l l cause c o m m i n u t i o n o f nasal b o n e s a n d
t h e sinus a n d t h e n o s e . S m a l l sinuses c a n b e o b l i t e r -
ated with fat after removing the sinus mucosa
completely.

2. Supraorbital Ridge

R i d g e f r a c t u r e s o f t e n cause p e r i o r b i t a l e c c h y m o s i s , flat-
t e n i n g o f the e y e b r o w , proptosis o r d o w n w a r d displace-
m e n t o f e y e . F r a g m e n t o f b o n e m a y also b e p u s h e d i n t o
t h e o r b i t a n d get i m p a c t e d . R i d g e fractures r e q u i r e o p e n
r e d u c t i o n t h r o u g h an i n c i s i o n i n the b r o w o r transverse
skin line o f the forehead.

3. Fractures of Frontal Bone

T h e y m a y be depressed o r linear, w i t h o r w i t h o u t separa-

t i o n . T h e y o f t e n extend i n t o the orbit. B r a i n i n j u r y and
c e r e b r a l o e d e m a are c o m m o n l y associated w i t h e a c h o t h e r
and require neurosurgical consultation.

B. FRACTURES OF MIDDLE THIRD

OF FACE

1. Nasal Bones and Septum

F r a c t u r e s o f nasal b o n e s are t h e m o s t c o m m o n b e c a u s e o f Types o f f r a c t u r e s . ( A ) N o r m a l , ( B ) Frontal blow causing

the p r o j e c t i o n o f nose o n t h e face. T r a u m a t i c forces m a y depressed fracture or open-book fracture and (C) Lateral
b l o w c a u s i n g d e v i a t i o n o f nasal b r i d g e o r d e p r e s s i o n o f one
a c t f r o m t h e f r o n t o r side. M a g n i t u d e o f f o r c e w i l l d e t e r -
nasal b o n e .
m i n e the d e p t h o f injury.
e v e n t h e f r o n t a l processes o f m a x i l l a e w i t h flattening and
w i d e n i n g o f nasal d o r s u m .

Angulated A l a t e r a l b l o w m a y cause u n i l a t e r a l d e p r e s s i o n
o f nasal b o n e o n t h e same side o r m a y f r a c t u r e b o t h t h e
nasal b o n e s a n d t h e s e p t u m w i t h d e v i a t i o n o f nasal b r i d g e .

N a s a l f r a c t u r e s are o f t e n a c c o m p a n i e d by injuries of
nasal s e p t u m w h i c h m a y b e s i m p l y b u c k l e d , d i s l o c a t e d o r
f r a c t u r e d i n t o several p i e c e s . S e p t a l h a e m a t o m a m a y f o r m .

Clinical Features

S w e l l i n g o f nose. Appears w i t h i n f e w h o u r s a n d m a y
o b s c u r e details o f e x a m i n a t i o n .
Periorbital ecchymosis.
Tenderness.
Nasal d e f o r m i t y . Nose m a y be depressed f r o m the
f r o n t o r s i d e , o r t h e w h o l e o f t h e nasal p y r a m i d d e v i -
ated t o o n e side.
Crepitus and m o b i l i t y o f fractured fragments.
Epistaxis.
N a s a l o b s t r u c t i o n d u e t o septal i n j u r y o r h a e m a t o m a .
L a c e r a t i o n s o f t h e nasal s k i n w i t h e x p o s u r e o f nasal b o n e s
a n d c a r t i l a g e m a y be seen i n c o m p o u n d f r a c t u r e s .

Diagnosis Fractured n a s a l b o n e ( a r r o w ) as seen in radiograph.

D i a g n o s i s is best m a d e o n p h y s i c a l e x a m i n a t i o n . X - r a y s
m a y or m a y n o t s h o w fracture (Fig. 34.2). Patient should S i m p l e fractures m a y n o t r e q u i r e intranasal p a c k i n g .
n o t b e d i s m i s s e d as h a v i n g n o f r a c t u r e b e c a u s e X - r a y s d i d Unstable fractures r e q u i r e intranasal p a c k i n g a n d external
n o t reveal it. splintage.

X - r a y s s h o u l d i n c l u d e W a t e r s ' v i e w , r i g h t a n d left lateral O p e n reduction E a r l y o p e n r e d u c t i o n i n nasal f r a c t u r e s

views and occlusal v i e w . is r a r e l y r e q u i r e d . T h i s is i n d i c a t e d w h e n c l o s e d m e t h o d s
f a i l . C e r t a i n septal i n j u r i e s c a n b e b e t t e r r e d u c e d b y o p e n
Treatment methods.

S i m p l e fractures w i t h o u t displacement need n o t r e a t m e n t ; H e a l e d nasal d e f o r m i t i e s r e s u l t i n g f r o m nasal t r a u m a c a n

others m a y r e q u i r e closed o r o p e n r e d u c t i o n . Presence o f be corrected by rhinoplasty o r septorhinoplasty.

oedema interferes w i t h accurate r e d u c t i o n b y closed m e t h -

o d s . T h e r e f o r e , t h e best t i m e t o r e d u c e a f r a c t u r e is b e f o r e
2 . Naso-orbital Fractures
t h e a p p e a r a n c e o f o e d e m a , o r a f t e r i t has s u b s i d e d , w h i c h
is u s u a l l y i n 5—7 days. I t is d i f f i c u l t t o r e d u c e a nasal f r a c -
D i r e c t f o r c e o v e r t h e n a s i o n f r a c t u r e s nasal b o n e s a n d d i s -
t u r e a f t e r 2 w e e k s because i t heals b y t h a t t i m e . H e a l i n g is
places t h e m p o s t e r i o r l y . P e r p e n d i c u l a r p l a t e o f e t h m o i d ,
faster in children and therefore earlier reduction is
e t h m o i d a l a i r cells a n d m e d i a l o r b i t a l w a l l are f r a c t u r e d
imperative.
and driven posteriorly. Injury may involve cribriform
Closed reduction Depressed fractures o f nasal bones p l a t e , f r o n t a l sinus, f r o n t o n a s a l d u c t , e x t r a o c u l a r m u s c l e s ,
sustained b y either f r o n t a l o r lateral b l o w , can be r e d u c e d eyeball a n d the lacrimal apparatus. M e d i a l canthal l i g a m e n t
b y a straight b l u n t elevator g u i d e d b y digital m a n i p u l a t i o n m a y be avulsed.
f r o m outside.
L a t e r a l l y , d i s p l a c e d nasal b r i d g e can be r e d u c e d b y f i r m Clinical Features
d i g i t a l pressure i n t h e o p p o s i t e d i r e c t i o n . I m p a c t e d f r a g -
ments sometimes require disimpaction w i t h Walsham or Telecanthus, due to lateral displacement o f m e d i a l
A s c h e ' s f o r c e p s b e f o r e r e a l i g n m e n t . S e p t a l f r a c t u r e s are also orbital wall.
r e d u c e d b y Asche's forceps. Septal h a e m a t o m a , i f present, P u g nose. B r i d g e o f nose is depressed a n d t i p t u r n e d u p .
must be drained. Periorbital ecchymosis.
 Orbital haematoma due to bleeding f r o m anterior and Zygomatico-frontal fracture Zygomaticotemporal fracture
p o s t e r i o r e t h m o i d a l arteries.
CSF leakage d u e t o fracture o f c r i b r i f o r m plate a n d
dura.

D i s p l a c e m e n t o f eyeball.

Diagnosis

V a r i o u s f a c i a l f i l m s w i l l be r e q u i r e d t o assess t h e e x t e n t of
fracture a n d i n j u r y t o o t h e r facial bones. C T scans are
m o r e useful.

Treatment

Closed reduction In uncomplicated cases, fracture is

r e d u c e d w i t h A s c h e ' s f o r c e p s a n d stabilised b y a w i r e passed
t h r o u g h fractured b o n y fragments and septum and t h e n tied
o v e r t h e l e a d plates. I n t r a n a s a l p a c k i n g is g i v e n . S p l i n t i n g is
k e p t f o r 10 days o r so. Infraorbital fractur
O p e n reduction T h i s is r e q u i r e d i n cases w i t h extensive
c o m m i n u t i o n o f nasal a n d o r b i t a l b o n e s , a n d t h o s e c o m -
p l i c a t e d b y o t h e r i n j u r i e s t o l a c r i m a l apparatus, medial
Fracture zygoma left.
c a n t h a l l i g a m e n t s , f r o n t a l s i n u s , etc.
A n H - t y p e i n c i s i o n gives adequate e x p o s u r e o f the f r a c -
O b l i q u e p a l p e b r a l fissure, d u e t o t h e d i s p l a c e m e n t of
t u r e d area. T h i s c a n b e e x t e n d e d t o t h e e y e b r o w s i f access
lateral palpebral l i g a m e n t .
to f r o n t a l sinuses is also r e q u i r e d .
Restricted ocular movements, due to entrapment of
N a s a l b o n e s are r e d u c e d u n d e r v i s i o n a n d b r i d g e h e i g h t
i n f e r i o r r e c t u s m u s c l e . I t m a y cause d i p l o p i a .
is a c h i e v e d . M e d i a l o r b i t a l w a l l s c a n b e r e d u c e d . M e d i a l c a n -
P e r i o r b i t a l e m p h y s e m a , d u e t o escape o f a i r f r o m t h e
t h a i l i g a m e n t s , i f a v u l s e d , are r e s t o r e d w i t h a t h r o u g h a n d
m a x i l l a r y sinus o n n o s e - b l o w i n g .
t h r o u g h w i r e . I n t r a n a s a l p a c k i n g m a y b e r e q u i r e d t o restore
t h e c o n t o u r . W h e n b o n e c o m m i n u t i o n is severe, r e s t o r a t i o n Diagnosis

o f m e d i a l c a n t h a l l i g a m e n t s a n d l a c r i m a l apparatus s h o u l d
W a t e r s ' o r exaggerated Waters' v i e w shows the fracture
r e c e i v e p r e f e r e n c e o v e r r e c o n s t r u c t i o n o f nasal c o n t o u r .
and displacement the best. M a x i l l a r y sinus may show
c l o u d i n g d u e to the presence o f b l o o d . C o m m i n u t i o n
w i t h d e p r e s s i o n o f o r b i t a l floor a n d h e r n i a t i o n o f o r b i t a l
3. Fractures of Zygoma (Tripod Fracture)
c o n t e n t s c a n n o t b e seen o n p l a i n X - r a y s . C T scan o f t h e
o r b i t a l w i l l be m o r e useful.
A f t e r nasal b o n e s , z y g o m a is t h e s e c o n d m o s t f r e q u e n t l y
f r a c t u r e d b o n e . U s u a l l y , t h e cause is d i r e c t t r a u m a . L o w e r Treatment
segment o f zygoma is p u s h e d m e d i a l l y a n d p o s t e r i o r l y
O n l y displaced fractures require treatment. O p e n reduc-
resulting i n f l a t t e n i n g o f the malar p r o m i n e n c e a n d a step-
t i o n a n d i n t e r n a l w i r e f i x a t i o n g i v e s best r e s u l t s . F r a c t u r e is
d e f o r m i t y at t h e i n f r a o r b i t a l m a r g i n . Z y g o m a is separated at
exposed at the frontozygomatic suture t h r o u g h lateral
its t h r e e processes ( F i g . 3 4 . 3 ) . F r a c t u r e l i n e passes t h r o u g h
b r o w i n c i s i o n a n d r e d u c e d b y passing a n e l e v a t o r b e h i n d
z y g o m a t i c o f r o n t a l suture, orbital f l o o r , infraorbital m a r g i n
the z y g o m a . Wire f i x a t i o n is d o n e at frontozygomatic
a n d f o r a m e n , a n t e r i o r w a l l o f m a x i l l a r y sinus a n d t h e z y g o -
s u t u r e a n d i n f r a o r b i t a l m a r g i n . T h e l a t t e r is e x p o s e d b y a
m a t i c o t e m p o r a l suture. O r b i t a l contents m a y herniate i n t o
separate i n c i s i o n i n t h e l o w e r l i d . F r a c t u r e o f o r b i t a l floor
t h e m a x i l l a r y sinus.
c a n also be r e p a i r e d t h r o u g h t h i s i n c i s i o n .
Transantral approach is less favourable. Antrum is
Clinical Features
e x p o s e d as i n C a l d w e l l - L u c o p e r a t i o n , b l o o d is a s p i r a t e d ,
Flattening o f malar p r o m i n e n c e . f r a c t u r e r e d u c e d a n d t h e n stabilised b y a p a c k i n t h e a n t r u m .
Step-deformity o f infraorbital margin. F r a c t u r e s o f o r b i t a l f l o o r c a n also be r e d u c e d . A n t r a l p a c k is
Anaesthesia i n the d i s t r i b u t i o n o f infraorbital n e r v e . removed in about 10 days t h r o u g h t h e b u c c a l i n c i s i o n ,
T r i s m u s , d u e to depression o f z y g o m a o n the u n d e r - w h i c h is l e f t o p e n at t h e e n d o f o p e r a t i o n , o r t h r o u g h t h e
l y i n g c o r o n o i d process. intranasal a n t r o s t o m y r o u t e .
Diseases of Nose and

Hypoaesthesia o r anaesthesia o f c h e e k a n d u p p e r l i p ,
4. Fractures of Zygomatic Arch
i f i n f r a o r b i t a l n e r v e is i n v o l v e d .

Z y g o m a t i c arch generally breaks i n t o t w o fragments w h i c h

Diagnosis
g e t d e p r e s s e d . T h e r e are t h r e e f r a c t u r e l i n e s , o n e at e a c h
e n d and t h i r d i n the centre o f the arch. Waters' v i e w shows a convex opacity b u l g i n g i n t o the
antrum from above (tear-drop opacity). C T scans may
Clinical Features
c o n f i r m the diagnosis (Fig. 3 4 . 5 ) . E n t r a p m e n t o f i n f e r i o r
Characteristic features are depression in the area of r e c t u s a n d i n f e r i o r o b l i q u e m u s c l e s is d i a g n o s e d b y a s k i n g
zygomatic arch, local pain aggravated b y t a l k i n g and c h e w - t h e p a t i e n t t o l o o k u p a n d d o w n , o r b y t h e t r a c t i o n test.
ing, trismus or l i m i t a t i o n o f the m o v e m e n t s o f mandible T h e l a t t e r is p e r f o r m e d b y g r a s p i n g t h e g l o b e a n d p a s s i v e l y
due to i m p i n g e m e n t o f fragments o n the condyle or c o r o - r o t a t i n g i t t o c h e c k f o r r e s t r i c t i o n o f its m o v e m e n t s .
n o i d process.
Treatment
Diagnosis
I n d i c a t i o n s f o r surgery i n c l u d e e n o p h t h a l m o s a n d persis-
A r c h f r a c t u r e s are best seen o n s u b m e n t o v e r t i c a l v i e w o f
tent d i p l o p i a due to entrapment o f muscle. O r b i t a l f l o o r
the skull. Waters 1
v i e w is also t a k e n .
fractures c a n b e s a t i s f a c t o r i l y r e d u c e d b y a f i n g e r passed
Treatment i n t o the a n t r u m t h r o u g h a transantral a p p r o a c h . A pack can
be k e p t i n the a n t r u m to support the fragments. Infra-
A v e r t i c a l i n c i s i o n is m a d e i n t h e h a i r - b e a r i n g area a b o v e o r
o r b i t a l a p p r o a c h , t h r o u g h a s k i n crease o f t h e l o w e r l i d , c a n
i n front o f t h e ear, c u t t i n g t h r o u g h t e m p o r a l fascia. A n e l e -
also b e u s e d e i t h e r a l o n e o r i n c o m b i n a t i o n w i t h t r a n s a n t -
v a t o r is passed d e e p t o t e m p o r a l fascia a n d c a r r i e d u n d e r t h e
ral a p p r o a c h . B a d l y c o m m i n u t e d f r a c t u r e s o f o r b i t a l floor
d e p r e s s e d b o n y f r a g m e n t s w h i c h are t h e n r e d u c e d . F i x a t i o n
c a n b e r e p a i r e d b y a b o n e g r a f t f r o m t h e i l i a c crest, nasal
is u s u a l l y n o t r e q u i r e d as t h e f r a g m e n t s r e m a i n stable.
septum or the anterior w a l l o f the a n t r u m . Silicon or teflon
sheets h a v e also b e e n u s e d t o r e c o n s t r u c t t h e o r b i t a l floor
5. Fractures of Orbital Floor b u t a u t o g e n o u s grafts are p r e f e r a b l e .

Z y g o m a t i c a n d L e F o r t I I m a x i l l a r y f r a c t u r e s are a l w a y s
a c c o m p a n i e d b y fractures o f o r b i t a l f l o o r . Isolated fractures 6. Fractures of Maxilla (Fig. 34.6)

o f o r b i t a l floor, w h e n a l a r g e b l u n t o b j e c t strikes t h e g l o b e s ,
are c a l l e d "blow out fractures" O r b i t a l contents m a y herniate T h e y are c l a s s i f i e d i n t o 3 t y p e s .

i n t o the a n t r u m (Fig. 34.4). Le Fort I (transverse) fracture runs above a n d parallel t o

Clinical Features t h e p a l a t e . I t crosses l o w e r p a r t o f nasal s e p t u m , m a x i l -

l a r y a n t r a a n d t h e p t e r y g o i d plates.
E c c h y m o s i s o f l i d , c o n j u n c t i v a a n d sclera.
E n o p h t h a l m o s w i t h i n f e r i o r displacement o f the eye-
b a l l . T h i s b e c o m e s a p p a r e n t w h e n o e d e m a subsides.
D i p l o p i a , w h i c h m a y be due to displacement o f the
eyeball o r e n t r a p m e n t o f i n f e r i o r rectus a n d i n f e r i o r
o b l i q u e muscles,

Figure 34.4

Blow out fracture with herniation o f orbital contents into the

maxillary sinus. C T scan showing b l o w out fracture o f right orbital floor.

 T r a u m a to t h e F a c e

Le Fort II (pyramidal) f r a c t u r e passes t h r o u g h t h e r o o t Diagnosis

o f nose, l a c r i m a l b o n e , floor o f orbit, upper part o f
X-rays, helpful i n diagnosis o f m a x i l l a r y fractures are
m a x i l l a r y sinus a n d p t e r y g o i d plates. T h i s f r a c t u r e has
W a t e r s ' v i e w , p o s t e r o a n t e r i o r v i e w , lateral v i e w a n d the
s o m e features c o m m o n w i t h t h e z y g o m a t i c f r a c t u r e s .
CT scans. T h e y h e l p t o d e l i n e a t e f r a c t u r e l i n e s a n d t h e
Le Fort III (craniofacial dysjunction). T h e r e is c o m p l e t e
displacement o f fragments.
separation o f facial bones f r o m the cranial bones. The
f r a c t u r e l i n e passes t h r o u g h r o o t o f n o s e , e t h m o f r o n -
Treatment
tal j u n c t i o n , s u p e r i o r o r b i t a l fissure, l a t e r a l w a l l of
o r b i t , f r o n t o z y g o m a t i c a n d t e m p o r o z y g o m a t i c sutures T r e a t m e n t o f m a x i l l a r y f r a c t u r e s is c o m p l e x . I m m e d i a t e

a n d t h e u p p e r p a r t o f p t e r y g o i d plates. a t t e n t i o n is p a i d t o r e s t o r e t h e a i r w a y a n d s t o p severe h a e -
m o r r h a g e f r o m m a x i l l a r y a r t e r y o r its b r a n c h e s . F o r g o o d

Clinical Features c o s m e t i c a n d f u n c t i o n a l results, fractures s h o u l d be t r e a t e d as

early as t h e p a t i e n t ' s c o n d i t i o n p e m i i t s . A s s o c i a t e d i n t r a c r a -
Malocclusion o f teeth w i t h anterior open bite.
n i a l a n d c e r v i c a l s p i n e i n j u r i e s m a y delay specific t r e a t m e n t .
Elongation o f midface.
F i x a t i o n o f m a x i l l a r y f r a c t u r e s c a n be a c h i e v e d b y :
M o b i l i t y i n the maxilla.
CSF rhinorrhoea. Cribriform plate is injured in Interdental w i r i n g .

L e F o r t I I a n d L e Fort I I I fractures. I n t e r m a x i l l a r y w i r i n g u s i n g a r c h bars.

O p e n r e d u c t i o n a n d i n t e r o s s e o u s w i r i n g as i n z y g o -
m a t i c fractures.
W i r e slings f r o m f r o n t a l b o n e , z y g o m a o r i n f r a o r b i t a l
r i m t o t h e t e e t h o r a r c h bars.

C. FRACTURES OF LOWER THIRD

Fractures of Mandible

Fractures o f m a n d i b l e have been classified a c c o r d i n g t o

t h e i r l o c a t i o n ( F i g . 3 4 . 7 ) . C o n d y l a r f r a c t u r e s are t h e m o s t
c o m m o n . T h e y are f o l l o w e d , i n f r e q u e n c y , b y f r a c t u r e s
o f the angle, b o d y a n d symphysis ( m n e m o n i c CABS).
F r a c t u r e s o f t h e r a m u s , c o r o n o i d a n d a l v e o l a r processes are
Figure 34.6 uncommon.
M u l t i p l e f r a c t u r e s are seen as f r e q u e n d y as s i n g l e o n e s .
Fractures o f maxilla: (A) L e F o r t I, ( B ) L e F o r t II, ( C ) Le F o r t III.
M o s t o f t h e m a n d i b u l a r f r a c t u r e s are t h e r e s u l t o f d i r e c t
t r a u m a ; h o w e v e r , c o n d y l a r f r a c t u r e s are caused b y i n d i r e c t

Coronoid
Condylar process
process \ 35% /
Alveolar process

Rar

Angle
Symphysis

Body

Fig. 34.7

F r a c t u r e s o f m a n d i b l e ( D i n g m a n ' s c l a s s i f i c a t i o n ) . C o n d y l a r f r a c t u r e s are the most c o m m o n , followed by those o f the angle, b o d y and

symphysis o f mandible. R e m e m b e r CABS.

t r a u m a t o t h e c h i n o r o p p o s i t e side o f t h e b o d y o f m a n - Aetiology

d i b l e . D i s p l a c e m e n t o f m a n d i b u l a r f r a c t u r e s is d e t e r m i n e d
D e n t a l e x t r a c t i o n , T h i s is t h e m o s t i m p o r t a n t cause.
by (i) the pull o f muscles attached to the fragments,
R o o t s o f s e c o n d p r e m o l a r a n d u p p e r molars (first a n d
(ii) d i r e c t i o n o f f r a c t u r e l i n e a n d ( i i i ) b e v e l o f t h e f r a c t u r e .
sometimes 2nd and 3rd) are closely related to the
antral c a v i t y a n d t h e i r e x t r a c t i o n m a y lead to fistula
Clinical Features
f o r m a t i o n . P r e s e n c e o f a p i c a l t o o t h abscess p r e d i s -
In fractures of condyle, i f f r a g m e n t s are n o t d i s p l a c e d , pain poses t o i t .
a n d t r i s m u s are t h e m a i n features a n d t e n d e r n e s s is e l i c i t e d Failure o f sublabial i n c i s i o n t o h e a l after C a l d w e l l -
at t h e site o f f r a c t u r e . I f f r a g m e n t s are d i s p l a c e d , t h e r e is i n Luc operation.
a d d i t i o n , malocclusion o f teeth and d e v i a t i o n o f j a w t o the Erosion o f a n t r u m by carcinoma.
o p p o s i t e side o n o p e n i n g t h e m o u t h . Fractures o r p e n e t r a t i n g injuries o f maxilla.
M o s t o f t h e fractures of angle, body and symphysis, can be Osteitis o f m a x i l l a , syphilis or m a l i g n a n t g r a n u l o m a .
diagnosed by intraoral and extraoral palpation. Step-
d e f o r m i t y , malocclusion o f teeth, ecchymosis o f oral mucosa, Clinical Features
t e n d e r n e s s at t h e site o f f r a c t u r e a n d c r e p i t u s m a y b e seen.
Regurgitation of food. F o o d o r f l u i d s pass f r o m o r a l c a v -
i t y i n t o t h e a n t r u m a n d t h e n c e i n t o the nose.
Diagnosis
Discharge. Antrum is a l w a y s i n f e c t e d . Foul-smelling
X - r a y s u s e f u l i n m a n d i b u l a r f r a c t u r e s are P A v i e w o f t h e d i s c h a r g e is s e e n , f i l l i n g t h e n o s e o r e x u d i n g f r o m t h e
skull (for condyle), r i g h t and left o b l i q u e v i e w s o f m a n d i - fistulous o p e n i n g i n t o the m o u t h .
ble and the panorex v i e w . Inability to build positive or negative pressure in the mouth.
Patient w i l l have difficulty to b l o w the w i n d i n s t r u -
Treatment ments o r d r i n k t h r o u g h a straw. T o d r i n k t h r o u g h a

B o t h c l o s e d a n d o p e n m e t h o d s are u s e d f o r r e d u c t i o n a n d s t r a w , n e g a t i v e pressure has t o be c r e a t e d i n t h e o r a l

f i x a t i o n o f the m a n d i b u l a r fractures. cavity. T h i s c a n n o t be d o n e i n the presence o f an

I n dosed methods, interdental w i r i n g and intermaxillary o r o a n t r a l f i s t u l a as a i r gets d r a w n f r o m n o s e t o a n t r u m

f i x a t i o n are u s e f u l . E x t e r n a l p i n f i x a t i o n c a n also b e u s e d . t o o r a l c a v i t y . R e v e r s e is t r u e w h e n b l o w i n g w i n d
i n s t r u m e n t s ; i n s t e a d o f b u i l d i n g a p o s i t i v e pressure i n
I n t h e open methods, fracture site is e x p o s e d a n d f r a g -
t h e o r a l c a v i t y , a i r is b l o w n o u t f r o m t h e o r a l c a v i t y t o
m e n t s f i x e d b y d i r e c t i n t e r o s s e o u s w i r i n g . T h i s is f u r t h e r
a n t r u m a n d o u t t h r o u g h the nose.
strengthened by a w i r e tied i n a figure o f eight manner.
T h e s e days, compression plates are available to fix the
Diagnosis
fragments. W i t h t h e i r use, p r o l o n g e d i m m o b i l i s a t i o n a n d
i n t e r m a x i l l a r y f i x a t i o n can be a v o i d e d . A p r o b e c a n b e passed f r o m t h e f i s t u l o u s o p e n i n g i n t h e
Condylar fractures are also t r e a t e d by intermaxillary oral cavity i n t o the a n t r u m .
f i x a t i o n w i t h a r c h bars a n d r u b b e r b a n d s . S o m e t i m e s , o p e n
r e d u c t i o n and interosseous w i r i n g m a y be r e q u i r e d i n adult Treatment
edentulous patients w i t h bilateral c o n d y l a r fractures o r i n
Recent fistula. W h e n f i s t u l a is d i s c o v e r e d i m m e d i a t e l y after
fractures o f c h i l d r e n .
t o o t h e x t r a c t i o n , a n d t h e r e is n o i n f e c t i o n o r a r e t a i n e d
I m m o b i l i s a t i o n o f mandible b e y o n d three weeks, i n c o n -
t o o t h i n the a n t r u m , conservative treatment w i t h suturing
dylar fractures, c a n cause a n k y l o s i s o f t e m p o r o m a n d i b u l a r
o f g u m m a r g i n s a n d a c o u r s e o f a n t i b i o t i c s is e f f e c t i v e .
j o i n t s . T h e r e f o r e , i n t e r m a x i l l a r y w i r e s are r e m o v e d a n d j a w
Chronic fistula or a large fistula. It requires surgical repair
exercises s t a r t e d . I f o c c l u s i o n is s t i l l d i s t u r b e d , i n t e r m a x i l -
b y a p a l a t a l o r a b u c c a l flap. M a x i l l a r y sinusitis is f i r s t t r e a t e d
l a r y w i r e s are r e a p p l i e d f o r a n o t h e r w e e k a n d t h e process
by repeated irrigations and antibiotics. Squamous-lined
r e p e a t e d t i l l t h e b i t e a n d j a w m o v e m e n t s are n o r m a l .
f i s t u l o u s t r a c k is e x c i s e d , b o n y edges o f t h e fistula are
smoothened and prepared for the flaps t o sit p r o p e r l y .
Caldwell-Luc operation may be required to remove a
OROANTRAL FISTULA
retained t o o t h r o o t or a f o r e i g n b o d y , clear the a n t r u m o f
diseased m u c o s a a n d t o p r o v i d e a n a s o a n t r a l w i n d o w f o r
I t is a c o m m u n i c a t i o n b e t w e e n t h e a n t r u m a n d o r a l c a v i t y . f r e e d r a i n a g e . S o m e fistulas are b e t t e r c l o s e d b y a d e n t a l
T h e f i s t u l o u s o p e n i n g m a y be s i t u a t e d o n t h e a l v e o l u s or obturator. The l a t t e r also p e r m i t s o b s e r v a t i o n o f antral
g i n g i v o l a b i a l sulcus. cavity particularly i n those treated f o r cancer.
A n a t o m y and Physiology o f
Paranasal Sinuses

p n e u m a t i s a t i o n o f the sinus, t h e roots o f all t h e molars,

ANATOMY OF PARANASAL SINUSES
sometimes the premolars and canine, are i n c l o s e r e l a -
tion to the floor o f m a x i l l a r y sinus separated f r o m i t b y
Paranasal sinuses are air-containing cavities in certain a t h i n l a m i n a o f b o n e o r e v e n n o b o n e at a l l . O r o a n t r a l
b o n e s o f s k u l l . T h e y are f o u r o n e a c h side. fistulae can result f r o m e x t r a c t i o n o f any o f these t e e t h .
C l i n i c a l l y , paranasal sinuses h a v e b e e n d i v i d e d i n t o t w o D e n t a l i n f e c t i o n is also a n i m p o r t a n t c a u s e o f m a x i l l a r y
groups: sinusitis.
Anterior group. This includes maxillary, frontal and ante- O s t i u m o f t h e m a x i l l a r y sinus is s i t u a t e d h i g h u p i n
r i o r e t h m o i d a l . T h e y all o p e n i n the m i d d l e meatus a n d m e d i a l w a l l and opens i n the posterior part o f e t h m o i d a l
t h e i r ostia He a n t e r i o r t o basal l a m e l l a o f m i d d l e t u r b i n a t e . i n f u n d i b u l u m i n t o t h e m i d d l e m e a t u s . I t is u n f a v o u r a b l y
Posterior groups. T h i s i n c l u d e s p o s t e r i o r e t h m o i d a l sinuses s i t u a t e d f o r n a t u r a l d r a i n a g e . A n accessory o s t i u m is also
w h i c h o p e n i n t h e s u p e r i o r m e a t u s , a n d t h e s p h e n o i d sinus p r e s e n t b e h i n d t h e m a i n o s t i u m i n 3 0 % o f cases.
w h i c h o p e n i n s p h e n o e t h m o i d a l recess. Roof o f t h e m a x i l l a r y sinus is f o r m e d b y t h e floor o f t h e
o r b i t . I t is t r a v e r s e d b y i n f r a o r b i t a l n e r v e a n d vessels.

Maxillary Sinus ( A n t r u m of Highmore)

I t is t h e largest o f paranasal sinuses a n d o c c u p i e s t h e b o d y

o f m a x i l l a . I t is p y r a m i d a l i n shape w i t h base t o w a r d s l a t e r a l
w a l l o f nose a n d apex d i r e c t e d laterally i n t o the z y g o m a t i c
process o f m a x i l l a a n d s o m e t i m e s i n the z y g o m a t i c bone
i t s e l f ( F i g . 3 5 . 1 ) . O n a n a v e r a g e , m a x i l l a r y sinus has a c a p a c -
i t y o f 15 m l i n a n a d u l t .

Relations

Anterior wall is f o r m e d b y f a c i a l s u r f a c e o f m a x i l l a a n d is
r e l a t e d t o t h e soft tissues o f c h e e k .
Posterior wall is r e l a t e d t o i n f r a t e m p o r a l a n d p t e r y g o p a l a -
t i n e fossae.
Medial ivall is r e l a t e d t o t h e m i d d l e a n d i n f e r i o r m e a t u s e s .
A t places, t h i s w a l l is t h i n a n d m e m b r a n o u s . I t is r e l a t e d t o
uncinate process, a n t e r i o r a n d p o s t e r i o r f o n t a n e l l e , and
inferior turbinate a n d meatus.
Floor is f o r m e d b y a l v e o l a r a n d p a l a t i n e p r o c e s s e s of
Coronal section showing relationship o f maxillary and ethmoi-
t h e m a x i l l a a n d is s i t u a t e d a b o u t 1 c m b e l o w t h e l e v e l o f
dal sinuses to orbit and the nasal cavity.
floor o f nose (Fig. 35.1). D e p e n d i n g o n the age and
Diseases of Nose and Paranasal Sinuses

I n t h e anterior part, r o o f is r e l a t e d t o t h e o l f a c t o r y tract,

Frontal Sinus
o p t i c chiasma a n d f r o n t a l l o b e w h i l e t h e lateral w a l l is related
to the optic nerve, internal carotid artery and maxillary nerve
E a c h f r o n t a l sinus is s i t u a t e d b e t w e e n t h e i n n e r a n d o u t e r
a n d these s t m c t u r e s m a y stand i n r e l i e f i n t h e sinus c a v i t y .
tables o f f r o n t a l b o n e , a b o v e a n d d e e p t o t h e s u p r a o r b i t a l
I n t h e posterior part, r o o f is r e l a t e d t o p i t u i t a r y g l a n d i n
m a r g i n . I t varies i n shape a n d size a n d is o f t e n l o c u l a t e d .
t h e sella t u r c i c a w h i l e e a c h l a t e r a l w a l l is r e l a t e d t o c a v e r n -
The t w o f r o n t a l sinuses are often asymmetric and the
o u s sinus, i n t e r n a l c a r o t i d a r t e r y a n d C N I I I , I V , V I a n d a l l
i n t e r v e n i n g b o n y s e p t u m is t h i n a n d o f t e n o b l i q u e l y p l a c e d
the divisions o f V (Fig. 35.3).
o r m a y e v e n b e d e f i c i e n t . F r o n t a l sinus m a y b e a b s e n t o n
D e g r e e o f p n e u m a t i s a t i o n o f s p h e n o i d sinus varies a n d
o n e o r b o t h sides o r i t m a y b e v e r y large e x t e n d i n g i n t o
so d o t h e e x t e n t o f sinus a n d t h e s t r u c t u r e s r e l a t e d t o i t .
o r b i t a l plate i n t h e r o o f o f t h e o r b i t .
S i n u s c a v i t y m a y b e large a n d e x t e n d i n t o t h e w i n g s of
Anterior wall o f t h e sinus is r e l a t e d t o t h e s k i n o v e r t h e
s p h e n o i d a n d e v e n p t e i y g o i d plates.
f o r e h e a d ; inferior wall, t o t h e o r b i t a n d its c o n t e n t s ; %adpos-
terior wall t o t h e m e n i n g e s and frontal lobe o f the b r a i n .
O p e n i n g o f f r o n t a l sinus is s i t u a t e d i n its floor a n d leads
i n t o t h e m i d d l e m e a t u s d i r e c t l y o r t h r o u g h a canal c a l l e d
M u c o u s M e m b r a n e of Paranasal Sinuses
I
f r o n t o n a s a l d u c t . I n t h e m i d d l e m e a t u s , f r o n t a l sinus d r a i n s
Paranasal sinuses are l i n e d b y m u c o u s m e m b r a n e w h i c h is
i n t o f r o n t a l recess ( 5 5 % ) , a b o v e b u t n o t i n t o t h e i n f u n d i b u -
c o n t i n u o u s w i t h t h a t o f t h e nasal c a v i t y t h r o u g h t h e ostia
l u m (30%), i n t o the i n f u n d i b u l u m (15%) and above the
bulla ethmoidalis (1%).
Superolateral ridge

Ethmoidal Sinuses ( E t h m o i d Air Cells)

Optic nerve
E t h m o i d a l sinuses are t h i n - w a l l e d a i r c a v i t i e s i n t h e l a t e r a l
masses o f e t h m o i d b o n e . T h e i r n u m b e r varies f r o m 3 t o 1 8 .
( ^ — Internol carotid
T h e y o c c u p y t h e space b e t w e e n u p p e r t h i r d o f l a t e r a l nasal
artery
w a l l a n d t h e m e d i a l w a l l o f o r b i t . C l i n i c a l l y , e t h m o i d a l cells
are d i v i d e d i n t o anterior ethmoid group w h i c h o p e n s i n t o t h e
m i d d l e meatus, a n d posterior ethmoid group which opens
Maxillary nerve
i n t o t h e s u p e r i o r m e a t u s a n d s p h e n o e t h m o i d a l recess.
E a c h e t h m o i d l a b y r i n t h has i m p o r t a n t r e l a t i o n s . R o o f is
f o r m e d b y a n t e r i o r c r a n i a l fossa, l a t e r a l t o t h e c r i b r i f o r m Vidian nerve
plate. M e n i n g e s o f b r a i n f o n n i m p o r t a n t relations here.
L a t e r a l w a l l is r e l a t e d t o t h e o r b i t . T h e t h i n p a p e r - l i k e l a m -
i n a o f b o n e ( l a m i n a p a p y r a c e a ) s e p a r a t i n g a i r cells f r o m t h e
o r b i t can be easily d e s t r o y e d l e a d i n g t o spread o f e t h m o i d a l
i n f e c t i o n s i n t o t h e o r b i t . O p t i c n e r v e f o r m s close r e l a t i o n -
s h i p w i t h t h e p o s t e r i o r e t h m o i d a l cells a n d is at risk d u r i n g Coronal section o f sphenoid sinuses. N o t e the reliefs m a d e by

e t h m o i d surgery. various structures in the cavity o f sphenoid sinus. O p t i c nerve

f o r m s the superolateral ridge.

Sphenoid Sinus
Pituitary
I t o c c u p i e s t h e b o d y o f s p h e n o i d . T h e t w o , right a n d l e f t Int. carotid
sinuses, are r a r e l y s y m m e t r i c a l a n d are separated b y a t h i n Cavernous
b o n y s e p t u m w h i c h is o f t e n o b l i q u e l y p l a c e d a n d may sinus

e v e n be d e f i c i e n t ( c o m p a r e f r o n t a l sinus). O s t i u m o f the
s p h e n o i d sinus is s i t u a t e d i n t h e u p p e r p a r t o f its a n t e r i o r
w a l l a n d d r a i n s i n t o s p h e n o e t h m o i d a l recess.
Sphenoid sinus
Relations o f t h e s p h e n o i d sinus are i m p o r t a n t t o the
surgeon w h i l e d o i n g trans-sphenoidal hypophysectomy.
T h e y are d e p i c t e d i n F i g . 3 5 . 2 . T h e r e l a t i o n s o f t h e s i n u s
Relations o f sphenoid sinus.
d i f f e r i n the a n t e r i o r a n d p o s t e r i o r parts.
o f sinuses. I t is t h i n n e r a n d less v a s c u l a r c o m p a r e d t o t h a t H 0 , depending o n the force o f inspiration. D u r i n g e x p i -
7

o f t h e nasal c a v i t y . H i s t o l o g i c a l l y , i t is c i l i a t e d c o l u m n a r
e p i t h e l i u m w i t h g o b l e t cells w h i c h s e c r e t e m u c u s . C i l i a are
m o r e m a r k e d n e a r t h e ostia o f sinuses a n d h e l p i n d r a i n a g e
o f m u c u s i n t o t h e nasal c a v i t y .
Development of Paranasal Sinuses
r a t i o n , p o s i t i v e p r e s s u r e is c r e a t e d i n t h e n o s e a n d t h i s sets
u p e d d i e s w h i c h v e n t i l a t e t h e sinuses. T h u s , v e n t i l a t i o n o f
sinuses is p a r a d o x i c a l ; t h e y are e m p t i e d o f a i r d u r i n g i n s p i -
r a t i o n a n d f i l l e d w i t h a i r d u r i n g e x p i r a t i o n . T h i s is j u s t t h e
r e v e r s e o f w h a t takes p l a c e i n l u n g s w h i c h f i l l d u r i n g i n s p i -
ration and empty during expiration.

Paranasal sinuses develop as outpouchings from the Mucus Drainage of Sinuses

m u c o u s m e m b r a n e o f lateral w a l l o f nose. A t b i r t h , o n l y
t h e m a x i l l a r y a n d e t h m o i d a l sinuses are p r e s e n t a n d are Mucus secreted i n the paranasal sinuses t r a v e l s to the
large e n o u g h t o be c l i n i c a l l y significant. o s t i u m i n a s p i r a l m a n n e r . H e r e t h e c i l i a are v e r y a c t i v e
G r o w t h o f sinuses c o n t i n u e s d u r i n g c h i l d h o o d a n d e a r l y a n d p r o p e l m u c u s i n t o t h e m e a t u s e s f r o m w h e r e i t is c a r -
a d u l t l i f e . R a d i o l o g i c a l f y , m a x i l l a r y sinuses c a n b e i d e n t i - ried to the pharynx. T h e mucus f r o m anterior groups of
f i e d at 4—5 m o n t h s , e t h m o i d s at 1 y e a r , f f o n t a l s at 6 years sinuses t r a v e l s a l o n g t h e r e s p e c t i v e l a t e r a l p h a r y n g e a l g u t -
a n d s p h e n o i d s at 4 ( T a b l e 3 5 . 1 ) . ter situated b e h i n d the posterior pillar, a n d that f r o m p o s -
t e r i o r g r o u p is s p r e a d o v e r t h e p o s t e r i o r p h a r y n g e a l w a l l t o
be f i n a l l y s w a l l o w e d . I n i n f e c t i o n s o f t h e a n t e r i o r g r o u p o f
Lymphatic Drainage
sinuses, l a t e r a l l y m p h o i d b a n d s , s i t u a t e d b e h i n d t h e p o s t e -
r i o r pillars, get h y p e r t r o p h i e d .
T h e lymphatics o f maxillary, ethmoid, frontal and sphe-
noid sinuses f o r m a capillary n e t w o r k i n their lining
m u c o s a a n d c o l l e c t w i t h l y m p h a t i c s o f nasal c a v i t y . T h e n Functions of Paranasal Sinuses
they d r a i n i n t o lateral r e t r o p h a r y n g e a l a n d / o r j u g u l o d i g a s -
tric nodes. It is n o t clear w h y nature p r o v i d e d paranasal sinuses.
P r o b a b l e f u n c t i o n s are:

A i r - c o n d i t i o n i n g o f the i n s p i r e d air b y p r o v i d i n g large

PHYSIOLOGY O F PARANASAL SINUSES
s u r f a c e area o v e r w h i c h t h e a i r is h u m i d i f i e d and
warmed.
Ventilation of Sinuses T o p r o v i d e resonance to voice.
To act as t h e r m a l i n s u l a t o r s t o p r o t e c t t h e delicate
V e n t i l a t i o n o f paranasal sinuses takes p l a c e t h r o u g h t h e i r structures i n the o r b i t and the c r a n i u m f r o m varia-
o s t i a . D u r i n g i n s p i r a t i o n , a i r c u r r e n t causes n e g a t i v e p r e s - tions o f intranasal t e m p e r a t u r e .
sure i n t h e n o s e . T h i s varies f r o m —6 m m t o — 2 0 0 m m o f T o l i g h t e n the skull bones.

Table 35. D e v e l o p m e n t and g r o w t h o f paranasal sinuses

Status at birth Growth First radiologic evidence

Maxillary Present at birth Rapid growth from birth to 3 years and from 4-5 m o n t h s after birth

7-1 2 years. A d u l t size - 1 5 years

E t h m o i d Present at birth R e a c h a d u l t size b y 12 years

1 year
Anterior group: 5 X 2 X 2 m m .

Posterior group: 5 X 4 X 2 m m .

Frontal N o t present Invades frontal bone at the age o f 4 years. Size

6 years
increases until teens

Sphenoid N o t present Reaches sella turcica by the age o f 7 years, d o r s u m 4 years

sellae by late teens and basisphenoid by adult age.

R e a c h e s full size b e t w e e n 1 5 years to adult age

A c u t e Sinusitis

A c u t e i n f l a m m a t i o n o f sinus m u c o s a is c a l l e d acute sinusitis. amount o f mucus, w h i c h by ciliary m o v e m e n t , is

T h e sinus m o s t c o m m o n l y i n v o l v e d is t h e m a x i l l a r y f o l l o w e d d i r e c t e d t o w a r d s t h e sinus ostia from w h e r e i t drains
i n t u r n b y e t h m o i d , frontal a n d s p h e n o i d - V e r y o f t e n , m o r e i n t o t h e nasal c a v i t y . A n y factor(s) w h i c h i n t e r f e r e w i t h
t h a n o n e sinus is i n f e c t e d (tuuitisinusitis). Sometimes, all the t h i s f u n c t i o n c a n cause sinusitis d u e t o stasis o f secre-
sinuses o f o n e o r b o t h sides are i n v o l v e d s i m u l t a n e o u s l y t i o n s i n t h e sinus. T h e y are:
(pansinusitis unilateral or bilateral). (a) Nasal p a c k i n g
Sinusitis m a y be ''open' o r 'closed' type depending on (b) Deviated septum
w h e t h e r t h e i n f l a m m a t o r y p r o d u c t s o f sinus c a v i t y c a n d r a i n (c) H y p e r t r o p h i c turbinates
f r e e l y i n t o t h e nasal c a v i t y t h r o u g h t h e n a t u r a l ostia o r n o t . (d) O e d e m a o f sinus ostia d u e t o a l l e r g y o r vasomo-
A ' c l o s e d ' sinusitis causes m o r e severe s y m p t o m s a n d is also tor rhinitis
l i k e l y t o cause c o m p l i c a t i o n s . (e) Nasal p o l y p i
(f) S t r u c t u r a l a b n o r m a l i t y o f e t h m o i d a l a i r cells
(g) B e n i g n o r m a l i g n a n t n e o p l a s m .
A E T I O L O G Y O F S I N U S I T I S IN GENERAL Stasis of secretions in the nasal cavity. N o r m a l s e c r e t i o n s
o f nose m a y n o t d r a i n i n t o t h e n a s o p h a r y n x because
of their viscosity (cystic fibrosis) or obstruction
A. Exciting Causes
( e n l a r g e d a d e n o i d s , c h o a n a l atresia), a n d get i n f e c t e d .
Previous attacks of sinusitis. Local defences of sinus
Nasal infections. S i n u s m u c o s a is a c o n t i n u a t i o n o f nasal
m u c o s a are a l r e a d y damaged.
mucosa and infections from nose can travel d i r e c t l y
by c o n t i n u i t y o r b y w a y o f submucosal lymphatics.
M o s t c o m m o n cause o f a c u t e s i n u s i t i s is v i r a l r h i n i t i s General
f o l l o w e d b y bacterial invasion.
Environment. S i n u s i t i s is c o m m o n i n c o l d a n d w e t c l i m a t e .
Swimming and diving. I n f e c t e d w a t e r can e n t e r t h e sinuses
Atmospheric pollution, smoke, dust and overcrowding
t h r o u g h t h e i r ostia. H i g h c o n t e n t o f c h l o r i n e gas i n
also p r e d i s p o s e t o sinus i n f e c t i o n .
s w i n m i i n g p o o l s can also set u p c h e m i c a l i n f l a m m a t i o n .
Poor general health. R e c e n t attack o f e x a n t h e m a t o u s fever
Trauma. C o m p o u n d fractures or p e n e t r a t i n g injuries
(measles, c h i c k e n p o x , w h o o p i n g c o u g h ) , n u t r i t i o n a l d e f i -
of sinuses—frontal, maxillary and ethmoid—may
ciencies, systemic disorders (diabetes, i m m u n e deficiency
p e r m i t d i r e c t i n f e c t i o n o f sinus m u c o s a . Similarly,
syndromes).
b a r o t r a u m a m a y be f o l l o w e d by i n f e c t i o n .
Dental infections. This applies to maxillary sinus.
I n f e c t i o n f r o m the m o l a r or premolar teeth or their Bacteriology

e x t r a c t i o n m a y b e f o l l o w e d b y acute sinusitis.
Most cases o f acute sinusitis start as viral infections
f o l l o w e d soon b y bacterial invasion. T h e bacteria most
B. Predisposing Causes
o f t e n r e s p o n s i b l e f o r a c u t e s u p p u r a t i v e s i n u s i t i s are Strept.
pneumoniae, H. influenzae, Moraxella catarrhalis, Strept.
Local
pyogenes, Staph, aureus a n d Kleb. pneumoniae. Anaerobic
Obstruction to sinus ventilation and drainage. Normally, organisms a n d m i x e d i n f e c t i o n s are s e e n i n s i n u s i t i s of
sinuses are well-ventilated. They also secrete small dental origin.
 itlS

Pain. T y p i c a l l y , i t is s i t u a t e d o v e r t h e u p p e r j a w , b u t
PATHOLOGY OF SINUSITIS
m a y b e r e f e r r e d t o t h e g u m s o r t e e t h . F o r this r e a s o n
p a t i e n t m a y p r i m a r i l y c o n s u l t a d e n t i s t . P a i n is a g g r a -
A c u t e i n f l a m m a t i o n o f sinus m u c o s a causes h y p e r a e m i a , vated by stooping, c o u g h i n g or c h e w i n g . Occasionally,
e x u d a t i o n o f fluid, o u t p o u r i n g o f p o l y m o r p h o n u c l e a r cells p a i n is r e f e r r e d t o t h e i p s i l a t e r a l s u p r a o r b i t a l r e g i o n
and increased activity o f serous and mucous glands. and t h u s m a y s i m u l a t e f r o n t a l sinus i n f e c t i o n .
D e p e n d i n g o n the v i r u l e n c e o f organisms, defences o f the Tenderness. Pressure o r t a p p i n g o v e r t h e a n t e r i o r w a l l
h o s t a n d c a p a b i l i t y o f t h e sinus o s t i u m t o d r a i n t h e e x u - o f a n t r u m produces pain.
dates, t h e disease m a y b e m i l d ( n o n - s u p p u r a t i v e ) o r s e v e r e Redness and oedema of cheek. C o m m o n l y seen i n c h i l -
( s u p p u r a t i v e ) . I n i t i a l l y , t h e e x u d a t e is s e r o u s ; l a t e r i t m a y dren. T h e l o w e r eyelid may become puffy.
b e c o m e m u c o p u r u l e n t o r p u r u l e n t . S e v e r e i n f e c t i o n s cause Nasal discharge. Anterior rhinoscopy shows pus or
destruction o f mucosal l i n i n g . Failure o f o s t i u m to drain m u c o p u s i n the m i d d l e meatus. M u c o s a o f the m i d d l e
results i n e m p y e m a o f t h e sinus a n d d e s t r u c t i o n o f its b o n y meatus a n d t u r b i n a t e m a y appear r e d a n d s w o l l e n .
w a l l s l e a d i n g t o c o m p l i c a t i o n s . D e n t a l i n f e c t i o n s are v e r y Postural test. I f n o pus seen i n t h e m i d d l e meatus, i t is
f u l m i n a t i n g a n d s o o n result i n s u p p u r a t i v e sinusitis. decongested w i t h a pledget o f c o t t o n soaked w i t h a

I n f e c t i o n s o f i n d i v i d u a l sinuses are d e a l t w i t h i n this v a s o c o n s t r i c t o r a n d t h e p a t i e n t is m a d e t o sit w i t h t h e

chapter. affected sinus t u r n e d u p . E x a m i n a t i o n after 10—15 min-

utes m a y s h o w discharge i n t h e m i d d l e m e a t u s .
Post nasal discharge. Pus m a y b e seen o n t h e u p p e r s o f t
palate o n p o s t e r i o r r h i n o s c o p y .
A C U T E MAXILLARY SINUSITIS

Diagnosis
Aetiology
Transillumination test. A f f e c t e d sinus w i l l b e f o u n d o p a q u e .
M o s t c o m m o n l y , i t is v i r a l r h i n i t i s w h i c h spreads t o X-rays. W a t e r s ' v i e w w i l l s h o w either an opacity or a
i n v o l v e t h e sinus m u c o s a . T h i s is f o l l o w e d b y b a c t e - fluid l e v e l i n t h e i n v o l v e d s i n u s . C T scan is t h e p r e f e r r e d
rial invasion. i m a g i n g m o d a l i t y t o i n v e s t i g a t e t h e sinuses.
D i v i n g and s w i m m i n g i n contaminated water.
Treatment
D e n t a l i n f e c t i o n s are i m p o r t a n t s o u r c e o f m a x i l l a r y
sinusitis. Roots o f premolar and molar teeth are Medical
r e l a t e d t o t h e floor o f sinus a n d m a y b e s e p a r a t e d o n l y
Antimicrobial drugs. A m p i c i l l i n a n d a m o x i c i l l i n are q u i t e
b y a t h i n layer o f mucosal c o v e r i n g . Periapical dental
effective a n d cover a w i d e range o f organisms. E r y t h r o -
abscess m a y b u r s t i n t o t h e sinus; o r t h e r o o t o f a t o o t h ,
m y c i n o r d o x y c y c l i n e o r c o t r i m o x a z o l e are equally
d u r i n g e x t r a c t i o n , m a y b e p u s h e d i n t o t h e sinus. I n
e f f e c t i v e a n d c a n b e g i v e n t o t h o s e w h o are sensitive t o
case o f o r o a n t r a l f i s t u l a , f o l l o w i n g t o o t h e x t r a c t i o n ,
p e n i c i l l i n . F j - l a c t a m a s e - p r o d u c i n g strains o f H . influenzae
bacteria f r o m o r a l c a v i t y enter t h e m a x i l l a r y sinus.
a n d M. catarrhalis m a y necessitate t h e use o f a m o x i c i l l i n /
Trauma to the sinus s u c h as c o m p o u n d fractures,
c l a v u l a n i c a c i d o r c e f u r o x i m e a x e t i l . S p a r f l o x a c i n is also
penetrating injuries or g u n shot w o u n d s m a y be f o l -
e f f e c t i v e , a n d has t h e a d v a n t a g e o f s i n g l e d a i l y d o s e .
l o w e d b y sinusitis.
Nasal decongestant drops. 1 % ephedrine or 0 . 1 % x y l o -
o r o x y m e t a z o l i n e are u s e d as nasal d r o p s o r sprays t o
Predisposing factors O n e or m o r e o f the predisposing
d e c o n g e s t sinus o s t i u m a n d e n c o u r a g e d r a i n a g e .
f a c t o r s e n u m e r a t e d f o r sinusitis i n g e n e r a l m a y b e r e s p o n -
Steam inhalation. Steam alone or medicated w i t h m e n -
sible f o r a c u t e o r r e c u r r e n t i n f e c t i o n .
t h o l or T r . B e n z o i n C o . provides symptomatic relief and
e n c o u r a g e s sinus d r a i n a g e . I n h a l a t i o n s h o u l d b e g i v e n
Clinical Features 15 t o 2 0 m i n u t e s a f t e r nasal d e c o n g e s t i o n for better
penetration.
C l i n i c a l f e a t u r e s d e p e n d o n (a) s e v e r i t y o f i n f l a m m a t o r y
p r o c e s s a n d (b) e f f i c i e n c y o f o s t i u m t o d r a i n t h e exudates. Analgesics. P a r a c e t a m o l o r a n y o t h e r s u i t a b l e analgesic

C l o s e d o s t i u m s i n u s i t i s is o f g r e a t e r s e v e r i t y a n d leads m o r e s h o u l d be g i v e n f o r r e l i e f o f p a i n a n d headache.

often to complications. Hot fomentation. L o c a l h e a t t o t h e a f f e c t e d sinus is o f t e n

s o o t h i n g a n d helps i n the r e s o l u t i o n o f i n f l a m m a t i o n .
Constitutional symptoms consist o f fever, general m a l -
aise a n d b o d y a c h e . T h e y are t h e r e s u l t o f t o x a e m i a . Surgical

Headache. U s u a l l y , t h i s is c o n f i n e d t o f o r e h e a d and Antral lavage. Most cases of acute maxillary sinusitis

m a y thus be confused w i t h f r o n t a l sinusitis. r e s p o n d t o m e d i c a l t r e a t m e n t . L a v a g e is r a r e l y necessary.
I t is d o n e o n l y w h e n m e d i c a l t r e a t m e n t has f a i l e d a n d t h a t d r a i n a g e a n d analgesics. A c o m b i n a t i o n o f a n t i h i s t a m i n i c
t o o o n l y under cover o f antibiotics. w i t h a n o r a l nasal d e c o n g e s t a n t ( p s e u d o e p h e d r i n e o r p h e -
n y l e p h r i n e h y d r o c h l o r i d e ) are u s e f u l . P l a c i n g a p l e d g e t o f
Complications
c o t t o n soaked i n a vasoconstrictor i n the m i d d l e meatus,
A c u t e m a x i l l a r y sinusitis m a y c h a n g e t o subacute or o n c e o r t w i c e d a i l y , h e l p s t o r e l i e v e ostia] o e d e m a a n d
chronic sinusitis. p r o m o t e s sinus d r a i n a g e a n d v e n t i l a t i o n . I f p a t i e n t s h o w s
Frontal sinusitis. Frontonasal d u c t w h i c h opens i n m i d - r e s p o n s e t o m e d i c a l t r e a t m e n t a n d p a i n is r e l i e v e d , t r e a t -
d l e m e a t u s is o b s t r u c t e d d u e t o i n f l a m m a t o r y o e d e m a . m e n t is c o n t i n u e d f o r f u l l 10 days t o 2 w e e k s .
Osteitis or osteomyelitis o f the maxilla.
Surgical
Orbital cellulitis or abscess. I n f e c t i o n spreads t o t h e o r b i t
e i t h e r d i r e c t l y , f r o m t h e r o o f o f m a x i l l a r y sinus or Trephination of frontal sinus. I f t h e r e is p e r s i s t e n c e o r

i n d i r e c t l y , after i n v o l v e m e n t o f e t h m o i d sinuses. exacerbation o f p a i n o r p y r e x i a i n spite o f m e d i c a l

t r e a t m e n t f o r 4 8 h o u r s , o r i f t h e l i d s w e l l i n g is i n c r e a s -
i n g a n d t h r e a t e n i n g o r b i t a l c e l l u l i t i s , f r o n t a l sinus is
A C U T E FRONTAL SINUSITIS d r a i n e d e x t e r n a l l y . A 2 c m l o n g h o r i z o n t a l i n c i s i o n is
m a d e i n t h e s u p e r o m e d i a l aspect o f t h e o r b i t b e l o w

Aetiology the eyebrow (Fig. 36.1). Floor o f f r o n t a l sinus is

e x p o s e d a n d a h o l e d r i l l e d w i t h a b u r r . Pus is t a k e n
Usually f o l l o w s viral infections o f upper respiratory
f o r c u l t u r e a n d s e n s i t i v i t y , a n d a plastic t u b e i n s e r t e d
tract f o l l o w e d later b y bacterial i n v a s i o n .
a n d f i x e d . Sinus can n o w be i r r i g a t e d w i t h normal
Entry of water into the sinus during diving or
saline t w o o r t h r e e t i m e s d a i l y u n t i l f r o n t o n a s a l d u c t
swimming.
becomes patent. T h i s can be d e t e r m i n e d by a d d i n g a
E x t e r n a l t r a u m a t o t h e sinus, e . g . f r a c t u r e s o r pene-
f e w drops o f methylene blue t o the irrigating fluid
trating injuries.
a n d its e x i t seen t h r o u g h t h e n o s e . D r a i n a g e t u b e is
Oedema o f m i d d l e meatus, secondary t o associated
r e m o v e d w h e n frontonasal duct becomes patent.
i p s i l a t e r a l m a x i l l a r y o r e t h m o i d sinus i n f e c t i o n .
Antral lavage. Co-existent m a x i l l a r y sinusitis may
P r e d i s p o s i n g f a c t o r s , p a t h o l o g y a n d b a c t e r i o l o g y are t h e r e q u i r e a n t r a l l a v a g e . T h i s w i l l e n c o u r a g e f r o n t a l sinus
same as i n a c u t e s i n u s i t i s i n g e n e r a l . drainage b y r e l i e v i n g oedema o f the m i d d l e meatus.

Clinical Features Complications

Frontal headache. U s u a l l y severe a n d l o c a l i s e d o v e r t h e O r b i t a l ceUulitis.

affected sinus. I t s h o w s characteristic p e r i o d i c i t y , i.e. O s t e o m y e l i t i s o f f r o n t a l b o n e a n d fistula f o r m a t i o n .
c o m e s u p o n w a k i n g , g r a d u a l l y increases a n d reaches M e n i n g i t i s , e x t r a d u r a l abscess o r frontal l o b e abscess, i f
its p e a k b y a b o u t m i d d a y a n d t h e n starts s u b s i d i n g . I t i n f e c t i o n breaks t h r o u g h t h e p o s t e r i o r w a l l o f t h e sinus.
is also c a l l e d " o f f i c e h e a d a c h e " b e c a u s e o f its p r e s e n c e Chronic f r o n t a l sinusitis, i f the acute infection is
o n l y d u r i n g the office hours. neglected o r i m p r o p e r l y treated.
Tenderness. Pressure u p w a r d s o n t h e floor o f frontal
sinus, j u s t a b o v e t h e m e d i a l c a n t h u s , causes e x q u i s i t e
p a i n . I t c a n also b e e l i c i t e d b y t a p p i n g o v e r t h e a n t e -
rior w a l l o f f r o n t a l sinus i n t h e m e d i a l p a r t o f s u p r a o r -
bital region.
Oedema of upper eyelid w i t h suffused c o n j u n c t i v a a n d
photophobia.
Nasal discharge. A v e r t i c a l streak o f m u c o p u s is seen
h i g h u p i n the anterior part o f the m i d d l e meatus. T h i s
m a y b e absent i f t h e o s t i u m is c l o s e d w i t h n o d r a i n a g e .
N a s a l m u c o s a is i n f l a m e d i n t h e m i d d l e m e a t u s .
X-rays. O p a c i t y o f t h e a f f e c t e d sinus o r fluid l e v e l c a n b e

seen. B o t h W a t e r s ' and lateral v i e w s s h o u l d be t a k e n . CT

scan is t h e p r e f e r r e d m o d a l i t y .

Treatment
Figure 36.1
Medical This is same as f o r a c u t e m a x i l l a r y sinusitis,
Trephination o f right frontal sinus.
i.e. antimicrobials, decongestion o f t h e sinus o s t i u m f o r
 A c u t e Sinusitis

C a v e r n o u s sinus t h r o m b o s i s .
A C U T E E T H M O I D SINUSITIS
E x t r a d u r a l abscess, m e n i n g i t i s o r b r a i n abscess.

Aetiology

Acute e t h m o i d i t i s is o f t e n associated w i t h infection of A C U T E S P H E N O I D SINUSITIS

o t h e r sinuses. E t h m o i d sinuses are m o r e o f t e n i n v o l v e d i n
infants and y o u n g c h i l d r e n .
Aetiology

Clinical Features I s o l a t e d i n v o l v e m e n t o f s p h e n o i d sinus is r a r e . I t is o f t e n a

p a r t o f p a n s i n u s i t i s o r is associated w i t h i n f e c t i o n o f p o s t e -
Pain. I t is l o c a l i s e d o v e r t h e b r i d g e o f t h e n o s e , m e d i a l
r i o r e t h m o i d sinuses.
a n d d e e p t o t h e e y e . I t is a g g r a v a t e d b y m o v e m e n t s of
the eye ball.
Oedema of lids. B o t h e y e l i d s b e c o m e p u f f y a n d s w o l - Clinical Features
l e n . T h e r e is i n c r e a s e d l a c r i m a t i o n . O r b i t a l c e l l u l i t i s is
Headache. Usually localised t o the o c c i p u t o r vertex.
a n e a r l y c o m p l i c a t i o n i n s u c h cases.
P a i n m a y also b e r e f e r r e d t o t h e m a s t o i d r e g i o n .
Nasal discharge. O n a n t e r i o r r h i n o s c o p y , p u s m a y be seen
Postnasal discharge. I t can o n l y b e seen o n posterior
i n m i d d l e o r superior meatus d e p e n d i n g o n the i n v o l v e -
r h i n o s c o p y . A streak o f p u s m a y b e seen o n t h e r o o f
m e n t o f a n t e r i o r o r p o s t e r i o r g r o u p o f e t h m o i d sinuses.
and posterior w a l l o f nasoph a r y n x o r above the poste-
Swelling of the middle turbinate.
rior end o f middle turbinate.

Treatment X-rays. O p a c i t y o r f l u i d l e v e l m a y b e seen i n t h e s p h e -

n o i d s i n u s . L a t e r a l v i e w o f t h e s p h e n o i d sinus is t a k e n i n
Medical treatment is t h e same as for acute m a x i l l a r y
s u p i n e o r p r o n e p o s i t i o n a n d is h e l p f u l t o d e m o n s t r a t e t h e
sinusitis.
fluid level.
V i s u a l d e t e r i o r a t i o n a n d e x o p h t h a l m o s i n d i c a t e abscess
i n the posterior o r b i t and may require drainage o f the
Differential Diagnosis
e t h m o i d sinuses i n t o t h e n o s e t h r o u g h a n e x t e r n a l eth-
m o i d e c t o m y incision. M u c o c e l e o f t h e s p h e n o i d sinus o r its n e o p l a s m s m a y c l i n -
i c a l l y s i m u l a t e f e a t u r e s o f a c u t e i n f e c t i o n o f s p h e n o i d sinus
Complications
a n d s h o u l d always be e x c l u d e d i n a n y case o f i s o l a t e d
O r b i t a l c e l l u l i t i s a n d abscess. s p h e n o i d sinus i n v o l v e m e n t .
V i s u a l d e t e r i o r a t i o n and blindness due to involve- Treatment is t h e s a m e as f o r a c u t e i n f e c t i o n o f other
m e n t o f optic nerve. sinuses.
C h r o n i c Sinusitis

t h i c k a n d p o l y p o i d a l ( h y p e r t r o p h i c sinusitis) o r undergoes
C H R O N I C S I N U S I T I S IN GENERAL
a t r o p h y (atrophic sinusitis). Surface e p i t h e l i u m m a y s h o w
desquamation, regeneration o r metaplasia. S u b m u c o s a is
S i n u s i n f e c t i o n l a s t i n g f o r m o n t h s o r years is c a l l e d c h r o n i c i n f i l t r a t e d w i t h l y m p h o c y t e s a n d plasma cells a n d m a y s h o w
s i n u s i t i s . M o s t i m p o r t a n t cause o f c h r o n i c s i n u s i t i s is f a i l - microabscesses, g r a n u l a t i o n s , f i b r o s i s o r p o l y p formation.
ure o f acute i n f e c t i o n to resolve.

Bacteriology
Pathophysiology
M i x e d a e r o b i c a n d a n a e r o b i c o r g a n i s m s are o f t e n p r e s e n t .
A c u t e i n f e c t i o n destroys n o r m a l c i l i a t e d e p i t h e l i u m i m p a i r i n g
d r a i n a g e from t h e sinus. P o o l i n g a n d s t a g n a t i o n o f secretions
i n t h e sinus i n v i t e s i n f e c t i o n . Persistence o f i n f e c t i o n causes Clinical Features

m u c o s a l changes, s u c h as loss o f c i l i a , o e d e m a a n d p o l y p f o r -
C l i n i c a l features are o f t e n v a g u e a n d s i m i l a r t o those of
m a t i o n , thus c o n t i n u i n g the vicious cycle (Fig. 37.1).
a c u t e sinusitis b u t o f lesser s e v e r i t y . P u r u l e n t nasal discharge
is t h e c o m m o n e s t c o m p l a i n t . F o u l - s m e l l i n g discharge sug-
Pathology
gests a n a e r o b i c i n f e c t i o n . L o c a l p a i n a n d h e a d a c h e are o f t e n
I n c h r o n i c i n f e c t i o n s , process o f d e s t r u c t i o n a n d a t t e m p t s at n o t m a r k e d except i n acute exacerbations. S o m e patients
healing proceed simultaneously. Sinus m u c o s a becomes c o m p l a i n o f nasal stuffiness a n d a n o s m i a .

Causative factors and pathophysiology o f chronic sinusitis.

Diagnosis drainage t h r o u g h the frontonasal duct. T r e a t m e n t of
associated m a x i l l a r y sinusitis also helps to resolve
X - r a y o f t h e i n v o l v e d sinus m a y s h o w m u c o s a l t h i c k -
chronic frontal sinusitis.
e n i n g or opacity.
Trephination of frontal sinus (see p a g e 206).
X - r a y s after i n j e c t i o n o f contrast m a t e r i a l m a y s h o w
External frontoethmoidectomy (Howarth's or Lynch opera-
soft tissue c h a n g e s i n t h e sinus mucosa.
tion). T h e f r o n t a l sinus is e n t e r e d t h r o u g h its floor b y
CT scan is p a r t i c u l a r l y u s e f u l i n e t h m o i d a n d sphe-
a curvilinear incision r o u n d the i n n e r m a r g i n o f the
n o i d sinus i n f e c t i o n s a n d has r e p l a c e d s t u d i e s with
orbit. Diseased mucosa is r e m o v e d , ethmoid cells
contrast materials.
exenterated a n d a n e w frontonasal d u c t created.
A s p i r a t i o n a n d i r r i g a t i o n : F i n d i n g o f pus i n t h e sinus
Osteoplastic flap operation. I t m a y be unilateral o r b i l a t -
is c o n f i r m a t o r y .
e r a l . A c o r o n a l o r a b r o w i n c i s i o n is u s e d . T h e ante-

Treatment rior w a l l o f f r o n t a l sinus is r e f l e c t e d as a n osteoplastic

flap, based i n f e r i o r l y . T h e diseased tissues are r e m o v e d
I t is essential t o search f o r u n d e r l y i n g a e t i o l o g i c a l factors
a n d t h e sinus d r a i n e d t h r o u g h a n e w f r o n t o n a s a l d u c t .
w h i c h o b s t r u c t sinus d r a i n a g e a n d v e n t i l a t i o n . A w o r k - u p f o r
I f i t is d e s i r e d t o o b l i t e r a t e t h e s i n u s , all diseased as
nasal a l l e r g y m a y b e r e q u i r e d . C u l t u r e a n d s e n s i t i v i t y o f sinus
w e l l as h e a l t h y m u c o s a are s t r i p p e d o f f a n d t h e sinus
discharge helps i n t h e p r o p e r s e l e c t i o n o f a n a n t i b i o t i c .
o b l i t e r a t e d w i t h fat.
Initial treatment o f chronic s i n u s i t i s is conservative,
i n c l u d i n g antibiotics, decongestants, antihistaminics and
sinus i r r i g a t i o n s . M o r e often, some f o r m o f surgery is Chronic E t h m o i d Sinusitis
r e q u i r e d e i t h e r t o p r o v i d e free drainage a n d v e n t i l a t i o n o r
r a d i c a l s u r g e r y t o r e m o v e a l l i r r e v e r s i b l e diseases so as t o Intranasal ethmoidectomy. T h i s o p e r a t i o n is d o n e for

p r o v i d e w i d e drainage o r t o o b l i t e r a t e the sinus. chronic ethmoiditis w i t h polyp formation. T h e eth-

Recently, endoscopic sinus s u r g e r y is r e p l a c i n g r a d i c a l moid a i r cells a n d the diseased tissue is removed

o p e r a t i o n s o n t h e sinuses a n d p r o v i d e s g o o d d r a i n a g e a n d b e t w e e n the m i d d l e turbinate a n d the medial w a l l o f

v e n t i l a t i o n . I t also a v o i d s e x t e r n a l i n c i s i o n s . o r b i t b y the intranasal r o u t e . T h e f r o n t a l and sphe-

n o i d sinuses c a n also b e d r a i n e d b y t h i s o p e r a t i o n .
External ethmoidectomy. I n this operation, ethmoid
S U R G E R Y FOR C H R O N I C SINUSITIS sinuses are a p p r o a c h e d through medial orbital inci-
s i o n . A c c e s s c a n also be obtained to sphenoid and
f r o n t a l sinuses a n d t h e o p e r a t i o n is c a l l e d frontosphe-
C h r o n i c Maxillary Sinusitis
no-ethmoidectomy.

Antral puncture and irrigation. S i n u s c a v i t y is i r r i g a t e d

w i t h a c a n n u l a passed t h r o u g h t h e i n f e r i o r m e a t u s . C h r o n i c Sphenoiditis
R e m o v a l o f p u s a n d e x u d a t e s h e l p s t h e sinus mucosa
to revert to n o r m a l . Sphenoidotomy. Access to the sphenoid sinus can be

Intranasal antrostomy. I t is i n d i c a t e d i f sinus i r r i g a t i o n s o b t a i n e d b y r e m o v a l o f its a n t e r i o r w a l l . T h i s is accom-

f a i l t o r e s o l v e i n f e c t i o n . A w i n d o w is c r e a t e d i n t h e p l i s h e d b y e x t e r n a l e t h m o i d e c t o m y o r transseptal a p p r o a c h ,

i n f e r i o r m e a t u s t o p r o v i d e a e r a t i o n t o t h e sinus a n d its u s u a l l y t h e f o r m e r , because o f t h e c o - e x i s t e n c e o f e t h m o i d

free drainage. disease w i t h c h r o n i c s p h e n o i d i t i s .

Caldwell-Luc operation. I n this o p e r a t i o n , antrum is

e n t e r e d t h r o u g h its a n t e r i o r w a l l b y a s u b l a b i a l i n c i s i o n .
Fungal Sinusitis
A l l i r r e v e r s i b l e diseases are r e m o v e d a n d a w i n d o w is
created b e t w e e n the a n t r u m and i n f e r i o r meatus.
M a n y d i f f e r e n t species o f f u n g i are f o u n d t o i n v o l v e t h e
D e t a i l s o f t h e a b o v e o p e r a t i o n s are d e s c r i b e d i n t h e sec- paranasal sinuses; t h e m o r e c o m m o n b e i n g t h e Aspergillus,
t i o n o n operative surgery. Alternaria, Mucor o r Rhizopus. T h e y m a y i n v o l v e single or
m u l t i p l e sinuses. F o u r d i f f e r e n t v a r i e t i e s o f f u n g a l i n f e c -
t i o n o f sinuses are seen:
C h r o n i c Frontal Sinusitis
Fungal ball. I t is d u e t o i m p l a n t a t i o n o f f u n g u s i n t o an
Intranasal drainage operations. C o r r e c t i o n o f deviated o t h e r w i s e h e a l t h y sinus w h i c h o n C T s h o w s a h y p e r -
septum, removal o f a polyp or anterior portion of d e n s e area w i t h no evidence o f bone erosion or
m i d d l e t u r b i n a t e , o r intranasal e t h m o i d e c t o m y , p r o v i d e expansion. M a x i l l a r y sinus is t h e most commonly
 involved followed by sphenoid, ethmoid and the
f r o n t a l i n t h a t o r d e r . T r e a t m e n t is s u r g i c a l r e m o v a l o f
the f u n g a l ball a n d adequate drainage o f t h e sinus. N o
a n t i f u n g a l t h e r a p y is r e q u i r e d .
Allergic fungal sinusitis. I t is a n a l l e r g i c r e a c t i o n t o t h e
c a u s a t i v e f u n g u s a n d presents w i t h s i n u - n a s a l p o l y p o -
sis and mucin. The latter contains eosinophils,
C h a r e o t - L e y d e n crystals a n d f u n g a l h y p h a e . T h e r e is
n o i n v a s i o n o f t h e sinus m u c o s a w i t h f u n g u s . U s u a l l y
m o r e than one sinus are i n v o l v e d o n o n e or b o t h
sides. C T scan s h o w s m u c o s a l t h i c k e n i n g w i t h h y p e r -
d e n s e areas. T h e r e m a y b e e x p a n s i o n o f t h e sinus o r
b o n e e r o s i o n d u e t o pressure, b u t n o f u n g a l i n v a s i o n .
Treatment is e n d o s c o p i c surgical clearance o f the
Functional endoscopic surgery o f paranasal sinuses.
sinuses w i t h p r o v i s i o n o f drainage and v e n t i l a t i o n .
T h i s is c o m b i n e d w i t h p r e - a n d p o s t - o p e r a t i v e sys-
t e m i c steroids. Unlike Mucor infection, there is no black eschar.
Chronic invasive sinusitis. H e r e the fungus invades i n t o T r e a t m e n t is a n t i f u n g a l t h e r a p y a n d s u r g e r y .
t h e sinus m u c o s a . T h e r e is b o n e e r o s i o n b y f u n g u s .

I
P a t i e n t presents w i t h c h r o n i c r h i n o s i n u s i t i s . C T scan
Functional Endoscopic Surgery
s h o w s t h i c k e n e d m u c o s a w i t h o p a c i f i c a t i o n o f sinus
of Sinuses (Fig. 37.2)
and bone erosion. Patient m a y have intracranial o r
intraorbital invasion. H i s t o p a t h o l o g y shows fungal
Better understanding o f the pathophysiology o f recurrent
invasion o f submucosa and granulomatous reaction
a n d c h r o n i c s i n u s i t i s a n d t h e fact t h a t m o s t o f t h e c h a n g e s
w i t h m u l t i n u c l e a t e d g i a n t cells.
are r e v e r s i b l e , i f p r o p e r d r a i n a g e a n d v e n t i l a t i o n is p r o v i d e d
Treatment consists of surgical removal of the
t o t h e sinuses has, i n m o r e r e c e n t years, l e d t o t h e d e v e l o p -
i n v o l v e d m u c o s a , b o n e a n d soft tissues f o l l o w e d b y
m e n t o f endoscopic s u r g e r y o f sinuses. T h i s has f u r t h e r
antifungal therapy w i t h i.v. amphotericin B. U p to
been m a d e p o s s i b l e b y a d v a n c e s i n t e c h n o l o g y , s u c h as
2—3 g o f t h e d r u g is g i v e n . T h i s is f o l l o w e d b y i t r a -
d e v e l o p m e n t of:
c o n a z o l e t h e r a p y f o r 12 m o n t h s o r m o r e m o n i t o r e d
b y serial C T o r M R I scans. R i g i d endoscopes, w h i c h p r o v i d e better i l l u m i n a t i o n
Fulminant fungal sinusitis. I t is a n a c u t e p r e s e n t a t i o n and m a g n i f i c a t i o n and p e r m i t visualisation o f struc-
and is m o s t l y seen i n i m m u n o c o m p r o m i s e d o r d i a - t u r e s s i t u a t e d at d i f f e r e n t angles.
b e t i c i n d i v i d u a l s . C o m m o n f u n g a l species are Mucor M i c r o s u r g i c a l i n s t r u m e n t s , w h i c h p e r m i t precise a n d
or Aspergillus. l i m i t e d s u r g e r y , d i r e c t e d at s p e c i f i c sites, t o remove
o b s t r u c t i o n t o t h e sinus ostia.
Mucor causes r h i n o c e r e b r a l disease. D u e t o i n v a s i o n o f
t h e b l o o d vessels, m u c o r f u n g u s causes i s c h a e m i c necrosis E n d o s c o p e s c a n also b e passed t h r o u g h a c a n n u l a into
p r e s e n t i n g as a b l a c k eschar, i n v o l v i n g i n f e r i o r t u r b i n a t e , t h e m a x i l l a r y sinus t o visualise its i n t e r i o r a n d t a k e accu-
palate o r t h e s i n u s . I t spreads t o t h e face, e y e , s k u l l base a n d rate biopsies o r deal w i t h certain p a t h o l o g i c a l c o n d i t i o n s
t h e b r a i n . T r e a t m e n t is s u r g i c a l d e b r i d e m e n t o f n e c r o t i c s u c h as s m a l l cysts a n d p o l y p s .
tissue a n d i . v . a m p h o t e r i c i n B . With endoscopic surgery, i t is n o w possible to cure
Aspergillus i n f e c t i o n can also cause a c u t e f u l m i n a n t s i n u s - selected cases o f c h r o n i c a n d r e c u r r e n t i n f e c t i o n s o f t h e fron-
i t i s w i t h tissue i n v a s i o n . S u c h p a t i e n t s p r e s e n t w i t h a c u t e tal, m a x i l l a r y , e t h m o i d a n d s p h e n o i d sinuses w i t h o u t resort
sinusitis a n d d e v e l o p sepsis a n d o t h e r sinus c o m p l i c a t i o n s . t o e x t e r n a l o p e r a t i o n s (see s e c t i o n o n O p e r a t i v e S u r g e r y ) .
C o m p l i c a t i o n s o f Sinusitis

A s l o n g as i n f e c t i o n is c o n f i n e d o n l y t o t h e sinus m u c o s a , sphenoidal. There are t w o v i e w s i n t h e genesis of a

i t is c a l l e d s i n u s i t i s . C o m p l i c a t i o n s are said t o arise w h e n mucocele:
i n f e c t i o n spreads i n t o o r b e y o n d t h e b o n y w a l l o f t h e sinus
Chronic o b s t r u c t i o n t o sinus ostium resulting i n
(see T a b l e 3 8 . 1 a n d F i g . 3 8 . 1 ) .
a c c u m u l a t i o n o f secretions w h i c h s l o w l y e x p a n d t h e
sinus a n d d e s t r o y its b o n y w a l l s .
C y s t i c d i l a t a t i o n o f m u c o u s g l a n d o f t h e sinus m u c o s a
A. L O C A L C O M P L I C A T I O N S
d u e t o o b s t r u c t i o n o f its d u c t . I n t h i s case, w a l l o f
m u c o c e l e is s u r r o u n d e d b y n o r m a l sinus m u c o s a . T h e
Mucocele of Paranasal Sinuses a n d c o n t e n t s o f m u c o c e l e are s t e r i l e .
M u c o u s Retention Cysts
Mucocele of the frontal sinus ( F i g . 3 8 . 2 ) . I t u s u a l l y p r e s e n t s
i n t h e superomedial quadrant o f the orbit (90%) a n d dis-
T h e sinuses c o m m o n l y a f f e c t e d b y m u c o c e l e i n t h e o r d e r
places t h e e y e b a l l f o r w a r d , d o w n w a r d a n d l a t e r a l l y . T h e
of frequency, are t h e frontal, ethmoidal, maxillary and
s w e l l i n g is c y s t i c a n d n o n - t e n d e r ; e g g - s h e l l c r a c k l i n g m a y
b e e l i c i t e d . S o m e t i m e s , i t presents as a cystic s w e l l i n g i n t h e
f o r e h e a d ( 1 0 % ) . P a t i e n t ' s c o m p l a i n t s are u s u a l l y m i l d a n d
Complications o f paranasal sinus infection m a y i n c l u d e headache, diplopia and proptosis. R a d i o g r a p h s
o f t h e frontal sinus u s u a l l y r e v e a l c l o u d i n g o f t h e sinus w i t h
A. Local (i) M u c o c e l e / M u c o p y o c e l e

(ii) M u c o u s retention cyst

loss o f s c a l l o p e d o u t l i n e w h i c h is so t y p i c a l o f t h e n o r m a l

(iii) Osteomyelitis f r o n t a l s i n u s . T r e a t m e n t is frontoethmoidectomy with free

- Frontal b o n e d r a i n a g e o f f r o n t a l sinus i n t o t h e m i d d l e m e a t u s .
(more c o m m o n )

- Maxilla

B. Orbital (i) Preseptal inflammatory Dura mater

o e d e m a o f lids Periosteum
Arachnoid mater
i) Subperiosteal abscess
Frontal bone
ii) Orbital cellulitis Pia mater
v v) Orbital abscess
Subdural abscess
(v) Superior orbital fissure Pott's puffy — Brain abscess
syndrome
tumour
(vi) Orbital apex syndrome
Meningitis
C. Intracranial (i) Meningitis Extradural
(ii) Extradural abscess abscess
(iii) Subdural abscess

(iv) Brain abscess

(v) Cavernous sinus

t h r o m b o s i s

D. Descending infections

C o m p l i c a t i o n s o f sinusitis.
 nuses

p a i n is l o c a l i s e d t o t h e o r b i t o r f o r e h e a d . S o m e m a y c o m -
p l a i n o f h e a d a c h e i n t h e o c c i p u t o r v e r t e x . T r e a t m e n t is
external ethmoidectomy with sphenoidotomy. Anterior
w a l l o f t h e s p h e n o i d sinus is r e m o v e d , cyst w a l l u n c a p p e d
a n d its fluid c o n t e n t s evacuated.
Pyocele or mucopyocele is s i m i l a r t o m u c o c e l e b u t its c o n -
t e n t s are p u r u l e n t . I t c a n r e s u l t f r o m i n f e c t i o n o f a m u c o -
c e l e o f a n y o f t h e sinuses.
Endoscopic s u r g e r y has r e p l a c e d e x t e r n a l o p e r a t i o n of
t h e sinuses f o r t r e a t m e n t o f a l l m u c o c e l e o r mucopyoceles
o f v a r i o u s sinuses.

ii. Osteomyelitis

O s t e o m y e l i t i s is i n f e c t i o n o f bone marrow and should be

d i f f e r e n t i a t e d f r o m o s t e i t i s w h i c h is i n f e c t i o n o f t h e compact
bone. Osteomyelitis, following sinus i n f e c t i o n , involves
either the maxilla or the frontal bone.

Osteomyelitis of the maxilla. I t is m o r e o f t e n seen i n

i n f a n t s a n d c h i l d r e n t h a n adults because o f t h e p r e s e n c e
o f spongy b o n e i n the anterior w a l l o f the maxilla.
Mucocele o f frontal sinus. N o t e swelling a b o v e the medial can-
I n f e c t i o n m a y start i n t h e d e n t a l sac a n d t h e n spread t o
t h u s o f left eye (arrow).
t h e m a x i l l a , b u t less o f t e n , i t is p r i m a r y i n f e c t i o n o f t h e
m a x i l l a r y sinus. C l i n i c a l features are e r y t h e m a , s w e l l i n g
Mucocele of ethmoid sinuses causes e x p a n s i o n o f t h e m e d i a l o f c h e e k , o e d e m a o f l o w e r l i d , p u r u l e n t nasal d i s c h a r g e
wall o f the o r b i t , displacing the eyeball f o r w a r d a n d later- a n d fever. Subperiosteal abscess f o l l o w e d b y fistulae
a l l y . I n a d d i t i o n , i t m a y cause a b u l g e i n t h e m i d d l e m e a t u s m a y f o r m i n infraorbital r e g i o n (Fig. 38.3), alveolus or
o f nose. A m u c o c e l e o f the e t h m o i d can be d r a i n e d b y a n palate, o r i n z y g o m a . S e q u e s t r a t i o n o f b o n e m a y o c c u r .
intranasal o p e r a t i o n , u n c a p p i n g the e t h m o i d a l bulge a n d
establishing free drainage. S o m e t i m e s , i t m a y r e q u i r e e x t e r -
nal e t h m o i d operation.
Mucous retention cyst of the maxillary sinus presents as a
r e t e n t i o n cyst d u e t o o b s t r u c t i o n o f t h e d u c t o f s e r o m u c i -
n o u s g l a n d a n d u s u a l l y does n o t cause b o n e e r o s i o n . I t is
a s y m p t o m a t i c a n d is o b s e r v e d as a n i n c i d e n t a l f i n d i n g o n
r a d i o g r a p h s . N o t r e a t m e n t is g e n e r a l l y r e q u i r e d f o r a s y m p -
t o m a t i c r e t e n t i o n cysts as m o s t o f t h e m regress s p o n t a n e -
ously over a p e r i o d o f t i m e .
Mucocele of the maxillary sinus c a n o c c u r as a c o m p l i c a t i o n
o f c h r o n i c sinus i n f l a m m a t i o n w h e n its o s t i u m is b l o c k e d .
T h e sinus fills w i t h m u c u s a n d its b o n y w a l l s g e t e x p a n d e d
d u e t o e x p a n s i l e process. C T scan a n d M R I can h e l p i n t h e
diagnosis. A p o l y p , t u m o u r o r t r a u m a i n the m i d d l e meatus
m a y also o b s t r u c t t h e sinus o s t i u m t o cause a m u c o c e l e .
Mucocele of sphenoid sinus or sphenoethmoidal mucocele
arises f r o m s l o w e x p a n s i o n and destruction o f sphenoid
a n d p o s t e r i o r e t h m o i d sinuses. C l i n i c a l f e a t u r e s are t h o s e
o f s u p e r i o r o r b i t a l fissure s y n d r o m e ( i n v o l v e m e n t o f C N
I I I , I V , V I and o p h t h a l m i c division o f V ) or orbital apex Figure 38.3
s y n d r o m e w h i c h is s u p e r i o r o r b i t a l fissure s y n d r o m e w i t h
Osteomyelitis o f maxilla with fistula formation in infraorbital
additional involvement o f optic and maxillary division of
region (arrow).
t r i g e m i n a l n e r v e . E x o p h t h a l m o s is a l w a y s p r e s e n t a n d t h e
 r o m D

characterises l i d abscess. It involves only preseptal

space, i . e . lies i n f r o n t o f o r b i t a l s e p t u m . E y e b a l l m o v e -
m e n t s a n d v i s i o n are n o r m a l . G e n e r a l l y , u p p e r l i d is
swollen i n frontal, l o w e r l i d in maxillary, and b o t h
u p p e r a n d l o w e r lids i n e t h m o i d sinusitis.
Subperiosteal abscess. Pus collects outside the bone
u n d e r the p e r i o s t e u m . A subperiosteal abscess f r o m
ethmoids forms o n the m e d i a l w a l l o f orbit and dis-
places t h e e y e b a l l f o r w a r d , d o w n w a r d a n d l a t e r a l l y ;
f r o m t h e f r o n t a l sinus, abscess is s i t u a t e d j u s t a b o v e a n d
b e h i n d t h e m e d i a l c a n t h u s a n d displaces the eyeball
d o w n w a r d s a n d l a t e r a l l y ; f r o m t h e m a x i l l a r y sinus,
abscess f o r m s i n t h e floor o f the o r b i t and displaces
the eyeball u p w a r d s and f o r w a r d s .
Orbital cellulitis. W h e n p u s breaks t h r o u g h t h e p e r i o s -
Case o f chronic frontal sinusitis presenting w i t h a fistula in the t e u m a n d f i n d s its w a y i n t o t h e o r b i t , i t spreads b e t w e e n
floor o f the sinus. t h e o r b i t a l fat, e x t r a o c u l a r muscles, vessels a n d n e r v e s .
C l i n i c a l features w i l l i n c l u d e o e d e m a o f l i d s , e x o p h t h a l -
mos, chemosis o f c o n j u n c t i v a and restricted move-
m e n t s o f t h e e y e b a l l . V i s i o n is a f f e c t e d c a u s i n g p a r t i a l
T r e a t m e n t consists o f large doses o f a n t i b i o t i c s , d r a i n a g e
o r t o t a l loss w h i c h is s o m e t i m e s permanent. Patient
o f a n y abscess a n d r e m o v a l o f t h e sequestra.
m a y r u n h i g h f e v e r . O r b i t a l c e l l u l i t i s is p o t e n t i a l l y d a n -
Osteomyelitis o f maxilla may cause d a m a g e to
g e r o u s because o f t h e risk o f m e n i n g i t i s a n d c a v e r n o u s
temporaiy or permanent tooth-buds, maldevelop-
sinus t h r o m b o s i s .
m e n t o f maxilla, oroantral fistula, persistently d r a i n i n g
Orbital abscess. I n t r a o r b i t a l abscess u s u a l l y f o r m s a l o n g
sinus o r e p i p h o r a .
l a m i n a p a p y r a c e a o r t h e floor o f f r o n t a l sinus. C l i n i c a l
Osteomyelitis of frontal bone ( F i g . 3 8 . 4 ) . I t is m o r e o f t e n
p i c t u r e is s i m i l a r t o t h a t o f o r b i t a l c e l l u l i t i s . D i a g n o s i s
seen i n a d u l t s as f r o n t a l sinus is n o t d e v e l o p e d i n i n f a n t s
can b e easily m a d e b y C T scan o r u l t r a s o u n d o f t h e
a n d c h i l d r e n . O s t e o m y e l i t i s o f f r o n t a l b o n e results f r o m
o r b i t . T r e a t m e n t is i . v . a n t i b i o t i c s a n d d r a i n a g e o f t h e
a c u t e i n f e c t i o n o f f r o n t a l sinus c i t h e r d i r e c t l y o r t h r o u g h
abscess a n d t h a t o f t h e sinus ( e t h m o i d e c t o m y o r t r e p h -
t h e v e n o u s spread. I t c a n also f o l l o w t r a u m a o r s u r g e r y
i n a t i o n o f f r o n t a l sinus).
o f f r o n t a l sinus i n t h e p r e s e n c e o f a c u t e i n f e c t i o n . Pus
Superior orbital fissure syndrome. Infection o f sphenoid
may form externally under the periosteum as soft
sinus c a n r a r e l y a f f e c t s t r u c t u r e s o f s u p e r i o r o r b i t a l f i s -
d o u g h y s w e l l i n g (Pott's p u f f y t u m o u r ) , o r i n t e r n a l l y as
sure. S y m p t o m s consist o f deep o r b i t a l p a i n , f r o n t a l
an e x t r a d u r a l abscess. T r e a t m e n t consists o f l a r g e doses
h e a d a c h e a n d p r o g r e s s i v e paralysis o f C N V I , I I I a n d
o f a n t i b i o t i c s , d r a i n a g e o f abscess a n d t r e p h i n i n g o f
I V , i n that order.
f r o n t a l sinus t h r o u g h its floor. Sometimes, i t requires
Orbital apex syndrome. I t is s u p e r i o r o r b i t a l f i s s u r e
r e m o v a l o f sequestra a n d n e c r o t i c b o n e b y r a i s i n g a
syndrome w i t h additional i n v o l v e m e n t o f the optic
scalp flap t h r o u g h a c o r o n a l i n c i s i o n ( F i g . 3 8 . 4 ) .
n e r v e a n d m a x i l l a r y d i v i s i o n o f t h e t r i g e m i n a l (V,)

I (Fig. 38.5).

B. ORBITAL COMPLICATIONS

C. INTRACRANIAL COMPLICATIONS
O r b i t a n d its c o n t e n t s are c l o s e l y r e l a t e d t o t h e e t h m o i d ,
f r o n t a l , a n d m a x i l l a r y sinuses, b u t m o s t o f t h e complica-
t i o n s , h o w e v e r , f o l l o w i n f e c t i o n o f e t h m o i d s as t h e y are F r o n t a l , e t h m o i d a n d s p h e n o i d sinuses are c l o s e l y r e l a t e d
separated f r o m t h e o r b i t o n l y b y a t h i n l a m i n a o f b o n e — to anterior cranial fossa a n d i n f e c t i o n f r o m these can
l a m i n a p a p y r a c e a . I n f e c t i o n travels f r o m t h e s e sinuses e i t h e r cause:
b y osteitis o r as t h r o m b o p h l e b i t i c p r o c e s s o f e t h m o i d a l
M e n i n g i t i s and encephalitis
veins.
E x t r a d u r a l abscess
Orbital complications include:
S u b d u r a l abscess
Inflammatory oedema of lids. T h i s is o n l y r e a c t i o n a r y . B r a i n abscess
T h e r e is n o e r y t h e m a o r t e n d e r n e s s o f t h e l i d s w h i c h C a v e r n o u s sinus t h r o m b o s i s .
Orbital c o m p l i c a t i o n s o f sinusitis: ( A ) N o r m a l . (B) Subperiosteal abscess. (C) Orbital abscess.

Source and route o f infection in cavernous Differences between orbital cellulitis and

sinus t h r o m b o s i s cavernous sinus t h r o m b o s i s

Source Disease Route Orbital cellulitis Cavernous sinus

Nose and danger Furuncle and Pharyngeal plexus
thrombosis
area o f face septal abscess Source C o m m o n l y ethmoid Nose, sinuses, orbit,

sinuses ear or pharynx

Ethmoid sinuses Orbital cellulites O p h t h a l m i c veins

or abscess Onset Slow; starts with Abrupt with high

o e d e m a o f eyelids the fever a n d chills with

Sphenoid sinus Sinusitis Direct
innercanthus —* near signs o f
Frontal sinus Sinusitis and Supraorbital and
c h e m o s i s —» proptosis toxaemia
osteomyelitis o f o p h t h a l m i c veins
O e d e m a o f eyelids,
frontal bone
chemosis and
Orbit Cellulitis and O p h t h a l m i c veins
proptosis
abscess
Cranial Involved concurrently Involved individually
U p p e r lid Abscess Angular vein and
nerve with complete and sequentially
o p h t h a l m i c veins
involvement o p h t h a l m o p l e g i a

Pharynx Acute tonsillitis Pharyngeal plexus

Laterality Often involves one eye Involves both eyes
or peritonsillar

abscess

Ear Petrositis Petrosal venous Clinical features. O n s e t o f c a v e r n o u s sinus t h r o m b o p h l e -

sinuses
Cavernous Sinus Thrombosis
Aetiology. I n f e c t i o n o f paranasal sinuses, p a r t i c u l a r l y t h o s e
o f e t h m o i d a n d s p h e n o i d a n d less c o m m o n l y t h e f r o n t a l ,
a n d o r b i t a l c o m p l i c a t i o n s f r o m these sinus i n f e c t i o n s c a n
cause t h r o m b o p h l e b i t i s o f t h e c a v e r n o u s sinus(es). O t h e r
sources o f i n f e c t i o n are l i s t e d i n T a b l e 3 8 . 2 . T h e valveless
n a t u r e o f t h e v e i n s c o n n e c t i n g t h e c a v e r n o u s s i n u s causes
easy s p r e a d o f i n f e c t i o n .
b i t i s is a b r u p t w i t h c h i l l s a n d r i g o r s . P a t i e n t is a c u t e l y i l l .
Eyelids get s w o l l e n w i t h chemosis a n d proptosis o f eyeball.
C r a n i a l n e r v e s I I I , I V , V I w h i c h are r e l a t e d t o t h e sinus g e t
i n v o l v e d individually and sequentially causing total o p h -
thalmoplegia. Pupil becomes d i l a t e d a n d f i x e d , o p t i c disc
shows congestion and oedema w i t h d i m i n u t i o n o f vision.
Sensation i n the d i s t r i b u t i o n o f V (ophthalmic division o f
CNV) is d i m i n i s h e d . C S F is u s u a l l y n o r m a l . Condition
needs t o b e d i f f e r e n t i a t e d f r o m o r b i t a l c e l l u l i t i s ( T a b l e 3 8 . 3 ) .
C T scan is u s e f u l f o r t h i s .
Treatment consists o f i . v . a n t i b i o t i c s a n d a t t e n t i o n t o t h e
focus o f i n f e c t i o n , drainage o f infected e t h m o i d o r sphe-
n o i d sinus. B l o o d c u l t u r e s h o u l d be t a k e n b e f o r e starting
a n t i b i o t i c t h e r a p y . R o l e o f a n t i c o a g u l a n t s is n o t c l e a r .
 Persistent laryngitis and tracheobronchitis. Sinusitis may
D. DESCENDING INFECTIONS b e associated w i t h r e c u r r e n t l a r y n g i t i s , b r o n c h i e c t a s i s
a n d a s t h m a b u t t h e l a t t e r are n o t necessarily c a u s e d b y

I n s u p p u r a t i v e s i n u s i t i s , d i s c h a r g e c o n s t a n t l y flows i n t o t h e sinusitis.

p h a r y n x a n d c a n cause o r aggravate:

E. FOCAL INFECTIONS
Otitis, media ( a c u t e o r c h r o n i c ) .
Pharyngitis and tonsillitis. H y p e r t r o p h y o f lateral l y m -
p h o i d b a n d s b e h i n d t h e p o s t e r i o r p i l l a r s (lateral p h a r - T h e r o l e o f sinus i n f e c t i o n t o act as f o c u s o f i n f e c t i o n is
y n g i t i s ) is i n d i c a t i v e o f c h r o n i c s i n u s i t i s . I t m a y be d o u b t f u l . A f e w c o n d i t i o n s s u c h as p o l y a r t h r i t i s , t e n o s y n o v i -
u n i l a t e r a l a n d a f f e c t t h e side o f t h e i n v o l v e d sinus. tis, f i b r o s i t i s a n d c e r t a i n s k i n diseases m a y r e s p o n d t o e l i m i -
C h r o n i c sinusitis m a y also cause r e c u r r e n t t o n s i l l i t i s o r n a t i o n o f i n f e c t i o n i n t h e sinuses. H o w e v e r , sinus i n f e c t i o n ,
granular pharyngitis. i f present i n these cases, is t r e a t e d o n its o w n m e r i t .
N e o p l a s m s o f Nasal Cavity

B o t h b e n i g n a n d m a l i g n a n t t u m o u r s o f t h e nasal c a v i t y u n d e r l y i n g s t r o m a r a t h e r t h a n o n t h e surface. M o s t l y seen

( T a b l e 3 9 . 1 ) p e r se are u n c o m m o n . V e r y o f t e n t h e i r separa- between 4 0 - 7 0 years w i t h m a l e p r e p o n d e r a n c e (5:1). It
t i o n f r o m t u m o u r s o f paranasal sinuses is d i f f i c u l t e x c e p t i n arises f r o m t h e l a t e r a l w a l l o f n o s e a n d is a l w a y s u n i l a t e r a l .
e a r l y stages. I n a d d i t i o n t o p r i m a r y t u m o u r s , nasal c a v i t y I t presents as r e d o r g r e y masses w h i c h m a y b e translucent
c a n b e i n v a d e d b y g r o w t h s f r o m paranasal sinuses, n a s o p h a r - and oedematous, s i m u l a t i n g s i m p l e nasal p o l y p i . I n v e r t e d
y n x , cranial or buccal cavity. p a p i l l o m a has a m a r k e d t e n d e n c y t o r e c u r after surgical
B e n i g n l e s i o n s are u s u a l l y s m o o t h , l o c a l i s e d a n d c o v e r e d r e m o v a l a n d m a y b e associated w i t h s q u a m o u s c e l l c a r c i -
w i t h mucous membrane. M a l i g n a n t ones are u s u a l l y f r i a - n o m a i n 10—15% o f p a t i e n t s . T r e a t m e n t is w i d e s u r g i c a l
b l e , h a v e a g r a n u l a r surface a n d t e n d t o b l e e d easily. excision b y lateral r h i n o t o m y o r m e d i a l m a x i l l e c t o m y a n d
en bloc ethmoidectomy.

3. P l e o m o r p h i c a d e n o m a R a r e t u m o u r , u s u a l l y arises
T u m o u r s o f nasal cavity f r o m t h e nasal s e p t u m . T r e a t m e n t is w i d e s u r g i c a l e x c i s i o n .

Benign M a l i g n a n t
4. S c h w a n n o m a and meningioma T h e y are uncom-
m o n t u m o u r s w h i c h are f o u n d i n t r a n a s a l l y . T r e a t m e n t is
S q u a m o u s papilloma C a r c i n o m a
surgical e x c i s i o n b y lateral r h i n o t o m y .
Inverted papilloma - S q u a m o u s cell c a r c i n o m a

Pleomorphic a d e n o m a - A d e n o c a r c i n o m a 5. H a e m a n g i o m a It m a y be:
S c h w a n n o m a Malignant m e l a n o m a
Capillary haemangioma (Bleeding polypus of the septum).
M e n i n g i o m a Olfactory n e u r o b l a s t o m a
I t is a soft, d a r k r e d , p e d u n c u l a t e d o r sessile t u m o u r
H a e m a n g i o m a H a e m a n g i o pericytoma
a r i s i n g f r o m a n t e r i o r p a r t o f nasal s e p t u m ( F i g . 3 9 . 2 ) .
C h o n d r o m a L y m p h o m a

A n g i o f i b r o m a Solitary p l a s m a c y t o m a

Encephalocele Various types o f sarcoma

G l i o m a

D e r m o i d

BENIGN NEOPLASMS

1. Squamous papilloma Verrucous lesions similar t o

s k i n w a r t s c a n arise f r o m t h e nasal v e s t i b u l e o r l o w e r p a r t
o f nasal s e p t u m . T h e y m a y b e s i n g l e o r m u l t i p l e , p e d u n -
c u l a t e d o r sessile ( F i g . 3 9 . 1 ) . T r e a t m e n t is l o c a l excision
w i t h c a u t e r i s a t i o n o f t h e base t o p r e v e n t r e c u r r e n c e . They
c a n also b e t r e a t e d b y c r y o s u r g e r y o r laser.

2. I n v e r t e d papilloma (Transitional cell papilloma

or Ringertz tumour) I t is s o - n a m e d because m i c r o -
S q u a m o u s papilloma n o s e , left side.
scopically neoplastic e p i t h e l i u m is seen t o g r o w t o w a r d s
 c h i l d r e n . A n i n t r a n a s a l g l i o m a p r e s e n t s as a f i r m p o l y p
s o m e t i m e s p r o t r u d i n g at t h e a n t e r i o r nares.

10. N a s a l d e r m o i d I t presents as w i d e n i n g o f u p p e r p a r t
o f nasal s e p t u m w i t h s p l a y i n g o f nasal b o n e s a n d h y p e r t e -
l o r i s m . A p i t o r a sinus m a y b e seen i n t h e m i d l i n e o f nasal
d o r s u m w i t h hair p r o t r u d i n g f r o m the o p e n i n g .

MALIGNANT NEOPLASMS

1. Carcinoma o f nasal cavity P r i m a r y c a r c i n o m a p e r se

is r a r e . I t m a y b e a n e x t e n s i o n o f maxillary or ethmoid
carcinoma. S q u a m o u s c e l l v a r i e t y is t h e m o s t common,
seen i n a b o u t 8 0 % . o f cases. R e s t m a y b e a d e n o i d c y s t i c
Bleeding polypus arising from right side o f nasal septum.
carcinoma or an adenocarcinoma.

Squamous cell carcinoma. I t m a y arise f r o m t h e v e s t i b u l e ,

a n t e r i o r p a r t o f nasal s e p t u m o r t h e l a t e r a l w a l l o f nasal
U s u a l l y i t is s m o o t h b u t m a y b e c o m e u l c e r a t e d and
c a v i t y . M o s t o f t h e m are seen i n m e n past 5 0 years
p r e s e n t w i t h r e c u r r e n t epistaxis a n d nasal o b s t r u c t i o n .
o f age.
T r e a t m e n t is l o c a l e x c i s i o n w i t h a c u f f o f s u r r o u n d i n g
(i) V e s t i b u l a r : I t arises f r o m t h e l a t e r a l w a l l o f nasal
mucoperichondrium.
vestibule and may extend into the columella,
Cavernous haemangioma. I t arises f r o m t h e t u r b i n a t e s o n
nasal floor a n d u p p e r l i p w i t h metastases t o p a r o t i d
t h e l a t e r a l w a l l o f n o s e . I t is t r e a t e d b y s u r g i c a l e x c i s i o n
nodes.
w i t h preliminary cryotherapy. Extensive lesions m a y
(ii) Septal: M o s t l y arises f r o m m u c o c u t a n e o u s junc-
require radiotherapy a n d surgical excision.
t i o n a n d causes b u r n i n g a n d soreness i n t h e n o s e .
6. C h o n d r o m a I t c a n arise f r o m t h e e t h m o i d , nasal c a v -
I t has o f t e n b e e n t e r m e d as " n o s e - p i c k e r ' s c a n c e r " .
i t y o r nasal s e p t u m . P u r e c h o n d r o m a s are s m o o t h , firm and
U s u a l l y , i t is o f l o w grade m a l i g n a n c y .
lobulated. Others m a y be m i x e d type f i b r o - , osteo-, or
(iii) Lateral wall: This is the site most commonly
angiochondromas. Treatment is surgical excision. For
i n v o l v e d . Easily e x t e n d s i n t o e t h m o i d o r m a x i l l a r y
recurrent o r large t u m o u r s , w i d e excision s h o u l d be done
sinuses. G r o s s l y , i t presents as a p o l y p o i d mass i n t h e
because o f t h e i r t e n d e n c y to malignant transformation
l a t e r a l w a l l o f n o s e . Metastases are rare. T r e a t m e n t is
after repeated interference.
c o m b i n a t i o n o f radiotherapy and surgery.
7. A n g i o f i b r o m a I t is i n c l u d e d i n nasal t u m o u r s b e c a u s e Adenocarcinoma and adenoid cystic carcinoma. T h e y arise
its p r i m a r y site o f o r i g i n is s u p p o s e d t o be p o s t e r i o r p a r t from the glands of mucous membrane or minor
o f nasal c a v i t y n e a r t h e s p h e n o p a l a t i n e f o r a m e n (see page salivary glands a n d m o s t l y i n v o l v e u p p e r p a r t o f the
261). l a t e r a l w a l l o f nasal c a v i t y .

8. Intranasal meningoencephalocele I t is h e r n i a t i o n 2. Malignant melanoma U s u a l l y seen i n p e r s o n s a b o u t

o f b r a i n tissues a n d m e n i n g e s t h r o u g h f o r a m e n c a e c u m o r 5 0 years o f age. B o t h sexes are e q u a l l y a f f e c t e d . G r o s s l y , i t
c r i b r i f o r m p l a t e . I t presents as a s m o o t h p o l y p i n t h e u p p e r p r e s e n t s as a s l a t y - g r e y or bluish-black p o l y p o i d mass.
p a r t o f nose b e t w e e n the septum and m i d d l e turbinate, W i t h i n t h e nasal c a v i t y , m o s t f r e q u e n t site is a n t e r i o r p a r t
u s u a l l y i n i n f a n t s a n d y o u n g c h i l d r e n . T h e mass increases i n o f nasal s e p t u m f o l l o w e d b y m i d d l e a n d i n f e r i o r t u r b i n a t e .
size o n c r y i n g o r s t r a i n i n g . U n l e s s care is t a k e n , i t m a y b e A m e l a n o t i c v a r i e t i e s are n o n p i g m e n t e d . T u m o u r spreads
misdiagnosed as a s i m p l e p o l y p a n d m i s t a k e n l y avulsed, b y l y m p h a t i c s a n d b l o o d s t r e a m . C e r v i c a l n o d a l metastases
resulting i n CSF r h i n o r r h o e a o r m e n i n g i t i s . F o r t h e same m a y b e p r e s e n t at t h e t i m e o f i n i t i a l e x a m i n a t i o n . T r e a t m e n t
r e a s o n b i o p s y s h o u l d n o t b e t a k e n . C T scan is essential t o is w i d e s u r g i c a l e x c i s i o n . I m m u n o l o g i c a l d e f e n c e s o f t h e
d e m o n s t r a t e a d e f e c t i n t h e base o f s k u l l . T r e a t m e n t is f r o n - patient play a great r o l e i n t h e c o n t r o l o f t h i s disease.
tal c r a n i o t o m y , s e v e r i n g t h e stalk f r o m t h e b r a i n , a n d r e p a i r Radiotherapy and chemotherapy suppress t h e immune
o f d u r a l a n d b o n y d e f e c t . I n t r a n a s a l mass is r e m o v e d as processes a n d are a v o i d e d . A f i v e - y e a r s u r v i v a l r a t e o f 3 0 %
s e c o n d a r y p r o c e d u r e after c r a n i a l d e f e c t has sealed. c a n b e e x p e c t e d after s u r g i c a l e x c i s i o n .

9. Gliomas O f all t h e g l i o m a s , 3 0 % are i n t r a n a s a l and 3. O l f a c t o r y neuroblastoma I t is a t u m o u r o f o l f a c t o r y

10%i b o t h i n t r a a n d e x t r a n a s a l . T h e y are seen i n i n f a n t s a n d p l a c o d e seen i n persons o f e i t h e r sex at a n y age g r o u p . I t
! >iseases o f N o s e a n d P<> nuses

ment is s u r g i c a l e x c i s i o n followed by radiation. Cran-

iofacial resection may be required for tumours o f the
c r i b r i f o r m plate.

4. H a e m a n g i o p e r i c y t o m a I t is a r a r e t u m o u r o f v a s c u -
l a r o r i g i n . I t arises f r o m t h e p e r i c y t e — a c e l l s u r r o u n d i n g
t h e c a p i l l a r i e s . I t is u s u a l l y seen i n t h e age g r o u p o f 6 0 - 7 0
a n d presents w i t h epistaxis. B r i s k b l e e d i n g m a y o c c u r on
biopsy. T h e t u m o u r m a y be b e n i g n o r m a l i g n a n t b u t i t
c a n n o t b e d i s t i n g u i s h e d h i s t o l o g i c a l l y . T r e a t m e n t is w i d e
s u r g i c a l e x c i s i o n . R a d i o t h e r a p y is u s e d f o r i n o p e r a b l e or
r e c u r r e n t lesions.

5. L y m p h o m a R a r e l y a n o n - H o d g k i n l y m p h o m a pres-
ents o n t h e s e p t u m .

6. P l a s m a c y t o m a Solitary plasmacytoma without gen-

R h a b d o m y o s a r c o m a o f the nose in a 2'/2-years o l d male c h i l d .
eralised osseous disease m a y be seen i n t h e nasal c a v i t y . I t
p r e d o m i n a n t l y affects m a l e s o v e r 4 0 years. T r e a t m e n t is b y
radiotherapy f o l l o w e d three m o n t h s later b y surgery if
total regression does n o t o c c u r . L o n g - t e r m f o l l o w u p is
p r e s e n t s as a c h e r r y r e d , p o l y p o i d a l mass i n t h e u p p e r t h i r d
essential t o e x c l u d e d e v e l o p m e n t o f m u l t i p l e m y e l o m a .
o f t h e nasal c a v i t y . I t is a v a s c u l a r t u m o u r a n d b l e e d s p r o -
f u s e l y o n b i o p s y . L y m p h n o d e o r s y s t e m i c metastases c a n 7. S a r c o m a s Osteogenic sarcoma, chondrosarcoma, rhab-
occur. T h e t u m o u r is m o d e r a t e l y r a d i o s e n s i t i v e a n d has domyosarcoma (Fig. 39.3), angiosarcoma, malignant histio-
b e e n c u r e d b y r a d i a t i o n alone. Presently, f a v o u r e d treat- c y t o m a are o t h e r r a r e t u m o u r s a f f e c t i n g t h e n o s e .
N e o p l a s m s o f Paranasal Sinuses

Paranasal sinuses m a y b e a f f e c t e d b y b o t h b e n i g n a n d m a l i g - Fibrous dysplasia I n t h i s c o n d i t i o n , b o n e is r e p l a c e d b y

n a n t n e o p l a s m s b u t t h e l a t t e r are m u c h m o r e c o m m o n .
BENIGN NEOPLASMS
f i b r o u s tissue; m o s t l y i n v o l v e s m a x i l l a r y b u t sometimes
t h e e t h m o i d a n d f r o n t a l sinuses. P a t i e n t seeks a d v i c e f o r
d i s f i g u r e m e n t o f t h e face, nasal o b s t r u c t i o n a n d d i s p l a c e -
m e n t o f t h e e y e . T r e a t m e n t is s u r g i c a l r e s c u l p t u r i n g o f
the i n v o l v e d b o n e to achieve a g o o d cosmetic and f u n c -

Osteomas T h e y are m o s t c o m m o n l y seen i n t h e f r o n t a l t i o n a l result (Fig. 4 0 . 2 ) .

sinus f o l l o w e d i n t u r n b y those o f e t h m o i d a n d m a x i l l a r y . Ossifying fibroma Seen i n y o u n g adults. T h e t u m o u r

T h e y may remain asymptomatic, b e i n g discovered inci- c a n b e s h e l l e d o u t easily.
dentally o n X-rays (Fig. 40.1). Treatment is i n d i c a t e d
Ameloblastoma (adamantinoma) I t is a l o c a l l y a g g r e s -
w h e n they b e c o m e s y m p t o m a t i c , causing o b s t r u c t i o n to
sive t u m o u r t h a t arises f r o m t h e o d o n t o g e n i c tissue a n d
t h e sinus o s t i u m , f o r m a t i o n o f m u c o c e l e , pressure s y m p -
i n v a d e s t h e m a x i l l a r y s i n u s . T r e a t m e n t is s u r g i c a l e x c i s i o n .
t o m s d u e to t h e i r g r o w t h i n the o r b i t , nose o r c r a n i u m .
O t h e r r a r e t u m o u r s i n c l u d e inverted papilloma, menin-
gioma a n d haemangioma (see C h a p t e r 3 9 ) .

MALIGNANT NEOPLASMS

Incidence C a n c e r o f n o s e a n d paranasal sinuses c o n s t i -

tutes 0 . 4 4 % o f a l l b o d y c a n c e r s i n I n d i a (0.57%> i n males
and 0.44% i n females). Its i n c i d e n c e during the same
p e r i o d (year 2 0 0 0 ) w a s 0 . 3 per 100,000 p e r s o n s * Most
f r e q u e n t l y i n v o l v e d are t h e m a x i l l a r y sinuses f o l l o w e d i n
turn by ethmoids, frontal and sphenoid.

Aetiology C a u s e o f sinus m a l i g n a n c y is l a r g e l y u n k n o w n .
People w o r k i n g i n h a r d w o o d furniture industry, nickel
refining, l e a t h e r w o r k a n d m a n u f a c t u r e o f m u s t a r d gas
have s h o w n h i g h e r i n c i d e n c e o f smunasal cancer. C a n c e r
o f t h e m a x i l l a r y sinus is c o m m o n i n B a n t u s o f S o u t h A f r i c a
w h e r e l o c a l l y m a d e s n u f f is u s e d , w h i c h is f o u n d rich in
nickel and c h r o m i u m .
W o r k e r s o f furniture industry develop adenocarcinoma o f
t h e e t h m o i d s a n d u p p e r nasal c a v i t y , w h i l e those e n g a g e d i n
n i c k e l r e f i n i n g get s q u a m o u s cell a n d anaplastic c a r c i n o m a .

Histology M o r e t h a n 8 0 % o f t h e m a l i g n a n t t u m o u r s are
o f s q u a m o u s c e l l v a r i e t y . R e s t are a d e n o c a r c i n o m a , a d e n o i d
O s t e o m a right frontal sinus (arrow).
cystic c a r c i n o m a , m e l a n o m a a n d v a r i o u s t y p e s o f sarcomas.
 C a r c i n o m a of Maxillary Sinus Early features o f m a x i l l a r y sinus m a l i g n a n c y are nasal
s t u f f i n e s s , b l o o d - s t a i n e d nasal d i s c h a r g e , f a c i a l p a r e s t h e s i a s

I t arises f r o m t h e sinus l i n i n g a n d m a y r e m a i n s i l e n t f o r a o r p a i n and epiphora. These s y m p t o m s m a y be missed or

l o n g t i m e g i v i n g o n l y vague s y m p t o m s o f "sinusitis". It s i m p l y t r e a t e d as s i n u s i t i s .

t h e n spreads t o d e s t r o y t h e b o n y c o n f i n e s o f t h e m a x i l l a r y Late features w i l l d e p e n d o n the d i r e c t i o n o f spread a n d

sinus a n d invades the s u r r o u n d i n g structures. extent o f g r o w t h .

Medial spread t o nasal c a v i t y g i v e s rise t o nasal o b s t r u c -
Clinical Features (Fig. 40.3)
t i o n , d i s c h a r g e a n d epistaxis. I t m a y also s p r e a d i n t o a n t e -
Disease is c o m m o n i n 4 0 - 6 0 age g r o u p w i t h p r e p o n d e r - r i o r a n d p o s t e r i o r e t h m o i d sinuses a n d t h a t is w h y m o s t
ance i n males. a n t r a l m a l i g n a n c i e s are a n t r o e t h m o i d a l i n n a t u r e .

Figure 40.2

F i b r o u s d y s p l a s i a o f m a x i l l a in a 1 3 - y e a r s - o l d g i r l . ( A ) A s seen externally. ( B ) A f t e r r e t r a c t i o n o f t h e lip.

A n t r o e t h m o i d a l c a r c i n o m a left side. N o t e ( A ) Swelling o f left cheek, (B) Expansion o f alveolus and palate.
 Anterior spread causes s w e l l i n g o f t h e c h e e k a n d l a t e r
i n v a s i o n o f the facial s k i n .
Inferior spread causes e x p a n s i o n o f a l v e o l u s w i t h dental
pain, loosening o f teeth, p o o r f i t t i n g o f dentures, ulceration
o f g i n g i v a a n d s w e l l i n g i n the h a r d palate.
Superior spread i n v a d e s t h e o r b i t c a u s i n g p r o p t o s i s , d i p l o -
pia, ocular p a i n and epiphora.
Posterior spread is i n t o p t e r y g o m a x i l l a r y fossa, p t e r y g o i d
plates a n d t h e muscles c a u s i n g t r i s m u s . G r o w t h m a y also
spread t o t h e n a s o p h a r y n x , s p h e n o i d sinus a n d base o f s k u l l .
Intracranial spread can o c c u r t h r o u g h e t h m o i d s , cribri-
f o r m plate o r f o r a m e n l a c e r u m .
Lymphatic spread. N o d a l metastases are u n c o m m o n a n d
o c c u r o n l y i n t h e late stages o f disease. S u b m a n d i b u l a r a n d
u p p e r j u g u l a r n o d e s are e n l a r g e d . M a x i l l a r y a n d e t h m o i d O h n g r e n ' s line extends f r o m m e d i a l c a n t h u s o f eye to the angle

sinuses d r a i n p r i m a r i l y i n t o r e t r o p h a r y n g e a l n o d e s , but o f mandible. Growths anteroinferior to this plane (infrastruc-

tural) have a better prognosis than those posterosuperior to it

t h e s e n o d e s are i n a c c e s s i b l e t o p a l p a t i o n .
(suprastructural).
Systemic metastases are r a r e . M a y be s e e n i n t h e l u n g s
(most c o m m o n l y ) and occasionally i n b o n e .

Diagnosis

Radiograph of sinuses. O p a c i t y o f t h e i n v o l v e d sinus with

expansion and destruction o f the b o n y walls.
CT scan. I f a v a i l a b l e , t h i s is t h e best n o n - i n v a s i v e m e t h o d
t o f i n d t h e e x t e n t o f disease. C T scan s h o u l d b e d o n e b o t h
i n a x i a l a n d c o r o n a l p l a n e s . I t also h e l p s i n t h e s t a g i n g o f
disease.
Biopsy. I f g r o w t h presents i n t h e n o s e o r m o u t h , b i o p s y
c a n b e easily t a k e n . I n e a r l y cases, w i t h s u s p i c i o n o f m a l i g -
n a n c y , sinus s h o u l d b e e x p l o r e d b y C a l d w e l l - L u c o p e r a -
t i o n . D i r e c t v i s u a l i s a t i o n o f t h e site o f t u m o u r i n t h e sinus
also h e l p s i n s t a g i n g o f t h e t u m o u r .
E n d o s c o p y o f t h e nose a n d m a x i l l a r y sinus w i l l p r o v i d e
d e t a i l e d e x a m i n a t i o n . A n a c c u r a t e b i o p s y c a n also b e t a k e n .

Classification
Figure 40.5

T h e r e is n o u n i v e r s a l l y a c c e p t e d c l a s s i f i c a t i o n f o r m a x i l l a r y Lederman's classification.
carcinoma.

Ohngren's classification. A n i m a g i n a r y p l a n e is d r a w n , I n h i s t o p a t h o l o g y , n o t e s h o u l d also b e m a d e o f v a s c u -

extending between m e d i a l canthus o f eye and the lar o r p e r i n e u r a l i n v a s i o n .
angle o f m a n d i b l e (Fig. 4 0 . 4 ) . G r o w t h s situated above Lederman's classification ( F i g . 4 0 . 5 ) . I t uses t w o h o r i -
this plane (suprastructural) have a p o o r e r prognosis z o n t a l l i n e s o f S e b i l e a u ; o n e passing t h r o u g h t h e f l o o r s
than those b e l o w i t (intrastructural). o f orbits and t h e other t h r o u g h floors o f antra, thus
AJCC (American Joint Committee on Cancer) classification. d i v i d i n g t h e area i n t o :
( T a b l e s 4 0 . 1 t o 4 0 . 3 ) . A J C C c l a s s i f i c a t i o n is o n l y f o r (a) Suprastructure: E t h m o i d , sphenoid and frontal
s q u a m o u s cell c a r c i n o m a a n d does n o t i n c l u d e n o n - sinuses a n d t h e o l f a c t o r y area o f n o s e .
epithelial tumours of lymphoid tissue, soft tissue, (b) Mesostructure: M a x i l l a r y sinus a n d t h e respira-
cartilage and bone. Histopathologically, squamous t o r y part o f nose.
c e l l c a r c i n o m a is f u r t h e r g r a d e d i n t o : (c) I n f r a s t r u c t u r e : C o n t a i n i n g a l v e o l a r process. This
(a) W e l l differentiated c l a s s i f i c a t i o n f u r t h e r uses v e r t i c a l l i n e s , e x t e n d i n g
(b) Moderately differentiated and d o w n t h e m e d i a l w a l l s o f o r b i t t o separate e t h m o i d
(c) Poorly differentiated sinuses a n d nasal fossa f r o m t h e m a x i l l a r y sinuses.
 T N M c l a s s i f i c a t i o n a n d s t a g i n g system o f c a n c e r o f m a x i l l a r y sinus

Maxillary sinus
T, T u m o u r l i m i t e d t o m a x i l l a r y sinus m u c o s a w i t h n o erosion o r d e s t r u c t i o n o f b o n e
T 2 T u m o u r c a u s i n g b o n e e r o s i o n o r d e s t r u c t i o n i n c l u d i n g extension i n t o t h e h a r d p a l a t e a n d / o r m i d d l e nasal m e a t u s ,
except extension t o p o s t e r i o r w a l l o f m a x i l l a r y sinus a n d p t e r y g o i d p l a t e s
T, T u m o u r invades any o f t h e f o l l o w i n g : b o n e o f t h e p o s t e r i o r w a l l o f m a x i l l a r y sinus, s u b c u t a n e o u s tissues, f l o o r o r
m e d i a l w a l l o f o r b i t , p t e r y g o i d fossa a n d e t h m o i d sinuses
T 4 a T u m o u r invades a n t e r i o r o r b i t a l c o n t e n t s , skin o f cheek, p t e r y g o i d plates, i n f r a t e m p o r a l fossa, c r i b r i f o r m p l a t e ,
s p h e n o i d o r f r o n t a l sinuses
T 4 b T u m o u r invades any o f t h e f o l l o w i n g : o r b i t a l apex, d u r a , b r a i n , m i d d l e c r a n i a l fossa, c r a n i a l nerves o t h e r t h a n
m a x i l l a r y d i v i s i o n o f t r i g e m i n a l nerve ( V ) , n a s o p h a r y n x o r clivus
;

Regional lymph nodes (N)

N Regional l y m p h n o d e s c a n n o t be assessed
N N o regional l y m p h node metastasis
N, M e t a s t a s i s in a single i p s i l a t e r a l l y m p h n o d e , 3 c m o r less in greatest d i m e n s i o n
N 2 M e t a s t a s i s in a single i p s i l a t e r a l l y m p h n o d e , m o r e t h a n 3 c m b u t n o t m o r e t h a n 6 c m in greatest d i m e n s i o n ; o r i n
m u l t i p l e ipsilateral l y m p h n o d e s , n o n e m o r e t h a n 6 c m in greatest d i m e n s i o n ; o r in b i l a t e r a l o r c o n t r a l a t e r a l l y m p h
nodes, n o n e m o r e t h a n 6 c m in greatest d i m e n s i o n
N 2 a M e t a s t a s i s in a single ipsilateral l y m p h n o d e , m o r e t h a n 3 c m b u t n o t m o r e t h a n 6 c m in greatest d i m e n s i o n
N ; b M e t a s t a s i s in m u l t i p l e i p s i l a t e r a l l y m p h n o d e s , n o n e m o r e t h a n 6 c m in g r e a t e s t d i m e n s i o n
N 2 c M e t a s t a s i s in b i l a t e r a l o r c o n t r a l a t e r a l l y m p h nodes, n o n e m o r e t h a n 6 c m in greatest d i m e n s i o n
N 3 M e t a s t a s i s in a l y m p h n o d e , m o r e t h a n 6 c m in g r e a t e s t d i m e n s i o n

Distant metastasis (M)

M s D i s t a n t metastasis c a n n o t be assessed
M Q N o distant metastasis
M, Distant metastasis

*Source: AJCC, Cancer Staging Manual, fifth ed. Chicago, 2002.

Stage g r o u p i n g o f cancer o f maxillary a n d C l a s s i f i c a t i o n o f c a n c e r o f nasal cavity a n d

e t h m o i d sinuses e t h m o i d sinuses (AJCC, 2 0 0 2 )

Stage 1 T, N D M 0
T, T u m o u r restricted t o any one subsite, w i t h o r
w i t h o u t bony invasion
Stage II T N M 2 0 0

T 2 T u m o u r i n v a d i n g t w o subsites in a single r e g i o n o r
Stage III 3 0 0
e x t e n d i n g t o involve an a d j a c e n t r e g i o n w i t h i n t h e
T N M

T ( orT orT 2 3 with N, M Q

n a s o e t h m o i d a l c o m p l e x , w i t h o r w i t h o u t b o n y invasion
Stage IV A
T 3 T u m o u r extends t o invade the m e d i a l w a l l o r f l o o r o f
T N, M
4 0

t h e o r b i t , m a x i l l a r y sinus, p a l a t e o r c r i b r i f o r m plate
Stage IV B AnyTN 2 M Q

T^ T u m o u r invades a n y o f the f o l l o w i n g : a n t e r i o r o r b i t a l
AnyTN 3 M Q

c o n t e n t s , skin o f nose o r cheek, m i n i m a l extension t o

Stage IV C Any T Any N M 1
a n t e r i o r c r a n i a l fossa, p t e r y g o i d plates, s p h e n o i d o r

Regional lymph nodes and distant m e t a s t a s i s . T h e y are divided

f r o n t a l sinuses
in the usual manner into N ,Q N,, N 2 St N 3 (see page 241) and T T u m o u r invades any o f t h e f o l l o w i n g : o r b i t a l apex,
d b

M , 0 M,.
d u r a , b r a i n , m i d d l e c r a n i a l nerves o t h e r t h a n ( V ) ,2

n a s o p h a r y n x o r clivus

The student may note here that suprastructure and

i n f r a s t r u c t u r e o f L e d e r m a n ' s c l a s s i f i c a t i o n is n o t t h e same
as i n O h n g r e n ' s classification.
F o r squamous cell carcinoma, a combination of radio-
t h e r a p y a n d s u r g e r y g i v e s b e t t e r results t h a n e i t h e r alone.
Treatment
Radiotherapy c a n b e g i v e n b e f o r e o r after s u r g e r y . Very
H i s t o l o g i c a l l y , n a t u r e o f m a l i g n a n c y is i m p o r t a n t i n d e c i d i n g often, a full course o f pre-operative t e l e c o b a l t t h e r a p y is
t h e l i n e o f t r e a t m e n t as is t h e l o c a t i o n a n d e x t e n t o f disease. g i v e n , f o l l o w e d 4—6 w e e k s l a t e r b y s u r g i c a l e x c i s i o n o f t h e
g r o w t h b y t o t a l o r e x t e n d e d m a x i l l e c t o m y (Figs 4 0 . 6 and
Ethmoid Sinus Malignancy
40.7A.B).

E t h m o i d sinuses are o f t e n i n v o l v e d f r o m e x t e n s i o n o f t h e
Prognosis
p r i m a r y g r o w t h s o f the m a x i l l a r y sinus. P r i m a r y g r o w t h o f
Overall, 5-years cure rate of 30% can be expected. e t h m o i d sinuses p e r se are n o t c o m m o n .
H o w e v e r , the present c o n c e p t o f m u l t i m o d a l t r e a t m e n t ,
Clinical Features
i.e. c o m b i n i n g c h e m o t h e r a p y , r a d i a t i o n a n d surgery w i l l
f u r t h e r i m p r o v e t h e results. Early features include nasal obstruction, blood-stained
nasal d i s c h a r g e a n d r e t r o - o r b i t a l p a i n .
L a t e f e a t u r e s are: b r o a d e n i n g o f t h e nasal r o o t , l a t e r a l
displacement o f eyeball and d i p l o p i a (Fig. 40.8). Extension
t h r o u g h c r i b r i f o r m p l a t e m a y cause m e n i n g i t i s .
N o d a l i n v o l v e m e n t is n o t c o m m o n . U p p e r n o d e s m a y
be i n v o l v e d .

Treatment

CT scan is essential t o k n o w t h e e x t e n t o f disease a n d

intracranial spread.
I n e a r l y cases, t r e a t m e n t is p r e - o p e r a t i v e r a d i a t i o n , f o l -
l o w e d b y lateral r h i n o t o m y a n d t o t a l e t h m o i d e c t o m y .
I f c r i b r i f o r m p l a t e is i n v o l v e d , a n t e r i o r c r a n i a l fossa is
exposed b y a neurosurgeon and total exenteration o f the
g r o w t h i n one p i e c e is a c c o m p l i s h e d b y w h a t is c a l l e d
craniofacial resection.

Prognosis
Weber-Fergusson's incision used in maxillectomy.
F i v e - y e a r s - c u r e rate o f a b o u t 3 0 % can b e expected.

A B

(A) Maxillectomy with orbital exenteration on the right side. (B) S a m e patient after rehabilitation w i t h a maxillary prosthesis and an

artificial eye.
 and Paranasal Sinuses

Clinical Features

P a i n a n d s w e l l i n g o f t h e f r o n t a l r e g i o n are t h e p r e s e n t i n g
features. G r o w t h s m a y e r o d e t h r o u g h the f l o o r o f f r o n t a l
s i n u s a n d p r e s e n t as a s w e l l i n g a b o v e t h e m e d i a l c a n t h u s .
G r o w t h s o f f r o n t a l sinus m a y e x t e n d t h r o u g h t h e eth-
m o i d s i n t o t h e o r b i t . D u r a o f a n t e r i o r c r a n i a l fossa m a y
be i n v o l v e d i f g r o w t h penetrates the posterior w a l l o f t h e

Treatment

F r o n t a l s i n u s m a l i g n a n c y is t r e a t e d b y p r e - o p e r a t i v e r a d i a -
t i o n f o l l o w e d b y surgery. Surgery includes f r o n t a l sinusec-
t o m y w i t h e t h m o i d and orbital exenteration. Neurosurgical
a p p r o a c h m a y b e r e q u i r e d t o resect t h e d u r a o f a n t e r i o r
c r a n i a l fossa, i f i n v o l v e d .

Carcinoma ethmoit

Sphenoid Sinus Malignancy

Frontal Sinus Malignancy P r i m a r y m a l i g n a n c y o f t h e sinus is r a r e . I t has t o b e dif-

f e r e n t i a t e d f r o m t h e i n f l a m m a t o r y lesions i n t h i s area. P l a i n
F r o n t a l sinus m a l i g n a n c i e s are u n c o m m o n a n d are seen i n X-rays, C T scan a n d b i o p s y t h r o u g h s p h e n o i d o t o m y are
t h e age g r o u p o f 40—50 years w i t h m a l e predominance essential to know the nature and extent of disease.
(5:1). R a d i o t h e r a p y is t h e m a i n s t a y o f t r e a t m e n t .
Salivary G l a n d s
41. Anatomy o f Oral Cavity 227
42. Common Disorders o f Oral Cavity 229
43. Tumours o f Oral Cavity 236
44. Non-neoplastic Disorders o f Salivary Glands 244
45. Neoplasms o f Salivary Glands 247
A n a t o m y o f O r a l Cavity

4. Retromolar trigone I t is a t r i a n g u l a r area o f m u c o s a

Applied Anatomy
c o v e r i n g a n t e r i o r surface o f t h e a s c e n d i n g ramus of
m a n d i b l e . Its base is p o s t e r i o r t o t h e last m o l a r w h i l e
T h e oral cavity extends f r o m the lips to the o r o p h a r y n g e a l
its a p e x is a d j a c e n t t o t h e t u b e r o s i t y o f m a x i l l a .
i s t h m u s , i . e . u p t o t h e l e v e l o f a n t e r i o r p i l l a r o f t o n s i l s . I t is
5. H a r d palate It forms r o o f o f the oral cavity.
d i v i d e d i n t o t h e f o l l o w i n g sites ( F i g . 4 1 . 1 ) :
6. O r a l t o n g u e O n l y a n t e r i o r t w o - t h i r d s o f t o n g u e are
1. Lips They form anterior boundary of the oral i n c l u d e d i n t h e o r a l c a v i t y . P o s t e r i o r o n e - t h i r d o r base
vestibule. o f t o n g u e is s i t u a t e d b e h i n d t h e c i r c u m v a l l a t e p a p i l l a e
2. Buccal or cheek m u c o s a I t lines t h e i n n e r surface a n d f o r m s p a r t o f t h e o r o p h a i y n x . O r a l t o n g u e is d i v i d e d
o f cheeks a n d lips a n d extends u p to p t e r y g o m a n d i - i n t o t i p , lateral b o r d e r s , d o r s u m a n d t h e u n d e r s u r f a c e .
bular raphe. A n t e r i o r l y , i t extends to the m e e t i n g line 7. Floor of mouth I t is a c r e s c e n t - s h a p e d area b e t w e e n
o f lips. the gingivae and undersurface o f tongue. Anterior
3. Gums (gingivae) They surround the teeth and p o r t i o n o f t h e f l o o r is best seen w h e n p a t i e n t raises t h e
c o v e r the u p p e r a n d l o w e r alveolar ridges. t i p o f t o n g u e t o t o u c h t h e h a r d palate. F r e n u l u m a n d

Figure 41.1

V a r i o u s sites in o r a l cavity.
Diseases of O r a l Cavity and Salivary G l a n d s

sublingual papillae w i t h openings of submandibular L i n g u a l aspect o f u p p e r a l v e o l u s d r a i n s i n t o u p p e r

d u c t s c a n b e easily seen. L a t e r a l p o r t i o n o f floor of d e e p c e r v i c a l a n d lateral r e t r o p h a r y n g e a l n o d e s .
m o u t h is best seen b y d i s p l a c i n g t h e l a t e r a l surface o f L i n g u a l aspect o f l o w e r a l v e o l u s d r a i n s i n t o sub-
tongue i n medial d i r e c t i o n w i t h the help o f a tongue mandibular nodes.
depressor. 4. H a r d palate U p p e r deep cervical a n d lateral r e t r o -
p h a r y n g e a l n o d e s . A n t e r i o r p a r t o f palate d r a i n s i n t o
submandibular nodes.
m Lymphatic Drainage of Oral Cavity H
5. Floor of mouth A n t e r i o r p o r t i o n o f floor o f m o u t h
1. Lips Lower. M e d i a l p o r t i o n o f l o w e r h p drains i n t o drains i n t o s u b m a n d i b u l a r nodes. L y m p h a t i c s from
s u b m e n t a l a n d lateral p o r t i o n t o s u b m a n d i b u l a r nodes. t h i s area also cross t h e m i d l i n e .
Upper. D r a i n into preauricular, infraparotid and sub- Posterior p o r t i o n drains i n t o u p p e r deep cervical
m a n d i b u l a r nodes. nodes.
2. Buccal mucosa Submental and submandibular 6. Tongue T i p o f tongue drains i n t o s u b m e n t a l and
nodes. jugulo-omohyoid nodes; lateral p o r t i o n drains i n t o
3. U p p e r and lower alveolar ridges B u c c a l aspect o f ipsilateral, s u b m a n d i b u l a r and deep cervical nodes.
mucosa drains into submental and submandibular Central p o r t i o n a n d base d r a i n i n t o d e e p cervical
nodes. n o d e s o f b o t h sides.
C o m m o n Disorders o f O r a l Cavity

Herpetic gingivostomatitis Also k n o w n as o r o l a b i a l

Ulcers of O r a l Cavity
h e r p e s . I t is c a u s e d b y h e r p e s s i m p l e x v i r u s a n d is o f t w o
types: p r i m a r y a n d secondary.
S o m e o f t h e c o m m o n u l c e r s are d e s c r i b e d i n t h i s c h a p t e r .
The causes o f t h e ulcers o f oral cavity are listed i n T h e primary infection affects c h i l d r e n a n d is c h a r a c t e r i s e d

Table 42.1. b y clusters o f m u l t i p l e vesicles w h i c h s o o n r u p t u r e t o f o r m

ulcers. Any part o f the oral cavity may be affected.
C o n s t i t u t i o n a l s y m p t o m s l i k e f e v e r , malaise a n d h e a d a c h e
1. Infection m a y a c c o m p a n y sore t h r o a t a n d l y m p h a d e n o p a t h y .
Secondary or recurrent h e r p e s c h i e f l y affects a d u l t s . I t is
Viral milder i n form as a d u l t s h a v e some i m m u n i t y to this

Herpangina I t is a c o x s a c k i e v i r a l i n f e c t i o n m o s t l y a f f e c t - virus. M o s t c o m m o n l y , it involves the v e r m i l i o n b o r d e r

i n g c h i l d r e n . T o b e g i n w i t h , m u l t i p l e s m a l l vesicles a p p e a r o f t h e l i p ( h e r p e s l a b i a l i s ) b u t less o f t e n l e s i o n s appear

o n the faucial pillars, tonsils, soft palate a n d u v u l a . They i n t r a o r a l f y o n t h e h a r d palate a n d g i n g i v a . I n r e c u r r e n t

r u p t u r e t o f o r m u l c e r s w h i c h are u s u a l l y 2 - 4 m m i n size, herpes, i t is p r e s u m e d t h a t v i r u s lies dormant in the

h a v e a y e l l o w base a n d r e d a r e o l a a r o u n d t h e m . T h e y s e l - t r i g e m i n a l g a n g l i o n a n d , w h e n reactivated, travels a l o n g

d o m persist b e y o n d o n e w e e k . peripheral sensory nerves to involve oropharyngeal

mucosa. P r e c i p i t a t i n g factors i n c l u d e e m o t i o n a l stress,
fatigue, fever, pregnancy or i m m u n e deficiency states.
Table 42.1 Causes o f ulcers o f t h e o r a l c a v i t y
Treatment is m o s t l y s y m p t o m a t i c . A c y c l o v i r , 2 0 0 m g ,
1. Infections f i v e t i m e s a d a y f o r 5 days h e l p s t o c u t d o w n t h e course
(i) V i r a l : H e r p a n g i n a ; herpes s i m p l e x ( p r i m a r y a n d o f r e c u r r e n t herpes labialis.
s e c o n d a r y ) ; h a n d , f o o t a n d m o u t h disease
H a n d , foot and m o u t h disease I t is also a v i r a l i n f e c -
( i i ) B a c t e r i a l : V i n c e n t ' s i n f e c t i o n , T B , syphilis
(iii) Fungal: Candidiasis t i o n a f f e c t i n g c h i l d r e n . O r a l l e s i o n s are seen o n t h e p a l a t e ,

2. Immune disorders: A p h t h o u s ulcer, Behcet's s y n d r o m e t o n g u e a n d b u c c a l m u c o s a . V e s i c l e s also d e v e l o p o n t h e

3. Trauma s k i n o f hands, feet a n d sometimes b u t t o c k s .

(i) Physical: Cheek b i t e , j a g g e d t o o t h , i l l - f i t t i n g
denture Bacterial
(ii) C h e m i c a l : Silver n i t r a t e , p h e n o l , a s p i r i n b u r n s
Vincent's infection (Acute necrotising ulcerative gingivitis).
( i i i ) T h e r m a l : H o t f o o d o r f l u i d , reverse s m o k i n g
4. Neoplasms I t is s i m i l a r t o V i n c e n t ' s a n g i n a . C a u s a t i v e o r g a n i s m s are

5. Skin disorders: Erythema m u l t i f o r m e , lichen planus, t h e s a m e (a f u s i f o r m b a c i l l u s a n d a s p i r o cha etc —Borrelia

B M M P , bullous p e m p h i g o i d , lupus erythematosus vincentii). M o r e o f t e n t h e disease affects y o u n g a d u l t s a n d

6. Blood disorders: Leukaemia, agranulocytosis, m i d d l e - a g e d persons. I t starts at t h e i n t e r d e n t a l p a p i l l a e
p a n c y t o p e n i a , cyclic n e u t r o p e n i a , sickle cell a n a e m i a a n d t h e n spreads t o f r e e m a r g i n s o f t h e g i n g i v a e w h i c h g e t
7. Drugallergy: M o u t h washes, t o o t h paste, etc. c o v e r e d w i t h n e c r o t i c s l o u g h . G i n g i v a e also b e c o m e r e d
R e a c t i o n s t o systemic d r u g s and oedematous. Similar ulcer and necrotic membrane
8. Vitamin deficiencies
m a y also f o r m o v e r t h e t o n s i l (Vincent's angina). Diagnosis
9. Miscellaneous: Radiation mucositis, cancer
is m a d e b y s m e a r f r o m t h e a f f e c t e d area. T r e a t m e n t is
chemotherapy, diabetes mellitus, uraemia
systemic antibiotics (penicillin or erythromycin and
Diseases of O r a l Cavity and Salivary G l a n d s

metronidazole), frequent mouth washes {with sodium

bicarbonate solution) a n d a t t e n t i o n to dental h y g i e n e .

Specific bacterial infections. Tuberculosis, syphilis and

a c t i n o m y c o s i s m a y p r e s e n t as c h r o n i c u l c e r s .

Fungal

Moniliasis (candidiasis)
a n d occurs i n t w o forms:

(a) Thrush.
I t is c a u s e d b y Candida

I t appears as w h i t e g r e y p a t c h e s o n t h e o r a l
albicans,

0a K
m u c o s a a n d t o n g u e . W h e n w i p e d o f f , t h e y leave an
e r y t h e m a t o u s m u c o s a . T h e c o n d i t i o n is seen i n i n f a n t s
a n d c h i l d r e n . A d u l t s are also a f f e c t e d w h e n t h e y are
suffering f r o m systemic m a l i g n a n c y a n d diabetes or
taking broad spectrum antibiotics, cytotoxic drugs,
steroids o r r a d i a t i o n .
(b) Chronic hypertrophic candidiasis. A l s o c a l l e d candidal leu-
koplakia. The l e s i o n appears as w h i t e p a t c h which Figure 42.1
c a n n o t b e w i p e d o f f M o s t l y affects a n t e r i o r b u c c a l
Multiple aphthous ulcers on the uvula and faucial pillars
mucosa j u s t b e h i n d the angle o f m o u t h .
(arrowheads).

T h r u s h can be treated b y topical application o f nystatin

o r clotrimazole. H y p e r t r o p h i c f o n n usually requires e x c i -
cavity, (ii) genital ulcerations and (iii) uveitis. T h e edge o f
sional surgery.
t h e u l c e r is c h a r a c t e r i s t i c a l l y p u n c h e d o u t . T h e r e m a y also
be lesions o f t h e s k i n , j o i n t s a n d c e n t r a l n e r v o u s s y s t e m .
2. I m m u n e Disorders

| 3. T r a u m a J
Aphthous ulcers They are recurrent and superficial,
usually i n v o l v i n g m o v a b l e mucosa, i . e . i n n e r surfaces of
l i p s , b u c c a l m u c o s a , t o n g u e , floor o f m o u t h a n d s o f t p a l - Traumatic ulcer A t r a u m a t i c ulcer o n the lateral b o r d e r
ate, w h i l e s p a r i n g m u c o s a o f t h e h a r d palate a n d g i n g i v a e . o f t o n g u e m a y be due to j a g g e d t o o t h o r i l l - f i t t i n g d e n -
In the minor form, which is m o r e common, ulcers arc ture; o n the buccal mucosa due to cheek bite; a n d o n the
2 - 1 0 m m i n size a n d m u l t i p l e w i t h a c e n t r a l n e c r o t i c area palate d u e t o i n j u r y w i t h a f o r e i g n o b j e c t s u c h as p e n c i l o r
and a red halo (Fig. 42.1). T h e y heal i n about 2 weeks t o o t h brush (Fig. 42.2).
w i t h o u t l e a v i n g a scar. I n t h e major form, u l c e r is v e r y b i g , S i m i l a r l y , acute u l c e r a t i v e lesions o f o r a l a n d o r o p h a -
2 - 4 c m i n size, a n d heals w i t h a scar b u t is s o o n f o l l o w e d ryngeal mucosa can result f r o m accidental ingestion of
by another ulcer. acids o r alkalies o r h o t fluids.
A e t i o l o g y o f a p h t h o u s u l c e r s is u n k n o w n . I t m a y b e a n Aspirin burn is seen i n t h e b u c c a l sulcus w h e n a t a b l e t o f
a u t o i m m u n e process, n u t r i t i o n a l d e f i c i e n c y ( v i t a m i n B ,
1 2
a s p i r i n is k e p t against a p a i n f u l t o o t h t o g e t r e l i e f f r o m
folic acid and i r o n ) , viral or bacterial i n f e c t i o n , f o o d aller- toothache.
gies o r d u e t o h o r m o n a l c h a n g e s o r stress.
A p h t h o u s ulcers c a n b e d i f f e r e n t i a t e d f r o m v i r a l u l c e r s
J 4. Neoplasms ~~^|
by their frequent recurrence, involvement of movable
m u c o s a as o n t h e soft p a l a t e o r c h e e k , a n d t h e absence o f
M a l i g n a n c i e s o f the oral cavity o r o r o p h a r y n x m a y present
c o n s t i t u t i o n a l s y m p t o m s l i k e fever, malaise a n d enlarge-
as c h r o n i c u l c e r s . T h o u g h m o s t c o m m o n l y i t is s q u a m o u s
m e n t o f cervical nodes.
c e l l c a r c i n o m a , i t c o u l d be c a r c i n o m a o f m i n o r salivary
T r e a t m e n t consists o f t o p i c a l a p p l i c a t i o n o f s t e r o i d s a n d
glands o r n o n - H o d g k i n ' s l y m p h o m a .
cauterisation with 10% silver nitrate. I n severe cases,
2 5 0 m g o f t e t r a c y c l i n e d i s s o l v e d i n 5 0 m l o f w a t e r is g i v e n
as m o u t h r i n s e a n d t h e n t o b e s w a l l o w e d , f o u r t i m e s a d a y . ^ 5. Skin Disorders [
L o c a l p a i n can b e r e l i e v e d w i t h l i g n o c a i n e v i s c o u s .

Behcet's syndrome {Oculo-oro-genital syndrome) I t is c h a r - (i) E r y t h e m a multiforme I t is a disease o f r a p i d o n s e t

acterised b y a t r i a d o f (i) a p h t h o u s - l i k e ulcers i n t h e o r a l involving the skin and mucous membranes, either of
 C o m m o n Disorders o f O r a l Cavity

Figure 42.2

Ulcer on lateral border o f tongue simulating carcinoma (arrowheads). It w a s caused by a sharp jagged tooth (A) and healed c o m -

pletely following t o o t h extraction (B).

w h i c h m a y b e i n v o l v e d a l o n e . T h e a e t i o l o g y is u n k n o w n p a p u l e s . T h e y are seen o n t h e f o r e a r m s a n d m e d i a l side o f

b u t m a y b e associated w i t h d r u g a l l e r g y ( s u l p h o n a m i d e s ) t h i g h . O r a l lesions o c c u r s i n t w o f o r m s :
o r r e c e n t herpes s i m p l e x i n f e c t i o n . O r a l m u c o s a l lesions
c o n s i s t o f vesicles o r b u l l a e w h i c h s o o n r u p t u r e t o f o r m (a) Reticular: W h i t e striae f o r m i n g l a c e - l i k e p a t t e r n are

u l c e r s c o v e r e d w i t h p s e u d o m e m b r a n e . A n y area o f o r a l seen o n t h e b u c c a l m u c o s a o n b o t h sides. T h e y are

m u c o s a is i n v o l v e d b u t t h e c o m m o n sites are l i p s , b u c c a l asymptomatic and require no treatment.

m u c o s a a n d t o n g u e . T h e l e s i o n s b l e e d easily. T h e d i s t i n c - (b) Erosive: I t is c h a r a c t e r i s e d b y p a i n f u l u l c e r a t i o n o n t h e

t i v e f e a t u r e is t o f o r m h a e m o r r h a g i c crusts o n t h e l i p s . b u c c a l mucosa, g i n g i v a o r lateral t o n g u e . Each ulcer

S k i n lesions consist o f e r y t h e m a t o u s patches o n t h e palms, is s u r r o u n d e d b y a k e r a t o t i c p e r i p h e r y . T r e a t m e n t

soles a n d e x t e n s o r surfaces o f t h e e x t r e m i t i e s . O r a l l e s i o n s consists o f t o p i c a l s t e r o i d s .

may o c c u r w i t h o u t skin i n v o l v e m e n t i n 2 5 % o f patients. (v) C h r o n i c d i s c o i d l u p u s e r y t h e m a t o s u s O r a l lesions

T h e disease is s e l f - l i m i t i n g a n d m a n a g e m e n t is m a i n l y s u p - are a l m o s t a l w a y s associated w i t h s k i n lesions. O r a l lesions
p o r t i v e . S t e r o i d s are u s e d t o t r e a t t h e severe f o r m . are s i m i l a r t o t h o s e o f e r o s i v e f o r m o f l i c h e n p l a n u s .

(ii) Pemphigus vulgaris I t is a n a u t o i m m u n e d i s o r d e r

a f f e c t i n g o l d e r age g r o u p (50—70). O r a l l e s i o n s are s e e n i n
5 0 % o f t h e cases a n d m a y p r e c e d e s k i n l e s i o n s . 6. B l o o d Disorders

O r a l u l c e r a t i o n s are s u p e r f i c i a l a n d i n v o l v e p a l a t e , b u c -
cal m u c o s a a n d t o n g u e . T r e a t m e n t consists of systemic B l o o d dyscrasias cause u l c e r a t i o n s i n t h e o r a l c a v i t y a n d

steroids a n d c y t o t o x i c drugs. p h a r y n x . D u e t o l a c k o f defence m e c h a n i s m , e.g. g r a n u l o -

cytes, i n f e c t i o n s q u i c k l y s u p e r v e n e c a u s i n g u l c e r s . Acute
(iu) Benign mucous membrane pemphigoid
leukaemia is m a i n l y o f 2 t y p e s - a c u t e l y m p h o b l a s t i c t y p e ,
(BMMP) I t is also an a u t o i m m u n e d i s o r d e r . Mucosal
w h i c h occurs i n y o u n g c h i l d r e n a n d acute m y e l o i d t y p e ,
l e s i o n s i n v o l v e c h e e k , g i n g i v a e a n d p a l a t e . C o n j u n c t i v a is
o c c u r r i n g i n t h e m i d d l e - a g e d o r t h e e l d e r l y . B o t h cause
t h e n e x t i m p o r t a n t site. L e s i o n starts as a b u l l a f i l l e d w i t h
hypertrophy of gums with ulceration and bleeding.
clear o r h a e m o r r h a g i c f l u i d w h i c h r u p t u r e s t o f o r m s u p e r -
Agranulocytosis is c h a r a c t e r i s e d b y u l c e r a t i o n s i n t h r o a t w i t h
ficial u l c e r a t i o n c o v e r e d w i t h shaggy collapsed mucosa.
severe n e u t r o p e n i a . Cyclical neutropenia is a c o n d i t i o n w i t h
Skin lesions may be absent. Treatment consists of
p e r i o d i c falls i n n e u t r o p h i l c o u n t w h e n t h e p e r s o n b e c o m e s
steroids.
p r o n e to infections and oral ulceration. I n pancytopenia,
(iv) L i c h e n planus O r a l lesions are seen w i t h o r w i t h o u t there is a d r o p i n RJ3C count, white cell c o u n t and
s k i n lesions. S k i n l e s i o n s are p r u r i t i c , p u r p l e , p o l y g o n a l platelets.
Diseases of O r a l Cavity and Salivary G l a n d s

When suspected, b l o o d dyscrasias are i n v e s t i g a t e d by h y d r o g e n p e r o x i d e a n d i m p r o v i n g the general n u t r i t i o n a l

peripheral b l o o d f i l m , b l o o d counts, and bone marrow status o f the patient by v i t a m i n s . Causative factors, if
aspiration. k n o w n , s h o u l d be r e m o v e d .

Fissured tongue I t m a y b e c o n g e n i t a l o r seen i n cases o f

syphilis, deficiency of vitamin B complex or anaemia.
^ 7. D r u g Allergy J
Congenital f i s s u r i n g associated facial palsy is seen in
Melkersson-Rosenthal syndrome.
Systemic administration o f drugs l i k e p e n i c i l l i n , tetracy-
c l i n e , s u l p h a d r u g s , b a r b i t u r a t e s , p h e n y t o i n , etc. m a y cause Ankyloglossia ( t o n g u e tie) ( F i g . 42.4) True tongue
erosive, vesicular o r b u l l o u s lesions i n the oral cavity. tie w h i c h p r o d u c e s s y m p t o m s is u n c o m m o n . I f t o n g u e
Contact stomatitis may occur due to local reaction to c a n b e p r o t r u d e d b e y o n d t h e l o w e r i n c i s o r s , i t is u n l i k e l y
m o u t h w a s h e s , l o z e n g e s , c h e w i n g g u m , t o o t h pastes o r t o t o cause s p e e c h d e f e c t s . A m o b i l e t o n g u e is i m p o r t a n t t o
prosthetic d e n t a l m a t e r i a l s . O r a l lesions may vary from m a i n t a i n o r o d e n t a l h y g i e n e — t o clean the debris and p r e -
e r y t h e m a t o vesicles a n d b u l l a e f o r m a t i o n . v e n t f o r m a t i o n o f dental plaques. T r e a t m e n t o f any sig-
n i f i c a n t t o n g u e t i e is transverse release a n d v e r t i c a l c l o s u r e .
T h i n m u c o s a l f o l d s c a n be s i m p l y i n c i s e d .
8. V i t a m i n Deficiencies

9. Miscellaneous

Radiation mucositis. It follows radiation o f oral cavity or

o r o p h a r y n x f o r cancer. A t first, t h e m u c o s a b e c o m e s r e d
a n d t h e n f o r m s s p o t t y areas o f m u c o s i t i s w h i c h coalesce t o
f o r m l a r g e u l c e r a t e d areas c o v e r e d b y s l o u g h .
M u c o s i t i s o f cancer c h e m o t h e r a p y can be caused b y
drugs l i k e m e t h o t r e x a t e , 5 - F U a n d b l e o m y c i n . I t manifests
as e r y t h e m a , o e d e m a a n d u l c e r a t i o n .

MISCELLANEOUS LESIONS OF TONGUE

AND ORAL CAVITY
Figure 42.3

Geographical tongue.
Median rhomboid glossitis I t is r e d r h o m b o i d area,
d e v o i d o f p a p i l l a e , seen o n t h e d o r s u m o f t o n g u e i n f r o n t
o f f o r a m e n c a e c u m . I t is a d e v e l o p m e n t a l a n o m a l y that
o c c u r s due t o p e r s i s t e n c e o f t u b e r c u l u m i m p a r , w h i c h fails
t o i n v a g i n a t e . R e c e n t studies reveal this c o n d i t i o n t o be
d u e t o c h r o n i c Candida i n f e c t i o n . T h e c o n d i t i o n is a s y m p -
t o m a t i c a n d n o t r e a t m e n t is necessary.

Geographical tongue I t is c h a r a c t e r i s e d by erythema-

t o u s areas, d e v o i d o f p a p i l l a e , s u r r o u n d e d b y an i r r e g u l a r
keratotic white outline (Fig. 42.3). The lesions keep
c h a n g i n g t h e i r shape a n d h e n c e t h e c o n d i t i o n is also c a l l e d
" m i g r a t o r y g l o s s i t i s " . T h e c o n d i t i o n is a s y m p t o m a t i c a n d
m a y n o t require any treatment.

Hairy tongue D u e t o excessive formation o f keratin, the

filiform papillae o n the d o r s u m o f the t o n g u e become
elongated. They get c o l o u r e d , b r o w n or black, due to
c h r o m o g e n i c b a c t e r i a a n d l o o k l i k e h a i r . S m o k i n g seems Figure 42.4
t o b e o n e o f t h e f a c t o r s . T r e a t m e n t consists o f s c r a p i n g the
Tongue tie.
lesions with a t o n g u e c l e a n e r , a p p l i c a t i o n o f h a l f - s t r e n g t h
 C o m m o n Disorders o f O r a l Cavity

Fordyce's spots They are aberrant sebaceous glands 6. Immune process. OSF is c o n s i d e r e d a cell-mediated
present under the buccal or labial mucosa and shine i m m u n e r e a c t i o n t o a r e c o l i n e i n areca n u t s . I t m a y
t h r o u g h i t as y e l l o w i s h o r y e l l o w - b r o w n spots. T h e y are also r e f l e c t a l o c a l i z e d c o l l a g e n d i s o r d e r o r a n a u t o -
seen w i t h e q u a l f r e q u e n c y i n b o t h m a l e s a n d f e m a l e s a n d i m m u n e process i n t h e o r a l c a v i t y .
are c o n s i d e r e d n o r m a l . 7. Multifactorial. Several factors m a y operate t o g e t h e r i n
the causation o f OSF. Habit of betel-nut chewing,
Nicotine stomatitis T h i s d i s o r d e r is seen i n smokers
d r i n k i n g or s m o k i n g tobacco coupled w i t h dietary
p a r t i c u l a r l y t h o s e i n t h e h a b i t o f r e v e r s e s m o k i n g . Palatal
deficiencies m a y have synergistic effect.
m u c o s a s h o w s p i n - p o i n t r e d spots i n t h e c e n t r e o f u m b i l i -
c a t e d p a p u l a r l esions. T h e y are d u e t o i n f l a m m a t i o n o f t h e
m i n o r s a l i v a r y g l a n d s a n d t h e i r d u c t o p e n i n g s as a r e a c t i o n J ~~ Pathogenesis
t o t h e h e a t o f t h e s m o k e . T h e n i c o t i n e s t o m a t i t i s is a m i s -
n o m e r as n i c o t i n e is n o t t h e cause. M a n a g e m e n t is e l i m i - H i s t o p a t h o l o g y i n early cases o f O S F s h o w s presence of
nation o f smoking. p o l y m o r p h o n u c l e a r leukocytes, eosinophils and a f e w l y m -
p h o c y t e s w h i l e a d v a n c e d cases s h o w l y m p h o c y t e s a n d plasma
cells. I m m u n o c h e m i s t r y o f i n f l a m m a t o r y cells s h o w e d h i g h e r
SUBMUCOUS FIBROSIS population of activated T-lymphocytes especially the
T-helper/inducer lymphocytes but minor population of
B-cells a n d macrophages. L a t e r studies also s h o w e d s i g n i f i -
O r a l s u b m u c o u s fibrosis (OSF) is a c h r o n i c i n s i d i o u s p r o -
c a n t increase i n n u m b e r o f T - l y m p h o c y t e s , macrophages
cess c h a r a c t e r i s e d b y j u x t a - e p i t h e l i a l d e p o s i t i o n o f f i b r o u s
and high C D 4 + to C D 8 + l y m p h o c y t e ratio i n the subepi-
tissue i n t h e o r a l c a v i t y a n d p h a r y n x . T h e c o n d i t i o n w a s
thelial connective tissue s u g g e s t i n g t h a t O S F is a c e l l u l a r
first described i n I n d i a b y J o s h i i n 1953. The disease is
i m m u n e response. S m a l l n u m b e r o f B - l y m p h o c y t e s suggests
w i d e l y seen i n I n d i a , P a k i s t a n , T a i w a n , S r i L a n k a , N e p a l
m i n o r r o l e o f h u m o r a l i m m u n i t y i n O S F . I n a d v a n c e d stages,
and Thailand due to habit o f betel-nut chewing.
t h e r e was severe fibrosis a n d loss o f v a s c u l a r i t y i n t h e l a m i n a
p r o p r i a a n d s u b m u c o s a . T h e process m a y e x t e n d d e e p e r i n t o
m u s c l e layers also. A c t i v a t e d m a c r o p h a g e s a n d T - l y m p h o c y t e s
Aetiology
p r o d u c e f i b r o g e n i c c y t o k i n e s w h i c h act o n mesenchymal
cells t o p r o d u c e f i b r o s i s . A l s o c e r t a i n c y t o k i n e s l i b e r a t e d b y
1. Socio-economic status. In India poor socio-economic
T - l y m p h o c y t e s u p r e g u l a t e synthesis o f c o l l a g e n b u t d o w n -
status has b e e n associated w i t h h i g h e r risk o f p r e c a n -
r e g u l a t e coUagenase p r o d u c t i o n f u r t h e r p r o m o t i n g f i b r o s i s .
c e r o u s lesions l i k e l e u k o p l a k i a , e r y t h r o p l a k i a a n d s u b -
I t is t h u s b e l i e v e d t h a t O S F is d u e t o increased p r o d u c t i o n o f
mucous f i b r o s i s . T h i s is r e l a t e d t o e d u c a t i o n , diet,
c o l l a g e n a n d its decreased d e g r a d a t i o n i n s u b e p i t h e l i a l layers
l i f e - s t y l e a n d access t o m e d i c a l c a r e .
o f the oral mucosa (Fig. 42.5).
2. Tobacco chewing. I t is a m a j o r risk f a c t o r i n s u b m u c o u s
fibrosis as it is in lesions of leukoplakia and
erythroplakia.
J Pathology |
3. Areca nuts. A r e c a n u t s are c h e w e d a l o n e , w i t h t o b a c c o
o r i n t h e f o r m of pan (containing l i m e , catechu and
T h e basic c h a n g e is f i b r o e l a s t o t i c t r a n s f o r m a t i o n o f c o n -
o t h e r ingredients o n a betel leaf). B e t e l q u i d w i t h o u t
n e c t i v e tissues i n l a m i n a p r o p r i a associated w i t h e p i t h e l i a l
t o b a c c o also increases t h e risk o f o r a l p r e c a n c e r o u s
a t r o p h y , sometimes p r e c e d e d b y vesicle f o r m a t i o n . I n later
lesions, b u t causes h i g h e r r i s k f o r o r a l submucous
stages, w h e n f i b r o s i s is m a r k e d , t h e r e is p r o g r e s s i v e t r i s m u s
fibrosis relative t o l e u k o p l a k i a , e r y t h r o p l a k i a o r m u l -
and difficulty to p r o t r u d e the tongue.
t i p l e p r e c a n c e r o u s lesions. International agency for
L e u k o p l a k i a a n d s q u a m o u s c e l l c a r c i n o m a m a y b e asso-
r e s e a r c h o n c a n c e r has classified b e t e l q u i d without
ciated w i t h s u b m u c o u s fibrosis possibly because o f c o m -
t o b a c c o also as a c a r c i n o g e n f o r h u m a n s .
m o n aetiological factors i n v o l v e d .
4. Alcohol. I t is o b s e r v e d t h a t d r i n k i n g increases t h e risk
I t is a p r e m a l i g n a n t c o n d i t i o n a n d m a l i g n a n t t r a n s f o r -
o f leukoplakia b y 1.5-fold, O S F b y 2 - f o l d a n d that o f
m a t i o n has b e e n seen i n 3—7.6% o f cases.
erythroplakia by 3-fold.
5. Nutritional. Deficiency o f vitamins and micronutrients
has b e e n s u g g e s t e d . T h e r a p y o f O S F w i t h v i t a m i n A , Clinical Features
zinc and antioxidants has shown some beneficial
e f f e c t . Lesser i n t a k e o f f r u i t s a n d v e g e t a b l e s has b e e n Age and s e x N o age o r sex is i m m u n e b u t t h e disease
associated w i t h o r a l p r e m a l i g n a n t l e s i o n s . m o s t l y affects age g r o u p o f 20—40.
Diseases o f O r a l Cavity and Salivary G l a n d s

Symptoms P a t i e n t o f t e n presents w i t h : 3. R e p e a t e d v e s i c u l a r e r u p t i o n o n t h e palate a n d p i l l a r s .

4. D i f f i c u l t y to open the m o u t h fully.
1. I n t o l e r a n c e to chillies and spicy f o o d .
5. D i f f i c u l t y to p r o t r u d e the tongue.
2. Soreness o f m o u t h w i t h c o n s t a n t b u r n i n g sensation;
w o r s e n e d d u r i n g meals p a r t i c u l a r l y o f p u n g e n t s p i c y Findings C h a n g e s o f s u b m u c o u s f i b r o s i s are m o s t m a r k e d
type. o v e r (i) s o f t p a l a t e , ( i i ) f a u c i a l p i l l a r s a n d ( i i i ) b u c c a l m u c o s a
(Fig. 42.6). I n i n i t i a l stages, t h e r e is p a t c h y redness of

Areca nui chewing mucous membrane with formation o f vesicles w h i c h r u p -

Activated T-lymphocytes
Reduced production of
antifibrotic cytokines
I
Collection of activated T-lymphocytes
t u r e to f o r m superficial ulcers.
I n l a t e r stages, w h e n f i b r o s i s d e v e l o p s i n t h e s u b m u c o s a l
l a y e r s , t h e r e is b l a n c h i n g o f m u c o s a w i t h loss o f s u p p l e -
and macrophages in subepithelial
layers of oral mucosa ness. F i b r o t i c bands c a n b e seen a n d f e l t i n t h e affected
areas. F i b r o s i s a n d s c a r r i n g has also b e e n d e m o n s t r a t e d i n
the u n d e r l y i n g muscle leading to f u r t h e r restrictive m o b i l -
i t y o f s o f t p a l a t e , t o n g u e a n d j a w . T r i s m u s is p r o g r e s s i v e ,
Macrophages
so m u c h so t h a t p a t i e n t m a y n o t b e able t o p u t h i s f i n g e r
i n t h e m o u t h o r b r u s h his t e e t h . O r o d e n t a l h y g i e n e is
affected badly a n d teeth b e c o m e carious. E x a m i n a t i o n o f
Increased production of o r a l c a v i t y is d i f f i c u l t p a r t i c u l a r l y t o r u l e o u t o t h e r a s s o c i -
fibrinogenic cytokines
ated p r e m a l i g n a n t lesions o r m a l i g n a n c y .
Act on

Less collagenase Mesenchymal cells

| Treatment J

1 Medical
Proliferation of fibroblasts
1. Steroids: T o p i c a l i n j e c t i o n o f steroids i n t o the affected
area is m o r e e f f e c t i v e t h a n t h e i r s y s t e m i c use as i t also
Increased production of collagen has t h e a d v a n t a g e o f f e w e r side effects. It may be
c o m b i n e d w i t h hylase. D e x a m e t h a s o n e 4 m g (1 m l )
Figure 42.5
c o m b i n e d w i t h h y l a s e , 1 5 0 0 I . U . i n o n e m l is i n j e c t e d
Cellular i m m u n e response t o areca n u t s in o r a l s u b m u c o u s i n t o t h e a f f e c t e d area b i w e e k l y f o r 8—10 w e e k s . T h i s
fibrosis a n d possible pathogenesis. (Based o n CP C h i a n g et a l . brings m a r k e d i m p r o v e m e n t i n s y m p t o m s a n d relieves
in O r a l O n c o l o g y 2 0 0 2 ; 3 8 : 5 6 - 6 3 . ) trismus.

Figure 42.6

S u b m u c o u s fibrosis. ( A ) N o t e the b l a n c h e d appearance o f the s o f t palate a n d faucial pillars. ( B ) M a r k e d t r i s m u s d u e t o s u b m u c o u s

fibrosis.
 Common Disorders of Oral Cavity

2. A v o i d i r r i t a n t f a c t o r s , e . g . areca n u t s , p a n , t o b a c c o , 3. Nasolabial flaps. T h e y are s m a l l t o c o v e r t h e defect

p u n g e n t f o o d s , etc. c o m p l e t e l y , cause f a c i a l scar a n d r e q u i r e d i v i s i o n of
3. T r e a t existent anaemia o r v i t a m i n deficiencies. flaps at s e c o n d stage.
4. E n c o u r a g e j a w o p e n i n g exercises. 4. Island palatal inucoperiosteal flap. I t is b a s e d o n g r e a t e r
palatine artery. Possible only in selected cases.
Surgical R e q u i r e s e x t r a c t i o n o f 2 n d m o l a r f o r t h e flap t o sit
w i t h o u t t e n s i o n . N o t s u i t a b l e f o r b i l a t e r a l cases.
I t is i n d i c a t e d i n a d v a n c e d cases t o r e l i e v e t r i s m u s . V a r i o u s
5. Bilateral radial forearm free flap. I t is b u l k y a n d h a i r -
s u r g i c a l t e c h n i q u e s u s e d are:
bearing. M a y require debulking procedure, 3 r d molar
1. Simple release of fibrosis and skin grafting. T h e r e is h i g h may require extraction.
r e c u r r e n c e rate d u e t o g r a f t c o n t r a c t u r e . 6. Surgical excision and buccal fat pad graft.
2. Bilateral tongue flaps. R e q u i r e s f l a p d i v i s i o n at a s e c o n d 7. Superficial temporal fascia flap and split skin graft.
stage. 8. Coronoidectomy and temporal muscle myotomy.
T u m o u r s o f O r a l Cavity

Classification A n i n f e c t e d h a e m a n g i o m a m a y be d i f f i c u l t t o d i f f e r e n t i a t e
f r o m a p y o g e n i c g r a n u l o m a . H a e m a n g i o m a s t h a t are large
a n d persistent o r diose w h i c h c o n t i n u e t o g r o w are p r o b l e m -
T h e t u m o u r s o f o r a l c a v i t y c a n b e classified as f o l l o w s :
atic. U s e o f c r y o s u r g e r y o r laser is n o t possible i n large diffuse
I. Benign tumours
lesions. Sclerotherapy has also n o t b e e n found effective.
(a) Solid
However, m i c r o e m b o l i s a t i o n a l o n e o r as a p r e - o p e r a t i v e
(b) Cystic
a d j u n c t t o s u r g e r y has b e e n f o u n d v e r y u s e f u l .
II. P r e m a l i g n a n t lesions
III. M a l i g n a n t lesions
(a) Carcinoma
(b) N o n - s q u a m o u s m a l i g n a n t l e s i o n s

I. B E N I G N T U M O U R S

Solid T u m o u r s

1. Papilloma P a p i l l o m a s are c o m m o n i n t h e o r a l c a v i t y .
Peak i n c i d e n c e is i n t h e t h i r d t o f i f t h decades. M o s t o f t h e m
appear o n t h e soft a n d h a r d palate, u v u l a , t o n g u e a n d lips. Figure 43.1
M o s t l y t h e y are less t h a n 1 c m i n size, p e d u n c u l a t e d a n d
Fibroepithelial polyp left cheek.
w h i t e i n c o l o u r . T h e i r surface is i r r e g u l a r b u t sometimes
s m o o t h . T r e a t m e n t is e x c i s i o n a l b i o p s y . R e c u r r e n c e is r a r e .

2. Fibroma (fibroepithelial polyp) I t is a smooth,

mucosa-covered pedunculated tumour, usually about
1 c m i n size a n d s o f t t o f i r m i n c o n s i s t e n c y . I t c a n occur
a n y w h e r e i n the oral or oropharyngeal mucosa (Fig. 43.1).
T h e u s u a l cause is c h r o n i c i r r i t a t i o n . I t is easily t r e a t e d b y
conservative surgical excision.

3. H a e m a n g i o m a M u c o s a l haemangiomas can o c c u r i n
t h e o r a l c a v i t y o r o r o p h a r y n x ( F i g . 4 3 . 2 ) . T h e y are m o s t l y
seen i n c h i l d r e n . T h r e e t y p e s o f h a e m a n g i o m a s are k n o w n :
capillary, cai'emous a n d mixed. W h e n h a e m a n g i o m a s are p r e s -
e n t at b i r t h o r i n y o u n g c h i l d r e n , t h e y s h o u l d b e o b s e r v e d
f o r s o m e p e r i o d as s p o n t a n e o u s r e g r e s s i o n c a n o c c u r . Figure 43.2
I n p a t i e n t s o f 4 0 - 5 0 years, h a e m a n g i o m a - k k e d i l a t e d v e i n s
H a e m a n g i o m a on the lateral border o f tongue.
(phlcbostasis) m a y o c c u r o n t h e o r a l o r l i n g u a l m u c o s a .
 T u m o u r s of O r a l Cavity

4. L y m p h a n g i o m a L y m p h a n g i o m a s mostly i n v o l v e ante- cells. T h e t u m o u r presents as a f i r m s u b m u c o s a l nodule;

rior t w o - t h i r d s o f tongue. T h e y m a y i n v o l v e the tongue T r e a t m e n t is c o n s e r v a t i v e s u r g i c a l e x c i s i o n . R e c u r r e n c e is
d i f f u s e l y a n d cause m a c r o g l o s s i a o r m a y p r e s e n t as l o c a l i s e d uncommon.
soft s w e l l i n g w h i c h is c o m p r e s s i b l e . T h e y d o n o t i n v o l u t e Congenital epulis is also a g r a n u l a r c e l l t u m o u r i n v o l v i n g
spontaneously. Small lesions can be excised surgically. the g u m s o f f u t u r e incisors i n female infants.
S y m p t o m a t i c large lesions can be p a r t i a l l y e x c i s e d t o r e d u c e
9. M i n o r s a l i v a r y g l a n d n e o p l a s m s P l e o m o r p h i c ade-
t h e b u l k . T o t a l e x c i s i o n o f t h e s e l e s i o n s is n o t p o s s i b l e .
n o m a is t h e m o s t c o m m o n . Site o f p r e d i l e c t i o n is soft o r

5. T o r u s I t is a s u b m u c o s a l bony outgrowth. It may h a r d palate b u t can o c c u r a n y w h e r e i n the oral c a v i t y . I t

i n v o l v e t h e h a r d palate o r m a n d i b l e . P a l a t i n e t o r u s is m o r e presents as a painless s u b m u c o s a l nodule. Treatment is

c o m m o n a n d presents as a n a r r o w ridge, s o l i t a r y n o d u l e o r w i d e s u r g i c a l e x c i s i o n because o f t h e h i g h i n c i d e n c e of

a l o b u l a t e d mass i n t h e m i d l i n e o f t h e h a r d p a l a t e . recurrence.

M a n d i b u l a r t o r i p r o j e c t f r o m t h e l i n g u a l aspect o f t h e g i n -
g i v a , n e a r t h e b i c u s p i d area, a n d are b i l a t e r a l . T o r i are i n n o c -
| Cystic Lesions
u o u s a n d r e s e c t i o n is i n d i c a t e d o n l y w h e n t h e y i n t e r f e r e
w i t h speech, mastication o r the f i t t i n g o f dentures.
1. Mucocele Most common site is the lower lip
6. Pyogenic granuloma (Fig. 43.3) I t is a reactive
( F i g . 4 3 . 4 ) . I t is a r e t e n t i o n cyst o f m i n o r salivary g l a n d s o f
g r a n u l o m a usually occurs i n response to t r a u m a o r c h r o n i c
t h e l i p . T h e l e s i o n appears as a soft a n d c y s t i c mass o f b l u -
irritation. It mostly involves anterior gingivae b u t some-
ish c o l o u r . T r e a t m e n t is s u r g i c a l e x c i s i o n .
t i m e s t h e o t h e r sites s u c h as t o n g u e , b u c c a l m u c o s a o r l i p s .
2. R a n u l a ( F i g . 43.5) I t is a c y s t i c t r a n s l u c e n t l e s i o n s e e n
U s u a l l y i t is s o f t , s m o o t h , r e d d i s h t o p u r p l e mass w h i c h
i n the floor o f m o u t h o n o n e side o f t h e f r e n u l u m a n d
b l e e d s o n t o u c h . T r e a t m e n t is s u r g i c a l e x c i s i o n . R e c u r r e n c e
p u s h i n g t h e t o n g u e u p . I t arises f r o m t h e s u b l i n g u a l s a l i -
is u n l i k e l y a f t e r c o m p l e t e excision.
v a r y g l a n d d u e t o o b s t r u c t i o n o f its d u c t s . S o m e r a n u l a e
7. P r e g n a n c y g r a n u l o m a I t is c l i n i c a l l y a n d h i s t o l o g i -
extend i n t o the neck (plunging type).
c a l l y s i m i l a r t o p y o g e n i c g r a n u l o m a . I t u s u a l l y starts i n t h e
Treatment is c o m p l e t e s u r g i c a l e x c i s i o n i f s m a l l , o r m a r -
f i r s t t r i m e s t e r o f p r e g n a n c y a n d regresses o n c e p r e g n a n c y
s u p i a l i s a t i o n , i f l a r g e . O f t e n i t is n o t p o s s i b l e t o e x c i s e t h e
has e n d e d . I t is e x c i s e d o n l y i f i t persists a f t e r p r e g n a n c y . I t
r a n u l a c o m p l e t e l y because o f its t h i n w a l l o r r a m i f i c a t i o n s
is l i k e l y t o r e c u r i f o p e r a t e d d u r i n g p r e g n a n c y .
i n v a r i o u s tissue p l a n e s .
8. Granular cell myoblastoma or granular cell
Dermoid A s u b l i n g u a l d e r m o i d is m e d i a n o r l a t e r a l , s i t u -
tumour M o s t o f these t u m o u r s o c c u r i n t h e o r a l c a v i t y
a t e d a b o v e t h e m y l o h y o i d . I t shines t h r o u g h t h e m u c o s a as
a n d t h e site o f p r e d i l e c t i o n is t o n g u e . E a r l i e r t h e y were
t h o u g h t t o arise f r o m t h e m u s c l e ( h e n c e c a l l e d m y o b l a s -
t o m a ) b u t are n o w c o n s i d e r e d t o be d e r i v e d f r o m S c h w a n n

Figure 43.4

Pyogenic granuloma. M u c o c e l e o f the l o w e r lip.

Diseases of O r a l Cavity and Salivary G l a n d s

Histology. A b o u t 25% o f leukoplakias may s h o w some

f o r m o f e p i t h e l i a l dysplasia f r o m m i l d t o s e v e r e . H i g h e r
t h e g r a d e o f dysplasia m o r e are t h e c h a n c e s o f its g o i n g
into malignant change.
Malignant potential. T h e chances o f l e u k o p l a k i a b e c o m -
i n g m a l i g n a n t are c i t e d f r o m 1 t o 17.5%o. O n a n a v e r a g e
a b o u t 5%> b e c o m e m a l i g n a n t . M a l i g n a n t p o t e n t i a l varies
a c c o r d i n g t o t h e site a n d t y p e o f l e u k o p l a k i a , a n d the
duration o f follow up.

Management

1. M a n y o f the lesions w i l l disappear s p o n t a n e o u s l y if

c a u s a t i v e a g e n t is r e m o v e d .
2. I n lesions w i t h h i g h e r p o t e n t i a l f o r m a l i g n a n t c h a n g e ,
a b i o p s y is t a k e n t o r u l e o u t m a l i g n a n c y .
Figure 43.5 3. I n s u s p i c i o u s s m a l l lesions, s u r g i c a l e x c i s i o n o r a b l a -

Ranula. N o t e a translucent swelling u n d e r the tongue.

t i o n w i t h laser o r c r y o t h e r a p y c a n b e d o n e .

Erythroplakia S i m i l a r t o l e u k o p l a k i a , w h i c h is a w h i t e
p a t c h , e i y t h r o p l a k i a is a r e d p a t c h o r p l a q u e o n t h e m u c o s a l
a w h i t e mass i n c o n t r a s t t o t h e t r a n s l u c e n t n a t u r e o f t h e
surface. R e d c o l o u r is d u e t o decreased k e r a t i n i s a t i o n , a n d
ranula. A submental d e m i o i d develops b e l o w the m y l o h y o i d
as a result t h e r e d vascular c o n n e c t i v e tissue o f t h e s u b m u -
a n d p r e s e n t s as a s u b m e n t a l s w e l l i n g b e h i n d t h e c h i n .
cosa shines t h r o u g h . T h e r e is n o sex p r e d i l e c t i o n . M o s t
c o m m o n sites are l o w e r a l v e o l a r m u c o s a , g i n g i v o b u c c a l s u l -
cus a n d t h e f l o o r o f t h e m o u t h . M o s t o f lesions o f e r y t h r o -
IE. P R E M A L I G N A N T L E S I O N S
p l a k i a s h o w severe dysplasia, c a r c i n o m a i n s i t u o r a f r a n k
i n v a s i v e c a r c i n o m a w h e n f i r s t seen. M a l i g n a n t p o t e n t i a l is
Leukoplakia W H O d e f i n e d l e u k o p l a k i a as a clinical w h i t e 17 t i m e s h i g h e r t h a n i n l e u k o p l a k i a . G r o s s l y , t h e l e s i o n m a y
p a t c h that cannot be characterised clinically o r p a t h o l o g i - be o f three varieties—homogenous, speckled or granular,
c a l l y as a n y o t h e r disease. I t is a c l i n i c a l d e f i n i t i o n a n d does and e r y t h r o p l a k i a , interspersed w i t h areas o f l e u k o p l a k i a
n o t t a k e p a t h o l o g y i n t o c o n s i d e r a t i o n . O t h e r w h i t e lesions (often indistinguishable f r o m erythroleukoplakia, type of
o f o r a l m u c o s a , i.e. l i c h e n p l a n u s , d i s c o i d l u p u s e r y t h e m a - l e u k o p l a k i a ) . T r e a t m e n t is e x c i s i o n b i o p s y a n d f o l l o w u p .
t o s u s , w h i t e s p o n g y n e v u s a n d c a n d i d i a s i s are e x c l u d e d .
Melanosis and mucosal hyper pigmentation Benign
Aetiologic factors include smoking, tobacco chewing,
p i g m e n t e d lesions o f oral mucosa may transform into
alcohol abuse p a r t i c u l a r l y , i f c o m b i n e d with smoking.
malignant melanomas; however, the incidence of this
C h r o n i c t r a u m a c a n also o c c u r d u e t o i l l - f i t t i n g d e n t u r e s
c h a n g e is n o t k n o w n . A b o u t o n e - f o u r t h o f m u c o s a l m e l a -
o r c h e e k b i t e s . I t m a y also b e associated w i t h submucous
n o m a s m a y r e s e m b l e b e n i g n lesions a n d h e n c e b i o p s y m a y
fibrosis, hyperplastic candidiasis or Plummer- Vinson
become mandatory.
syndrome.
Sites involved. B u c c a l m u c o s a a n d o r a l c o m m i s s u r e s are t h e
m o s t c o m m o n sites. I t m a y h o w e v e r i n v o l v e f l o o r o f m o u t h , MALIGNANT LESIONS
t o n g u e , g i n g i v o b u c c a l sulcus a n d t h e m u c o s a l surface o f l i p .
B u c c a l m u c o s a is the m o s t c o m m o n site i n I n d i a .
| C a r c i n o m a O r a l Cavity |
Age and Sex. M o s t l y , i t is seen i n t h e f o u r t h decade,
m a l e s are a f f e c t e d t w o t o t h r e e t i m e s m o r e o f t e n .
Aetiology
Clinical types, (a) Homogenous v a r i e t y presents w i t h a s m o o t h
o r w r i n k l e d w h i t e p a t c h . I t is less o f t e n associated w i t h m a l i g - C o m p a r e d t o w e s t e r n c o u n t r i e s , I n d i a has h i g h i n c i d e n c e o f
n a n c y ; (b) Nodular (speckled) v a r i e t y presents as w h i t e patches o r a l cancers. A g e a d j u s t e d i n c i d e n c e rate i n I n d i a is 4 4 . 8 a n d
o r n o d u l e s o n e r y t h e m a t o u s base; (c) Erosive (erythroleuko- 2 3 . 7 i n males a n d females, r e s p e c t i v e l y . C o m p a r e d t o 11.2
plakia) variety where leukoplakia is interspersed with p e r 1 0 0 , 0 0 0 i n U S A . Several a e t i o l o g i c a l factors are r e s p o n -
e r y t h r o p l a k i a a n d has e r o s i o n s a n d fissures. T h e l a t t e r t w o sible. (6-S a e t i o l o g y , i.e. s m o k i n g , spirits, sharp j a g g e d t o o t h ,
varieties h a v e h i g h e r i n c i d e n c e o f m a l i g n a n t t r a n s f o m r a t i o n . sepsis, s y n d r o m e o f P l u m m e r - V i n s o n a n d s y p h i l i t i c glossitis).
 Tumours of Oral Cavity

(a) Smoking. I n c i d e n c e o f o r a l c a n c e r is six t i m e s m o r e i n 2. Carcinoma Buccal Mucosa (Fig. 43.7)

smokers than i n non-smokers. I n c e r t a i n parts of
Buccal mucosa c o v e r s a l a r g e area. I t e x t e n d s f r o m the
I n d i a , t h e r e is an u n u s u a l h a b i t o f r e v e r s e smoking
m e e t i n g p o i n t o f lips i n f r o n t t o the p t e r y g o m a n d i b u l a r
w h e r e b u r n i n g e n d o f the " c h u r a t " (rolled tobacco
r a p h e b e h i n d a n d f r o m u p p e r g i n g i v o b u c c a l sulcus t o t h e
leaf) is p u t i n t h e m o u t h . T h i s g i v e s h i g h incidence
lower one.
o f cancer o f the h a r d palate.
C a r c i n o m a o f b u c c a l m u c o s a is v e r y c o m m o n . Its i n c i -
(b) Tobacco chewing. P o w d e r e d tobacco, m i x e d w i t h l i m e ,
d e n c e is n e x t o n l y t o t o n g u e c a n c e r . E q u a l l y seen i n b o t h
is p l a c e d i n s o m e p a r t o f t h e v e s t i b u l e o f t h e m o u t h .
sexes.
C a r c i n o m a d e v e l o p s at t h e site o f t h e q u i d . C h e w i n g
Site of origin: M o s t c o m m o n site is t h e a n g l e o f m o u t h o r
" p a n " a n d k e e p i n g t h e q u i d i n t h e v e s t i b u l e is l a r g e l y
t h e l i n e o f o c c l u s i o n o f u p p e r a n d l o w e r t e e t h . I t m a y also
responsible f o r oral cancer i n o u r c o u n t r y .
arise f r o m t h e b u c c a l sulcus w h e r e " p a n " o r t o b a c c o q u i d
(c) Alcohol. C a n c e r o f u p p e r aerodigestive tract occurs
is k e p t . A s t h e w h o l e o f b u c c a l m u c o s a is " c o n d e m n e d " ,
s i x t i m e s m o r e i n h e a v y d r i n k e r s as c o m p a r e d to
carcinoma m a y be m u l t i c e n t r i c .
nondrinkers.
(d) Dietary deficiencies. T h e i r r o l e i n genesis o f c a n c e r has
n o t b e e n d e f i n i t e l y established. R i b o f l a v i n d e f i c i e n c y
m a y be responsible f o r cancer i n alcoholics. Paterson-
B r o w n - K e l f y s y n d r o m e also c a l l e d P l u m m e r - V i n s o n
s y n d r o m e ( i r o n d e f i c i e n c y a n a e m i a ) is r e s p o n s i b l e f o r
cancer o f the oral cavity and h y p o p h a r y n x .
(e) Dental sepsis, jagged sharp teeth a n d ill fitting dentures, all
cause c h r o n i c i r r i t a t i o n a n d m a y l e a d t o d e v e l o p m e n t
o f cancer.

Sites o f c a n c e r i n the H p a n d o r a l cavity are

(AJCC 2002):

1. Mucosal lip (from j u n c t i o n o f skin—vermilion border

to line o f contact o f upper and l o w e r lip)
2. B u c c a l mucosa (includes mucosa o f cheek a n d i n n e r
surface o f l i p s u p t o l i n e o f c o n t a c t o f o p p o s i n g l i p )
Figure 43.6
3. A n t e r i o r t w o thirds o f tongue (oral tongue)
4. H a r d palate Carcinoma upper lip and oral commissure. Note associated

5. L o w e r alveolar ridge leukoplakia.

6. U p p e r alveolar ridge
7. Floor o f m o u t h
8. Retromolar trigone.

C l i n i c a l presentation and treatment o f cancer o f the oral

c a v i t y at d i f f e r e n t sites are d e s c r i b e d b e l o w .

1. Carcinoma Lip (Fig. 43.6)

M o s t l y , i t is s q u a m o u s c e l l c a r c i n o m a , o f t e n seen i n m a l e s
in the age group of 40-70. L o w e r l i p is m o r e often
i n v o l v e d . S i t e o f p r e d i l e c t i o n is b e t w e e n t h e m i d l i n e a n d
c o m m i s s u r e o f t h e l i p . L e s i o n is o f e x o p h y t i c o r u l c e r a t i v e
t y p e . L y m p h n o d e metastases d e v e l o p l a t e . S u b m e n t a l a n d
s u b m a n d i b u l a r n o d e s are t h e f i r s t t o b e i n v o l v e d ; other
d e e p c e r v i c a l n o d e s m a y also g e t i n v o l v e d l a t e r .
Treatment is s u r g i c a l e x c i s i o n w i t h a d e q u a t e safety m a r g i n
o f h e a l t h y tissue a n d plastic r e p a i r o f t h e d e f e c t . Lymph
n o d e metastases r e q u i r e b l o c k d i s s e c t i o n .
Carcinoma buccal mucosa.
R a d i o t h e r a p y also g i v e s g o o d results i n e a r l y cases.
Diseases o f O r a l Cavity and Salivary G l a n d s

Gross appearance. Lesion m a y be e x o p h y t i c or u l c e r o i n -

Incidence o f cancer per 1 0 0 , 0 0 population
filtrative; the latter may infiltrate deeply. E x o p h y t i c type
in I n d i a in year 2 0 0 0 *
m a y b e associated w i t h e r y t h r o l e u k o p l a k i a . B u c c a l m u c o s a
is also t h e m o s t common site f o r v e r r u c o u s carcinoma Males Females Average Proportion

which is a white papillary g r o w t h w i t h considerable relative to all

body c a n c e r s
keratinisation.
Local spread. F r o m its site o f o r i g i n , t h e l e s i o n m a y s p r e a d Lip 0.25 0.12 0.18 0.32%

deeply i n v o l v i n g s u b m u c o s a —> m u s c l e —* s u b c u t a n e o u s M o u t h 3.42 2.97 3.19 4.46%

fat - > s k i n . I n v o l v e m e n t o f b u c c i n a t o r m u s c l e o r a n t e r i o r
T o n g u e 3.23 1.15 2.19 3.13%
m a s s e t e r causes t r i s m u s .
' N a t i o n a l Cancer Registry P r o g r a m m e (Indian Council o f Medical
T u m o u r m a y s p r e a d r a d i a l l y f r o m its site o f o r i g i n a n d Research), Bangalore, published, April 2005.

i n v o l v e angle o f t h e m o u t h a n d l i p a n t e r i o r l y , r e t r o m o l a r
trigone and medial pterygoid posteriorly, upper gingi-
v o b u c c a l sulcus a n d m a x i l l a s u p e r i o r l y , l o w e r g i n g i v o b u c -
cal sulcus a n d a l v e o l a r ridge a n d g u m s i n f e r i o r l y .
Lymphatic spread. N o d a l i n v o l v e m e n t occurs i n about
5 0 % o f cases. S u b m a n d i b u l a r a n d l a t e r t h e u p p e r j u g u l a r
n o d e s m a y get i n v o l v e d . U p p e r j u g u l a r n o d e s m a y also b e
i n v o l v e d , directly s k i p p i n g the submandibular g r o u p .
Clinical features. E a r l y l e s i o n s are asymptomatic. Pain
a n d b l e e d i n g are seen w h e n l e s i o n s are ulcerative and
i n v a d e d e e p l y . I n v o l v e m e n t o f the b u c c i n a t o r , masseter o r
t h e p t e r y g o i d m u s c l e s causes t r i s m u s . F u n g a t i n g mass o v e r
t h e c h e e k , o r a f o u l - s m e l l i n g b l e e d i n g mass i n t h e o r a l
c a v i t y are l a t e features.
Histological type: Squamous cell c a r c i n o m a is t h e most
common. Tumours can also arise f r o m minor salivary
g l a n d s w i t h h i s t o l o g y as i n s a l i v a r y g l a n d t u m o u r s .
Investigations. Biopsy o f the lesion f o r histological type Figure 43.8
o f t h e g r o w t h . C T scan f o r i n v o l v e m e n t o f b o n e ( m a n d i -
Carcinoma lateral border o f the tongue (arrow). Note associ-
b l e o r m a x i l l a ) a n d e x t e n s i o n i n t o i n f r a t e m p o r a l fossa.
ated leukoplakia o f floor o f m o u t h (Double arrows).

Treatment

Stage I ( T j N ) : S u r g i c a l
0 excision.
Stage I I ( T , N ) : (a) R a d i o t h e r a p y t o p r i m a r y l e s i o n a n d
Q u l c e r o r s y p h i l i t i c glossitis ( F i g . 4 3 . 8 ) . V a s t m a j o r i t y are
also n o d e s i f b o n e is n o t i n v o l v e d . squamous cell t y p e .
(b) I f b o n e ( m a x i l l a / m a n d i b l e ) is i n v o l v e d o r g r o w t h Site. M o s t c o m m o n site is m i d d l e o f t h e l a t e r a l b o r d e r
i n f i l t r a t e s t h e m u s c l e , s u r g e r y is t h e t r e a t m e n t o f c h o i c e . I t o r t h e v e n t r a l aspect o f t h e t o n g u e . U n c o m m o n l y , t h e t i p
involves excision o f the g r o w t h , marginal or segmental or the d o r s u m m a y be i n v o l v e d .
m a n d i b u l e c t o m y (or partial m a x i l l e c t o m y ) a n d reconstruc- Spread. Locally, it m a y infiltrate deeply into the lingual
t i o n o f t h e area w i t h s k i n o r m u c o s a l flaps. musculature causing ankyloglossia o r m a y spread t o the
Stage I I I a n d I V : S u r g i c a l r e s e c t i o n , r e c o n s t r u c t i o n w i t h f l o o r o f m o u t h , alveolus a n d m a n d i b l e . L y m p h node metas-
s k i n a n d / o r m y o c u t a n e o u s flaps a n d p o s t - o p e r a t i v e r a d i o - tases g o t o t h e s u b m a n d i b u l a r a n d u p p e r j u g u l a r nodes
t h e r a p y t o t h e site o f l e s i o n a n d n o d e s . S u r g i c a l resection ( f r o m the lateral b o r d e r o f t o n g u e ) and t o the submental
is c o m b i n e d w i t h n e c k d i s s e c t i o n i f n o d e s are c l i n i c a l l y and j u g u l o - o m o h y o i d g r o u p ( f r o m the tip). Bilateral or
palpable. c o n t r a l a t e r a l n o d a l i n v o l v e m e n t can also o c c u r .
C l i n i c a l l y , c a n c e r o f t h e o r a l t o n g u e presents as:
3. Carcinoma Oral Tongue (Table. 43.1}
(i) A n e x o p h y t i c lesion like a papilloma (Fig. 43.9),
C a r c i n o m a i n v o l v i n g a n t e r i o r t w o t h i r d s o f t o n g u e is c o m - (ii) A n o n - h e a l i n g u l c e r w i t h r o l l e d edges, g r e y i s h w h i t e
m o n l y seen i n m e n i n t h e age g r o u p o f 5 0 - 7 0 years. I t m a y s h a g g y base a n d i n d u r a t i o n ( F i g . 4 3 . 1 0 ) .
also o c c u r i n y o u n g e r age g r o u p a n d i n f e m a l e s . I t m a y also (iii) A submucous nodule with induration o f the sur-
develop o n a pre-existing leukoplakia, longstanding dental r o u n d i n g tissue.
 T u m o u r s o f O r a l Cavity

I T N M classification (AJCC-2002) o f cancers

I o f lip a n d oral cavity a n d oral cavity

Primary tumour ( T )
T u m o u r 2 c m o r less i n g r e a t e s t dimension

T 2 T u m o u r > 2 c m b u t n o t m o r e than 4 c m in greatest

dimension

T 3 T u m o u r > 4 c m in greatest dimension

T* O'P) T u m o u r invades adjacent structures (e.g.

cortical bone, inferior alveolar nerve, floor o f

mouth, skin o f face).

T a 4 (oral cavity) T u m o u r invades adjacent structures

(e.g. cortical bone, deep (extrinsic) muscles o f

tongue, maxillary sinus, skin. Superficial erosion

alone o f bone/tooth socket by gingival primary is

Figure 43.9 n o t sufficient t o classify as T , .

Exophytic growth o n the right lateral border o f tongue in a

Regional lymph n o d e s (N)
N Metastasis in a single ipsilateral lymph node 3 c m or
60-years-old m a l e . It w a s s q u a m o u s cell carcinoma. 1

less i n g r e a t e s t diameter.

N 2 Metastasis in a single ipsilateral lymph node > 3 c m

but n o t more than 6 c m in greatest dimension (N a);;

or multiple ipsilateral lymph nodes none more than

6 c m in greatest dimension ( N b )
2 o r bilateral o r

contralateral lymph nodes none more than 6 c m in

greatest dimension (N c).;

N 3 Metastasis in lymph node m o r e than 6 c m in greatest

dimension.

Distant metastasis (M)

M Q N o distant metastasis

M ] Distant metastasis

Source: AJCC, Cancer Staging M a n u a l , Chicago, 2002.

Figure 43.10
Table 43.3 Staging o f carcinoma ip a n d oral cavity

Ulcerative type o f squamous cell carcinoma o f tongue in a

Stage 1 T, N 0
40-years-old female.

S t a g e II N
c
Symptomatology Stage III N
o M 0

(i) E a r l y l e s i o n s are painless a n d r e m a i n a s y m p t o m a t i c T,

T N, 0
for a long time, 2

T
(u) P a i n i n t h e t o n g u e l o c a l l y at t h e site o f u l c e r . 3

(iii) P a i n i n t h e i p s i l a t e r a l ear; i t is d u e t o c o m m o n n e r v e
Stage IV A T 4 M
o

s u p p l y o f t h e t o n g u e ( U n g u a l n e r v e ) a n d ear ( a u r i c u l o Ti Ni M 0

Any T
Mo
temporal) from the mandibular division o f the
Stage IVB A n y T
trigeminal nerve. M 0

(iv) A l u m p i n the m o u t h . Stage IV C A n y T Any N M ,

(v) E n l a r g e d l y m p h n o d e mass i n t h e n e c k .
(vi) Dysphagia, difficulty t o protrude the tongue, slurred
S m a l l t u m o u r s ( T N ) g i v e e q u a l results i f t r e a t e d w i t h
] ( |

speech a n d b l e e d i n g f r o m t h e m o u t h are late features.

radiotherapy o r surgery.
F o r staging, see T N M classification (Tables 4 3 . 2 a n d 4 3 . 3 ) . T,N ( J t u m o u r s c a n also b e t r e a t e d b y r a d i o t h e r a p y i n c l u d -
Treatment. A i m o f t r e a t m e n t is t o t r e a t p r i m a r y t u m o u r i n g t h e n e c k nodes, t o e l i m i n a t e micrometastases. They
i n t h e t o n g u e , c o n t r o l n e c k disease ( n o d a l metastasis) a n d c a n also b e t r e a t e d b y s u r g i c a l e x c i s i o n w i t h p r o p h y l a c t i c
p r e s e r v e f u n c t i o n o f t h e t o n g u e as m u c h as p o s s i b l e . neck dissection.
Diseases of Oral Cavity and Salivary Glands

Stage I I I o r I V t u m o u r s r e q u i r e c o m b i n e d treatment start a n t e r i o r l y n e a r t h e o p e n i n g o f s u b m a n d i b u l a r d u c t

w i t h s u r g e i y a n d p o s t - o p e r a t i v e r a d i o t h e r a p y . I t gives b e t - w h i c h m a y get obstructed, leading to enlargement o f sub-
t e r results t h a n e i t h e r m o d a l i t y a l o n e . Block dissection mandibular gland (Fig. 43.11).
n e c k is a l w a y s d o n e . U s u a l l y , t h e lesion is u l c e r a t i v e o r i n f i l t r a t i v e t y p e a n d
D e p e n d i n g o n t h e size a n d e x t e n t o f t h e p r i m a r y l e s i o n spreads l o c a l l y i n t o t h e a d j o i n i n g areas such as v e n t r a l aspect
o f the t o n g u e , surgery m a y consist of hemiglossectomy o f the tongue, lingual gingiva, mandibular periosteum or
i n c l u d i n g a p o r t i o n o f the floor o f m o u t h , segmental or deeply into the floor of mouth and submental space.
hemimandibulectomy and block dissection of neck L y m p h a t i c metastases g o t o s u b m a n d i b u l a r nodes. Lesions o f
n o d e s — t h e so-called " c o m m a n d o operation". the floor o f m o u t h r e m a i n a s y m p t o m a t i c f o r a l o n g t i m e o r
cause soreness o r i r r e g u l a r i t y i n t h e floor o f the m o u t h .
4. Carcinoma Hard Palate A s w e l l i n g i n t h e s u b m a n d i b u l a r r e g i o n m a y be e i t h e r d u e t o
o b s t r u c t i v e e n l a r g e m e n t o f s u b m a n d i b u l a r salivary g l a n d o r
I t is e i t h e r s q u a m o u s cell o r glandular v a r i e t y ; the latter
l y m p h n o d e metastases, a n d this m a y r e q u i r e d i f f e r e n t i a t i o n .
b e i n g m o r e c o m m o n . G l a n d u l a r v a r i e t y arises f r o m m i n o r
Treatment. S m a l l lesions w i t h o u t i n v o l v e m e n t o f t o n g u e ,
s a l i v a r y g l a n d s o f t h e palate a n d m a y b e a d e n o i d cystic,
lingual g i n g i v a or nodes can be treated b y surgical excision
m u c o e p i d e r m o i d or adenocarcinoma. I t is c o m m o n i n o u r
or radiotherapy w i t h e q u a l results. Larger lesions with
c o u n t r y especially i n people w h o have the h a b i t o f reverse
extension to the tongue, gingiva or mandible require w i d e
s m o k i n g , i.e. k e e p i n g t h e b u r n i n g e n d o f b i d i o r cigar i n
excision including marginal or segmental mandibular
t h e m o u t h . B o t h m e n a n d w o m e n are a f f e c t e d .
resection. Block dissection is indicated when cervical
C a n c e r starts as a s u p e r f i c i a l u l c e r w i t h r o l l e d o u t edges
nodes s h o w clinical evidence o f metastases. P r o p h y l a c t i c
a n d gives n o s y m p t o m s e x c e p t painless i r r e g u l a r i t y o n t h e
n e c k d i s s e c t i o n o r i r r a d i a t i o n is a d v i s e d f o r N neck in
palate f e l t b y t h e t o n g u e . I t m a y spread t o t h e g i n g i v a , l i p ,
n

stage I I c a n c e r b e c a u s e o f h i g h i n c i d e n c e o f m i c r o m e t a -
soft palate o r i n v a d e t h e b o n e o f h a r d palate, floor o f the
stases ( 4 0 % ) , stage I I I a n d I V c a n c e r s r e q u i r e s u r g e i y a n d
nasal c a v i t y o r t h e a n t r u m . L y m p h a t i c metastases m a y spread
radiotherapy.
t o t h e s u b m a n d i b u l a r a n d u p p e r j u g u l a r n o d e s . C a n c e r palate
s h o u l d b e d i f f e r e n t i a t e d from cancer o f m a x i l l a r y a n t r u m o r
7. Carcinoma Retromolar Trigone
nose w h i c h has spread t o t h e palate.
Treatment. S m a l l t u m o u r s are r e s e c t e d a l o n g w i t h the I n v o l v e m e n t o f r e t r o m o l a r t r i g o n e m a y be p r i m a r y , o r
u n d e r l y i n g b o n e ; larger ones r e q u i r e partial m a x i l l e c t o m y . secondaiy t o extension o f g r o w t h s f r o m the gingiva, floor
I f n o d e s are e n l a r g e d , b l o c k d i s s e c t i o n is also c o m b i n e d . o f m o u t h , buccal mucosa o r the palatine arch.
Surgical defect i n the palate, l e f t after e x c i s i o n of the Treatment depends o n the extent o f lesion. W i d e s u r g i -
g r o w t h , is c l o s e d b y a s u i t a b l e p r o s t h e s i s . cal excision often combined with block dissection is
required.
5. Carcinoma of Alveolar Ridges

I t is also c a l l e d g i n g i v a l c a r c i n o m a ; i t is m o s t l y seen i n
m e n . U s u a l site o f i n v o l v e m e n t is l o w e r j a w b e h i n d t h e
f i r s t m o l a r . T u m o u r m a y spread t o t h e c h e e k , floor of
m o u t h , r e t r o m o l a r t r i g o n e o r t h e h a r d palate. G i n g i v a l
cancer m a y invade the u n d e r l y i n g b o n e and t h e n spread
r a p i d l y a l o n g t h e n e u r o v a s c u l a r b u n d l e . N o d a l metastases
go to s u b m a n d i b u l a r a n d u p p e r j u g u l a r nodes.
Treatment. R a d i o t h e r a p y is a v o i d e d b e c a u s e o f t h e risk
o f radio-osteo-necrosis. S u r g e r y is t h e t r e a t m e n t o f c h o i c e .
E a r l y m u c o s a l l e s i o n o n t h e l o w e r a l v e o l u s is t r e a t e d b y
local excision w i t h marginal resection o f the mandible.
E x t e n s i v e lesions r e q u i r e w i d e e x c i s i o n w h i c h m a y n e c e s -
sitate s e g m e n t a l or h e m i m a n d i b u l e c t o m y . B l o c k dissec-
t i o n m a y b e c o m b i n e d i f n o d e s are also p a l p a b l e . Upper
a l v e o l a r lesions m a y r e q u i r e p a r t i a l m a x i l l e c t o m y .

Figure 43.11
6. Cancer Floor of Mouth
Ulcerative s q u a m o u s cell c a r c i n o m a in t h e f l o o r o f o r a l cavity
S q u a m o u s c e l l c a r c i n o m a is t h e m o s t c o m m o n . I t affects
( a r r o w ) in a 55-years-old m a l e .
m a l e s m o r e t h a n f e m a l e s i n r a t i o o f 4 : 1 . T y p i c a l l y , lesions
 T u m o u r s of O r a l Cavity

Multiple Primary Cancers

A b o u t 15% o f patients w i t h carcinoma o f the oral cavity

have m u l t i p l e p r i m a r y cancers a f f e c t i n g t h e u p p e r a e r o d i -
gestive t r a c t . T h i s is because o f t h e c o m m o n risk factors
s u c h as s m o k i n g a n d a l c o h o l s i m u l t a n e o u s l y o p e r a t i n g at
f f .
4* '
v a r i o u s sites.

J| Non-squamous Malignant Lesions

In addition to carcinoma, other m a l i g n a n t lesions that

i n v o l v e t h e o r a l c a v i t y are:

r J
1 . M i n o r salivary gland t u m o u r s I n o n e series, 8 0 - 9 0 %
o f all m i n o r s a l i v a r y g l a n d t u m o u r s w e r e m a l i g n a n t . Palate
is t h e m o s t c o m m o n site b u t can i n v o l v e t o n g u e , c h e e k ,
H p , g u m s a n d floor o f m o u t h ( F i g . 4 3 . 1 2 ) .
A d e n o i d cystic v a r i e t y is t h e m o s t c o m m o n ( 4 0 % ) . N e x t i n
Figure 43.12
frequency are t h e a d e n o c a r c i n o m a (30%)) a n d m u c o e p i d e r -
m o i d c a r c i n o m a ( 2 0 % ) . T r e a t m e n t is w i d e surgical e x c i s i o n Mixed salivary t u m o u r palate.

a l o n g w i t h b l o c k dissection, i f t h e n e c k nodes are p o s i t i v e .

2. Melanoma Mucosal melanomas o f oral cavity and Kaposi's sarcoma i n n o n - A I D S patients m a y respond to
o r o p h a r y n x are r a r e . Peak age i n c i d e n c e is t h e s i x t h d e c a d e ; c h e m o t h e r a p y b u t its r e s p o n s e i n p a t i e n t s s u f f e r i n g f r o m
m a l e s are a f f e c t e d m o r e ( 2 : 1 ) . Palate a n d g i n g i v a are the A I D S is p o o r (sec also p a g e 3 7 5 ) .
m o s t c o m m o n sites. T h e y appear as areas o f h i g h e r p i g -
m e n t a t i o n and later m a y ulcerate a n d bleed. Amelanotic
v a r i e t y is also seen. B o t h c e r v i c a l n o d a l a n d d i s t a n t m e t a s - C h e m o prevention

tases are seen. T r e a t m e n t o f c h o i c e is w i d e s u r g i c a l e x c i s i o n

i n c l u d i n g u n d e r l y i n g b o n e . L o c a l r e c u r r e n c e is c o m m o n . I t is t h e use o f c e r t a i n p h a r m a c o l o g i c a l agents t o halt, delay
P r o g n o s i s is p o o r w i t h 5 - y e a r c u r e rate o f o n l y 15%. o r reverse t h e process o f c a r c i n o g e n e s i s . I t has b e e n u s e d t o
p r e v e n t o r a l p r e m a l i g n a n t lesions t o d e v e l o p i n t o c a n c e r
3. L y m p h o m a L y m p h o m a s can i n v o l v e oral cavity o r
o r t o p r e v e n t the d e v e l o p m e n t o f s e c o n d p r i m a r y cancers
o r o p h a r y n x , m a j o r i t y o f t h e m o c c u r r i n g i n the palatine
a f t e r t h e m a i n p r i m a r y c a n c e r has b e e n t r e a t e d . Agents
t o n s i l s . M a l e s are a f f e c t e d m o r e . U s u a l p r e s e n t a t i o n is t h a t
used have b e e n v i t a m i n A , beta c a r o t e n e , alpha t o c o p h e r o l
o f a s m o o t h , s u b m u c o s a l b u l k y mass w h i c h is o c c a s i o n a l l y
(vitamin E), selenium and natural or synthetic retinoids
ulcerated. They are mostly of n o n - H o d g k i n variety.
s u c h as 1 3 - c i s r e t i n o i c a c i d . B e t a c a r o t e n e a n d v i t a m i n A
C e r v i c a l nodes m a y be i n v o l v e d i n 4 0 - 7 0 % o f the patients.
i n d u c e d r e m i s s i o n o f o r a l l e u k o p l a k i a is seen i n 25—50%> o f
Treatment is r a d i a t i o n , a l o n e or in combination with
patients. S i m i l a r l y , i n a c o n t r o l l e d trial, 13-cis r e t i n o i c acid
chemotherapy.
reduced the incidence o f s e c o n d p r i m a r y lesions i n t h e
4. Kaposi's sarcoma I t is a v a s c u l a r t u m o u r , m u l t i f o c a l aerodigestive tract. T h e b e n e f i c i a l e f f e c t o f t h e s e agents
i n o r i g i n , p r i m a r i l y affecting skin b u t may occur i n the m a y be l i m i t e d t o the d u r a t i o n o f t r e a t m e n t o n l y .
oral cavity. Its incidence is h i g h in AIDS (Acquired I n a d d i t i o n t o t h e i r use i n h e a d a n d n e c k , r e t i n o i d s h a v e
i m m u n e d e f i c i e n c y s y n d r o m e ) p a t i e n t s . T h e l e s i o n appears s h o w n s i g n i f i c a n t c h e m o p r e v e n t i v e a c t i v i t y i n cancers o f
as a r e d d i s h p u r p l e n o d u l e o r a p l a q u e m o s t l y o n t h e p a l - l u n g , s k i n , c e r v i x , b l a d d e r a n d o v a r y . T r i a l s are also b e i n g
ate. M i c r o s c o p i c a l l y , i t consists o f s p i n d l e cells w i t h haem- conducted in Cox-2 i n h i b i t o r s (e.g. celecoxib) i n the
orrhagic c l e f t - l i k e spaces. T r e a t m e n t is n o t satisfactory. p r e v e n t i o n o f oral p r e m a l i g n a n t lesions.
 Non-neoplastic D i s o r d e r s o
Salivary Glands

I g G i n d i c a t e s past e x p o s u r e a n d p o s s i b l e i m m u n i t y .
M u m p s (Viral Parotitis)
However rise i n I g G titre ^ 4 times from acute to
convalescent s e r u m indicates recent i n f e c t i o n . S i m i l a r l y
I t is a v i r a l i n f e c t i o n c a u s e d b y p a r a m y x o v i r u s . Disease is
p r e s e n c e o f I g M also i n d i c a t e s r e c e n t i n f e c t i o n . I g M is
c o n t r a c t e d b y d r o p l e t i n f e c t i o n a n d f o m i t e s . C h i l d r e n are
p r e s e n t i n 1 0 0 % p a t i e n t s b y d a y 5.
m o s t o f t e n a f f e c t e d b u t a d u l t s c a n also c o n t r a c t t h e disease.
Incubation p e r i o d is 2—3 w e e k s (7—23 days). P a t i e n t is Treatment P a r o t i t i s is t r e a t e d b y p r o p e r h y d r a t i o n , rest,
infective even b e f o r e the appearance o f clinical manifesta- analgesics a n d c o l d o r h o t c o m p r e s s e s o v e r t h e p a r o t i d t o
t i o n s a n d r e m a i n s so 7 - 1 0 days a f t e r p a r o t i d s w e l l i n g s u b - relieve p a i n . F o o d w h i c h e n c o u r a g e salivary f l o w s h o u l d
sides. V i r u s is e x c r e t e d t h r o u g h s a l i v a r y , nasal a n d u r i n a r y b e a v o i d e d as t h e y cause p a i n . P a r o t i d s w e l l i n g persists f o r
excretions. about 1 week.

C l i n i c a l f e a t u r e s I n i t i a l p e r i o d o f v i r a e m i a causes f e v e r O r c h i t i s is t r e a t e d b y c o l d c o m p r e s s e s a n d s u p p o r t to

(up to 1 0 3 ° F ) , malaise, a n o r e x i a a n d m u s c u l a r p a i n . P a r o t i d the scrotum, and administration o f analgesics. Steroids

s w e l l i n g m a y a p p e a r o n l y o n o n e side. O t h e r p a r o t i d g l a n d have n o t b e e n f o u n d useful.

may be enlarged simultaneously or after some time.

Prevention A n i n f a n t has m a t e r n a l i m m u n i t y f o r 1 y e a r .
S u b m a n d i b u l a r a n d s u b l i n g u a l s a l i v a r y glands m a y also b e
A f t e r that i m m u n i s a t i o n can be g i v e n b y M M R (Mumps,
enlarged b u t isolated i n v o l v e m e n t o f s u b m a n d i b u l a r g l a n d
M e a s l e s , R u b e l l a ) v a c c i n e at t h e age o f 15 m o n t h s . Older
is r a r e . S w e l l i n g subsides i n a b o u t a w e e k .
c h i l d r e n , adolescents a n d adults w h o w e r e n o t protected
Complications by M M R a n d h a v e n o t h a d m u m p s , a n d are i n c o n t a c t
Orchitis w i t h p a i n f u l a n d t e n d e r testis, o n o n e b u t u n c o m - with children should receive monoclonal mumps or
m o n l y b o t h sides, m a y o c c u r . S t e r i l i t y f o l l o w i n g m u m p s is M M R vaccine.
rare. M u m p s i m m u n o g l o b u l i n is o f n o v a l u e as a p r o p h y l a x i s
Ophritis causes l o w e r a b d o m i n a l p a i n . F e m a l e s t e r i l i t y is o r i n e s t a b l i s h e d disease.
a l m o s t n e v e r seen.
Pancreatitis causes p a i n i n abdomen.
Aseptic meningitis or meningoencephalitis may occur Acute Suppurative Parotitis
w i t h o r w i t h o u t the salivary g l a n d i n v o l v e m e n t . Headaches,
n e c k stiffness a n d d r o w s i n e s s m a y o c c u r . I t is m o s t c o m m o n l y seen i n t h e e l d e r l y , d e b i l i t a t e d a n d
Unilateral sensorineural hearing loss can occur due to d e h y d r a t e d p a t i e n t s . D r y m o u t h d u e t o a n y cause is a p r e -
i n v o l v e m e n t o f the l a b y r i n t h . Sudden deafness has been d i s p o s i n g f a c t o r . Staph, aureus is t h e u s u a l c a u s a t i v e o r g a n -
noticed. ism t h o u g h other gram-positive and anaerobic organisms
Other complications include thyroiditis, myocarditis, h a v e also b e e n o b s e r v e d . U s u a l r o u t e o f i n f e c t i o n is f r o m
nephritis and arthritis. t h e m o u t h t h r o u g h t h e Stensen's d u c t .

Diagnosis U s u a l l y c l i n i c a l ; d i f f i c u l t i e s arise w h e n parot-

C l i n i c a l f e a t u r e s T h e o n s e t is s u d d e n w i t h severe p a i n
ids are n o t enlarged. and enlargement o f gland. M o v e m e n t s of jaw aggravate
1. S e r u m a n d u r i n a r y a m y l a s e are raised d u r i n g t h e f i r s t t h e p a i n . O p e n i n g o f t h e Stensen's d u c t is s w o l l e n a n d r e d
w e e k o f parotitis. and may be discharging pus or the latter can also be
2. Serology. S e r u m I g G a n d I g M are m e a s u r e d as e a r l y as e x p r e s s e d b y g e n t l e p r e s s u r e o v e r t h e g l a n d . P a t i e n t is u s u -
possible a n d after 1 0 - 1 4 days o f illness. P r e s e n c e of ally febrile and t o x a e m i c .

ft
 Non-neoplastic Disorders of Salivary Glands

Investigations W h i t e cell c o u n t shows leukocytosis w i t h T r e a t m e n t is s u r g i c a l d r a i n a g e a n d l a r g e doses o f p e n i c i l l i n

increase i n p o l y m o r p h s . Causative organisms should be or tetracycline.
i d e n t i f i e d a n d t h e i r sensitivity established by culture of
blood and the pus c o l l e c t e d from the opening of the
parotid duct.
Salivary Calculi

Treatment I t consists o f a p p r o p r i a t e a n t i b i o t i c s , p r e f e r a - C a l c u l i m a y f o r m i n the ducts o f s u b m a n d i b u l a r o r p a r o t i d

bly administered t h r o u g h i . v . route, adequate h y d r a t i o n , glands. T h e y are f o r m e d by the deposition o f calcium
measures t o p r o m o t e salivary flow a n d attention to oral phosphate on the organic matrix o f m u c i n or cellular
h y g i e n e . I f t e m p e r a t u r e does n o t s u b s i d e a n d t h e r e is p r o - d e b r i s . A b o u t 9 0 % o f t h e stones are seen i n s u b m a n d i b u l a r
gressive i n d u r a t i o n o f t h e g l a n d , i n spite o f a d e q u a t e m e d i - a n d 1 0 % i n t h e p a r o t i d . Stones m a y f o r m i n t h e d u c t o r
cal m a n a g e m e n t , s u r g i c a l d r a i n a g e s h o u l d be done. parenchyma o f the gland.
The p r e s e n t i n g f e a t u r e is i n t e r m i t t e n t s w e l l i n g o f t h e
i n v o l v e d gland, and pain due to obstruction to o u t f l o w o f
| C h r o n i c Recurrent Sialadenitis
saliva. S o m e t i m e s , s t o n e is v i s i b l e at t h e d u c t o p e n i n g o r
can b e p a l p a t e d . A b o u t 8 0 % o f t h e stones are r a d i o - o p a q u e
T h i s usually involves p a r o t i d gland w h i c h shows recurrent
and can be seen on appropriate X-rays (Fig. 44.1).
bacterial i n f e c t i o n . D u r i n g acute exacerbation, p a r o t i d is
S i a l o g r a p h y m a y b e r e q u i r e d f o r r a d i o l u c e n t stones.
e n l a r g e d a n d t e n d e r , a n d p u s c a n b e e x p r e s s e d f r o m its
Stones i n p e r i p h e r a l part o f s u b m a n d i b u l a r or p a r o t i d
d u c t . B e t w e e n t h e a c u t e e p i s o d e s , g l a n d is f i r m a n d s l i g h t l y
d u c t s can b e r e m o v e d i n t r a o r a l l y , w h i l e t h o s e at t h e h i l u m
e n l a r g e d . C u l t u r e o f pus f r o m t h e d u c t reveals staphylococci
or i n the parenchyma require excision o f the gland.
or streptococci. Sialography shows normal duct system.
T r e a t m e n t o f a c u t e e p i s o d e is s i m i l a r t o t h a t o f a c u t e b a c -
t e r i a l s i a l a d e n i t i s . B e t w e e n t h e attacks, p a t i e n t is i n s t r u c t e d Sjogren's Syndrome (Sicca S y n d r o m e )
to keep g o o d oral hygiene, a v o i d drugs w h i c h dry oral
m u c o s a a n d use s i a l o g o g u e s t o p r o m o t e s a l i v a t i o n . I t is a n a u t o i m m u n e d i s o r d e r i n v o l v i n g e x o c r i n e g l a n d s o f
the b o d y . I t m a y be p r i m a r y o r secondary.
Primary Sjogren's syndrome consists o f x e r o s t o m i a and
^ Sialectasis ^
xero-ophthalmia a n d is d u e t o i n v o l v e m e n t o f s a l i v a r y

A s t h e n a m e i m p l i e s , t h e r e is d i l a t a t i o n o f t h e d u c t a l sys-
t e m , l e a d i n g t o stasis o f s e c r e t i o n s , w h i c h predisposes t o
i n f e c t i o n . C l i n i c a l l y , sialectasis r e s e m b l e s c h r o n i c r e c u r r e n t
sialadenitis, b u t can b e d i f f e r e n t i a t e d from i t b y s i a l o g r a p h y .
D i f f e r e n t degrees o f d i l a t a t i o n o f t h e d u c t a l system—punc-
t u a t e , g l o b u l a r o r c a v i t a r y t y p e s — m a y b e s e e n . Sialectasis
m a y b e c o n g e n i t a l , associated w i t h g r a n u l o m a t o u s disease
o r a u t o i m m u n e disease s u c h as S j o g r e n ' s s y n d r o m e .

G r a n u l o m a t o u s Diseases

Tuberculosis, sarcoidosis a n d a c t i n o m y c o s i s may involve

the salivary glands.
Tubercular infection may involve parenchyma or lymph
nodes o f the p a r o t i d a n d present as a n o n - t e n d e r mass.
S o m e t i m e s , o v e r l y i n g skin undergoes necrosis l e a d i n g t o a
f i s t u l a f o r m a t i o n . S u r g i c a l e x c i s i o n o f t h e i n v o l v e d tissue
a n d a n t i t u b e r c u l a r t r e a t m e n t u s u a l l y c o n t r o l t h e disease.
U v e o p a r o t i d f e v e r is d u e t o sarcoidosis o f the p a r o t i d . It
is c h a r a c t e r i s e d b y f e v e r , e n l a r g e m e n t o f the p a r o t i d and
l a c r i m a l g l a n d s , c h o r i o r e t i n i t i s , a n d c r a n i a l n e r v e palsies. Figure 44.1

Actinomycosis o f p a r o t i d is u n c o m m o n . I t m a y p r e s e n t as
A radio-opaque stone seen in the right submandibular duct
a n a c u t e abscess w i t h sinus f o r m a t i o n d i s c h a r g i n g s u l p h u r - (arrow).

like granules, o r as a n i n d o l e n t s w e l l i n g i n t h e p a r o t i d .
a n d l a c r i m a l g l a n d s . P a r o t i d is m o s t o f t e n i n v o l v e d . I t has (iii) a u t o i m m u n e c o n n e c t i v e tissue d i s o r d e r , u s u a l l y t h e
also b e e n k n o w n as benign lyniphoepithelia! lesion o f p a r o t i d r h e u m a t o i d a r t h r i t i s . O f t e n t h e r e is b i l a t e r a l s w e l l i n g o f t h e
o r Mikulicz's disease. B o t h sexes are e q u a l l y i n v o l v e d . s a l i v a r y g l a n d s . I t is also m o r e c o m m o n i n f e m a l e s ( 9 0 % ) .
Secondary Sjogren's syndrome consists o f t h r e e m a j o r c o m - Diagnosis d e p e n d s o n raised E S R , positive r h e u m a t o i d
p o n e n t s : (i) k e r a t o c o n j u n c t i v i t i s sicca ( d u e t o i n v o l v e m e n t factor, positive antinuclear antibodies and biopsy f r o m the
o f l a c r i m a l g l a n d ) ; (ii) x e r o s t o m i a (due t o i n v o l v e m e n t o f l o w e r l i p f o r e v i d e n c e o f i n v o l v e m e n t o f m i n o r salivary
salivary glands and mucous glands o f the oral cavity); glands.
N e o p l a s m s o f Salivary Glands

T h e t u m o u r s o f m a j o r o r m i n o r s a l i v a r y g l a n d s are either m i n o r salivary g l a n d s . I n t h e p a r o t i d i t u s u a l l y arises f r o m

f r o m epithelial or mesenchymal tissues ( F i g . 4 5 . 1 ) . L a r g e r its t a i l . I t can also arise f r o m t h e d e e p l o b e o f t h e p a r o t i d
t h e size o f s a l i v a r y g l a n d , m o r e are t h e c h a n c e s o f a t u m o u r and present as a parapharyngeal tumour in the
being benign. 80% o f parotid, 5 0 - 6 0 % o f submandibular oropharynx.
a n d o n l y a b o u t 2 5 % o f o t h e r m i n o r salivary g l a n d t u m o u r s P l e o m o r p h i c a d e n o m a s are s l o w - g r o w i n g t u m o u r s a n d
are b e n i g n . I n o t h e r w o r d s , chances o f m a l i g n a n t t u m o u r s m a y b e q u i t e l a r g e at i n i t i a l p r e s e n t a t i o n . T h e y are u s u a l l y
i n m i n o r s a l i v a r y glands are h i g h e r . seen i n t h e t h i r d o r f o u r t h d e c a d e , w i t h p r o p e n s i t y f o r
Rapid growth, restricted mobility, fixity of overlying skin, pain f e m a l e s . T h e y are c a l l e d " m i x e d t u m o u r s " because b o t h
and facial nerve involvement indicate the possibility of tumour epithelial and mesenchymal e l e m e n t s are s e e n i n h i s t o l -
being malignant. o g y . T h e stroma o f the t u m o u r m a y be m u c o i d , f i b r o i d ,
vascular, m y x o c h o n d r o i d o r c h o n d r o i d a n d its p r o p o r t i o n
to the epithelial element m a y vary.
BENIGN T U M O U R S
T h o u g h t u m o u r is e n c a p s u l a t e d , i t sends pseudopods
i n t o t h e s u r r o u n d i n g g l a n d w h i c h are l e f t b e h i n d i f t h e
Pleomorphic Adenoma t u m o u r is s i m p l y s h e l l e d o u t . I t is t h e r e f o r e essential t h a t
surgical excision o f the t u m o u r should i n c l u d e n o r m a l gland
I t is t h e m o s t c o m m o n b e n i g n t u m o u r o f s a l i v a r y g l a n d s . tissue a r o u n d i t . I n t h e p a r o t i d , i t a m o u n t s t o s u p e r f i c i a l

It can arise f r o m the parotid, submandibular or other parotidectomy.

S q u a m o u s cell c a r c i n o m a o f the right parotid. Patient presented with a parotid swelling (A) and facial palsy (B).
Diseases of O r a l Cavity and Salivary G l a n d s

A d e n o l y m p h o m a (Papillary Cystadenoma Lymphangiomas

I Lymphomatosum, Warthin's Tumour)

1
T h e y are less c o m m o n a n d m a y i n v o l v e p a r o t i d a n d s u b m a n -
T h e y are c o n m i o i i l y seen b e t w e e n f i f t h a n d s e v e n t h decade d i b u l a r glands. O n p a l p a t i o n , t h e y feel soft a n d cystic. T h e y
w i t h p r e p o n d e r a n c e i n males ( 5 : 1 ) . T h e y m o s t l y i n v o l v e t h e d o n o t regress s p o n t a n e o u s l y a n d are s u r g i c a l l y excised.
t a i l o f t h e p a r o t i d a n d are b i l a t e r a l i n 1 0 % o f t h e patients. L i p o m a a n d n e u r o f i b r o m a are r a r e .
They m a y be multiple. A d e n o l y m p h o m a is a r o u n d e d ,
encapsulated t u m o u r , at t i m e s cystic, w i t h m u c o i d o r b r o w n -
ish f l u i d . H i s t o l o g i c a l l y , e p i t h e l i a l a n d l y m p h o i d elements
MALIGNANT TUMOURS
are seen. T r e a t m e n t is s u p e r f i c i a l p a r o t i d e c t o m y t h o u g h t h e y
can be e n u c l e a t e d w i t h o u t d a n g e r o f r e c u r r e n c e .
^| Mucoepidermoid Carcinoma __B

11 Oncocytoma (Oxyphil Adenoma) J Some pathologists d o n o t consider i t to be malignant a n d

T h e y arise f r o m a c i d o p h i l i c cells called oncocytes a n d c o m p r i s e
less t h a n 1 % o f all salivary g l a n d t u m o u r s . M o s t l y seen i n t h e
e l d e r l y , t h e y usually d o n o t g r o w larger t h a n 5 c m a n d i n v o l v e
t h e s u p e r f i c i a l l o b e o f p a r o t i d . B e n i g n o n c o c y t o m a s are cystic
rather than solid. M a l i g n a n t oncocytomas are also seen.
O n c o c y t o m a s s h o w increased u p t a k e o f t e c h n e t i u m - 9 9 .
Treatment for parotid oncocytomas is also s u p e r f i c i a l
parotidectomy.
Haemangiomas
H a e m a n g i o m a s are t h e m o s t c o m m o n b e n i g n t u m o u r s o f t h e
p a r o t i d i n c h i l d r e n , p r e d o m i n a n t l y a f f e c t i n g females. M o s t o f
t h e m are d i s c o v e r e d at b i r t h , g r o w r a p i d l y i n t h e n e o n a t a l
p e r i o d a n d t h e n i n v o l u t e spontaneously. Cutaneous h a e m a n -
g i o m a m a y c o - e x i s t i n 5 0 % o f t h e patients. T h e y are soft a n d
painless a n d increase i n size w i t h c r y i n g o r s t r a i n i n g . O v e r l y i n g
s k i n m a y s h o w b l u i s h d i s c o l o r a t i o n . S u r g i c a l e x c i s i o n is i n d i -
c a t e d i f t h e y d o n o t regress s p o n t a n e o u s l y .
c a l l i t m u c o e p i d e r m o i d t u m o u r a n d n o t c a n c e r , b u t i t is
k n o w n t o metastasise a n d k i l l . G e n e r a l l y , i t is s l o w - g r o w i n g
b u t c a n i n v a d e t h e f a c i a l n e r v e . H i s t o l o g i c a l l y , t h e r e are
areas o f m u c i n - p r o d u c i n g cells a n d t h e s q u a m o u s cells,
and hence the name. Greater the e p i d e r m o i d element,
more m a l i g n a n t is t h e b e h a v i o u r o f t h e tumour. The
t u m o u r s h a v e b e e n f u r t h e r classified as low grade a n d high
grade. L o w grade t u m o u r s have g o o d prognosis (90%,
5 - y e a r s s u r v i v a l r a t e ) , h i g h g r a d e t u m o u r s are m o r e aggres-
sive a n d h a v e p o o r p r o g n o s i s ( 3 0 % , 5 - y e a r s s u r v i v a l r a t e ) .
L o w g r a d e t u m o u r s are m o r e c o m m o n i n c h i l d r e n .
B e h a v i o u r o f m u c o e p i d e r m o i d t u m o u r s o f m i n o r sali-
v a r y glands is m o r e aggressive a n d a k i n t o a d e n o i d c y s t i c
c a r c i n o m a , b u t i n t h e m a j o r s a l i v a r y glands t h e y behave
like pleomorphic adenoma.
L o w g r a d e t u m o u r s o f t h e p a r o t i d are t r e a t e d b y s u p e r -
ficial o r total p a r o t i d e c t o m y , d e p e n d i n g o n the location o f
t h e t u m o u r . F a c i a l n e r v e is p r e s e r v e d .
H i g h g r a d e t u m o u r s b e i n g m o r e aggressive, are t r e a t e d
b y total p a r o t i d e c t o m y . Facial n e r v e m a y be sacrificed i f
i n v a d e d b y t u m o u r . S o m e s u r g e o n s also c o m b i n e r a d i c a l
n e c k dissection because o f h i g h i n c i d e n c e o f m i c r o s c o p i c

k ^ j 3 k n l T u m o u r s o f sali v a r y glands
spread o f t h e t u m o u r .

Benign Malignant
Epithelial Epithelial Adenoid Cystic Carcinoma (Cylindroma)
Pleomorphic a d e n o m a M u c o e p i d e r m o i d

A d e n o l y m p h o m a c a r c i n o m a
I t is a s l o w - g r o w i n g t u m o u r b u t i n f i l t r a t e s w i d e l y i n t o t h e
(Warthin's t u m o u r ) - L o w grade
tissue planes a n d m u s c l e s . I t also i n v a d e s p e r i n e u r a l spaces
O n c o c y t o m a - High grade
a n d l y m p h a t i c s a n d t h u s causes p a i n a n d V l l t h n e r v e p a r a l -
O t h e r a d e n o m a s Adenoid cystic c a r c i n o m a
ysis. I t c a n metastasise t o l y m p h n o d e s . L o c a l recurrences
Mesenchymal (cylindroma)

H a e m a n g i o m a Acinic cell carcinoma

a f t e r s u r g i c a l e x c i s i o n are c o m m o n a n d c a n o c c u r as l a t e as

L y m p h a n g i o m a A d e n o c a r c i n o m a 10-20 years a f t e r s u r g e r y . D i s t a n t metastases g o t o the

Lipoma Malignant mixed t u m o u r lung, brain and bone.
N e u r o f i b r o m a S q u a m o u s cell c a r c i n o m a T r e a t m e n t is r a d i c a l p a r o t i d e c t o m y w i t h largest c u f f o f
Undifferentiated carcinoma grossly n o r m a l tissue a r o u n d t h e b o u n d a r i e s o f t h e t u m o u r .
Mesenchymal R a d i c a l n e c k is n o t d o n e unless n o d a l metastases are p r e s -
L y m p h o m a
ent. Post-operative r a d i a t i o n is g i v e n i f m a r g i n s o f t h e
S a r c o m a
r e s e c t e d s p e c i m e n are n o t f r e e o f t u m o u r .
 Neoplasms of Salivary G l a n d s

Acinic Cell Carcinoma

1 E Undifferentiated Carcinoma

I t is a l o w g r a d e t u m o u r w h i c h appears s i m i l a r t o a b e n i g n I t is a r a r e , b u t aggressive t u m o u r . I t has a t e n d e n c y to

m i x e d t u m o u r . I t presents as a s m a l l , f i r m , m o v a b l e a n d spread r a p i d l y , causes p a i n , b e c o m e s fixed to skin and
encapsulated t u m o u r , sometimes b i l a t e r a l . Metastases are u l c e r a t e s . I t causes f a c i a l paralysis a n d c e r v i c a l n o d a l m e t a s -
rare. A conservative approach o f superficial o r t o t a l p a r o - tasis. T r e a t m e n t is w i d e e x c i s i o n , r a d i c a l n e c k a n d p o s t -
t i d e c t o m y is a d o p t e d . operative radiation.

Adenocarcinoma
1 I Lymphoma

M o r e o f t e n i t arises i n m i n o r s a l i v a r y g l a n d s . I t is h i g h l y I t is a r a r e t u m o u r u s u a l l y associated w i t h s y s t e m i c disease,

aggressive l o c a l l y a n d sends d i s t a n t metastasis. b u t m a y o c c a s i o n a l l y b e a p r i m a r y t u m o u r . T r e a t m e n t is

same as f o r o t h e r l y m p h o m a s .

Malignant Mixed T u m o u r
J Sarcoma

T h e r e are t w o v a r i e t i e s o f this t u m o u r :
R a r e l y o t h e r s a r c o m a s , e . g . r h a b d o m y o s a r c o m a m a y arise
(a) carcinoma developing i n old benign m i x e d t u m o u r , f r o m the parotid.
and
(b) a ' d e n o v o ' t u m o u r . T h e l a t t e r has m u c h s h o r t e r h i s -
J Frey's Syndrome (Gustatory Sweating)
tory. R a p i d g r o w t h and pain developing i n a benign
t u m o u r s h o u l d always arouse a s u s p i c i o n o f m a l i g -
F r e y ' s s y n d r o m e arises as a c o m p l i c a t i o n o f p a r o t i d s u r g e r y
n a n t c h a n g e . T r e a t m e n t o f m a l i g n a n t t u m o u r is r a d i -
u s u a l l y m a n i f e s t i n g several m o n t h s a f t e r t h e o p e r a t i o n . I t is
cal parotidectomy. Facial nerve sacrificed during
characterised b y s w e a t i n g a n d f l u s h i n g o f the preauricular
o p e r a t i o n is g r a f t e d i m m e d i a t e l y .
skin d u r i n g mastication causing nuisance t o the person or
social embarrassment. I t is t h e r e s u l t o f a b e r r a n t i n n e r v a -
| S q u a m o u s Cell C a r c i n o m a (Fig. 4 5 . 1 ) tion o f sweat glands b y parasympathetic secretomotor
fibres w h i c h w e r e destined f o r the p a r o t i d . N o w instead o f
I t is a r a p i d l y g r o w i n g t u m o u r t h a t i n f i l t r a t e s , causes p a i n , causing salivary secretion from the parotid, they cause
a n d u l c e r a t e s t h r o u g h t h e s k i n . I t c a n metastasise t o n e c k secretion f r o m t h e sweat glands. T h e c o n d i t i o n can be
nodes. Treatment is r a d i c a l p a r o t i d e c t o m y w h i c h may treated b y t y m p a n i c n e u r e c t o m y w h i c h intercepts these
include c u f f o f muscle or even a p o r t i o n o f mandible, p a r a s y m p a t h e t i c f i b r e s at t h e l e v e l o f m i d d l e ear. Some
temporal bone and the i n v o l v e d skin. Radical neck is p e o p l e l i k e t o p l a c e a sheet o f fascia lata b e t w e e n t h e s k i n
combined i f nodal metastases are present. Surgery is and the underlying fat t o prevent secretomotor fibres
f o l l o w e d b y p o s t - o p e r a t i v e r a d i a t i o n t o p r i m a r y site a n d r e a c h i n g the sweat glands. Generally, n o t r e a t m e n t o t h e r
the neck. t h a n reassurance is r e q u i r e d i n m o s t o f these p a t i e n t s .
46. Anatomy and Physiology o f Pharynx 253
47. Adenoids and Other Inflammations o f Nasopharynx 258
48. Tumours o f Nasopharynx 261
49. Acute and Chronic Pharyngitis 268
50. Acute and Chronic Tonsillitis 271
51. Head and Neck Space Infections 277
52. Tumours o f Oropharynx 284
53. Tumours o f the Hypopharynx and Pharyngeal Pouch 288
54. Snoring and Sleep Apnoea 291
A n a t o m y a n d Physiology o f Pharynx

P H A R Y N X IN GENERAL Base of sku

P h a r y n x is a c o n i c a l f i b r o m u s c u l a r t u b e f o r m i n g upper Eust. tube

Sinus of
p a r t o f t h e a i r a n d f o o d passages. I t is 1 2 - 1 4 c m long, morgagni
e x t e n d i n g f r o m base o f t h e s k u l l ( b a s i o c c i p u t a n d b a s i s p h e -
n o i d ) to the l o w e r b o r d e r o f c r i c o i d cartilage w h e r e i t
becomes c o n t i n u o u s w i t h the oesophagus. The width of
p h a r y n x is 3.5 c m at its base a n d t h i s n a r r o w s t o 1.5 c m at
pharyngo-oesophageal junction which is t h e narrowest
p a r t o f digestive tract apart f r o m the a p p e n d i x .

S t r u c t u r e o f Pharyngeal W a l l (Fig. 46.1)

F r o m w i t h i n o u t w a r d s i t consists o f f o u r layers:

S. Mucous membrane

2. P h a r y n g e a l a p o n e u r o s i s ( p h a r y n g o basilar fascia) Figure 46.1

3. M u s c u l a r coat
Structure o f pharyngeal wall. From within o u t w a r d s it consists
4. B u c c o p h a r y n g e a l fascia o f (a) M u c o u s m e m b r a n e , (b) Pharyngobasilar fascia,

(c) Muscular coat, and (d) Buccopharyngeal fascia.

1. Mucous membrane It lines t h e p h a r y n g e a l c a v i t y
a n d is c o n t i n u o u s w i t h m u c o u s m e m b r a n e o f e u s t a c h i a n
t u b e s , nasal c a v i t i e s , m o u t h , l a r y n x a n d o e s o p h a g u s . The
4. Buccopharyngeal fascia I t c o v e r s o u t e r surface of
e p i t h e l i u m is c i l i a t e d c o l u m n a r i n t h e n a s o p h a r y n x and
the c o n s t r i c t o r muscles, a n d i n t h e u p p e r p a r t , i t is also
stratified squamous elsewhere. There are numerous
prolonged forwards to cover the buccinator muscles.
m u c o u s glands scattered i n i t .
A b o v e the upper b o r d e r o f superior constrictor, it blends
2. P h a r y n g e a l aponeurosis (pharyngobasilar fascia) w i t h pharyngeal aponeurosis.
I t is a f i b r o u s l a y e r w h i c h l i n e s t h e m u s c u l a r c o a t a n d is
p a r t i c u l a r l y t h i c k n e a r t h e base o f s k u l l b u t is t h i n and
i n d i s t i n c t i n f e r i o r i y . I t fills u p t h e g a p l e f t i n t h e m u s c u l a r K i I Man's D e h i s c e n c e
c o a t n e a r t h e base o f s k u l l .
I n f e r i o r c o n s t r i c t o r m u s c l e has t w o p a r t s ; t h y r o p h a r y n g e u s
3. M u s c u l a r coat I t consists o f t w o layers o f muscles
w i t h o b l i q u e fibres a n d cricopharyngeus w i t h transverse
w i t h three muscles i n each layer.
f i b r e s . B e t w e e n these t w o parts exists a p o t e n t i a l gap c a l l e d
(a) E x t e r n a l layer: contains superior, m i d d l e and i n f e r i o r Killian's dehiscence. I t is also c a l l e d t h e " g a t e w a y o f t e a r s " as
c o n s t r i c t o r muscles. p e r f o r a t i o n c a n o c c u r at t h i s site d u r i n g oesophagoscopy.
(b) I n t e r n a l layer: contains stylopharyngeus, salpingopha- T h i s is also t h e site f o r h e r n i a t i o n o f p h a r y n g e a l m u c o s a i n
ryngeus and palatopharyngeus muscles. cases o f p h a r y n g e a l p o u c h .
Diseases of Pharynx

Adenoids
Lateral
Tubal tonsil
pharyngeal band

Nodules on posterior Palatine tonsil

pharyngeal wa
Lingual tonsil

Figure 46.2

Waldeyer's ring.

Figure 46.3

Divisions o f pharynx and the vertebrae related to their posterior

wall.
J Waldeyer's Ring ( F i g . 4 6 . 2 ) J

S c a t t e r e d t h r o u g h o u t t h e p h a r y n x i n its s u b e p i t h e l i a l l a y e r
is t h e l y m p h o i d tissue w h i c h is a g g r e g a t e d at places t o
form masses, collectively called Waldeyer's ring. The ^ Nasopharynx (Epjpharynx)
masses are:
Applied Anatomy
1. Nasopharyngeal tonsil or the adenoids
2. Palatine tonsils o r s i m p l y the tonsils N a s o p h a r y n x is t h e u p p e r m o s t p a r t o f t h e p h a r y n x a n d
3. Lingual tonsil therefore, also c a l l e d t h e e p i p h a r y n x . I t lies b e h i n d t h e
4. T u b a l t o n s i l s ( i n fossa o f R o s e n m u l l e r ) nasal c a v i t i e s a n d e x t e n d s f r o m t h e base o f s k u l l t o t h e soft
5. Lateral p h a r y n g e a l bands palate o r t h e l e v e l o f t h e h o r i z o n t a l p l a n e passing t h r o u g h
6. N o d u l e s (in posterior pharyngeal wall). t h e h a r d palate ( F i g . 4 6 . 4 ) .
Roof o f t h e n a s o p h a r y n x is f o r m e d b y b a s i s p h e n o i d a n d
basiocciput.
J Pharyngeal Spaces Posterior w a l l is f o r m e d b y a r c h o f t h e atlas v e r t e b r a c o v -
e r e d b y p r e v e r t e b r a l m u s c l e s a n d fascia. B o t h t h e r o o f a n d
T h e r e are t w o p o t e n t i a l spaces i n r e l a t i o n t o t h e p h a r y n x
the posterior w a l l i m p e r c e p t i b l y merge w i t h each other.
w h e r e abscesses c a n f o r m .
Floor is f o r m e d b y t h e soft palate a n t e r i o r l y b u t is d e f i -

1. R e t r o p h a r y n g e a l space, s i t u a t e d b e h i n d t h e p h a r y n x c i e n t p o s t e r i o r l y . I t is t h r o u g h this s p a c e — t h e nasopharyn-

a n d e x t e n d i n g f r o m t h e base o f s k u l l t o t h e b i f u r c a - geal isthmus, that the nasopharynx communicates w i t h the

t i o n o f t r a c h e a (see page 2 H 0 ) . oropharynx.

2. P a r a p h a r y n g e a l space, s i t u a t e d o n t h e side o f p h a r y n x . Anterior wall is f o r m e d b y p o s t e r i o r nasal a p e r t u r e s or

I t c o n t a i n s c a r o t i d vessels, j u g u l a r v e i n , last f o u r c r a n i a l choanae, s e p a r a t e d f r o m e a c h o t h e r b y t h e p o s t e r i o r b o r d e r

n e r v e s a n d c e r v i c a l s y m p a t h e t i c c h a i n (see p a g e 2 8 1 ) . o f t h e nasal s e p t u m . P o s t e r i o r ends o f nasal t u r b i n a t e s a n d

meatuses are seen i n t h i s w a l l .
Lateral wall. E a c h l a t e r a l w a l l presents t h e pharyngeal

DIVISIONS O F PHARYNX o p e n i n g o f eustachian t u b e s i t u a t e d 1.25 c m b e h i n d the

p o s t e r i o r e n d o f i n f e r i o r t u r b i n a t e . I t is b o u n d e d a b o v e a n d
b e h i n d b y a n e l e v a t i o n c a l l e d torus tubarius raised b y the
A n a t o m i c a l l y , p h a r y n x is d i v i d e d i n t o t h r e e parts ( F i g . 4 6 . 3 ) :
cartilage o f the t u b e . A b o v e a n d b e h i n d the tubal e l e v a t i o n
1. Nasopharynx is a recess c a l l e d fossa of Rosenmuller w h i c h is t h e c o m m o n -
2. Oropharynx est site f o r o r i g i n o f c a r c i n o m a . A ridge e x t e n d s from the
3. H y p o p h a r y n x or Laryngopharynx. l o w e r e n d o f t o r u s t u b a r i u s t o t h e lateral p h a r y n g e a l w a l l
 Anatomy and Physiology of Pharynx

Sinus ofMorgagni

I t is a space b e t w e e n t h e base o f t h e s k u l l a n d u p p e r f r e e
b o r d e r o f s u p e r i o r c o n s t r i c t o r m u s c l e . T h r o u g h i t enters
(i) t h e e u s t a c h i a n t u b e , (ii) t h e l e v a t o r v e l i p a l a t i n i , ( i i i )
tensor v e l i palatini a n d (iv) ascending palatine artery—

Rolhke's pouch b r a n c h o f the facial artery (Fig. 4 6 . 1 ) .

Nasopharyngeal Passavant's Ridge

bursa
I t is a m u c o s a l ridge r a i s e d b y f r b r e s o f p a l a t o p h a r y n g e u s .
Adenoids
I t encircles the p o s t e r i o r a n d lateral walls o f n a s o p h a r y n -
geal i s t h m u s . S o f t p a l a t e , d u r i n g its c o n t r a c t i o n , makes
firm contact w i t h this ridge to cut o f f n a s o p h a r y n x from
the o r o p h a r y n x d u r i n g the d e g l u t i t i o n o r speech.

Epithelial Lining of Nasopharynx

Figure 46.4
Functionally, nasopharynx is t h e p o s t e r i o r e x t e n s i o n of
Rathke's pouch is represented by a dimple, high in nasophar-
nasal c a v i t y . I t is l i n e d b y p s e u d o s t r a t i f i e d c i l i a t e d c o l u m -
ynx. Inferior to this, within the adenoid mass, is t h e nasopha-
nar e p i t h e l i u m .
ryngeal bursa.

Lymphatic Drainage

L y m p h a t i c s o f t h e n a s o p h a r y n x , i n c l u d i n g those o f t h e a d e -
a n d is c a l l e d t h e s a l p i n g o p h a r y n g e a l f o l d . I t is raised b y t h e
n o i d s a n d p h a r y n g e a l e n d o f eustachian t u b e , d r a i n i n t o upper-
corresponding muscle.
deep cervical n o d e s e i t h e r d i r e c t l y o r i n d i r e c t l y t h r o u g h r e t -
r o p h a r y n g e a l a n d p a r a p h a r y n g e a l l y m p h nodes. T h e y also
Nasopharyngeal Tonsil (Adenoids)
d r a i n i n t o spinal accessory c h a i n o f n o d e s i n t h e p o s t e r i o r
I t is a s u b e p i t h e l i a l c o l l e c t i o n o f l y m p h o i d tissue at t h e t r i a n g l e o f t h e n e c k . L y m p h a t i c s o f t h e n a s o p h a r y n x m a y also
j u n c t i o n o f r o o f and posterior wall o f nasopharynx and cross m i d l i n e t o d r a i n i n t o c o n t r a l a t e r a l l y m p h nodes.
causes t h e o v e r l y i n g m u c o u s m e m b r a n e t o b e t h r o w n i n t o
r a d i a t i n g f o l d s . I t increases i n size u p t o t h e age o f s i x years Functions of Nasopharynx
and t h e n gradually atrophies.
1. A c t s as a c o n d u i t f o r a i r , w h i c h has b e e n w a n n e d a n d

Nasopharyngeal Bursa ( F i g . 46.4) h u m i d i f i e d i n t h e n o s e , i n its passage t o t h e l a r y n x a n d

trachea.
I t is a n e p i t h e l i a l - l i n e d m e d i a n recess f o u n d w i t h i n the
2. T h r o u g h the eustachian t u b e , it ventilates the m i d d l e
a d e n o i d mass a n d e x t e n d s f r o m p h a r y n g e a l m u c o s a t o t h e
ear a n d equalises a i r pressure o n b o t h sides o f t y m p a n i c
p e r i o s t e u m o f t h e basiocciput. I t represents t h e a t t a c h m e n t
m e m b r a n e . T h i s f u n c t i o n is i m p o r t a n t f o r h e a r i n g .
o f n o t o c h o r d t o the pharyngeal e n t o d e r m d u r i n g e m b r y -
3. E l e v a t i o n o f t h e soft palate against p o s t e r i o r p h a r y n g e a l
o n i c l i f e . W h e n i n f e c t e d , i t m a y b e t h e cause o f p e r s i s t e n t
w a l l a n d t h e Passavant's ridge helps t o c u t o f f n a s o p h a r -
postnasal d i s c h a r g e o r c r u s t i n g . S o m e t i m e s a n abscess c a n
y n x f r o m o r o p h a r y n x . T h i s f u n c t i o n is i m p o r t a n t d u r -
f o r m i n t h e b u r s a ( T h o r n w a l d t ' s disease).
i n g s w a l l o w i n g , v o m i t i n g , g a g g i n g a n d speech.
4. A c t s as a r e s o n a t i n g c h a m b e r d u r i n g v o i c e p r o d u c t i o n .
Rathke's Pouch
V o i c e d i s o r d e r s are seen i n n a s o p h a r y n g e a l o b s t r u c t i o n
I t is r e p r e s e n t e d c l i n i c a l l y b y a d i m p l e a b o v e t h e a d e n o i d s and velopharyngeal incompetence (see C h a p t e r 6 2 ) .
a n d is r e m i n i s c e n t o f t h e b u c c a l m u c o s a l i n v a g i n a t i o n , t o 5. A c t s as a d r a i n a g e c h a n n e l f o r t h e m u c u s s e c r e t e d b y
f o r m the anterior lobe o f pituitary. A c r a n i o p h a r y n g i o m a nasal a n d n a s o p h a r y n g e a l glands.
m a y arise f r o m i t .

Tubal Tonsil Oropharynx

I t is c o l l e c t i o n o f s u b e p i t h e l i a l l y m p h o i d tissue s i t u a t e d at
Applied Anatomy
t h e t u b a l e l e v a t i o n . I t is c o n t i n u o u s w i t h a d e n o i d tissue
and forms a part o f the Waldeyer's ring. W h e n enlarged O r o p h a r y n x extends f r o m t h e plane o f h a r d palate above
d u e t o i n f e c t i o n , i t causes e u s t a c h i a n t u b e o c c l u s i o n . t o t h e p l a n e o f h y o i d b o n e b e l o w . I t lies o p p o s i t e t h e o r a l
Diseases of Pharynx

cavity w i t h w h i c h it communicates through oropharyngeal Median and lateral

isthmus. T h e l a t t e r is b o u n d e d a b o v e , b y t h e soft p a l a t e ; glossoepiglottic folds Vallecula

b e l o w , b y t h e u p p e r surface o f t o n g u e , a n d o n e i t h e r s i d e ,
b y palatoglossal arch (anterior pillar).

Boundaries of Oropharynx Tonsil

Base of tongue
P o s t e r i o r w a l l I t is r e l a t e d t o r e t r o p h a r y n g e a l space a n d
Sulcus terminalis -
lies o p p o s i t e t h e s e c o n d a n d u p p e r p a r t o f t h e t h i r d c e r v i -
cal v e r t e b r a e .

Anterior w a l l I t is d e f i c i e n t a b o v e , where oropharynx

c o m m u n i c a t e s w i t h t h e o r a l c a v i t y , b u t b e l o w i t presents: Circumvallate
papillae
(a) Base of tongue, p o s t e r i o r t o c i r c u m v a l l a t e p a p i l l a e .
(b) Lingual tonsils, o n e o n e i t h e r side, s i t u a t e d i n t h e base
o f tongue. T h e y may show compensatory enlarge-
m e n t f o l l o w i n g t o n s i l l e c t o m y o r m a y b e t h e seat o f
infection.
(c) Vallcculae. They are cup-shaped depressions lying
b e t w e e n t h e base o f t o n g u e a n d a n t e r i o r surface o f e p i -
Figure 46.5
g l o t t i s . E a c h is b o u n d e d m e d i a l l y b y t h e m e d i a n g l o s -
Base o f t o n g u e and valleculae.
s o e p i g l o t t i c f o l d a n d laterally b y p h a r y n g o e p i g l o t t i c
f o l d ( F i g . 4 6 . 5 ) . T h e y are t h e seat o f r e t e n t i o n cysts.

L a t e r a l w a l l I t presents:

Uvula Soft palate

(a) Palatine (faucial) tonsil ( f o r details, see p a g e 2 7 1 ) .
(b) Anterior pillar (palatoglossal arch) formed by the Anterior pillar
palatoglossus muscle.
Posterior Posterior pillar
(c) Posterior pillar (palatopharyngeal arch) f o r m e d b y the pharyngeal
palatopharyngeus muscle. wall Tonsil

B o t h a n t e r i o r a n d p o s t e r i o r p i l l a r s d i v e r g e f r o m t h e soft jllate
papilla
palate a n d e n c l o s e a t r i a n g u l a r d e p r e s s i o n called tonsillar
fossa i n w h i c h is s i t u a t e d t h e p a l a t i n e t o n s i l ( F i g . 4 6 . 6 ) .
Boundary between o r o p h a r y n x above and the hypo-
p h a r y n x b e l o w is f o r m e d b y u p p e r b o r d e r o f e p i g l o t t i s a n d
the p h a r y n g o e p i g l o t t i c folds.

Lymphatic Drainage
Figure 46.6
Lymphatics from the o r o p h a r y n x drain i n t o upper j u g u l a r
V a r i o u s structures seen in the o r o p h a r y n x .
c h a i n p a r t i c u l a r l y t h e j u g u l o d i g a s t r i c (tonsillar) n o d e . The
soft palate, lateral a n d p o s t e r i o r p h a r y n g e a l w a l l s a n d t h e base
5. P r o v i d e s l o c a l d e f e n c e a n d i m m u n i t y against h a r m f u l
o f t o n g u e also d r a i n i n t o r e t r o p h a r y n g e a l a n d p a r a p h a r y n g e a l
i n t r u d e r s i n t o t h e a i r a n d f o o d passages. T h i s f u n c t i o n
nodes and f r o m there to the jugulodigastric a n d posterior
is s u b s e r v e d b y s u b e p i t h e l i a l masses o f l y m p h o i d t i s -
c e r v i c a l g r o u p . T h e base o f t o n g u e m a y d r a i n b i l a t e r a l l y .
sues s c a t t e r e d as W a l d e y e r ' s r i n g . T h e y are s t r a t e g i -
c a l l y p l a c e d at t h e p o r t a l s o f a i r a n d f o o d e n t r y a n d act
Functions of Oropharynx
as p r o t e c t i v e s e n t i n e l s . B - l y m p h o c y t e s i n t h e g e r m i -
1. A s a c o n d u i t f o r passage o f a i r a n d f o o d . nal centres o f the follicles p r o d u c e secretory a n t i b o d -
2. H e l p s i n t h e p h a r y n g e a l phase o f d e g l u t i t i o n . ies o f I g A class w h e r e a s T - l y m p h o c y t e s i n p a r a f o l l i c u l a r
3. F o r m s p a r t o f v o c a l tract f o r c e r t a i n speech sounds. r e g i o n p r o d u c e c e l l - m e d i a t e d i m m u n i t y against v a r i -
4. H e l p s i n a p p r e c i a t i o n o f t h e taste. T a s t e b u d s are p r e s - ous viruses, bacteria a n d f u n g i . P a t h o g e n s w h i c h h a p -
e n t i n t h e base o f t o n g u e , soft p a l a t e , a n t e r i o r p i l l a r s p e n t o e n t e r i n t o these l y m p h o i d masses are d e a l t b y
and posterior pharyngeal wall. I g M a n d I g G a n t i b o d i e s s e c r e t e d b y p l a s m a cells.
 Anatomy and Physiology o f Pharynx

Choana with turbinates

Eustachian tube

Salpingopharyngeal Nasopharynx
fold
Soft palate
(posterior surface)
Tonsil
- Oropharynx
Base of tongue

Laryngeal inlet
Laryngopharynx
Pyriform fossa

Post-cricoid area

Figure 46.7

Pharynx opened from behind showing structures related to nasopharynx, oropharynx and laryngopharynx.

i n females s u f f e r i n g f r o m P l u m m e r - V i n s o n s y n d r o m e
^ Hypopharynx (Laryngopharynx)
(Fig. 46.7).
3. Posterior pharyngeal wall. I t extends f r o m the level o f
Applied Anatomy
M h y o i d b o n e t o the level o f cricoarytenoid j o i n t .
H y p o p h a r y n x is t h e l o w e s t p a r t o f t h e p h a r y n x a n d lies
b e h i n d a n d p a r t l y o n t h e sides o f t h e l a r y n x . Its s u p e r i o r Lymphatic Drainage
l i m i t is*the p l a n e passing f r o m the b o d y o f h y o i d b o n e t o
P y r i f o r m sinus is r i c h l y s u p p l i e d b y l y m p h a t i c s w h i c h e x i t
t h e p o s t e r i o r p h a r y n g e a l w a l l , w h i l e t h e i n f e r i o r l i m i t is
through the thyrohyoid membrane and drain into the
lower border o f c r i c o i d cartilage where hypopharynx
upper jugular chain.
becomes continuous with oesophagus. Hypopharynx
L y m p h a t i c s o f t h e p o s t e r i o r w a l l t e r m i n a t e i n the lateral
lies opposite the 3 r d , 4 t h , 5 t h , 6 t h cervical vertebrae.
pharyngeal or parapharyngeal nodes a n d thence to the
C l i n i c a l l y , i t is s u b d i v i d e d i n t o t h r e e r e g i o n s - — t h e p y r i f o r m
deep cervical l y m p h nodes.
sinus, p o s t - c r i c o i d r e g i o n a n d the p o s t e r i o r pharyngeal
L y m p h a t i c s o f p o s t - c r i c o i d r e g i o n also d r a i n i n t o t h e
wall.
p a r a p h a r y n g e a l n o d e s b u t m a y also d r a i n i n t o n o d e s of
1. Pyriform sinus (fossa). I t lies o n e i t h e r side o f t h e l a r y n x
supraclavicular a n d paratracheal c h a i n .
a n d extends f r o m p h a r y n g o e p i g l o t t i c f o l d to the u p p e r
R i c h l y m p h a t i c n e t w o r k o f p y r i f o r m fossae e x p l a i n s t h e
e n d o f oesophagus.
h i g h f r e q u e n c y w i t h w h i c h n o d a l metastases are seen i n
I t is b o u n d e d l a t e r a l l y b y t h e t h y r o h y o i d m e m b r a n e
c a r c i n o m a o f this r e g i o n .
a n d t h e t h y r o i d cartilage a n d m e d i a l l y b y t h e a r y e p i g l o t -
t i c f o l d , p o s t e r o l a t e r a l surfaces o f a r y t e n o i d a n d c r i c o i d
Functions of Hypopharynx
cartilages. I t f o r m s t h e lateral c h a n n e l f o r f o o d . F o r e i g n
b o d i e s m a y l o d g e i n t h e p y r i f o r m fossa. I n t e r n a l l a r y n - L a r y n g o p h a r y n x , l i k e o r o p h a r y n x , is a c o m m o n p a t h w a y
geal n e r v e r u n s s u b m u c o s a l l y i n t h e lateral w a l l o f t h e f o r air a n d f o o d , p r o v i d e s a v o c a l tract f o r resonance of
sinus a n d t h u s is easily accessible f o r l o c a l anaesthesia. I t c e r t a i n s p e e c h s o u n d s a n d h e l p s i n d e g l u t i t i o n . T h e r e is a
is also t h r o u g h this n e r v e t h a t p a i n is r e f e r r e d t o t h e ear c o o r d i n a t i o n b e t w e e n c o n t r a c t i o n o f p h a r y n g e a l muscles
i n c a r c i n o m a o f t h e p y r i f o r m sinus. a n d r e l a x a t i o n o f c r i c o p h a r y n g e a l s p h i n c t e r at t h e u p p e r
2. Post-cricoid region. I t is t h e p a r t o f t h e a n t e r i o r w a l l o f e n d o f oesophagus. L a c k o f this c o o r d i n a t i o n , i.e. failure o f
laryngopharynx between the upper and l o w e r borders cricopharyngeal sphincter to relax w h e n pharyngeal m u s -
o f c r i c o i d l a m i n a . I t is a c o m m o n site f o r carcinoma cles are c o n t r a c t i n g causes h y p o p h a r y n g e a l d i v e r t i c u l u m .
A d e n o i d s and O t h e r I n f l a m m a t i o n s
o f Nasopharynx

(iv) A s c e n d i n g cervical branch o f i n f e r i o r t h y r o i d artery

ADENOIDS
o f thyrocervical trunk.

Lymphatics f r o m the adenoid drain i n t o upper j u g u l a r

A n a t o m y and Physiology nodes directly or indirectly via retropharyngeal and
parapharyngeal nodes.
T h e n a s o p h a r y n g e a l t o n s i l , c o m m o n l y c a l l e d " a d e n o i d s " , is
s i t u a t e d at t h e j u n c t i o n o f t h e r o o f a n d p o s t e r i o r w a l l o f t h e
n a s o p h a r y n x . I t is c o m p o s e d o f v e r t i c a l ridges o f l y m p h o i d Aetiology J
tissue separated b y deep clefts and covered by ciliated
c o l u m n a r e p i t h e l i u m (Fig. 47.1). U n l i k e palatine tonsils, A d e n o i d s are s u b j e c t t o p h y s i o l o g i c a l e n l a r g e m e n t i n c h i l d -

a d e n o i d s h a v e n o c r y p t s a n d n o c a p s u l e . A d e n o i d tissue is hood. Certain c h i l d r e n have a t e n d e n c y to generalised

p r e s e n t at b i r t h , s h o w s p h y s i o l o g i c a l e n l a r g e m e n t u p t o t h e l y m p h o i d h y p e r p l a s i a i n w h i c h a d e n o i d s also t a k e p a r t .

age o f six years, a n d t h e n t e n d s t o a t r o p h y at p u b e r t y a n d R e c u r r e n t attacks o f r h i n i t i s , s i n u s i t i s o r c h r o n i c t o n s i l -

a l m o s t c o m p l e t e l y disappears b y t h e age o f 2 0 . litis m a y cause c h r o n i c a d e n o i d i n f e c t i o n a n d h y p e r p l a s i a .

A d e n o i d s receive their b l o o d supply f r o m : A l l e r g y o f t h e u p p e r r e s p i r a t o r y t r a c t m a y also c o n t r i b -

ute to the enlargement o f adenoids.
(i) A s c e n d i n g palatine b r a n c h o f facial.
(ii) A s c e n d i n g pharyngeal branch o f external carotid.
(iii) Pharyngeal branch o f the third part o f maxillary J Clinical Features
artery.

Symptoms a n d signs d e p e n d n o t m e r e l y o n t h e absolute

size o f t h e a d e n o i d mass b u t are r e l a t i v e t o t h e available
space i n t h e nasopharynx.
E n l a r g e d a n d i n f e c t e d a d e n o i d s m a y cause nasal, aural
or general symptoms.

A. Nasal Symptoms

1. Nasal obstruction is t h e c o m m o n e s t s y m p t o m . T h i s leads

t o m o u t h b r e a t h i n g . N a s a l o b s t r u c t i o n also i n t e r f e r e s
w i t h feeding or suckling i n a c h i l d . As respiration and
f e e d i n g c a n n o t take place s i m u l t a n e o u s l y , a c h i l d w i t h
a d e n o i d e n l a r g e m e n t fails t o t h r i v e .
2. Nasal discharge. I t is p a r t l y d u e t o c h o a n a l o b s t r u c t i o n ,
as the normal nasal secretions cannot drain into
nasopharynx and partly due to associated chronic

Figure 47.1 r h i n i t i s . T h e c h i l d o f t e n has a w e t b u b b l y n o s e .

3. Sinusitis. Chronic m a x i l l a r y sinusitis is commonly
Adenoid mass after removal with curette. Note ridges o f lym-
associated w i t h adenoids. I t is d u e t o p e r s i s t e n c e of
phoid tissue separated by deep clefts.
nasal d i s c h a r g e a n d i n f e c t i o n . R e v e r s e is also t r u e t h a t
 Adenoids and O t h e r Inflammations of Nasopharynx

a p r i m a r y m a x i l l a r y sinusitis m a y lead t o i n f e c t e d a n d
enlarged adenoids.
4. Epistaxis. When adenoids are acutely inflamed,
epistaxis c a n o c c u r w i t h n o s e b l o w i n g .
5. Voice change. V o i c e is toneless a n d loses nasal q u a l i t y
d u e t o nasal o b s t r u c t i o n .

B. Aural Symptoms

1. Tubal obstruction. A d e n o i d mass b l o c k s t h e eustachian

tube leading to retracted tympanic membrane and
c o n d u c t i v e h e a r i n g loss.
2. Recurrent attacks of acute otitis media m a y o c c u r d u e t o
spread o f i n f e c t i o n v i a t h e eustachian tube.
3. Chronic suppurative otitis media m a y fail t o resolve i n
the presence o f infected adenoids.
4. Serous otitis media. A d e n o i d s f o r m a n i m p o r t a n t cause
o f serous o t i t i s m e d i a i n c h i l d r e n . T h e w a x i n g and
w a n i n g size o f a d e n o i d s causes i n t e r m i t t e n t e u s t a c h i a n
Figure 47.2
tube obstruction w i t h fluctuating h e a r i n g loss.
Enlarged a d e n o i d s ( a r r o w s ) in a 7-year-old girl. T h e r e is very

C. General Symptoms little b r e a t h i n g space in the nasopharynx.

1. Adenoid fades. C h r o n i c nasal o b s t r u c t i o n a n d m o u t h

breathing lead to characteristic facial appearance
nasal allergy can cure the condition without resort to
c a l l e d adenoid fades. T h e c h i l d has a n e l o n g a t e d f a c e
surgeiy.
with d u l l expression, open m o u t h , p r o m i n e n t and
W h e n s y m p t o m s are m a r k e d , a d e n o i d e c t o m y is d o n e .
c r o w d e d upper teeth, and hitched up upper lip. Nose
I n d i c a t i o n s a n d details o f t h e o p e r a t i o n are discussed i n t h e
g i v e s a p i n c h e d - i n a p p e a r a n c e d u e t o disuse a t r o p h y
section o n operative surgeiy.
o f alae n a s i . H a r d p a l a t e i n these cases is h i g h l y a r c h e d
as t h e m o u l d i n g a c t i o n o f t h e t o n g u e o n p a l a t e is
lost.
2. Pulmonary hypertension. L o n g - s t a n d i n g nasal obstruc-
ACUTE NASOPHARYNGITIS

t i o n d u e t o a d e n o i d h y p e r t r o p h y c a n cause p u l m o -
nary hypertension and cor pulmonale.
| Aetiology
3. Aprosexia. i.e. lack o f c o n c e n t r a t i o n .

A c u t e infection o f the nasopharynx m a y be an isolated

i n f e c t i o n c o n f i n e d t o this part o n l y o r be a part o f the
Diagnosis
generalised u p p e r a i r w a y i n f e c t i o n . I t m a y be caused b y
viruses ( c o m m o n c o l d , i n f l u e n z a , p a r a - i n f l u e n z a , r h i n o o r
E x a m i n a t i o n o f postnasal space is p o s s i b l e i n s o m e y o u n g
adenovirus) o r bacteria (especially streptococcus, pneumococ-
c h i l d r e n a n d a n a d e n o i d mass c a n b e seen w i t h a m i r r o r . A
cus o r Haemophilus influenzae).
rigid or a flexible nasopharyngoscope is also u s e f u l t o see
details o f t h e n a s o p h a r y n x . S o f t tissue l a t e r a l r a d i o g r a p h o f
n a s o p h a r y n x w i l l r e v e a l t h e size o f a d e n o i d s a n d also t h e
e x t e n t t o w h i c h n a s o p h a r y n g e a l a i r space has b e e n com- ^1 Clinical Features
p r o m i s e d ( F i g . 4 7 . 2 ) . D e t a i l e d nasal e x a m i n a t i o n s h o u l d
always be conducted to exclude other causes o f nasal D r y n e s s a n d b u r n i n g o f t h e t h r o a t a b o v e t h e s o f t p a l a t e is

obstruction. u s u a l l y t h e f i r s t s y m p t o m as is c o m m o n l y n o t e d i n c o m -
m o n c o l d . T h i s is f o l l o w e d b y p a i n a n d d i s c o m f o r t l o c a l -
i z e d to the back o f nose w i t h s o m e d i f f i c u l t y o n s w a l l o w i n g .
Treatment I n s e v e r e i n f e c t i o n s , t h e r e is p y r e x i a a n d e n l a r g e d c e r v i c a l
l y m p h nodes. E x a m i n a t i o n o f n a s o p h a r y n x reveals con-
W h e n s y m p t o m s are n o t m a r k e d , b r e a t h i n g exercises, d e c o n - gested a n d s w o l l e n mucosa often covered w i t h whitish
gestant nasal d r o p s a n d a n t i h i s t a m i n i c s f o r any co-existent exudate.
Diseases of Pharynx

d r i n k i n g s h o u l d be corrected. P r e v e n t i v e measures s h o u l d
Treatment
b e t a k e n t o a v o i d d u s t a n d f u m e s . A l k a l i n e nasal d o u c h e
h e l p s t o r e m o v e crusts a n d m u c o p u s . S t e a m i n h a l a t i o n s are
M i l d cases c l e a r u p s p o n t a n e o u s l y . S o m e analgesic m a y b e
soothing.
r e q u i r e d f o r r e l i e f o f p a i n a n d d i s c o m f o r t . I n severe cases
with general s y m p t o m s , systemic antibiotic or chemo-
t h e r a p y m a y b e necessary. I n c h i l d r e n , t h e r e is associated
THORNWALDT'S DISEASE
a d e n o i d i t i s w h i c h causes nasal o b s t r u c t i o n , a n d r e q u i r e s
(PHARYNGEAL BURSITIS)
nasal d e c o n g e s t a n t d r o p s .

I t is i n f e c t i o n o f t h e p h a r y n g e a l b u r s a w h i c h is a m e d i a n
CHRONIC NASOPHARYNGITIS recess r e p r e s e n t i n g a t t a c h m e n t o f n o t o c h o r d t o e n d o d e r m
o f t h e p r i m i t i v e p h a r y n x . P h a r y n g e a l b u r s a is l o c a t e d i n
the m i d l i n e o f posterior w a l l o f the nasopharynx i n the
Aetiology
adenoid'mass. *»

I t is o f t e n associated w i t h c h r o n i c i n f e c t i o n s o f n o s e , p a r a -
nasal sinuses a n d p h a r y n x . I t is c o m m o n l y seen i n h e a v y
| Clinical Features J
smokers, d r i n k e r s a n d those exposed t o dust a n d fumes.

1. Persistent postnasal discharge with crusting i n the

nasopharynx.
Clinical Features
2. Nasal o b s t r u c t i o n due to swelling i n the nasopharynx.
3. O b s t r u c t i o n t o eustachian t u b e a n d serous o t i t i s m e d i a .
Postnasal d i s c h a r g e a n d c r u s t i n g w i t h i r r i t a t i o n at t h e b a c k
4. D u l l t y p e o f o c c i p i t a l headache.
o f nose is t h e m o s t c o m m o n c o m p l a i n t . P a t i e n t has a c o n -
5. R e c u r r e n t sore t h r o a t .
s t a n t desire t o c l e a r t h e t h r o a t b y h a w k i n g o r i n s p i r a t o r y
6. L o w grade fever.
s n o r t i n g ( f o r c i b l y d r a w i n g nasal s e c r e t i o n s back into the
throat). E x a m i n a t i o n w o u l d r e v e a l a cystic a n d fluctuant swell-
E x a m i n a t i o n o f n a s o p h a r y n x reveals c o n g e s t e d mucosa i n g i n t h e p o s t e r i o r w a l l o f n a s o p h a r y n x . I t m a y also s h o w
a n d m u c o p u s o r d r y crusts. I n c h i l d r e n , a d e n o i d s are o f t e n crusts i n t h e n a s o p h a r y n x d u e t o d r i e d u p d i s c h a r g e .
enlarged and infected (chronic adenoiditis).

Treatment
Treatment
A n t i b i o t i c s are g i v e n t o treat i n f e c t i o n a n d m a r s u p i a l i s a t i o n
Chronic infections o f the nose, paranasal sinuses and o f t h e c y s t i c s w e l l i n g a n d a d e q u a t e r e m o v a l o f its l i n i n g
o r o p h a r y n x s h o u l d be a t t e n d e d t o . Excessive s m o k i n g a n d membrane.
Tumours o f Nasopharynx

0 ?

Extensions of Nasopharyngeal Fibroma

BENIGN TUMOURS
N a s o p h a r y n g e a l f i b r o m a is a b e n i g n t u m o u r b u t l o c a l l y i n v a -
sive a n d destroys t h e a d j o i n i n g structures. I t m a y e x t e n d i n t o :
Nasopharyngeal Fibroma (Juvenile
Nasal cavity c a u s i n g nasal o b s t r u c t i o n , epistaxis a n d
I Nasopharyngeal Angiofibroma)
1 (a)
nasal d i s c h a r g e .
Paranasal sinuses. Maxillary, sphenoid and ethmoid
I t is a r a r e t u m o u r , t h o u g h i t is t h e c o m m o n e s t o f all «
sinuses c a n a l l b e i n v a d e d .
benign tumours o f nasopharynx.
(c) Pterygomaxillary fossa, infratemporal fossa a n d cheek.

(d) Orbits g i v i n g rise t o p r o p t o s i s a n d " f r o g - f a c e d e f o r m i t y ' ' .

Aetiology
I t e n t e r s t h r o u g h t h e i n f e r i o r o r b i t a l fissure a n d also
T h e e x a c t cause is u n k n o w n . A s t h e t u m o u r is p r e d o m i - d e s t r o y s a p e x o f t h e o r b i t . I t c a n also e n t e r t h e o r b i t
n a n t l y seen i n adolescent males i n the s e c o n d decade of t h r o u g h s u p e r i o r o r b i t a l fissure.
life, i t is thought to be testosterone dependent. Such
(el Cranial cavity. M i d d l e c r a n i a l fossa is t h e m o s t com-
patients have a hamartomatous n i d u s o f v a s c u l a r tissue i n m o n . T h e r e are t w o r o u t e s o f e n t r y :
t h e n a s o p h a r y n x a n d t h i s is a c t i v a t e d t o f o r m a n g i o f i b r o m a (i) B y e r o s i o n o f f l o o r o f m i d d l e c r a n i a l fossa, a n t e -
w h e n m a l e sex h o r m o n e appears. rior t o f o r a m e n l a c e r u m . T h e t u m o u r lies l a t e r a l
t o c a r o t i d a r t e r y a n d c a v e r n o u s sinus.
Site of Origin and Growth (ii) T h r o u g h s p h e n o i d s i n u s , i n t o t h e sella. T u m o u r

T h e site o f o r i g i n o f t h e t u m o u r is s t i l l a m a t t e r o f d i s p u t e . lies m e d i a l t o c a r o t i d a r t e r y .

E a r l i e r i t w a s t h o u g h t t o arise f r o m t h e r o o f o f n a s o p h a r -
A n t e r i o r c r a n i a l fossa ( t h r o u g h e t h m o i d r o o f o r c r i b r i -
y n x o r t h e a n t e r i o r w a l l o f s p h e n o i d b o n e b u t n o w i t is
f o r m plate).
believed t o arise f r o m t h e p o s t e r i o r p a r t o f nasal c a v i t y
close t o t h e s u p e r i o r m a r g i n o f s p h e n o p a l a t i n e foramen. Clinical Features
From here the tumour grows into the nasal cavity,
1. Age and sex. T u m o u r is seen a l m o s t exclusively in
nasopharynx a n d i n t o t h e p t e r y g o p a l a t i n e fossa, r u n n i n g
m a l e s i n t h e age g r o u p o f 1 0 - 2 0 years. R a r e l y , i t m a y
behind the posterior wall o f m a x i l l a r y sinus which is
b e seen i n o l d e r p e o p l e a n d f e m a l e s .
p u s h e d f o r w a r d as t h e t u m o u r g r o w s . L a t e r a l l y , i t e x t e n d s
2. Profuse and recurrent epistaxis. T h i s is t h e m o s t common
i n t o p t e r y g o m a x i l l a r y fossa a n d t h e n c e t o infratemporal
presentation. Patient m a y be m a r k e d l y anaemic d u e
fossa a n d c h e e k .
t o r e p e a t e d b l o o d loss.
3. Progressive nasal obstruction and denasal speech due to
Pathology
mass i n t h e p o s t n a s a l space.
A n g i o f i b r o m a , as t h e n a m e i m p l i e s , is m a d e u p o f v a s c u l a r 4. Conductive hearing loss and serous otitis media due to
and fibrous tissues: t h e ratio o f the two components o b s t r u c t i o n o f eustachian tube.
m a y v a r y . M o s t l y , t h e vessels are j u s t endothelium-lined 5. Mass in the nasopharynx. T u m o u r is sessile, l o b u l a t e d
spaces w i t h n o m u s c l e c o a t . T h i s a c c o u n t s f o r t h e severe or s m o o t h and obstructs one o r b o t h c h o a n a e . I t is
b l e e d i n g as t h e vessels lose t h e a b i l i t y t o c o n t r a c t , a n d also p i n k o r p u r p l i s h i n c o l o u r . C o n s i s t e n c y is f i r m b u t
the bleeding cannot be controlled by application of digital palpation s h o u l d never be d o n e u n t i l at the
adrenaline. time o f operation.
Diseases of Pharynx

6. O t h e r c l i n i c a l features l i k e b r o a d e n i n g o f nasal b r i d g e , d i s p l a c e m e n t o f nasal s e p t u m , o p a c i f i c a t i o n o f sinuses,

p r o p t o s i s , s w e l l i n g o f c h e e k , i n f r a t e m p o r a l fossa o r a n t e r i o r b o w i n g o f p o s t e r i o r w a l l o f m a x i l l a r y sinus,
i n v o l v e m e n t o f I l n d , I l l r d , I V t h , V l t h cranial nerves d e s t r u c t i o n o f m e d i a l antral w a l l , erosion o f greater
w i l l d e p e n d o n the extent o f t u m o u r (Fig. 48.1). wing o f s p h e n o i d o r p t e r y g o i d plates, w i d e n i n g of
l o w e r l a t e r a l m a r g i n o f s u p e r i o r o r b i t a l fissure.
Investigations 3. CT scan o f t h e h e a d w i t h c o n t r a s t e n h a n c e m e n t is
now the investigation o f choice ( F i g . 4 8 . 2 ) . I t has
1. S o f t tissue h u r r a ! f i l m o f n a s o p h a r y n x s h o w s s o f t tissue
replaced conventional radiographs. It shows the
mass i n t h e n a s o p h a r y n x .
extent o f t u m o u r , b o n y destruction o r displacements.
2. X - r a y s o f paranasal sinuses a n d base o f s k u l l m a y s h o w
A n t e r i o r b o w i n g o f the posterior wall of maxillary
sinus ( o f t e n c a l l e d t h e a n t r a l s i g n o r H o l m a n - M i l l e r
s i g n ) is p a t h o g n o m i c o f a n g i o f i b r o m a .
4. M a g n e t i c r e s o n a n c e i m a g i n g ( M R I ) is c o m p l e m e n -
t a r y t o C T scans, w h e n soft tissue e x t e n s i o n s are p r e s -
e n t i n t r a c r a n i a l l y , i n t h e i n f r a t e m p o r a l fossa o r i n t o
the orbit.
5. C a r o t i d a n g i o g r a p h y s h o w s e x t e n s i o n o f t u m o u r , its
v a s c u l a r i t y a n d f e e d i n g vessels. I t is d o n e w h e n e m b o -
l i s a t i o n is p l a n n e d b e f o r e o p e r a t i o n .

Diagnosis

I t is m o s t l y based o n c l i n i c a l p i c t u r e . B i o p s y o f t h e t u m o u r
is a t t e n d e d w i t h p r o f u s e b l e e d i n g a n d is t h e r e f o r e , a v o i d e d .
I f i t is essential to differentiate it f r o m other tumours,
biopsy can be done u n d e r general anaesthesia w i t h all
a r r a n g e m e n t s t o c o n t r o l b l e e d i n g a n d transfuse b l o o d .

Treatment

Surgery Earlier, nasopharyngeal angiofibromas were

Figure 48.1 considered to undergo spontaneous regression with
advancement o f age b u t i n p r a c t i c e i t does n o t h a p p e n .
Angiofibroma nasopharynx with extension into left cheek.
S u r g i c a l e x c i s i o n is n o w t h e t r e a t m e n t o f c h o i c e . V a r i o u s

A B

C T s c a n s h o w i n g extent o f angiofibroma: (A) Axial cut. (B) Coronal cut.

 Tumours of Nasopharynx

f o r i n t r a c r a n i a l e x t e n s i o n o f disease w h e n t u m o u r d e r i v e s
its b l o o d s u p p l y f r o m t h e i n t e r n a l c a r o t i d s y s t e m .
R e c u r r e n t a n g i o f i b r o m a s h a v e also b e e n t r e a t e d b y i n t e n -
sity m o d u l a t e d r a d i o t h e r a p y — a n e w e r m o d e o f t r e a t m e n t .

Hormonal S i n c e t h e t u m o u r o c c u r s i n y o u n g m a l e s at
p u b e r t y , h o r m o n a l t h e r a p y as t h e p r i m a r y o r a d j u n c t i v e
t r e a t m e n t has b e e n u s e d . D i e t h y l s t i l b o e s t r o l a n d f l u t a m i d e
have b e e n used.
Tumour
Chemotherapy Recurrent and residual lesions have
b e e n treated b y chemotherapy, d o x o r u b i c i n , vincristine
a n d dacarbazine i n c o m b i n a t i o n .

OTHER BENIGN T U M O U R S OF
NASOPHARYNX
Figure 48.3

N a s o p h a r y n g e a l f i b r o m a as seen after t r a n s p a l a t a l exposure.

T h e y are v e r y r a r e a n d arise f r o m t h e r o o f o r l a t e r a l w a l l o f
nasopharynx. T h e y include:

1. Teratomas. C o n g e n i t a l t u m o u r s , seen at b i r t h . Six t i m e s

s u r g i c a l a p p r o a c h e s t o a n g i o f i b r o m a , d e p e n d i n g o n its o r i -
more common i n f e m a l e s . V a r i o u s types i n c l u d e , a
g i n a n d e x t e n s i o n s , are l i s t e d b e l o w .
dermoid w i t h s k i n a p p e n d a g e s , also c a l l e d a h a i r y p o l y p ,

1. Transpalatine (Fig. 48.3) true teratoma h a v i n g e l e m e n t s o f all t h e t h r e e g e r m l a y -

2. T r a n s p a l a t i n e + S u b l a b i a l (Sardana's a p p r o a c h ) ers, a n d t h e epignathi w i t h w e l l - d e v e l o p e d f o e t a l parts.

3. E x t e n d e d lateral r h i n o t o m y 2. Pleomorphic adenoma.

• V i a facial i n c i s i o n 3. Chordoma. D e r i v e d f r o m the n o t o c h o r d .

• V i a degloving approach 4. Hamartoma. Malformed normal tissue, e.g.

4. Extended Denkefs approach haemangioma.

5. Intracranial—extracranial 5. Choristoma. M a s s o f n o n n a l tissues at a n a b n o r m a l site.

6. I n f r a t e m p o r a l fossa 6. Paraganglioma.

7. Endoscopic
8. T r a n s m a x i l l a r y (Le F o r t I approach)
9. Maxillary swing approach
MALIGNANT TUMOURS

Transpalatal approach is e m p l o y e d f o r t u m o u r s con-

fined to nasopharynx. Lateral r h i n o t o m y approach gives
J Nasopharyngeal Cancer
w i d e exposure a n d is g e n e r a l l y p r e f e r r e d f o r t h e t u m o u r
a n d its e x t e n s i o n s . T h e r e m a y b e a b o u t 2 l i t r e s o f b l o o d Epidemiology and Geographic Distribution

loss d u r i n g s u r g e r y . T h e r e f o r e , attempts are made pre-

N a s o p h a r y n g e a l c a n c e r is a m u l t i f a c t o r i a l disease. Its i n c i -
o p e r a t i v e l y , t o reduce the vascularity o f t u m o u r . A course
d e n c e a n d g e o g r a p h i c d i s t r i b u t i o n depends o n several fac-
o f o e s t r o g e n t h e r a p y ( s t i l b o e s t r o l 2.5 m g t h r e e t i m e s a d a y
t o r s s u c h as g e n e t i c s u s c e p t i b i l i t y , e n v i r o n m e n t , d i e t a n d
for 3 weeks) may reduce vascularity of tumour. Pre-
personal habits.
o p e r a t i v e r a d i a t i o n also h e l p s t o r e d u c e v a s c u l a r i t y b u t is
N a s o p h a r y n g e a l c a n c e r is m o s t c o m m o n i n C h i n a p a r -
n o t generally favoured. Cryotherapy o f the tumour or
t i c u l a r l y i n s o u t h e r n states a n d T a i w a n .
e m b o l i s a t i o n o f t h e f e e d i n g vessels m a y also h e l p t o r e d u c e
Its i n c i d e n c e i n N o r t h A m e r i c a n w h i t e s is 0 . 2 5 % o f all
b l o o d loss at s u r g e i y .
cancers, w h i l e i t is 1 8 % i n A m e r i c a n C h i n e s e . C h i n e s e b o m
Recurrence o f t u m o u r after surgical removal is not
i n A m e r i c a h a v e lesser i n c i d e n c e t h a n those b o m i n C h i n a .
uncommon.
B u r n i n g o f incense o r w o o d ( p o l y c y c l i c h y d r o c a r b o n ) , use
Radiotherapy R a d i o t h e r a p y has b e e n u s e d as a p r i m a r y o f p r e s e r v e d salted f i s h ( n k r o s a m i n e s ) a l o n g w i t h v i t a m i n C
m o d e o f t r e a t m e n t . A dose o f 3 0 0 0 t o 3 5 0 0 c G y i n 15-18 deficient diet ( v i t a m i n C blocks n i t r o s i f i c a t i o n o f amines and
fractions is d e l i v e r e d i n 3 - 3 . 5 weeks. R e s p o n s e is not is t h u s p r o t e c t i v e ) m a y b e o t h e r factors o p e r a t i v e i n C h i n a .
immediate. Tumour regresses s l o w l y i n about a year, N a s o p h a r y n g e a l c a n c e r is u n c o m m o n i n I n d i a a n d c o n -
s o m e t i m e s e v e n u p t o 3 years. R a d i o t h e r a p y is also u s e d s t i t u t e s o n l y 0 . 4 1 % (0.66%> i n m a l e s a n d 0 . 1 7 % i n females)
Diseases of Pharynx

o f all cancers e x c e p t i n t h e N o r t h East r e g i o n w h e r e p e o p l e Clinical Features

are p r e d o m i n a n t l y o f M o n g o l o i d o r i g i n . P e o p l e i n S o u t h e r n
Age. I t is m o s t l y seen i n f i f t h t o s e v e n t h decades b u t m a y
C h i n a , T a i w a n a n d I n d o n e s i a are m o r e p r o n e t o this cancer.
i n v o l v e y o u n g e r age g r o u p s . I t is n o t u n c o m m o n t o see
cancer o f nasopharynx i n twenties and thirties.
Aetiology
Sex. M a l e s are t h r e e t i m e s m o r e p r o n e t h a n f e m a l e s .
T h e e x a c t a e t i o l o g y is n o t k n o w n . T h e f a c t o r s responsible S y m p t o m a t o l o g y is d i v i d e d i n t o f o u r m a i n g r o u p s :
are: 1. N a s a l N a s a l o b s t r u c t i o n , nasal d i s c h a r g e , denasal speech
( r h i n o l a l i a clausa) a n d e p i s t a x i s .
1. Genetic. Chinese have a higher genetic susceptibility to
n a s o p h a r y n g e a l c a n c e r . E v e n after m i g r a t i o n t o o t h e r 2. Otologic D u e t o o b s t r u c t i o n o f eustachian t u b e , there
countries they c o n t i n u e to have h i g h e r incidence. is c o n d u c t i v e h e a r i n g loss, serous o r s u p p u r a t i v e o t i t i s
2. Viral. Epstein—Barr v i m s is c l o s e l y associated with m e d i a . T i n n i t u s a n d dizziness m a y o c c u r . Presence of unilat-
n a s o p h a r y n g e a l c a n c e r . S p e c i f i c v i r a l m a r k e r s are b e i n g eral serous otitis media in an adult should raise suspicion of
d e v e l o p e d t o s c r e e n p e o p l e i n h i g h i n c i d e n c e areas. nasopharyngeal growth. Rarely, t u m o u r grows u p the tube
3. Environmental. A i r pollution, s m o k i n g o f tobacco and i n t o t h e m i d d l e ear.
o p i u m , n i t r o s a m i n e s f r o m d r y salted f i s h , s m o k e from
3. O p h t h a l m o n e u r o l o g i c T h i s occurs due to extension
b u r n i n g o f incense a n d w o o d have all b e e n i n c r i m i n a t e d .
o f t u m o u r t o t h e s u r r o u n d i n g r e g i o n s . N e a r l y all t h e c r a -
nial nerves m a y be i n v o l v e d .
Pathology
Squint and diplopia due to i n v o l v e m e n t o f C N V I , o p h -
Squamous cell carcinoma i n v a r i o u s grades o f its d i f f e r -
t h a l m o p l e g i a ( C N I I I , r V a n d V I ) , facial p a i n a n d r e d u c e d
e n t i a t i o n o r its v a r i a n t s as t r a n s i t i o n a l c e l l c a r c i n o m a and
c o r n e a l reflex m a y ( i n v a s i o n o f C N V t h r o u g h f o r a m e n lace-
l y m p h o e p i t h e l i o m a , is t h e m o s t c o m m o n ( 8 5 % ) . L y m p h o m a s
m m ) occur. T u m o u r s may direcdy invade the orbit leading to
constitute 10% a n d t h e rest 5 % are rhabdomyosarcoma,
e x o p h t h a l m o s a n d blindness ( C N I I at t h e apex o f the o r b i t ) .
m a l i g n a n t m i x e d salivary t u m o u r o r m a l i g n a n t c h o r d o m a .
I n v o l v e m e n t o f I X t h , X t h a n d X l t h cranial nerves m a y o c c u r ,
O n t h e basis o f h i s t o l o g y , as seen o n l i g h t m i c r o s c o p y , c o n s t i t u t i n g jugular foramen syndrome. U s u a l l y , this is d u e t o
W H O has l a t e l y r e c l a s s i f i e d e p i t h e l i a l g r o w t h s i n t o t h r e e pressure o f enlarged lateral r e t r o p h a r y n g e a l l y m p h nodes o n
t y p e s (see T a b l e 4 8 . 1 ) . these nerves i n t h e n e c k . C N X I I m a y be i n v o l v e d d u e t o
G r o s s l y , t h e t u m o u r presents i n t h r e e f o m i s : e x t e n s i o n o f g r o w t h t o hypoglossal canal. H o m e r ' s s y n d r o m e
1. P r o l i f e r a t i v e W h e n a p o l y p o i d t u m o u r fills t h e n a s o - m a y occur due to i n v o l v e m e n t o f cervical sympathetic chain.
p h a r y n x , i t causes o b s t r u c t i v e nasal s y m p t o m s . N a s o p h a r y n g e a l c a n c e r c a n cause c o n d u c t i v e deafness
(eustachian tube blockage), ipsilateral temporoparietal
2. Ulcerative E p i s t a x i s is t h e c o m m o n s y m p t o m .
neuralgia (involvement o f C N V) a n d palatal paralysis
3. Infiltrative G r o w t h s infiltrate submucosally. ( C N X ) - — c o l l e c t i v e l y c a l l e d Trotter's triad.

S p r e a d o f n a s o p h a r y n g e a l c a r c i n o m a (see F i g . 4 8 . 4 ) . 4. Cervical nodal metastases T h i s m a y be the only

T h e c o m m o n e s t site o f o r i g i n is fossa o f R o s e n m u l l e r i n m a n i f e s t a t i o n o f n a s o p h a r y n g e a l c a n c e r . A l u m p o f n o d e s is
t h e lateral w a l l o f n a s o p h a r y n x . I t can spread i n t o t h e c r a n i u m f o u n d b e t w e e n the angle o f j a w a n d the m a s t o i d and some
t h r o u g h f o r a m e n l a c e r u m a n d cause i n v o l v e m e n t o f v a r i - n o d e s a l o n g t h e s p i n a l accessory i n t h e p o s t e r i o r t r i a n g l e o f
o u s c r a n i a l n e r v e s . L y m p h n o d e i n v o l v e m e n t is c o m m o n neck. N o d a l metastases are seen i n 7 5 % o f the patients,
because o f r i c h l y m p h a t i c n e t w o r k i n t h e n a s o p h a r y n x . w h e n f i r s t seen, a b o u t h a l f o f t h e m w i t h b i l a t e r a l n o d e s .

sSM W H O classification based on histopathology

Present WHO terminology Former terminology

Type 1 (25%) S q u a m o u s cell c a r c i n o m a S q u a m o u s cell c a r c i n o m a

Type II (12%) Non4<eratinising c a r c i n o m a Transitional cell c a r c i n o m a

- W i t h o u t lymphoid s t r o m a I n t e r m e d i a t e cell carcinoma

- W i t h lymphoid s t r o m a Lymphoepithelial c a r c i n o m a (Regaud)

Type III (63%) Undifferentiated c a r c i n o m a Anaplastic c a r c i n o m a

- W i t h o u t lymphoid s t r o m a C l e a r cell c a r c i n o m a

- W i t h lymphoid stroma Lymphoepithelial carcinoma (Schminke)

S p i n d l e cell c a r c i n o m a
 Tumours of Nasopharynx

Figure 48.4

Routes o f spread (green area) and clinical features (blue area) o f nasopharyngeal cancer.

5. Distant metastases involve bone, lung, liver and

o t h e r sites.

P r e s e n t i n g s y m p t o m s a n d signs o f n a s o p h a r y n g e a l c a n -
c e r i n o r d e r o f f r e q u e n c y are:

" Cervical l y m p h a d e n o p a t h y (most c o m m o n ) (60-90%)

8
H e a r i n g loss
B
Nasal obstruction
• Epistaxis
• Cranial nerve palsies. C N VI paralysis is t h e most
c o m m o n o f these
• Headache
a
Earache
• N e c k pain
• W e i g h t loss.

Diagnosis

E x a m i n a t i o n o f p o s t n a s a l space b y a n a s o p h a r y n g e a l mir-
r o r o r n a s o p h a r y n g o s c o p e is t h e m o s t i m p o r t a n t . Figure 48.5
Skull X-rays, tomograms or preferably C T scans are Supraclavicular fossa (or Ho's triangle) is bounded by medial

d o n e t o d e m o n s t r a t e e r o s i o n o f b o n e at t h e base o f s k u l l (A) and lateral (B) e n d s o f clavicle a n d the point (C) where neck

and the extent o f t u m o u r . M R I w i t h g a d o l i n i u m enhance- meets the s h o u l d e r . It includes c a u d a l p o r t i o n s o f levels IV a n d V.

m e n t reveals t h e i n t r a c r a n i a l e x t e n s i o n .
B i o p s y is essential t o s h o w t h e e x a c t h i s t o l o g y o f t h e
m a l i g n a n c y . I n t h e absence o f a nasopharyngeal lesion b u t be taken a n d subjected t o histology. Submucosal spread,
with strong suspicion of malignancy, nasopharynx is b e n e a t h a n o r m a l a p p e a r i n g surface m u c o s a , is q u i t e c o m -
e x p o s e d b y transpalatal a p p r o a c h a n d a strip o f m u c o s a a n d mon. N a s o p h a r y n x is also a common site for occult
s u b m u c o s a f r o m t h e r e g i o n o f fossa o f R o s e n m u l l e r s h o u l d primaries.
Diseases of Pharynx

Classification (see Table 48.2) R a d i c a l n e c k d i s s e c t i o n is r e q u i r e d f o r p e r s i s t e n t n o d e s

w h e n p r i m a r y has b e e n c o n t r o l l e d . R e c u r r e n t o r r e s i d u a l
W H O classified nasopharyngeal carcinoma on histo-
t u m o u r requires a second course o f external r a d i a t i o n or
p a t h o l o g i c a l basis i n t o t h r e e types ( T a b l e 4 8 . 1 ) . T y p e I I I is
intracavitary implants (brachytherapy). R e c u r r e n c e s have
the most c o m m o n i n N o r t h A m e r i c a . H o w e v e r , the fre-
also b e e n t r e a t e d w i t h c r y o s u r g e r y t h r o u g h a p a l a t a l f e n e s -
q u e n c y o f d i f f e r e n t h i s t o p a t h o l o g i c a l types m a y differ f r o m
t r a t i o n o r i n s e l e c t e d cases b y s k u l l base s u r g e r y .
c o u n t r y t o c o u n t r y . T h e s e t y p e s h a v e also b e e n c o r r e l a t e d
t o t i t r e s o f E p s t e i n - B a r r ( E B ) v i r u s a n d also i n r e s p o n s e t o Chemotherapy Some stages III and IV cancers of

r a d i o t h e r a p y . I t is o b s e r v e d t h a t t y p e I I a n d t y p e I I I are nasopharynx can be c u r e d b y r a d i o t h e r a p y alone b u t cure

associated w i t h h i g h e r t i t r e s o f E B v i r u s a n d h a v e h i g h e r r a t e is d o u b l e d w h e n c h e m o t h e r a p y is c o m b i n e d with

l o c a l c o n t r o l rates w i t h r a d i o t h e r a p y . r a d i o t h e r a p y . C h e m o t h e r a p y can be g i v e n c o n c o m i t a n t l y
o r postradiotherapy. Cisplatin o r cisplatin w i t h 5 - F U have
b e e n u s e d . C h e m o t h e r a p y has also b e e n f o u n d u s e f u l t o
Treatment
c o n t r o l metastases f r o m l y m p h o e p i t h e l i o m a a n d u n d i f f e r -
I r r a d i a t i o n is t h e t r e a t m e n t o f c h o i c e . S u p e r v o l t a g e t h e r a p y entiated carcinoma of nasopharynx. Goal of chemo-
u s i n g large ports w h i c h i n c l u d e cervical nodes, d e l i v e r i n g a r a d i o t h e r a p y i n n a s o p h a r y n g e a l c a r c i n o m a is t o i m p r o v e
t u m o u r dose o f 6 0 0 0 — 7 0 0 0 rads, is e m p l o y e d . l o c a l c o n t r o l o f t u m o u r a n d t r e a t d i s t a n t metastases.

Table 48.2 T N M classification o f nasopharyngeal c a r c i n o m a ( A j C 2 0 0 2 )

Primary tumour Distant metastasis

T 1 T u m o u r confined to the nasopharynx M x D i s t a n t metastasis c a n n o t be assessed
T u m o u r extends t o s o f t tissues o f o r o p h a r y n x M Q N o d i s t a n t metastasis
a n d / o r nasal fossa M 1 D i s t a n t metastasis
T w i t h o u t p a r a p h a r y n g e a l extension
Stage grouping
2 a

T 2 b w i t h p a r a p h a r y n g e a l extension
T u m o u r invades b o n y s t r u c t u r e s a n d / o r p a r a n a s a l 0 Tis N 0 M
0

sinuses
T u m o u r w i t h i n t r a c r a n i a l extension a n d / o r
1
% N
o Mo
MA M
i n v o l v e m e n t o f c r a n i a l nerves, i n f r a t e m p o r a l N
o 0

fossa, h y p o p h a r y n x o r o r b i t o r m a s t i c a t o r space MB N, M
c

Regional lymph nodes T

2 N- Mo
The d i s t r i b u t i o n a n d the prognostic i m p a c t o f regional N, M
o
l y m p h n o d e s p r e a d f r o m n a s o p h a r y n x cancer,
M
o
p a r t i c u l a r l y o f t h e u n d i f f e r e n t i a t e d t y p e , is d i f f e r e n t f r o m
t h a t o f o t h e r head a n d neck m u c o s a l cancers a n d
III
% N
. M 0

j u s t i f i e s use o f a d i f f e r e n t N c l a s s i f i c a t i o n scheme N 2 M
o

N,
N x R e g i o n a l l y m p h n o d e s c a n n o t be assessed
N N o regional lymph node metastasis
IVA N
-AW*
Q

T
< 2
«;q
N ] U n i l a t e r a l m e t a s t a s i s in l y m p h n o d e ( s ) , 6 c m m

IVB AnyT
o r less in greatest d i m e n s i o n , above the
s u p r a c l a v i c u l a r fossa IVC AnyT Any N

N 2 B i l a t e r a l m e t a s t a s i s in l y m p h n o d e s , 6 c m o r less
in greatest d i m e n s i o n , a b o v e t h e s u p r a c l a v i c u l a r
fossa.
»ogir
N 3 M e t a s t a s i s in a l y m p h n o d e ( s )
ro 2fhingoitio3 . e / n - X llisA'd
N 3 a G r e a t e r t h a n 6 c m in d i m e n s i o n
•
N In the s u p r a c l a v i c u l a r fossa

Note: In nasopharyngeal carcinoma, N. classification is different from that o f other mucosal cancers o f the head and neck. Enlarged nodes in
the lower neck (supraclavicular fossa) places them in N, category. Less weiehtage is given to nodes in upper neck. Nodes even up to 6 c m size
are still categorised as N as against N, at other sites.
1

.
:
''= ' :
. l B 5 g i r ( i i ; f I q o ? i : n
:
ETO ^ m ^ a d i ; Dili rd .vpjafiin^ilcrii
Supraclavicular fossa or Ho's triangle is defined as area o f neck lying between three rpoints: (i) medial end o f clavicle, f ii) lateral end o f clavicle and
. . , 7-Jy i i i j ,|—. —,
(III) the point where neck meets the shoulder (Fig. 4S.5).
.ir,aqo?.a(i tyjui,mti\{,m To n o m q a m m i o - m a f i w
b h c cM-jsurnTo nhu r. brie riowjqqt; IinrdLqamnj y d bt>?oqy.'j
Enlarged node(s) in this triangle, irrespective o f the size, are categorised as N, ,.
lilaom imMsmo&iQM i o v.m>\ to n o n r r r -jrii m o i l fooiuittaut
 Tumours of Nasopharynx

2. Rhabdomyosarcoma. Commonly seen i n Children.

OTHER MALIGNANT TUMOURS OF E m b r y o n a l r h a b d o m y o s a r c o m a presents as a p o l y p o i d

NASOPHARYNX mass i n t h e n a s o p h a r y n x .
3. Plasmacytoma. I t m a y be solitary o r part o f generalised
multiple myelomatosis.
T h e y are rare a n d i n c l u d e :
Chordoma (from remnant o f notochord).
1. Lymphomas. N o n - H o d g k i n ' s t y p e is m o r e common 5. Adenoid cystic carcinoma { f r o m m i n o r salivary glands).
t h a n H o d g k i n ' s . A l m o s t a l l are B - c e l l t y p e . 6. Melanoma (rare).
A c u t e a n d C h r o n i c Pharyngitis

g e n e r a l l y m i l d a n d are a c c o m p a n i e d b y r h i n o r r h o e a a n d
ACUTE PHARYNGITIS
hoarseness w h i l e t h e b a c t e r i a l o n e s are s e v e r e . Gonococcal
p h a r y n g i t i s is m i l d a n d m a y e v e n b e a s y m p t o m a t i c .

Aetiology

A c u t e p h a r y n g i t i s is v e r y c o m m o n a n d o c c u r s d u e t o v a r - J Diagnosis
i e d a e t i o l o g i c a l factors l i k e v i r a l , bacterial, f u n g a l o r others
C u l t u r e o f t h r o a t s w a b is h e l p f u l i n t h e d i a g n o s i s o f b a c t e -
( T a b l e 4 9 . 1 ) . V i r a l causes are m o r e c o m m o n . A c u t e s t r e p t o -
rial p h a r y n g i t i s . It can detect 9 0 % o f G r o u p A Streptococci.
c o c c a l p h a r y n g i t i s ( d u e t o G r o u p A b e t a haemolyticstreptococci)
Diphtheria is c u l t u r e d o n special m e d i a . S w a b f r o m a sus-
has r e c e i v e d m o r e i m p o r t a n c e because o f its a e t i o l o g y i n
p e c t e d case o f g o n o c o c c a l p h a r y n g i t i s s h o u l d b e c u l t u r e d
rheumatic fever and post-streptococcal g l o m e m l o n e p h r i t i s .
i m m e d i a t e l y w i t h o u t delay. Failure to get any bacterial
g r o w t h suggests a v i r a l a e t i o l o g y .

Clinical Features

P h a r y n g i t i s m a y o c c u r i n d i f f e r e n t grades o f s e v e r i t y . Milder J Treatment

infections present with discomfort i n the throat, some
m a l a i s e a n d l o w g r a d e f e v e r . P h a r y n x i n these cases is c o n - General measures B e d rest, p l e n t y o f f l u i d s , w a r m saline

gested b u t t h e r e is n o l y m p h a d e n o p a t h y . Moderate and gargles o r p h a r y n g e a l i r r i g a t i o n s a n d analgesics f o r m the

severe infections present w i t h p a i n i n throat, dysphagia, mainstay o f treatment.

h e a d a c h e , m a l a i s e a n d h i g h f e v e r . P h a r y n x i n these cases L o c a l d i s c o m f o r t i n t h e t h r o a t i n severe cases c a n be

s h o w s e r y t h e m a , exudate a n d e n l a r g e m e n t o f tonsils a n d r e l i e v e d b y l i g n o c a i n e viscous before meals t o f a c i l i t a t e

l y m p h o i d follicles o n the posterior pharyngeal w a l l . Very swallowing.

severe cases s h o w o e d e m a o f s o f t palate a n d u v u l a w i t h Specific treatment Streptococcal pharyngitis ( G r o u p A ,

enlargement o f cervical nodes. b e t a - h a e m o l y t i c u s ) is t r e a t e d w i t h p e n i c i l l i n G , 2 0 0 , 0 0 0 t o
I t is n o t p o s s i b l e , o n c l i n i c a l e x a m i n a t i o n , t o d i f f e r e n t i - 2 5 0 , 0 0 0 u n i t s o r a l l y f o u r t i m e s a d a y f o r 10 days o r b e n z a -
ate v i r a l f r o m b a c t e r i a l i n f e c t i o n s b u t , v i r a l i n f e c t i o n s are thine penicillin G , 600,000 units once i . m . f o r patient

Table 49.1 Causes o f acute pharyngitis

Viral Bacterial Fungal Miscellaneous

• Rhinoviruses Streptococcus ( G r o u p A, Candida albicans Toxoplasmosis (parasitic, rare)

• Influenza beta-haemolyticus) Chlamydia trachomatis

• Parainfluenza Diphtheria
• Measles and chickenpox Gonococcus
• Coxsackie virus

• Herpes simplex

• Infectious mononucleosis

• Cytomegalovirus
 Acute and Chronic Pharyngitis

< 6 0 lb i n weight and 1.2 million units once i . m . for

patient > 6 0 lb. I n penicillin-sensitive individuals, e r y t h -
CHRONIC PHARYNGITIS

r o m y c i n , 20 to 40 m g / k g b o d y w e i g h t daily, i n d i v i d e d
o r a l doses f o r 10 days is e q u a l l y effective. I t is a c h r o n i c i n f l a m m a t o r y c o n d i t i o n o f t h e p h a r y n x . P a t h o -
D i p h t h e r i a is t r e a t e d b y d i p h t h e r i a a n t i t o x i n a n d a d m i n - l o g i c a l l y , i t is c h a r a c t e r i s e d b y h y p e r t r o p h y o f m u c o s a , s e r o -
i s t r a t i o n o f p e n i c i l l i n o r e r y t h r o m y c i n {see p a g e 274). m u c i n o u s glands, s u b e p i t h e l i a l l y m p h o i d f o l l i c l e s a n d e v e n
G o n o c o c c a l p h a r y n g i t i s r e s p o n d s t o c o n v e n t i o n a l doses the muscular coat o f the p h a r y n x .
of penicillin or tetracycline. C h r o n i c p h a r y n g i t i s is o f t w o t y p e s :

1. C h r o n i c catarrhal pharyngitis
2. C h r o n i c h y p e r t r o p h i c (granular) pharyngitis.
Viral Infections C a u s i n g Pharyngitis

Herpangina. I t is c a u s e d b y G r o u p A c o x s a c k i e v i r u s a n d Aetiology
mostly affects children. Characteristic features include
f e v e r , s o r e t h r o a t a n d v e s i c u l a r e r u p t i o n o n t h e soft p a l a t e A l a r g e n u m b e r o f f a c t o r s are responsible:
a n d p i l l a r s . V e s i c l e s are s m a l l a n d s u r r o u n d e d b y a z o n e o f
1. Persistent infection in the neighbourhood In
erythema.
c h r o n i c r h i n i t i s a n d sinusitis, p u r u l e n t discharge c o n -
Infectious mononucleosis. I t is caused by Epstein-Barr
stantly trickles d o w n the p h a r y n x a n d provides a c o n -
v i r u s . I t affects o l d e r c h i l d r e n a n d y o u n g a d u l t s , a n d is
stant s o u r c e o f i n f e c t i o n . T h i s causes h y p e r t r o p h y o f
c h a r a c t e r i s e d b y f e v e r , sore t h r o a t , e x u d a t i v e p h a r y n g i t i s ,
the lateral p h a r y n g e a l bands.
lymphadenopathy, splenomegaly and hepatitis.
Similarly, chronic t o n s i l l i t i s a n d d e n t a l sepsis are
Cytomegalovirus. It mostly affects immunosuppressed
also r e s p o n s i b l e f o r c h r o n i c p h a r y n g i t i s a n d r e c u r r e n t
transplant patients. Clinically, i t m i m i c s infectious mono-
sore t h r o a t s .
n u c l e o s i s b u t h e t e r o p h i l a n t i b o d y test is n e g a t i v e .
2. Mouth breathing Breathing through the mouth
Pharyngoconjunctival fever. I t is c a u s e d b y a n adenovirus,
exposes t h e p h a r y n x t o a i r w h i c h has n o t b e e n fil-
a n d is c h a r a c t e r i s e d b y s o r e t h r o a t , f e v e r a n d c o n j u n c t i v i -
tered, h u m i d i f i e d and adjusted to b o d y temperature
tis. There may be pain in abdomen, mimicking
thus m a k i n g i t m o r e susceptible to infections. M o u t h
appendicitis.
b r e a t h i n g is d u e t o :
Acute lymphonodular pharyngitis. I t is u s u a l l y c a u s e d b y a
(i) O b s t r u c t i o n i n t h e n o s e , e.g. nasal p o l y p i , a l l e r g i c
coxsackie v i r u s a n d characterised b y fever, malaise and
or vasomotor rhinitis, turbinal hypertrophy, devi-
sore t h r o a t . W h i t e — y e l l o w , s o l i d n o d u l e s appear o n the
ated s e p t u m o r t u m o u r s ,
p o s t e r i o r p h a r y n g e a l w a l l i n this t y p e o f p h a r y n g i t i s .
(ii) O b s t r u c t i o n i n the nasopharynx, e.g. adenoids
Measles and chickenpox also cause p h a r y n g i t i s . M e a s l e s is
and tumours,
c h a r a c t e r i s e d b y t h e a p p e a r a n c e o f K o p l i k ' s spots ( w h i t e
(iii) P r o t r u d i n g t e e t h w h i c h p r e v e n t a p p o s i t i o n o f Hps,
spots s u r r o u n d e d b y r e d areola) o n t h e b u c c a l mucosa
( i v ) H a b i t u a l , w i t h o u t a n y o r g a n i c cause.
o p p o s i t e t h e m o l a r t e e t h . T h e spots a p p e a r 3 - 4 days b e f o r e
3. Chronic i r r i t a n t s Excessive s m o k i n g , c h e w i n g of
t h e a p p e a r a n c e o f rash.
tobacco a n d pan, heavy d r i n k i n g , h i g h l y spiced f o o d
c a n all l e a d t o c h r o n i c p h a r y n g i t i s .
4. Environmental pollution Smoky or dusty envi-
Fungal Pharyngitis
ronment or irritant industrial fumes may also be
responsible for c h r o n i c pharyngitis.
Candida i n f e c t i o n o f t h e o r o p h a r y n x c a n o c c u r as a n e x t e n -
5. Faulty voice production Less o f t e n realised b u t a n
s i o n o f o r a l t h r u s h . I t is seen i n p a t i e n t s w h o are i m m u n o -
i m p o r t a n t cause o f c h r o n i c pharyngitis i n the faulty
s u p p r e s s e d , d e b i l i t a t e d o r t a k i n g h i g h doses o f a n t i m i c r o b i a l s .
v o i c e p r o d u c t i o n . Excessive use o f v o i c e o r f a u l t y v o i c e
Often patient complains of pain in the throat with
p r o d u c t i o n seen i n c e r t a i n professionals o r i n " p h a r y n -
d y s p h a g i a . N y s t a t i n is t h e d r u g o f c h o i c e .
geal n e u r o s i s " w h e r e p e r s o n resorts t o c o n s t a n t t h r o a t
clearing, h a w k i n g or snorting, and that may cause
c h r o n i c p h a r y n g i t i s , especially o f h y p e r t r o p h i c v a r i e t y .
Miscellaneous Causes of Pharyngitis

Chlamydia trachomatis infection causes a c u t e pharyngitis Symptoms

and can be treated b y e r y t h r o m y c i n or sulphonamides.
T o x o p l a s m o s i s is c a u s e d b y Toxoplasma gondii, an obligate S e v e r i t y o f s y m p t o m s i n c h r o n i c p h a r y n g i t i s varies f r o m
i n t r a c e l l u l a r parasite. T h i s i n f e c t i o n is v e r y r a r e . person t o person.
Diseases of Pharynx

Discomfort or pain i n the throat T h i s is e s p e - 2. Voice rest a n d s p e e c h t h e r a p y is essential f o r t h o s e

cially n o t i c e d i n the m o r n i n g s . w i t h faulty v o i c e p r o d u c t i o n . H a w k i n g , clearing the
Foreign body s e n s a t i o n i n t h r o a t Patient has a t h r o a t f r e q u e n t l y o r a n y o t h e r s u c h h a b i t s h o u l d be
c o n s t a n t desire t o s w a l l o w o r clear his t h r o a t t o g e t r i d stopped.
o f this " f o r e i g n b o d y " . 3. W a r m saline gargles, especially i n t h e m o r n i n g , are
T i r e d n e s s o f v o i c e Patient c a n n o t speak f o r l o n g a n d s o o t h i n g and relieve d i s c o m f o r t .
has t o m a k e u n d u e e f f o r t t o speak as t h r o a t starts a c h i n g . 4. M a n d l ' s paint m a y be applied to pharyngeal mucosa.
T h e v o i c e m a y also lose its q u a l i t y a n d m a y e v e n c r a c k . 5. C a u t e r y o f l y m p h o i d g r a n u l e s is s u g g e s t e d . T h r o a t is
4. Cough T h r o a t is i r r i t a b l e a n d t h e r e is t e n d e n c y to s p r a y e d w i t h l o c a l a n a e s t h e t i c a n d granules are t o u c h e d
cough. Mere opening o f the mouth may induce w i t h 10—25% silver n i t r a t e . E l e c t r o c a u t e r y o r d i a t h e r m y
retching or gagging. o f n o d u l e s m a y r e q u i r e g e n e r a l anaesthesia.

Signs
ATROPHIC PHARYNGITIS

Chronic catarrhal pharyngitis I n t h i s , t h e r e is a c o n -

gestion o f posterior pharyngeal w a l l w i t h engorgement
vessels; f a u c i a l p i l l a r s m a y b e t h i c k e n e d . T h e r e is i n c r e a s e d
mucus secretion w h i c h m a y cover pharyngeal mucosa.
C h r o n i c hypertrophic (granular) pharyngitis
I t is a f o r m o f c h r o n i c p h a r y n g i t i s o f t e n seen i n p a t i e n t s o f
of
a t r o p h i c r h i n i t i s . P h a r y n g e a l m u c o s a a l o n g w i t h its m u c o u s
glands shows a t r o p h y . Scanty m u c u s p r o d u c t i o n b y glands
leads t o f o r m a t i o n o f crusts w h i c h later get i n f e c t e d g i v i n g
rise t o f o u l s m e l l .

1. Pharyngeal w a l l appears t h i c k a n d o e d e m a t o u s with

c o n g e s t e d m u c o s a a n d d i l a t e d vessels.
Clinical Features
2. Posterior pharyngeal w a l l m a y be studded w i t h r e d -
dish nodules (hence the t e r m granular pharyngitis).
D r y n e s s a n d d i s c o m f o r t i n t h r o a t are t h e m a i n c o m p l a i n t s .
T h e s e n o d u l e s are d u e t o h y p e r t r o p h y o f s u b e p i t h e l i a l
H a w k i n g a n d d r y c o u g h m a y be present d u e t o crust f o r -
lymphoid follicles normally seen in pharynx
mation. Examination shows d r y a n d glazed pharyngeal
(Fig. 49.1).
m u c o s a o f t e n c o v e r e d w i t h crusts.
3. Lateral pharyngeal bands b e c o m e h y p e r t r o p h i e d .
4. U v u l a m a y be e l o n g a t e d a n d a p p e a r oedematous.

Treatment

[ Treatment J
T h i s is t h e same as f o r c o - e x i s t e n t a t r o p h i c r h i n i t i s . A i m is
to remove t h e crusts a n d p r o m o t e s e c r e t i o n . The crusts
1. I n e v e r y case o f c h r o n i c p h a r y n g i t i s , a e t i o l o g i c a l f a c t o r
can b e r e m o v e d b y s p r a y i n g t h e t h r o a t w i t h a l k a l i n e s o l u -
s h o u l d be sought and eradicated.
t i o n , or pharyngeal irrigation. M a n d l ' s paint applied locally
has a s o o t h i n g e f f e c t .
Potassium i o d i d e , 325 m g , administered orally for a f e w
days h e l p s t o p r o m o t e s e c r e t i o n a n d p r e v e n t s c r u s t i n g .

KERATOSIS PHARYNGITIS

I t is a b e n i g n c o n d i t i o n c h a r a c t e r i s e d b y h o r n y e x c r e s -
cences o n t h e s u r f a c e o f t o n s i l s , p h a r y n g e a l w a l l o r l i n g u a l
tonsils a p p e a r i n g as w h i t e o r y e l l o w i s h d o t s . T h e s e e x c r e s -
cences are t h e r e s u l t o f h y p e r t r o p h y a n d k e r a t i n i s a t i o n o f
e p i t h e l i u m . T h e y are f i r m l y a d h e r e n t a n d c a n n o t b e w i p e d
o f f . T h e r e is n o a c c o m p a n y i n g i n f l a m m a t i o n n o r a n y c o n -
s t i t u t i o n a l s y m p t o m s , t h u s i t c a n b e easily differentiated
Figure 49.1
from acute follicular tonsillitis. T h e disease m a y show

Granular pharyngitis. Note: Reddish nodules on the posterior spontaneous regression and does n o t r e q u i r e any specific
pharyngeal wall. t r e a t m e n t e x c e p t f o r reassurance t o t h e p a t i e n t .
Acute and Chronic Tonsillitis

Lateral surface o f the t o n s i l presents a w e l l - d e f i n e d

APPLIED ANATOMY OF PALATINE
f i b r o u s capsule. B e t w e e n t h e capsule a n d t h e b e d o f t o n s i l
(FAUCIAL) TONSILS
is t h e l o o s e a r e o l a r tissue w h i c h m a k e s i t easy t o dissect t h e
t o n s i l i n t h e p l a n e d u r i n g t o n s i l l e c t o m y . I t is also t h e site
P a l a t i n e tonsils are t w o i n n u m b e r . E a c h t o n s i l is a n o v o i d f o r c o l l e c t i o n o f pus i n p e r i t o n s i l l a r abscess. S o m e f i b r e s o f
mass o f l y m p h o i d tissue situated i n the lateral w a l l of palatoglossus a n d p a l a t o p h a r y n g e u s m u s c l e s are a t t a c h e d t o
oropharynx between the anterior and posterior pillars. t h e capsule o f the t o n s i l .
A c t u a l size o f t h e t o n s i l is b i g g e r t h a n t h e o n e t h a t appears
Upper pole o f the tonsil extends i n t o soft p a l a t e . Its
f r o m its surface as parts o f t o n s i l e x t e n d u p w a r d s i n t o t h e
m e d i a l surface is c o v e r e d b y a semilunar fold, extending
soft palate, d o w n w a r d s i n t o t h e base o f t o n g u e a n d a n t e r i -
between anterior and posterior pillars a n d enclosing a
o r l y i n t o palatoglossal a r c h . A t o n s i l presents t w o s u r f a c e s — a
p o t e n t i a l space c a l l e d supratonsillarfossa.
m e d i a l and a lateral, a n d t w o p o l e s — a n u p p e r and a l o w e r .

M e d i a l s u r f a c e o f t h e t o n s i l is c o v e r e d b y n o n - k e r a t i n i s i n g Lower pole o f t h e t o n s i l is a t t a c h e d t o t h e t o n g u e . A tri-

s t r a t i f i e d s q u a m o u s e p i t h e l i u m w h i c h dips i n t o t h e substance angular fold o f mucous membrane extends from anterior

o f t o n s i l i n t h e f o r m o f c r y p t s . O p e n i n g s o f 12—15 c r y p t s can p i l l a r t o t h e a n t e r o i n f e r i o r p a r t o f t o n s i l a n d encloses a

be seen o n t h e m e d i a l surface o f t h e t o n s i l . O n e o f t h e c r y p t s , space c a l l e d anterior tonsillar space. T h e t o n s i l is separated

s i t u a t e d n e a r t h e u p p e r p a r t o f t o n s i l is v e r y large a n d d e e p f r o m t h e t o n g u e b y a sulcus c a l l e d t o n s i l l o l i n g u a l sulcus

a n d is called crypta magna o r intratonsillar cleft ( F i g . 5 0 . 1 ) . I t w h i c h m a y b e t h e seat o f c a r c i n o m a .

represents t h e v e n t r a l p a r t o f s e c o n d p h a r y n g e a l p o u c h . F r o m
B e d o f the tonsil I t is f o r m e d b y t h e s u p e r i o r c o n s t r i c t o r
t h e m a i n c r y p t s arise t h e s e c o n d a r y crypts, w i t h i n t h e s u b -
a n d styloglossus m u s c l e s . T h e g l o s s o p h a r y n g e a l n e r v e a n d
stance o f t o n s i l . C r y p t s m a y be f i l l e d w i t h cheesy m a t e r i a l
s t y l o i d process, i f enlarged, m a y lie i n r e l a t i o n t o t h e l o w e r
c o n s i s t i n g o f e p i t h e l i a l cells, bacteria a n d f o o d debris w h i c h
p a r t o f t o n s i l l a r fossa. B o t h these s t r u c t u r e s c a n b e s u r g i -
can b e expressed b y pressure o v e r t h e a n t e r i o r p i l l a r .
cally approached t h r o u g h the t o n s i l b e d after tonsillec-
t o m y . O u t s i d e t h e s u p e r i o r c o n s t r i c t o r , t o n s i l is r e l a t e d t o
t h e facial artery, s u b m a n d i b u l a r salivary gland, p o s t e r i o r
belly o f digastric muscle, m e d i a l p t e r y g o i d muscle a n d the
angle o f m a n d i b l e (Fig. 50.2).
Crypto magna

Primary crypt Blood Supply

T h e t o n s i l is s u p p l i e d b y f i v e arteries ( F i g . 5 0 . 3 ) .

S. Tonsillar branch o f facial a r t e r y . T h i s is t h e main

artery.
2. A s c e n d i n g pharyngeal artery f r o m external carotid.
Figure 50.1
3. A s c e n d i n g palatine, a b r a n c h o f facial a r t e r y .

Primary and secondary crypts o f tonsils. 4. Dorsal linguae branches o f lingual artery.
5. D e s c e n d i n g palatine b r a n c h o f m a x i l l a r y artery.
Diseases of Pharynx

| Nerve Supply

Lesser p a l a t i n e b r a n c h e s o f s p h e n o p a l a t i n e ganglion ( C N
V) and glossopharyngeal nerve p r o v i d e sensory nerve
supply.

[ Functions of Tonsils [

L i k e o t h e r l y m p h o i d masses o f W a l d e y e r ' s r i n g , p a l a t i n e
t o n s i l s h a v e a p r o t e c t i v e r o l e a n d act as s e n t i n e l s at t h e
p o r t a l o f air a n d f o o d passage. T h e c r y p t s i n t o n s i l s increase
t h e surface area f o r c o n t a c t w i t h f o r e i g n substances. T o n s i l s
Figure 50.2 are larger in childhood and gradually diminish near

Relations o f t o n s i l . T o n s i l is related laterally t o its c a p s u l e ( 1 ) , p u b e r t y . T h e y are r e m o v e d w h e n t h e y t h e m s e l v e s b e c o m e

loose a r e o l a r tissue c o n t a i n i n g p a r a t o n s i l l a r vein ( 2 ) , s u p e r i o r t h e seat o f disease.

constrictor muscle (3), styloglossus (4), glossopharyngeal
nerve ( 5 ) , facial a r t e r y ( 6 ) , m e d i a l p t e r y g o i d m u s c l e ( 7 ) , angle
o f m a n d i b l e ( 8 ) a n d s u b m a n d i b u l a r salivary g l a n d ( 9 ) , p h a r -
ACUTE TONSILLITIS
y n g o b a s i l a r fascia ( 1 0 ) , b u c c o p h a r y n g e a l fascia ( 1 1 ) .

P r i m a r i l y , t h e t o n s i l consists o f (a) surface e p i t h e l i u m w h i c h

Maxillory artery is c o n t i n u o u s w i t h the oropharyngeal lining; (b) crypts

w h i c h are t u b e - l i k e i n v a g i n a t i o n s f r o m t h e surface e p i t h e -
Descending
l i u m ; a n d (c) t h e l y m p h o i d tissue. A c u t e i n f e c t i o n s o f t o n s i l
palatine artery
m a y i n v o l v e these c o m p o n e n t s a n d are t h u s classified as:
Tonsillar branches
of ascending 1. Acute catarrhal or superficial tonsillitis. H e r e t o n s i l l i t i s is a
pharyngeal artery p a r t o f g e n e r a l i s e d p h a r y n g i t i s a n d is m o s t l y seen i n
Ascending
pharyngeal viral infections.
artery Ascending
2. Acute follicular tonsillitis. I n f e c t i o n spreads i n t o the
palantine artery
crypts w h i c h b e c o m e filled w i t h p u r u l e n t material,
Facial artery Tonsillar artery
presenting at t h e openings o f crypts as y e l l o w i s h
spots ( F i g . 5 0 . 4 ) .
Dorsal linguae
Lingual artery
branches
External carotid
artery

Figure 50.3

Arterial supply o f t o n s i r

Venous Drainage

Veins from t h e tonsils d r a i n i n t o paratonsillar v e i n w h i c h

j o i n s t h e c o m m o n facial v e i n a n d p h a r y n g e a l v e n o u s p l e x u s .

Lymphatic Drainage

Lymphatics f r o m the tonsil pierce the superior constrictor

and drain i n t o u p p e r deep cervical nodes particularly the Figure 50.4
j u g u l o d i g a s t r i c (tonsillar) n o d e situated b e l o w the angle o f
Acute follicular tonsillitis.
mandible.
 Acute and Chronic Tonsillitis

3. Acute parenchymatous tonsillitis. H e r e t o n s i l substance is

a f f e c t e d . T o n s i l is u n i f o r m l y e n l a r g e d a n d r e d .
4. Acute membranous tonsillitis. I t is a stage a h e a d o f a c u t e
follicular tonsillitis w h e n e x u d a t i o n f r o m t h e crypts
coalesces t o f o r m a membrane o n t h e surface of
tonsil.

Aetiology

A c u t e t o n s i l l i t i s o f t e n affects s c h o o l - g o i n g c h i l d r e n , b u t
also affects a d u l t s . I t is r a r e i n i n f a n t s a n d i n p e r s o n s w h o
are a b o v e 5 0 years o f age. Figure 50.5
Haemolytic streptococcus is t h e m o s t c o m m o n l y i n f e c t i n g
A c u t e follicular tonsillitis. N o t e p u s b e a d s o n t h e s u r f a c e o f left
o r g a n i s m . O t h e r causes o f i n f e c t i o n m a y b e staphylococci,
tonsil. O n the right pus beads have coalesced together t o form
pneumococci o r H. influenzae. T h e s e bacteria m a y p r i m a r i l y
a m e m b r a n e .
infect t h e tonsil o r m a y be secondary t o a viral i n f e c t i o n .

4. T h e j u g u l o digastric l y m p h nodes are e n l a r g e d a n d

Symptoms
tender.

T h e s y m p t o m s vary w i t h severity o f i n f e c t i o n . T h e p r e -
d o m i n a n t s y m p t o m s are:
Treatment J
1. Sore throat.
2. Difficulty in swallowing. T h e c h i l d m a y refuse t o eat I. Patient is put to bed a n d e n c o u r a g e d t o t a k e p l e n t y o f

anything due t o local pain. fluids.

3. Fever. I t m a y v a r y from 3 8 t o 4 0 ° C a n d m a y b e a s s o c i - 2. Analgesics { a s p i r i n o r p a r a c e t a m o l ) are g i v e n a c c o r d i n g

a t e d w i t h c h i l l s a n d rigors. S o m e t i m e s , a child pres- t o t h e age o f t h e p a t i e n t t o r e l i e v e l o c a l p a i n a n d b r i n g

ents w i t h a n u n e x p l a i n e d f e v e r a n d i t is o n l y o n d o w n t h e fever.

e x a m i n a t i o n t h a t a n a c u t e t o n s i l l i t i s is d i s c o v e r e d . 3. Antimicrobial therapy. M o s t o f t h e i n f e c t i o n s are d u e t o

4. Earache. I t is e i t h e r r e f e r r e d p a i n from t h e t o n s i l o r t h e streptococcus, a n d p e n i c i l l i n is t h e d r u g o f c h o i c e . Patients

result o f acute otitis media w h i c h m a y occur as a allergic t o p e n i c i l l i n can be treated w i t h e r y t h r o m y -

complication. c i n . A n t i b i o t i c s s h o u l d b e c o n t i n u e d f o r 7—10 days.

5. Constitutional symptoms. T h e y are u s u a l l y m o r e m a r k e d

t h a n seen i n s i m p l e p h a r y n g i t i s a n d m a y i n c l u d e h e a d -
Complications
a c h e , g e n e r a l b o d y aches, m a l a i s e a n d c o n s t i p a t i o n .
There m a y be abdominal pain due to mesenteric
1. Chronic tonsillitis w i t h r e c u r r e n t a c u t e a t t a c k s . T h i s is
l y m p h a d e n i t i s s i m u l a t i n g a clinical p i c t u r e o f acute
due to incomplete resolution o f acute infection.
appendicitis.
C h r o n i c i n f e c t i o n m a y persist i n l y m p h o i d f o l l i c l e s o f
the t o n s i l i n t h e f o r m o f microabscesses.
2. Peritonsillar abscess.
3. Parapharyngeal abscess.
1. O f t e n t h e b r e a t h is f o e t i d a n d t o n g u e is c o a s t e d . 4. Cervical abscess d u e t o s u p p u r a t i o n o f j u g u l o d i g a s t r i c
2. T h e r e is h y p e r a e m i a o f p i l l a r s , s o f t p a l a t e a n d u v u l a . l y m p h nodes.
3. T o n s i l s are r e d a n d s w o l l e n w i t h y e l l o w i s h spots o f 5. Acute otitis media. Recurrent attacks o f acute otitis
p u r u l e n t m a t e r i a l p r e s e n t i n g at t h e o p e n i n g o f c r y p t s m e d i a m a y coincide w i t h recurrent tonsillitis.
(acute follicular tonsillitis) o r there m a y be a w h i t i s h 6. Rheumatic fever. O f t e n seen i n a s s o c i a t i o n w i t h t o n s i l -
m e m b r a n e o n t h e m e d i a l surface o f t o n s i l w h i c h c a n litis d u e t o G r o u p A b e t a - h a e m o l y t i c streptococci.
b e easily w i p e d a w a y w i t h a s w a b (acute membranous 7. Acute glomerulonephritis. R a r e these days.
tonsillitis, F i g . 5 0 . 5 ) . T h e tonsils m a y be enlarged a n d 8. Subacute bacterial endocarditis. Acute tonsillitis in a
congested so m u c h so t h a t t h e y a l m o s t m e e t i n t h e p a t i e n t w i t h v a l v u l a r h e a r t disease m a y b e c o m p l i -
midline along w i t h some oedema o f the uvula a n d c a t e d b y e n d o c a r d i t i s . I t is u s u a l l y d u e t o Streptococcus
soft palate (acute parenchymatous tonsillitis). viridans infection.
 Differential Diagnosis of Membrane 9. Traumatic ulcer. A n y i n j u r y t o o r o p h a r y n x heals b y f o r -

I O v e r the Tonsil 1 m a t i o n o f a m e m b r a n e . T r a u m a t o t h e t o n s i l area m a y

occur accidendy w h e n h i t w i t h a t o o t h brush, a pencil

1. Membranous tonsillitis. It occurs due to pyogenic held i n m o u t h or fingering i n the throat. Membrane

organisms. A n exudative m e m b r a n e forms over the appears w i t h i n 2 4 h o u r s .

m e d i a l surface o f t h e tonsils, a l o n g w i t h the features 10. Candidal infection of tonsil.

o f acute tonsillitis.
Diagnosis of ulceromembranous lesion o f throat thus
2. Diphtheria. U n l i k e a c u t e t o n s i l l i t i s w h i c h is a b r u p t i n
requires:
o n s e t , d i p h t h e r i a is s l o w e r i n o n s e t w i t h less l o c a l
discomfort, the membrane in diphtheria extends 1. History.

b e y o n d t h e t o n s i l s , o n t o t h e soft palate a n d is d i r t y 2. Physical examination.

g r e y i n c o l o u r . I t is a d h e r e n t a n d its r e m o v a l leaves a 3. T o t a l and differential counts (for agranulocytosis, l e u -

b l e e d i n g surface. U r i n e may show a l b u m i n . Smear kaemia, neutropenia, infectious mononucleosis).

and c u l t u r e o f throat swab w i l l reveal Corynebacterium 4. B l o o d s m e a r ( f o r a t y p i c a l cells).

diphtheriae. 5. Throat swab and culture (for p y o g e n i c bacteria),

3. Vincent's angina. I t is i n s i d i o u s i n o n s e t w i t h less f e v e r V i n c e n t ' s angina, diphtheria candidal i n f e c t i o n .

a n d less d i s c o m f o r t i n t h r o a t . M e m b r a n e , w h i c h u s u - 6. B o n e m a r r o w aspiration o r needle biopsy.

ally f o r m s o v e r o n e t o n s i l , can be easily removed 7. Other tests. Paul-Bunnell or mono spot test and

revealing an irregular ulcer o n the tonsil. T h r o a t swab biopsy o f the lesion.

will show both the organisms typical o f disease,

n a m e l y f u s i f o r m b a c i l l i a n d spirochaetes.
FAUCIAL DIPHTHERIA
4. Infectious mononucleosis. T h i s o f t e n affects y o u n g a d u l t s .
B o t h t o n s i l s are v e r y m u c h e n l a r g e d , c o n g e s t e d a n d
c o v e r e d w i t h m e m b r a n e . L o c a l d i s c o m f o r t is m a r k e d .
^ Aetiology J
L y m p h n o d e s are e n l a r g e d i n t h e p o s t e r i o r t r i a n g l e o f
n e c k a l o n g w i t h s p l e n o m e g a l y . A t t e n t i o n t o disease is I t is a n a c u t e s p e c i f i c i n f e c t i o n caused b y t h e G r a m - p o s i t i v e
attracted because o f failure o f t h e a n t i b i o t i c t r e a t m e n t . bacillus, Corynebacterium diphtheriae. I t spreads b y d r o p l e t
B l o o d smear m a y s h o w m o r e than 5 0 % l y m p h o c y t e s , i n f e c t i o n . I n c u b a t i o n p e r i o d is 2—6 days. S o m e persons are
o f w h i c h about 1 0 % are a t y p i c a l . W h i t e c e l l count " c a r r i e r s " o f this disease, i.e. t h e y h a r b o u r o r g a n i s m s i n t h e i r
m a y b e n o r m a l i n t h e f i r s t w e e k b u t rises i n t h e sec- throat b u t have n o symptoms.
ond w e e k . P a u l - B u n n e l l test ( m o n o test) w i l l show
high titre o f heterophil antibody.
Clinical Features
5 . Agranulocytosis. I t presents w i t h ulcerative necrotic
lesions n o t o n l y o n t h e t o n s i l s b u t e l s e w h e r e i n the
C h i l d r e n are a f f e c t e d m o r e o f t e n t h o u g h n o age g r o u p is
o r o p h a r y n x . P a t i e n t is s e v e r e l y i l l . I n a c u t e f u l m i n a n t
i m m u n e . O r o p h a r y n x is c o m m o n l y i n v o l v e d a n d t h e l a r -
f o r m , t o t a l l e u c o c y t i c c o u n t is d e c r e a s e d t o < 2 0 0 0 /
y n x a n d nasal c a v i t y m a y also b e a f f e c t e d .
c u m m o r e v e n as l o w as 5 0 / c u m m a n d p o l y m o r p h
I n the o r o p h a r y n x , a greyish w h i t e m e m b r a n e forms
n e u t r o p h i l s m a y b e r e d u c e d t o 5 % o r less. I n c h r o n i c
o v e r t h e t o n s i l s a n d spreads t o t h e s o f t p a l a t e a n d p o s t e r i o r
o r r e c u r r e n t f o r m , t o t a l c o u n t is r e d u c e d t o 2000/
p h a r y n g e a l w a l l . I t is q u i t e t e n a c i o u s a n d causes b l e e d i n g
c u m m w i t h less m a r k e d g r a n u l o c y t o p e n i a .
when r e m o v e d . Cervical l y m p h nodes, particularly the
6. Leukaemia. I n c h i l d r e n , 7 5 % o f l e u k a e m i a s are a c u t e
jugulodigastric, b e c o m e enlarged and tender, sometimes
l y m p h o b l a s t i c a n d 25%> a c u t e m y e l o g e n o u s o r c h r o n i c ,
p r e s e n t i n g a " b u l l - n e c k " a p p e a r a n c e . P a t i e n t is i l l a n d t o x -
w h i l e i n a d u l t s 2 0 % o f a c u t e l e u k a e m i a s are l y m p h o -
a e m i c b u t f e v e r s e l d o m rises a b o v e 3 8 ° C .
cytic and 80% n o n - l y m p h o c y t i c .
Peripheral b l o o d shows T L C > 100,000/cumm.
It m a y be n o r m a l o r less t h a n n o r m a l . A n a e m i a is Complications
a l w a y s p r e s e n t a n d m a y b e p r o g r e s s i v e . Blasts cells are
seen o n e x a m i n a t i o n o f t h e b o n e m a r r o w . E x o t o x i n p r o d u c e d b y C . diphtheriae is t o x i c t o t h e h e a r t
7. Aphthous ulcers. They m a y i n v o l v e any part o f oral a n d n e r v e s . I t causes myocarditis, cardiac arrhythmias a n d acute
c a v i t y o r o r o p h a r y n x . S o m e t i m e s , i t is s o l i t a r y a n d circu la tory failure.
m a y i n v o l v e t h e t o n s i l and pillars. I t m a y be small o r N e u r o l o g i c a l c o m p l i c a t i o n s usually appear a f e w w e e k s
q u i t e l a r g e a n d a l a r m i n g . I t is v e r y p a i n f u l . a f t e r i n f e c t i o n a n d i n c l u d e paralysis of soft palate, diaphragm
8. Malignancy tonsil (see p a g e 2 8 4 ) . a n d ocular muscles.
 Acute and Chronic Tonsillitis

I n t h e l a r y n x , d i p h t h e r i t i c m e m b r a n e m a y cause a i r w a y
obstruction.

Treatment J

Treatment o f d i p h t h e r i a is s t a r t e d o n c l i n i c a l suspicion
w i t h o u t w a i t i n g f o r t h e c u l t u r e r e p o r t . A i m is t o n e u t r a l i s e
the free e x o t o x i n still c i r c u l a t i n g i n the b l o o d and to k i l l
t h e o r g a n i s m s p r o d u c i n g this e x o t o x i n . D o s e o f a n t i t o x i n
is b a s e d o n t h e site i n v o l v e d a n d t h e d u r a t i o n a n d s e v e r i t y
o f disease. I t is 2 0 , 0 0 0 t o 4 0 , 0 0 0 u n i t s f o r d i p h t h e r i a i n less
than 48 hours, o r w h e n the m e m b r a n e is c o n f i n e d t o t h e
t o n s i l s o n l y ; a n d 8 0 , 0 0 0 t o 1 2 0 , 0 0 0 u n i t s , i f disease has
lasted l o n g e r t h a n 4 8 hours, or the membrane is more
e x t e n s i v e . A n t i t o x i n is g i v e n b y i . v . i n f u s i o n i n saline i n Figure 50.6
a b o u t 60 m i n u t e s . Sensitivity to horse s e r u m s h o u l d be
P a r e n c h y m a t o u s tonsillitis. The two t o n s i l s are almost touching
tested by c o n j u n c t i v a l o r intracutaneous test w i t h d i l u t e d
each other causing problems o f deglutition, speech and
a n t i t o x i n , a n d a d r e n a l i n e s h o u l d b e at h a n d f o r a n y i m m e - respiration.

diate hypersensitivity. I n the presence o f hypersensitivity

reaction, desensitization s h o u l d be done.
A n t i b i o t i c s u s e d are b e n z y l p e n i c i l l i n 6 0 0 m g 6 - h o u r l y Clinical Features
f o r 7 d a y s . E r y t h r o m y c i n is u s e d i n penicillin-sensitive
i n d i v i d u a l s (500 m g 6 h o u r l y o r a l l y ) . 1. Recurrent attacks o f s o r e t h r o a t o r a c u t e t o n s i l l i t i s .
2. C h r o n i c irritation i n throat w i t h cough.
3. B a d taste i n m o u t h a n d f o u l b r e a t h (halitosis) d u e t o
CHRONIC TONSILLITIS pus i n crypts.
4. Thick speech, d i f f i c u l t y i n s w a l l o w i n g a n d choking
spells at n i g h t ( w h e n tonsils are large a n d o b s t r u c t i v e ) .
Aetiology

1. I t m a y b e a c o m p l i c a t i o n ofacute tonsillitis. Pathologically, Examination

microabscesses w a l l e d o f f b y f i b r o u s tissue h a v e b e e n
seen i n t h e l y m p h o i d follicles o f t h e tonsils. 1. Tonsils may show v a r y i n g degree o f enlargement.
2. Subclinical infections o f tonsils w i t h o u t an acute Sometimes they meet i n the midline (chronic paren-
attack. chymatous type).
3. Mostly affects children and young adults. Rarely 2. T h e r e m a y b e y e l l o w i s h beads o f p u s o n t h e m e d i a l
occurs after 50 years. surface o f t o n s i l ( c h r o n i c f o l l i c u l a r t y p e ) .
4. C h r o n i c i n f e c t i o n i n sinuses o r t e e t h m a y b e a p r e d i s - 3. T o n s i l s are s m a l l b u t p r e s s u r e o n t h e a n t e r i o r p i l l a r
posing factor. expresses f r a n k p u s o r cheesy m a t e r i a l ( c h r o n i c f i b r o i d
type).
4. F l u s h i n g o f a n t e r i o r p i l l a r s c o m p a r e d t o t h e rest o f t h e
Types p h a r y n g e a l m u c o s a is a n i m p o r t a n t s i g n o f chronic
tonsillar i n f e c t i o n .
Chronic follicular tonsillitis. H e r e t o n s i l l a r c r y p t s are f u l l of
5. Enlargement o f j u g u l o d i g a s t r i c l y m p h n o d e s is a r e l i -
infected c h e e s y m a t e r i a l w h i c h s h o w s o n t h e s u r f a c e as
able sign o f c h r o n i c tonsillitis. D u r i n g acute attacks,
y e l l o w i s h spots.
the nodes enlarge f u r t h e r and b e c o m e tender.
Chronic parenchymatous tonsillitis. T h e r e is h y p e r p l a s i a of
lymphoid tissue. T o n s i l s are very much enlarged and
may interfere with speech, deglutition and respiration Treatment ^

(Fig. 50.6). Attacks o f sleep a p n o e a m a y occur. Long-

s t a n d i n g cases d e v e l o p features o f c o r p u l m o n a l e . 1. Conservative t r e a t m e n t consists o f a t t e n t i o n t o gen-
Chronic fibroid tonsillitis. T o n s i l s are s m a l l b u t infected, eral h e a l t h , d i e t , t r e a t m e n t o f c o - e x i s t e n t i n f e c t i o n o f
w i t h h i s t o r y o f repeated sore throats. t e e t h , n o s e a n d sinuses.
Diseases of Pharynx

2. T o n s i l l e c t o m y is i n d i c a t e d w h e n t o n s i l s i n t e r f e r e w i t h
s p e e c h , d e g l u t i t i o n a n d r e s p i r a t i o n o r cause r e c u r r e n t
DISEASES OF LINGUAL TONSILS

attacks (see C h a p t e r 91).

1. A c u t e l i n g u a l tonsillitis A c u t e infection o f a lingual

t o n s i l gives rise t o u n i l a t e r a l dysphagia a n d f e e l i n g o f
Complications
l u m p i n the throat. O n examination w i t h a laryngeal
m i r r o r , l i n g u a l t o n s i l m a y appear e n l a r g e d a n d c o n g e s t e d ,
1. P e r i t o n s i l l a r abscess.
s o m e t i m e s s a i d d e d w i t h follicles l i k e t h e ones seen i n
2. P a r a p h a r y n g e a l abscess.
acute f o l l i c u l a r t o n s i l l i t i s . C e r v i c a l l y m p h n o d e s m a y be
3. I n t r a t o n s i l l a r abscess.
e n l a r g e d . T r e a t m e n t is b y a n t i b i o t i c s .
4. Tonsilloliths.
2. Hypertrophy of lingual tonsils M o s t l y , i t is a
5. T o n s i l l a r cyst.
compensatory hypertrophy of lymphoid tissue in
6. Focus o f i n f e c t i o n i n r h e u m a t i c fever, acute g l o m e r u -
response t o repeated infections in tonsillectomised
l o n e p h r i t i s , eye a n d s k i n disorders.
p a t i e n t s . U s u a l c o m p l a i n t s are d i s c o m f o r t o n swal-
Tonsilloliths (calculus of the tonsil). I t is seen i n chronic l o w i n g , feeling o f l u m p i n the throat, d r y c o u g h and
t o n s i l l i t i s w h e n its c r y p t is b l o c k e d w i t h r e t e n t i o n o f d e b r i s . thick voice.
I n o r g a n i c salts o f c a l c i u m a n d m a g n e s i u m are t h e n d e p o s i t e d M i r r o r e x a m i n a t i o n o f t h e base o f t o n g u e w i l l s h o w
l e a d i n g to f o r m a t i o n o f a stone. I t m a y gradually enlarge enlargement o f l i n g u a l tonsils, sometimes associated
and t h e n ulcerate t h r o u g h the t o n s i l . w i t h d i l a t e d v e i n s o v e r i t . T r e a t m e n t is c o n s e r v a t i v e .
T o n s i l l o l i t h s are m o r e o f t e n seen i n a d u l t s a n d g i v e rise Sometimes, diathermy coagulation or excision o f l i n -
to local d i s c o m f o r t or f o r e i g n b o d y sensation. They are g u a l t o n s i l s has t o b e d o n e . T h e s e days t h e y are e x c i s e d
easily d i a g n o s e d b y p a l p a t i o n o r g r i t t y f e e l i n g o n p r o b i n g . b y laser s u r g e r y .
T r e a t m e n t is s i m p l e r e m o v a l o f t h e s t o n e o r t o n s i l l e c t o m y , 3. Abscess of lingual tonsil I t is a r a r e c o n d i t i o n b u t
i f t h a t b e i n d i c a t e d f o r associated sepsis o r f o r t h e d e e p l y can follow acute lingual tonsillitis. S y m p t o m s are
set s t o n e w h i c h c a n n o t b e r e m o v e d . severe unilateral dysphagia, pain in the tongue,
Intratonsillar abscess. I t is a c c u m u l a t i o n o f pus w i t h i n the excessive salivation and some degree of trismus.
substance o f t o n s i l . I t usually f o l l o w s b l o c k i n g o f t h e c r y p t P r o t r u s i o n o f t h e t o n g u e is p a i n f u l . J u g u l o d i g a s t r i c
o p e n i n g i n acute f o l l i c u l a r t o n s i l l i t i s . T h e r e is m a r k e d l o c a l n o d e s w i l l b e e n l a r g e d a n d t e n d e r . I t is a p o t e n t i a l l y
p a i n a n d dysphagia. T o n s i l appears s w o l l e n a n d r e d . T r e a t m e n t d a n g e r o u s c o n d i t i o n as l a r y n g e a l o e d e m a c a n easily
is a d m i n i s t r a t i o n o f a n t i b i o t i c s a n d drainage o f t h e abscess i f follow.
r e q u i r e d ; later t o n s i l l e c t o m y s h o u l d b e p e r f o r m e d . D i a g n o s i s is m a d e b y m i r r o r e x a m i n a t i o n a n d p a l -
Tonsillar cyst. I t is d u e t o b l o c k a g e o f a t o n s i l l a r c r y p t a n d p a t i o n o f t h e base o f t o n g u e . T r e a t m e n t is b y a n t i b i -
appears as a y e l l o w i s h s w e l l i n g o v e r t h e t o n s i l . V e r y o f t e n o t i c s , analgesics, p r o p e r h y d r a t i o n a n d i n c i s i o n a n d
i t is s y m p t o m l e s s . I t c a n b e easily d r a i n e d . d r a i n a g e o f t h e abscess.
Head and Neck Space I n f e c t i o n s

capsule. O p e n i n g o f t h e Stenson's d u c t b e c o m e s c o n g e s t e d
PAROTID ABSCESS
a n d m a y e x u d e p u s o n p r e s s u r e o v e r t h e p a r o t i d . P a t i e n t is
toxic, r u n n i n g h i g h fever and dehydrated.
I t is s u p p u r a t i o n o f t h e p a r o t i d space. D e e p c e r v i c a l fascia
splits i n t o t w o layers, s u p e r f i c i a l a n d d e e p , t o e n c l o s e t h e
[ Diagnosis [
p a r o t i d g l a n d a n d its associated s t r u c t u r e s . P a r o t i d space
lies d e e p t o its s u p e r f i c i a l l a y e r .
D i a g n o s i s o f t h e abscess c a n b e m a d e b y u l t r a s o u n d o r CT
Contents o f p a r o t i d space i n c l u d e p a r o t i d g l a n d a n d its
scan. M o r e t h a n o n e l o c u l i o f p u s m a y b e seen. A s p i r a t i o n
associated p a r o t i d l y m p h n o d e s , facial n e r v e , e x t e r n a l c a r o t i d
o f abscess c a n b e d o n e f o r c u l t u r e a n d s e n s i t i v i t y o f t h e
a r t e r y a n d r e t r o m a n d i b u l a r v e i n . Fascial l a y e r is v e r y t h i c k
causative organisms.
s u p e r f i c i a l l y b u t v e r y t h i n o n t h e d e e p side o f t h e p a r o t i d
g l a n d w h e r e p a r o t i d abscess c a n b u r s t t o f o r m a p a r a p h a -
r y n g e a l abscess a n d t h e n c e spread t o t h e m e d i a s t i n u m . Treatment

C o r r e c t the d e h y d r a t i o n , i m p r o v e oral hygiene and p r o -

Aetiology
m o t e salivary flow. I n t r a v e n o u s a n t i b i o t i c s are i n s t i t u t e d .
Surgical d r a i n a g e u n d e r l o c a l o r g e n e r a l anaesthesia is
D e h y d r a t i o n , p a r t i c u l a r l y i n p o s t - s u r g i c a l cases a n d d e b i l i -
carried o u t by a preauricular i n c i s i o n as e m p l o y e d for
t a t e d p a t i e n t s , w i t h stasis o f s a l i v a r y flow is t h e predispos-
p a r o t i d e c t o m y . S k i n flap is r a i s e d t o e x p o s e surface o f t h e
i n g cause. I n f e c t i o n f r o m t h e o r a l c a v i t y t r a v e l s v i a the
gland, and the abscess o r abscesses are b l u n t l y opened
Stenson's d u c t to invade the p a r o t i d g l a n d . M u l t i p l e small
w o r k i n g parallel t o the branches o f the V l l t h nerve. Skin
abscesses m a y f o r m i n t h e p a r e n c h y m a . They may then
i n c i s i o n is l o o s e l y a p p r o x i m a t e d o v e r a d r a i n a n d a l l o w e d
coalesce t o f o r m a s i n g l e abscess.
t o heal b y secondary i n t e n t i o n .

Bacteriology
LUDWIG'S ANGINA

Most common o r g a n i s m is Staph, aureus but Streptococci,

anaerobic organisms and rarely the g r a m negative organ- Applied Anatomy
isms have b e e n c u l t u r e d .

S u b m a n d i b u l a r space lies b e t w e e n mucous membrane of

t h e floor o f m o u t h a n d t o n g u e o n o n e side a n d s u p e r f i c i a l
Clinical Features
l a y e r o f d e e p c e r v i c a l fascia e x t e n d i n g b e t w e e n t h e h y o i d
b o n e a n d m a n d i b l e o n t h e o t h e r ( F i g . 5 1 . 1 ) . I t is d i v i d e d
Usually follows 5-7 days after o p e r a t i o n . T h e r e is s w e l l -
i n t o t w o compartments b y the m y l o h y o i d muscle:
i n g , redness, i n d u r a t i o n s a n d t e n d e r n e s s i n t h e p a r o t i d area
a n d at t h e a n g l e o f m a n d i b l e . (a) sublingual c o m p a r t m e n t (above the m y l o h y o i d )
P a r o t i d abscess is u s u a l l y u n i l a t e r a l , b u t b i l a t e r a l abscesses (b) submaxillary and submental compartment (below the
m a y o c c u r . F l u c t u a t i o n is d i f f i c u l t t o e l i c i t d u e t o t h i c k mylohyoid).
Diseases of Pharynx

Tongue

Sublingual
Attachment of
space
mylohyoid
Mylohyoid muscle
Submandibular muscle
gland
Submaxillary
Anterior be space
of digastric
Figure 51.2

Figure 51.1 Roots o f molar teeth project below, and those o f premolars

above the attachment o f mylohyoid muscle.

A n a t o m y o f submandibular space.

T h e t w o c o m p a r t m e n t s are c o n t i n u o u s a r o u n d t h e p o s - t h e tissues r a t h e r t h a n f r a n k abscess. T o n g u e is p r o g r e s -

terior border o f m y l o h y o i d muscle. sively pushed u p w a r d s a n d backwards threatening the air-
L u d w i g ' s a n g i n a is i n f e c t i o n o f s u b m a n d i b u l a r space. w a y . L a r y n g e a l o e d e m a m a y appear.

Aetiology
1 I Treatment

1. Dental infections. T h e y a c c o u n t f o r 8 0 % o f t h e cases. 1. Systemic antibiotics.

R o o t s o f premolars often lie above the attachment of 2. I n c i s i o n a n d d r a i n a g e o f abscess.

m y l o h y o i d a n d cause s u b l i n g u a l space i n f e c t i o n w h i l e (a) I n t r a o r a l — i f i n f e c t i o n is s t i l l l o c a l i s e d t o s u b l i n -

roots o f the molar teeth extend up to or b e l o w the g u a l space.

m y l o h y o i d l i n e a n d p r i m a r i l y cause s u b m a x i l l a r y space (b) External—-if infection involves submaxillary

i n f e c t i o n (Fig. 51.2). space. A transverse i n c i s i o n e x t e n d i n g f r o m one

2. Submandibular sialadenitis, injuries of oral mucosa and a n g l e o f m a n d i b l e t o t h e o t h e r is m a d e w i t h v e r t i -

f r a c t u r e s o f t h e m a n d i b l e a c c o u n t f o r o t h e r cases. cal o p e n i n g o f m i d l i n e m u s c u l a t u r e of tongue

w i t h a b l u n t haemostat. V e r y o f t e n i t is serous
f l u i d r a t h e r t h a n f r a n k p u s t h a t is e n c o u n t e r e d .
Bacteriology 3. Tracheostomy, i f a i r w a y is e n d a n g e r e d .

M i x e d i n f e c t i o n s i n v o l v i n g b o t h aerobes a n d anaerobes
J Complications J
are c o m m o n . A l p h a h a e m o l y t i c Streptococci, Staphylococci,
a n d b a c t e r o i d e s g r o u p s are c o m m o n . R a r e l y H. influenzae,
1. Spread o f i n f e c t i o n to parapharyngeal and r e t r o p h a -
Esch. coli a n d Pseudomonas are seen.
r y n g e a l spaces a n d t h e n c e t o t h e m e d i a s t i n u m .
2. Airway obstruction due to laryngeal oedema, or
Clinical Features swelling and p u s h i n g back o f the tongue.
3. Septicaemia.
There is m a r k e d d i f f i c u l t y i n s w a l l o w i n g ( o d y n o p h a g i a ) 4. Aspiration pneumonia.
w i t h v a r y i n g degrees o f t r i s m u s .
When i n f e c t i o n is l o c a l i s e d t o t h e s u b l i n g u a l space,
PERITONSILLAR ABSCESS (QUINSY)
s t r u c t u r e s i n t h e f l o o r o f m o u t h are s w o l l e n a n d tongue
seems t o b e p u s h e d u p a n d b a c k .
W h e n i n f e c t i o n spreads t o s u b m a x i l l a r y space, s u b m e n - I t is a c o l l e c t i o n o f pus i n t h e p e r i t o n s i l l a r space w h i c h lies
tal a n d s u b m a n d i b u l a r r e g i o n s b e c o m e s w o l l e n a n d t e n d e r , b e t w e e n t h e capsule o f t o n s i l a n d t h e s u p e r i o r c o n s t r i c t o r
a n d i m p a r t w o o d y - h a r d f e e l . U s u a l l y , t h e r e is c e l l u l i t i s o f muscle.
 Head and Neck Space Infections

| Aetiology |

P e r i t o n s i l l a r abscess u s u a l l y f o l l o w s a c u t e t o n s i l l i t i s t h o u g h
it may arise d e n o v o without p r e v i o u s h i s t o r y o f sore
throats. First, o n e o f the tonsillar crypts, usually the crypta
m a g n a , gets i n f e c t e d a n d sealed o f f . I t f o r m s a n i n t r a t o n s i l -
l a r abscess w h i c h t h e n bursts t h r o u g h t h e t o n s i l l a r capsule
t o set u p peritonsillitis a n d t h e n a n abscess.
C u l t u r e o f p u s f r o m t h e abscess m a y r e v e a l p u r e g r o w t h
o f Strept. pyogenes, Staph, aureus or anaerobic organisms.
M o r e o f t e n t h e g r o w t h is m i x e d , w i t h b o t h a e r o b i c a n d
anaerobic organisms.

Figure 51.3

Clinical Features Peritonsillar a b s c e s s left side.

P e r i t o n s i l l a r abscess m o s t l y affects a d u l t s a n d r a r e l y the

c h i l d r e n t h o u g h a c u t e t o n s i l l i t i s is m o r e c o m m o n i n c h i l -
d r e n . U s u a l l y , i t is u n i l a t e r a l t h o u g h o c c a s i o n a l l y bilateral 6. T o r t i c o l l i s . Patient keeps t h e n e c k t i l t e d t o the side
abscesses are r e c o r d e d . C l i n i c a l features are d i v i d e d i n t o : o f abscess.

1. G e n e r a l . T h e y are d u e t o s e p t i c a e m i a a n d r e s e m b l e
any acute i n f e c t i o n . T h e y i n c l u d e fever (up t o 1 0 4 ° F ) , Treatment ^
chills a n d rigors, g e n e r a l m a l a i s e , b o d y aches, head-
a c h e , nausea a n d c o n s t i p a t i o n . 1. Hospitalisation.
2. Local 2. Intravenous fluids to combat dehydration.
(i) Severe p a i n i n t h r o a t . U s u a l l y unilateral. 3. Antibiotics. Suitable a n t i b i o t i c s i n l a r g e i . v . doses t o
(ii) O d y n o p h a g i a . I t is so m a r k e d t h a t t h e patient cover b o t h aerobic and anaerobic organisms.
c a n n o t e v e n s w a l l o w his o w n saliva w h i c h d r i b - 4. Analgesics like paracetamol is g i v e n f o r r e l i e f o f p a i n
bles f r o m t h e a n g l e o f his m o u t h . P a t i e n t is u s u - a n d t o l o w e r the temperature. Sometimes, stronger
ally d e h y d r a t e d . analgesics l i k e p e t h i d i n e m a y b e r e q u i r e d . A s p i r i n is
(iii) M u f f l e d and thick speech, often called "Hot a v o i d e d because o f t h e d a n g e r o f b l e e d i n g .
potato voice". 5. Oral hygiene s h o u l d be m a i n t a i n e d b y h y d r o g e n p e r -
( i v ) F o u l b r e a t h d u e t o sepsis i n t h e o r a l c a v i t y a n d o x i d e o r saline m o u t h w a s h e s .
poor hygiene.
T h e above conservative measures m a y cure p e r i t o n s i l -
(v) I p s i l a t e r a l e a r a c h e . T h i s is r e f e r r e d p a i n v i a C N
l i t i s . I f a f r a n k abscess has f o r m e d , i n c i s i o n a n d drainage
I X w h i c h s u p p l i e s b o t h t h e t o n s i l a n d t h e ear.
w i l l be r e q u i r e d .
( v i ) T r i s m u s d u e t o spasm o f p t e r y g o i d m u s c l e s w h i c h
are i n close p r o x i m i t y t o t h e s u p e r i o r c o n s t r i c t o r . I n c i s i o n a n d d r a i n a g e o f a b s c e s s A p e r i t o n s i l l a r abscess
is o p e n e d at t h e p o i n t o f m a x i m u m b u l g e a b o v e t h e u p p e r
p o l e o f tonsil o r j u s t lateral t o the p o i n t o f j u n c t i o n of
Examination
a n t e r i o r p i l l a r w i t h a l i n e d r a w n t h r o u g h t h e base o f u v u l a
( F i g . 5 1 . 4 ) . W i t h t h e h e l p o f a g u a r d e d k n i f e , a s m a l l stab
1. T h e t o n s i l , pillars a n d soft palate o n t h e i n v o l v e d side
i n c i s i o n is m a d e a n d t h e n a sinus f o r c e p s i n s e r t e d t o o p e n
are c o n g e s t e d a n d s w o l l e n . T o n s i l i t s e l f m a y n o t appear
t h e abscess. P u t t i n g t h e sinus f o r c e p s t h e f o l l o w i n g day
enlarged as i t gets b u r i e d i n t h e o e d e m a t o u s p i l l a r s
m a y also b e necessary t o d r a i n a n y r e a c c u m u l a t i o n .
(Fig. 51.3).
Interval tonsillectomy T o n s i l s are r e m o v e d f o u r t o six
2. U v u l a is s w o l l e n a n d o e d e m a t o u s a n d p u s h e d t o t h e
w e e k s f o l l o w i n g an attack o f q u i n s y .
o p p o s i t e side.
3. B u l g i n g o f t h e soft palate a n d a n t e r i o r p i l l a r a b o v e t h e Abscess or hot tonsillectomy S o m e people prefer to

tonsil. do 'hot'tonsillectomy instead o f incision and drainage.

4. M u c o p u s m a y be seen c o v e r i n g t h e tonsillar r e g i o n . Abscess t o n s i l l e c t o m y has t h e risk o f r u p t u r e o f t h e abscess

5. C e r v i c a l l y m p h a d e n o p a t h y is c o m m o n l y seen. This d u r i n g anaesthesia, a n d excessive b l e e d i n g at t h e t i m e of

involves jugulodigastric l y m p h nodes. operation.

Diseases o f Pharynx

Complications
RETROPHARYNGEAL ABSCESS

Rare w i t h m o d e r n therapy.
Applied Anatomy
Parapharyngeal abscess (a p e r i t o n s i l l a r abscess is a
p o t e n t i a l p a r a p h a r y n g e a l abscess).
Retropharyngeal space It lies behind the pharynx
Oedema o f larynx. Tracheostomy may be required.
b e t w e e n t h e b u c c o p h a r y n g e a l fascia c o v e r i n g p h a r y n g e a l
Septicaemia. O t h e r complications like endocarditis,
c o n s t r i c t o r muscles a n d t h e p r e v e r t e b r a l fascia. I t e x t e n d s
n e p h r i t i s , b r a i n abscess m a y o c c u r .
from t h e base o f s k u l l t o t h e b i f u r c a t i o n o f trachea. T h e space
P n e u m o n i t i s o r l u n g abscess. D u e t o a s p i r a t i o n o f p u s ,
is d i v i d e d i n t o t w o lateral c o m p a r t m e n t s {spaces o f G i l l e t t e )
i f s p o n t a n e o u s r u p t u r e o f abscess has t a k e n p l a c e .
b y a f i b r o u s r a p h e ( F i g . 5 1 . 5 ) . E a c h lateral space c o n t a i n s
Jugular vein thrombosis.
r e t r o p h a r y n g e a l nodes w h i c h u s u a l l y disappear at 3—4 years
Spontaneous haemorrhage from carotid artery o r
o f age. P a r a p h a r y n g e a l space c o m m u n i c a t e s w i t h t h e r e t r o -
jugular vein.
p h a r y n g e a l space. I n f e c t i o n o f r e t r o p h a r y n g e a l space c a n pass
d o w n b e h i n d t h e oesophagus i n t o t h e m e d i a s t i n u m .

Prevertebral space I t lies b e t w e e n t h e v e r t e b r a l b o d i e s

Horizontal line
p o s t e r i o r l y a n d t h e p r e v e r t e b r a l fascia a n t e r i o r l y . I t e x t e n d s
through base
of uvula f r o m t h e base t o s k u l l o f c o c c y x . I n f e c t i o n o f t h i s space
usually comes f r o m t h e caries o f s p i n e . Abscess o f t h i s
Line along space p r o d u c e s a m i d l i n e b u l g e i n c o n t r a s t t o abscess o f
anterior pillar
r e t r o p h a r y n g e a l space w h i c h causes u n i l a t e r a l b u l g e .

ACUTE RETROPHARYNGEAL ABSCESS

Aetiology
Figure 51.4
I t is c o m m o n l y s e e n i n c h i l d r e n b e l o w 3 years. I t is t h e
P e r i t o n s i l l a r a b s c e s s . S i t e o f d r a i n a g e is j u s t l a t e r a l t o t h e junc-
r e s u l t o f s u p p u r a t i o n o f r e t r o p h a r y n g e a l l y m p h n o d e s sec-
tion o f vertical line t h r o u g h anterior pillar a n d horizontal line

through base o f uvula.

o n d a i y t o infection i n the adenoids, nasopharynx, poste-
rior nasal sinuses o r nasal c a v i t y . I n a d u l t s , i t m a y r e s u l t

Prevertebral space
Prevertebral

CN IX, X, XI fascia
Alar fascia
Parotid gland Danger space

Buccopharyngeal
fascia
Parapharyngeal space
Retropharyngeal space
• Anterior compartment
• Posterior compartment
Peritonsillar space
Medial pterygoid muscle

Figure 51.5

Spaces in relation t o p h a r y n x w h e r e abscesses c a n form.

 Head and Neck Space Infections

f r o m penetrating injury o f posterior pharyngeal wall o r d u r i n g i n t u b a t i o n . C h i l d is k e p t s u p i n e w i t h head

cervical oesophagus. Rarely, pus f r o m acute mastoiditis l o w . M o u t h is o p e n e d w i t h a g a g . A v e r t i c a l i n c i s i o n
t r a c k s a l o n g t h e u n d e r s u r f a c e o f p e t r o u s b o n e t o p r e s e n t as is g i v e n i n t h e m o s t fluctuant area o f t h e abscess.
r e t r o p h a r y n g e a l abscess. S u c t i o n s h o u l d a l w a y s b e a v a i l a b l e t o p r e v e n t aspira-
t i o n o f pus.
2. Systemic antibiotics. S u i t a b l e a n t i b i o t i c s are g i v e n .
Clinical Features
3. Tracheostomy. A l a r g e abscess m a y cause mechanical
o b s t r u c t i o n t o t h e a i r w a y o r lead t o laryngeal oedema.
1. Dysphagia a n d difficulty in breathing are p r o m i n e n t
T r a c h e o s t o m y b e c o m e s m a n d a t o r y i n these cases.
s y m p t o m s as t h e abscess o b s t r u c t s t h e air a n d f o o d
passages.
2. Stridor a n d croupy cough m a y b e p r e s e n t .
3. Torticollis. T h e n e c k b e c o m e s s t i f f a n d t h e h e a d is k e p t CHRONIC RETROPHARYNGEAL ABSCESS
extended.
4. Bulge in posterior pharyngeal wall. U s u a l l y seen o n o n e
Aetiology
side o f t h e m i d l i n e .

R a d i o g r a p h o f soft tissue l a t e r a l v i e w o f t h e n e c k s h o w s I t is t u b e r c u l a r i n n a t u r e a n d is t h e r e s u l t o f ( 1 ) caries o f

w i d e n i n g o f prevertebral s h a d o w a n d possibly even t h e c e r v i c a l s p i n e o r (2) t u b e r c u l o u s i n f e c t i o n o f r e t r o p h a r y n -
p r e s e n c e o f gas ( F i g . 5 1 . 6 ) . geal l y m p h n o d e s s e c o n d a r y t o t u b e r c u l o s i s o f d e e p c e r v i -
cal nodes. T h e former presents centrally behind the

Treatment p r e v e r t e b r a l fascia w h i l e t h e l a t t e r is l i m i t e d t o o n e side o f

m i d l i n e as i n t r u e r e t r o p h a i y n g e a l abscess b e h i n d t h e b u c -

1. c o p h a r y n g e a l fascia.
Incision and drainage of abscess. T h i s is u s u a l l y done
w i t h o u t anaesthesia as t h e r e is r i s k o f r u p t u r e o f abscess

Clinical Features

Patient m a y c o m p l a i n o f discomfort i n throat. Dysphagia,

t h o u g h p r e s e n t , is n o t m a r k e d . P o s t e r i o r p h a r y n g e a l w a l l
s h o w s a fluctuant s w e l l i n g c e n t r a l l y o r o n o n e side o f m i d -
l i n e . N e c k m a y s h o w t u b e r c u l o u s l y m p h n o d e s . I n cases
w i t h caries o f c e r v i c a l s p i n e , X - r a y s are d i a g n o s t i c .

g Treatment J

1. Incision and drainage of abscess. I t c a n b e d o n e t h r o u g h

a vertical incision along the anterior border o f sterno-
m a s t o i d ( f o r l o w abscess) o r a l o n g i t s p o s t e r i o r b o r d e r
( f o r h i g h abscess).
2. F u l l c o u r s e of antitubercular therapy s h o u l d b e g i v e n .

PARAPHARYNGEAL ABSCESS

( s y n . Abscess o f p h a r y n g o m a x i l l a r y o r l a t e r a l p h a r y n g e a l
space).

Figure 51.6
Applied Anatomy
Retropharyngeal abscess. Radiograph o f soft tissue, lateral

view neck showing widening o f prevertebral space with gas

P a r a p h a r y n g e a l space is p y r a m i d a l i n shape w i t h its base at
formation.
t h e base o f s k u l l a n d its a p e x at t h e h y o i d b o n e .
Diseases of Pharynx

3. Ear. B e z o l d ' s abscess, p e t r o s i t i s .

| Relations ( F i g s 5 1 . 5 t o Fig. 5 1 . 7 ) |
4. O t h e r spaces. I n f e c t i o n s o f p a r o t i d , retropharyngeal
a n d s u b m a x i l l a r y spaces.
Medial: Buccopharyngeal fascia c o v e r i n g t h e constric-
5. External trauma. P e n e t r a t i n g i n j u r i e s o f n e c k , i n j e c t i o n
t o r muscles.
o f l o c a l anaesthetic f o r t o n s i l l e c t o m y o r m a n d i b u l a r
Posterior: P r e v e r t e b r a l fascia c o v e r i n g p r e v e r t e b r a l muscles
nerve block.
a n d transverse processes o f c e r v i c a l v e r t e b r a e .
Lateral: M e d i a l p t e r y g o i d muscle, m a n d i b l e and deep
surface o f p a r o t i d g l a n d .

S t y l o i d process a n d t h e muscles a t t a c h e d t o i t d i v i d e t h e
p a r a p h a r y n g e a l space i n t o a n t e r i o r a n d p o s t e r i o r c o m p a r t -
| Clinical Features Jj^
m e n t s . Anterior compartment is related t o t o n s i l l a r fossa m e d i -
ally a n d m e d i a l p t e r y g o i d m u s c l e laterally. Posterior compartment C l i n i c a l features d e p e n d o n t h e c o m p a r t m e n t i n v o l v e d .

is r e l a t e d t o p o s t e r i o r p a r t o f lateral p h a r y n g e a l w a l l m e d i a l l y Anterior compartment infections produce a triad o f s y m p -

a n d p a r o t i d g l a n d laterally. T h r o u g h t h e p o s t e r i o r c o m p a r t - t o m s : (i) p r o l a p s e o f t o n s i l a n d t o n s i l l a r fossa, ( i i ) t r i s m u s

m e n t pass t h e c a r o r i d a r t e r y , j u g u l a r v e i n , I X t h , X t h , X l t h , ( d u e t o spasm o f m e d i a l p t e r y g o i d m u s c l e ) a n d ( i i i ) e x t e r -

X l l t h c r a n i a l nerves a n d s y m p a t h e t i c t r u n k . nal s w e l l i n g b e h i n d the angle o f j a w . T h e r e is m a r k e d

I t also c o n t a i n s u p p e r d e e p c e r v i c a l n o d e s . o d y n o p h a g i a associated w i t h i t .

P a r a p h a r y n g e a l space c o m m u n i c a t e s w i t h o t h e r spaces, Posterior compartment i n v o l v e m e n t produces (i) b u l g e of

viz. retropharyngeal, submandibular, parotid, carotid and p h a r y n x b e h i n d the p o s t e r i o r pillar, (ii) paralysis o f C N I X , X ,

visceral (Table 51.1). X I , a n d X I I a n d s y m p a t h e t i c c h a i n , a n d (ui) s w e l l i n g o f p a r o t i d

r e g i o n . T h e r e is m i n i m a l trismus o r tonsillar prolapse.
Fever, odynophagia, sore throat, torticollis (due to
[ Aetiology J spasm o f p r e v e r t e b r a l m u s c l e s ) a n d signs o f t o x a e m i a are
c o m m o n to b o t h compartments.
I n f e c t i o n o f p a r a p h a r y n g e a l space c a n o c c u r f r o m :
Complications
1. Pharynx. A c u t e and chronic infections o f tonsil and
a d e n o i d , b u r s t i n g o f p e r i t o n s i l l a r abscess. 1. A c u t e oedema o f larynx w i t h respiratory obstruction.
2. Teeth. D e n t a l i n f e c t i o n u s u a l l y c o m e s from t h e l o w e r 2. Thrombophlebitis ofjugular vein w i t h septicaemia.
last m o l a r t o o t h . 3. S p r e a d o f i n f e c t i o n t o r e t r o p h a r y n g e a l space.

Temporal bone
Superficial and deep
temporal space

-Zygoma

Masticator space
Parapharyngeal
space
Parotid space

Peritonsillar space
Mandible
Tonsil
Submandibular
space
Hyoid bone

Figure 51.7

Spaces o f head a n d neck seen in c o r o n a l section. M u c o s a ( 1 ) , p h a r y n g o b a s i l a r fascia ( 2 ) , b u c c o p h a r y n g e a l fascia ( 3 ) , s u p e r i o r c o n -

s t r i c t o r muscle ( 4 ) , superficial layer o f deep cervical fascia e n c l o s i n g s u b m a n d i b u l a r g l a n d ( 5 ) , p a r o t i d g l a n d ( 6 ) , masseter muscle
( 7 ) , t e m p o r a l i s muscle ( 8 ) , m e d i a l p t e r y g o i d muscle ( 9 ) .
 Head a n d N e c k Space Infections

I m p o r t a n t spaces o f the head and neck and their source o f infection

Space Extent Location Source of infection

Parotid space W i t h i n t w o layers o f superficial Parotid area Infection o f oral cavity via

layer o f d e e p cervical fascia Stenson's duct

S u b m a n d i b u l a r space Sublingual space Below the tongue • Sublingual sialadenitis, t o o t h

(submaxillary plus Oral m u c o s a to mylohyoid infection

sublingual) muscle • S u b m a n d i b u l a r gland

Submandibular space Submental and sialadenitis

Mylohyoid muscle to superficial s u b m a n d i b u l a r triangles • M o l a r t o o t h infection

layer o f d e e p cervical fascia

extending from mandible to

hyoid bone

Peritonsillar space Between superior constrictor and Lateral t o tonsil Infection o f tonsillar crypt

fibrous capsule o n the lateral

aspect o f tonsil

Retropharyngeal Base o f skull to tracheal Between alar fascia and • Extension o f infection

space bifurcation (T4) the buccopharyngeal from parapharyngeal space,

fascia covering parotid or masticator space

constrictor muscles • Oesophageal perforation

• Suppuration o f retropharyngeal

nodes

Danger space Base o f skull t o d i a p h r a g m Between prevertebral • Infected by rupture o f

fascia and alar fascia retropharyngeal abscess

Prevertebral space Base o f skull t o coccyx Between vertebrae o n one • Tuberculosis o f spine

side and prevertebral • Penetrating t r a u m a

muscles and the prevertebral

fascia on the other

Parapharyngeal space Base o f skull to hyoid bone Buccopharyngeal fascia • Peritonsillar abscess

(Lateral pharyngeal and s u b m a n d i b u l a r gland covering lateral aspect • Parotid abscess

space or pharyngo- o f pharynx medially, and • S u b m a n d i b u l a r gland infection

maxillary space) fascia covering pterygoid • Masticator space abscess

muscles, mandible and

parotid gland laterally

Masticator space Base o f skull to lower border Between superficial layer • Infection o f 3rd m o l a r

o f mandible o f deep cervical fascia

and the muscles o f

mastication—masseter,

medial and lateral pterygoids

insertion o f temporalis

muscle and the mandible

4. Spread o f i n f e c t i o n to m e d i a s t i n u m along t h e carotid Drainage of abscess. T h i s is u s u a l l y d o n e u n d e r g e n e r a l

space. a n a e s t h e s i a . I f t h e t r i s m u s is m a r k e d , p r e - o p e r a t i v e tra-
5. M y c o t i c aneurysm o f carotid artery f r o m w e a k e n i n g c h e o s t o m y b e c o m e s m a n d a t o r y . A b s c e s s is d r a i n e d b y a
o f its w a l l b y p u r u l e n t m a t e r i a l . I t m a y i n v o l v e c o m - horizontal incision, made 2-3 cm below t h e angle of
m o n c a r o t i d o r internal c a r o t i d artery. mandible. Blunt dissection a l o n g t h e i n n e r surface of
6. C a r o t i d b l o w o u t w i t h massive h a e m o r r h a g e . m e d i a l p t e r y g o i d m u s c l e t o w a r d s s t y l o i d p r o c e s s is c a r -
ried o u t a n d abscess evacuated. A drain is inserted.

Treatment Transoral drainage should never be done d u e t o danger

o f i n j u r y t o g r e a t vessels w h i c h pass t h r o u g h t h i s space.

Systemic antibiotics. Intravenous antibiotics m a y become

necessary t o c o m b a t i n f e c t i o n .
Tumours o f Oropharynx

Lipoma, fibroma a n d n e u r o m a are o t h e r rare b e n i g n

BENIGN TUMOURS tumours.

T h e y are far less c o m m o n c o m p a r e d t o m a l i g n a n t t u m o u r s .

MALIGNANT TUMOURS
T h e c o m m o n o n e s are d e s c r i b e d h e r e .

T h e c o m m o n sites o f m a l i g n a n c y i n t h e o r o p h a r y n x are:
Papilloma
(Table 52.1)

I t is u s u a l l y p e d u n c u l a t e d , arises f r o m t h e t o n s i l , soft palate 1. P o s t e r i o r o n e - t h i r d ( o r base) o f t o n g u e .

o r faucial pillars. O f t e n asymptomatic, it m a y be discov- 2. T o n s i l a n d t o n s i l l a r fossa.

ered accidentally b y the patient o r the physician. W h e n 3. Faucial palatine arch, i.e. soft palate and anterior

l a r g e , i t causes l o c a l i r r i t a t i o n i n t h e t h r o a t . T r e a t m e n t is pillar.

surgical excision. 4. P o s t e r i o r a n d lateral p h a r y n g e a l w a l l .

Gross appearances o f t h e t u m o u r can be divided into

4 types:
Haemangioma
(a) Superficially spreading
I t c a n o c c u r o n t h e palate, t o n s i l , p o s t e r i o r a n d lateral p h a r y n - (b) Exophytic
geal w a l l . I t m a y b e o f c a p i l l a r y o r c a v e r n o u s t y p e . C a p i l l a r y (c) Ulcerative
haemangioma or asymptomatic cavernous haemangioma (d) Infiltrative
m a y b e left a l o n e . I t is treated o n l y i f i t is i n c r e a s i n g i n size o r
T h e f i r s t t w o t y p e s are seen i n t h e p a l a t i n e a r c h ; t h e y
g i v i n g s y m p t o m s o f b l e e d i n g a n d dysphagia. T r e a t m e n t is
are r a r e l y associated w i t h metastasis. U l c e r a t i v e a n d i n f i l -
diathermy coagulation or injection o f sclerosing agents.
t r a t i v e t y p e s o f t e n i n v o l v e t h e base o f t o n g u e a n d t o n s i l .
C r y o t h e r a p y o r laser c o a g u l a t i o n is v e r y e f f e c t i v e .
T h e y have p o o r prognosis and deeply invade the a d j o i n -
ing structures a n d have marked tendency for regional
metastasis.
Pleomorphic A d e n o m a
Histologically, the t u m o u r s m a y be:

I t is m o s t l y seen s u b m u c o s a l l y o n t h e h a r d o r soft p a l a t e . I t (a) Squamous cell carcinoma. S h o w s v a r i o u s grades o f d i f -

is p o t e n t i a l l y m a l i g n a n t a n d s h o u l d b e e x c i s e d t o t a l l y . ferentiation (well, moderately or poorly differenti-
ated) a n d is t h e m o s t c o m m o n v a r i e t y .

Mucous Cyst

T a b l e S2.1 Subsites in the o r o p h a r y n x

I t is u s u a l l y seen i n t h e v a l l e c u l a . I t is y e l l o w i n a p p e a r a n c e
a n d m a y b e p e d u n c u l a t e d o r sessile. W h e n l a r g e , i t causes Base o f t o n g u e

f o r e i g n b o d y s e n s a t i o n i n t h e t h r o a t . T r e a t m e n t is s u r g i c a l Tonsil, tonsillar fossa

excision, i f p e d u n c u l a t e d ; or i n c i s i o n and drainage with Faucial arch

Pharyngeal wall
r e m o v a l o f its c y s t w a l l .
 Tumours of Oropharynx

(b) Lymphoepitkelioma. A poorly differentiated variant o f

Table 52.2 T N M classification a n d staging o f o r o p h a -
the above, w i t h a d m i x t u r e o f lymphocytes, w h i c h do
r y n g e a l c a n c e r (AJCC, 2 0 0 2 )
n o t s h o w a n y features o f m a l i g n a n c y . T h i s is o f t e n
seen i n t o n s i l , base o f t o n g u e a n d v a l l e c u l a . Primary tumour (T)
(c) Adenocarcinoma. I t arises f r o m m i n o r s a l i v a r y g l a n d s . I t T, T u m o u r 2 c m o r less in greatest d i m e n s i o n
T T u m o u r more than 2 cm but not more than 4 c m
is m o s t l y seen o n t h e palate a n d fauces.
in greatest d i m e n s i o n
(d) Lymphomas. B o t h H o d g k i n and n o n - H o d g k i n l y m -
T T u m o u r m o r e t h a n 4 c m in greatest d i m e n s i o n
p h o m a s arise from t h e t o n s i l a n d base o f t o n g u e . T h e y
3

T u m o u r invades the larynx, deep/extrinsic m u s c l e

are seen i n t h e y o u n g a d u l t s a n d s o m e t i m e s i n the
o f t o n g u e , m e d i a l p t e r y g o i d , h a r d palate o r
c h i l d r e n . Enlarged cervical nodes m a y co-exist. mandible
T.b T u m o u r invades lateral p t e r y g o i d muscle, p t e r y g o i d
T N M classification I t is s i m i l a r t o t h e o n e u s e d i n c a n -
plates, lateral n a s o p h a r y n x , o r base o f skull o r
c e r o f t h e o r a l c a v i t y , (see T a b l e 5 2 . 2 ) . encases c a r o t i d a r t e r y
Treatment. T r e a t m e n t o f o r o p h a r y n g e a l cancer depends
Regional lymph nodes (N)
u p o n t h e site a n d e x t e n t o f disease, p a t i e n t ' s g e n e r a l con-
N x Regional l y m p h n o d e s c a n n o t be assessed
d i t i o n , p h i l o s o p h y and experience o f the treating surgeon
N Q N o regional lymph node metastasis
a n d f a c i l i t i e s a v a i l a b l e at a p a r t i c u l a r c e n t r e . T h e various
N, M e t a s t a s i s in a single i p s i l a t e r a l l y m p h n o d e , 3 c m
o p t i o n s are: o r less in greatest d i m e n s i o n
N M e t a s t a s i s in a single i p s i l a t e r a l l y m p h n o d e , m o r e
(i) Surgery alone ?

t h a n 3 c m b u t n o t m o r e t h a n 6 c m in greatest
(ii) R a d i a t i o n alone
d i m e n s i o n , o r in m u l t i p l e i p s i l a t e r a l l y m p h n o d e s ,
(iii) C o m b i n a t i o n o f surgeiy and radiotherapy
n o n e m o r e t h a n 6 c m in greatest d i m e n s i o n , o r in
(iv) C h e m o t h e r a p y a l o n e o r as a n a d j u n c t t o s u r g e i y o r
bilateral or contralateral lymph nodes, none more
radiotherapy t h a n 6 c m in greatest d i m e n s i o n
(v) Palliative therapy. N M e t a s t a s i s in a single i p s i l a t e r a l l y m p h n o d e m o r e
2 a

t h a n 3 c m b u t n o t m o r e t h a n 6 c m in greatest

I
dimension
1. Carcinoma of Posterior One-third or M e t a s t a s i s in m u l t i p l e ipsilateral l y m p h n o d e s ,
Base of Tongue
1 n o n e m o r e t h a n 6 c m in greatest d i m e n s i o n
Metastasis in bilateral or contralateral l y m p h nodes,
T h i s is c o m m o n l y seen i n o u r c o u n t r y ( F i g . 5 2 . 1 ) . The none m o r e t h a n 6 c m in greatest d imension
lesion remains asymptomatic for a l o n g t i m e and patient M e t a s t a s i s in a l y m p h n o d e m o r e t h a n 6 c m in

presents w h e n metastases i n c e r v i c a l n o d e s m a k e their greatest d i m e n s i o n

appearance. Earlier s y m p t o m s o f sore-throat, feeling of Distant metastasis (M)

l u m p i n t h e t h r o a t a n d s l i g h t d i s c o m f o r t o n s w a l l o w i n g are D i s t a n t m e t a s t a s i s c a n n o t be assessed
o f t e n i g n o r e d o r a t t r i b u t e d to lingual tonsils. Late features M
o N o distant metastasis

are r e f e r r e d p a i n i n t h e ear, d y s p h a g i a , b l e e d i n g f r o m t h e M, Distant metastasis

m o u t h , a n d change i n the q u a l i t y o f speech (hot potato Stage grouping

voice).
0 Tis N
o M
o
1 T
!
N 0 M Q

Spread II T
2 N 0
M
0

III 3 N Mo
Local. L e s i o n s are d e e p l y i n f i l t r a t i v e a n d s p r e a d t o t h e rest T 0

o f t o n g u e m u s c u l a t u r e , e p i g l o t t i s a n d p r e - e p i g l o t t i c space, T, N, M
o

t o n s i l a n d its p i l l a r s , a n d h y p o p h a r y n x . Ni M
c

, o
M

Lymphatic. 70% o f t h e cases s h o w c e r v i c a l metastases N

IVA M
o
e i t h e r u n i l a t e r a l o r b i l a t e r a l at t h e t i m e o f i n i t i a l c o n s u l t a -
t i o n . J u g u l o d i g a s t r i c n o d e s are t h e f i r s t t o b e i n v o l v e d .
Distant metastases. Bones, liver, l u n g m a y be i n v o l v e d .
V
T,
N , M

K
o

T 2 N, M
o

Diagnosis
T 3
N, M

M
o
V N
3
0

IVB Any N o
L e s i o n s c a n b e seen o n i n d i r e c t l a r y n g o s c o p y b u t p a l p a t i o n
M

AnyT M
o
o f t h e t u m o u r s h o u l d never b e o m i t t e d . P a l p a t i o n u n d e r
IVC AnyT Any N M,
anaesthesia w h e n tissues are r e l a x e d g i v e s b e t t e r i d e a o f t h e
Diseases of Pharynx

d e g r e e o f i n f i l t r a t i o n o f tissues. L e s i o n is u s u a l l y far m o r e
e x t e n s i v e t h a n i t appears o n m i r r o r e x a m i n a t i o n . C T scan
is r e c o m m e n d e d f o r t u m o u r a n d n o d a l s t a g i n g . B i o p s y is
essential t o k n o w its h i s t o l o g y .

Treatment

T r e a t m e n t m a y vary f r o m centre t o centre, some f a v o u r -

i n g r a d i o t h e r a p y , others surgery a n d still others r a d i o t h e r -
a p y f o l l o w e d b y salvage s u r g e r y .
Tumours which are radiosensitive such as anaplastic
c a r c i n o m a , l y m p h o e p i t h e l i o m a o r l y m p h o m a are t r e a t e d
b y radiotherapy to the p r i m a r y a n d neck nodes.
For T : a n d T , squamous cell carcinoma w i t h N ( | or N (

Figure 52.3
n e c k , s u r g i c a l e x c i s i o n w i t h b l o c k d i s s e c t i o n is p r e f e r r e d
a n d i f n e c k d i s s e c t i o n s p e c i m e n reveals a stage m o r e t h a n L y m p h o m a tonsil p r e s e n t i n g as unilateral tonsillar enlargement.

N p p o s t - o p e r a t i v e r a d i a t i o n is a d d e d .
T 3 and T lesions r e q u i r e surgical e x c i s i o n w i t h man-
dibular resection, neck dissection and post-operative
radiation. L y m p h o m a s m a y present as u n i l a t e r a l t o n s i l l a r enlarge-
T 4 l e s i o n s , w h i c h also e x t e n d i n t o a n t e r i o r 2/3 o f t o n g u e m e n t w i t h or w i t h o u t ulceration and m a y simulate i n d o -
o r vallecula, r e q u i r e extensive s u r g e r y w i t h t o t a l glossec- l e n t p e r i t o n s i l l a r abscess ( F i g . 5 2 . 3 ) .
tomy and laryngectomy in addition to the block
dissection. Spread
Chemotherapy m a y be combined with radiotherapy
Local. T u m o u r m a y s p r e a d l o c a l l y t o soft palate a n d p i l l a r s ,
a n d s u r g e r y i n s u c h cases.
base o f t o n g u e , p h a r y n g e a l w a l l a n d h y p o p h a r y n x . I t m a y
F o r a d v a n c e d cancers, i n p a t i e n t s w i t h p o o r h e a l t h , o n l y
invade p t e r y g o i d muscles a n d m a n d i b l e resulting i n pain
palliation w i t h r a d i o - o r c h e m o t h e r a p y m a y be r e q u i r e d .
a n d t r i s m u s . P a r a p h a r y n g e a l space m a y also get i n v a d e d .
T h e y often e n d up into tracheostomy and gastrostomy i n
Lymphatic. F i f t y percent o f the patients have initial cer-
t h e t e r m i n a l phase t o r e s t o r e t h e i r a i r a n d f o o d passages
vical node involvement at the time of presentation.
a n d s t r o n g analgesics f o r r e l i e f o f p a i n .
J u g u l o d i g a s t r i c n o d e s are t h e f i r s t t o b e i n v o l v e d .
Distant metastases. T h e y are seen i n late cases.

2. Carcinoma Tonsil and Tonsillar Fossa

Clinical Features

Squamous c e l l c a r c i n o m a is t h e m o s t c o m m o n a n d p r e s - Persistent sore t h r o a t , d i f f i c u l t y i n s w a l l o w i n g , p a i n i n the

e n t s as a n u l c e r a t e d l e s i o n w i t h n e c r o t i c base ( F i g . 5 2 . 2 ) . ear o r l u m p i n the neck are t h e p r e s e n t i n g s y m p t o m s .
 Tumours of Oropharynx

Later o n , b l e e d i n g f r o m the m o u t h , f e t o r oris a n d trismus

may occur.

Diagnosis

P a l p a t i o n o f t o n s i l l a r area s h o u l d n e v e r b e o m i t t e d t o f i n d
t h e e x t e n t o f t u m o u r . B i o p s y is essential f o r h i s t o l o g i c a l
typing.

Treatment

Radiotherapy. E a r l y a n d r a d i o s e n s i t i v e t u m o u r s are t r e a t e d
b y r a d i o t h e r a p y a l o n g w i t h i r r a d i a t i o n o f cervical nodes.
Surgery. E x c i s i o n o f the t o n s i l can be d o n e f o r early
s u p e r f i c i a l l e s i o n s . L a r g e r lesions a n d t h o s e w h i c h i n v a d e Figure 52.4
bone require w i d e surgical excision with hemimandi-
An ulcerative lesion o f palatine arch. It w a s well-differentiated
b u l e c t o m y and neck dissection ( c o m m a n d o o p e r a t i o n ) .
s q u a m o u s cell carcinoma.
Combination therapy. Surgery m a y be combined with
pre- or post-operative radiation. Chemotherapy may be
g i v e n as a n a d j u n c t t o s u r g e r y o r r a d i a t i o n .
dissection w h e n n o d e s are p a l p a b l e . Access t o posterior
p h a r y n g e a l w a l l is t h r o u g h l a t e r a l p h a r y n g o t o m y w i t h or
w i t h o u t mandibular osteotomy.
J 3. C a r c i n o m a of Faucial (Palatine) A r c h J

Soft palate, u v u l a a n d a n t e r i o r tonsillar p i l l a r c o m p r i s e the

faucial a r c h . C a r c i n o m a i n these sites is o f t e n o f s q u a m o u s c e l l PARAPHARYNGEAL TUMOURS
v a r i e t y . Lesions are s u p e r f i c i a l l y s p r e a d i n g a n d w e l l - d i f f e r e n -
t i a t e d w i t h late t e n d e n c y f o r n o d a l metastases ( F i g . 5 2 . 4 ) .
P a r a p h a r y n g e a l space is d e s c r i b e d o n p a g e 2 8 1 (refer F i g .
T h u s t h e y b e h a v e m o r e l i k e carcinomas o f t h e o r a l c a v i t y .
5 1 . 6 ) . I t lies l a t e r a l t o t h e p h a i y n x . B o t h b e n i g n a n d m a l i g -
Spread m a y occur locally t o the contiguous structures
n a n t t u m o u r s are seen. T h e y cause a b u l g e i n l a t e r a l p h a -
o r l y m p h nodes. U p p e r deep cervical and s u b m a n d i b u l a r
r y n g e a l w a l l a n d d i s t o r t t h e p i l l a r s a n d soft p a l a t e , a n d t h u s
nodes m a y be i n v o l v e d .
mimic neoplasms o f the oropharynx. C o m m o n l y seen
Patients w i t h p a l a t i n e a r c h cancer usually p r e s e n t w i t h p e r -
t u m o u r s are t h o s e f r o m t h e d e e p l o b e o f p a r o t i d , n e u r o -
sistent sore t h r o a t , l o c a l p a i n o r earache. G r o w t h m a y h a v e
genic (e.g. n e u r i l e m m o m a ) , c h e m o d e c t o m a (from carotid
b e e n n o t i c e d b y t h e p a t i e n t w h i l e u s i n g t h e m i r r o r , o r b y his
body), l i p o m a or aneurysm o f internal carotid arteiy.
p h y s i c i a n w h i l e e x a m i n i n g his t h r o a t o r b y t h e dentist.
T r e a t m e n t is i r r a d i a t i o n o r s u r g i c a l e x c i s i o n .

STYALGIA (EAGLE'S SYNDROME)

4. Carcinoma of Posterior and Lateral

I Pharyngeal Wall
1 I t is d u e t o e l o n g a t e d s t y l o i d process o r c a l c i f i c a t i o n
s t y l o h y o i d ligament. Patient complains o f pain i n tonsillar
of

Lesions r e m a i n asymptomatic f o r a l o n g t i m e . T h e y may fossa a n d u p p e r n e c k w h i c h radiates t o t h e i p s i l a t e r a l ear.

s p r e a d s u b m u c o s a l l y t o t h e a d j o i n i n g areas s u c h as t o n s i l ,
soft p a l a t e , t o n g u e , n a s o p h a r y n x or hypopharynx. They
m a y also i n v a d e p a r a p h a r y n g e a l space o r a n t e r i o r s p i n a l
ligaments. Sixty percent o f patients m a y have l y m p h n o d e
metastases. B i l a t e r a l n o d a l i n v o l v e m e n t is c o m m o n .
T r e a t m e n t is i r r a d i a t i o n o r s u r g i c a l e x c i s i o n o f g r o w t h
with s k i n g r a f t i n g . T h i s is o f t e n c o m b i n e d w i t h block
I t gets a g g r a v a t e d o n s w a l l o w i n g . D i a g n o s i s c a n b e made
b y transoral p a l p a t i o n o f the s t y l o i d process i n the tonsillar
fossa a n d b y a r a d i o g r a p h s u c h as a n t e r o p o s t e r i o r view
w i t h o p e n m o u t h o r lateral v i e w o f skull. M a n y persons
m a y have e l o n g a t e d s t y l o i d process b u t r e m a i n a s y m p t o m -
atic a n d d o n o t n e e d t r e a t m e n t . S y m p t o m a t i c s t y l o i d p r o -
cess c a n b e e x c i s e d b y t r a n s o r a l o r c e r v i c a l a p p r o a c h .
Tumours o f the Hypopharynx and
Pharyngeal Pouch

Distant metastases o f t e n o c c u r late a n d m a y b e seen i n

TUMOURS OF HYPOPHARYNX lung, liver and bones.

Benign tumours They are exceptionally uncommon Clinical Features

a n d i n c l u d e papilloma, adenoma, lipoma, fibroma a n d leio-

E a r l y s y m p t o m s are f e w . S o m e t h i n g s t i c k i n g i n t h e t h r o a t
myoma. T h e y p r e s e n t as s m o o t h w e l l - d e f i n e d masses w h i c h
and " p r i c k i n g sensation" o n s w a l l o w i n g m a y be the earli-
are s o m e t i m e s p e d u n c u l a t e d a n d m o b i l e .
est s y m p t o m s . R e f e r r e d o t a l g i a , p a i n o n s w a l l o w i n g a n d
Malignant tumours Carcinoma o f t h e h y p o p h a r y n x is i n c r e a s i n g d y s p h a g i a m a y f o l l o w . A mass o f l y m p h n o d e s
very common i n our countiy. Practically, most of the h i g h u p i n t h e n e c k m a y be the first sign. Hoarseness a n d
t u m o u r s are s q u a m o u s cell t y p e w i t h v a r i o u s grades o f d i f - l a r y n g e a l o b s t r u c t i o n i n d i c a t e l a r y n g e a l o e d e m a o r spread
f e r e n t i a t i o n . T h e v a r i o u s sub-sites i n v o l v e d are: (1) p y r i f o r m o f disease t o t h e l a r y n x .
sinus, (2) p o s t c r i c o i d r e g i o n , a n d (3) p o s t e r i o r p h a r y n g e a l
w a l l , i n that order o f frequency. Diagnosis

G r o w t h a n d its e x t e n t c a n o f t e n b e seen o n m i r r o r e x a m i -
nation. Sometimes, p o o l i n g o f secretions obstructs the
| 1. Carcinoma Pyriform Sinus | v i e w . B a r i u m s w a l l o w a n d C T scan are h e l p f u l t o e v a l u a t e
t h e e x t e n t o f g r o w t h a n d status o f l y m p h nodes.
I t constitutes 6 0 % o f all h y p o p h a r y n g e a l cancers, m o s t l y Endoscopic examination is necessary f o r b i o p s y and
a f f e c t i n g m a l e s a b o v e 4 0 years o f age. G r o w t h is e i t h e r a c c u r a t e assessment o f t h e e x t e n t o f g r o w t h a n d also t o
e x o p h y t i c o r ulcerative and deeply infiltrative. Because o f f i n d o u t a n y s y n c h r o n o u s p r i m a r y at a n y o t h e r site.
t h e l a r g e size o f t h e p y r i f o r m sinus, g r o w t h s o f t h i s r e g i o n
remain asymptomatic for a l o n g t i m e . Metastatic neck Treatment
nodes m a y be t h e first t o attract a t t e n t i o n .
Early g r o w t h w i t h o u t nodes can be c u r e d b y radiotherapy
w i t h the advantage o f preserving the laryngeal f u n c t i o n .
Spread
If growth is l i m i t e d t o p y r i f o r m fossa a n d d o e s n o t
Locally, t h e g r o w t h m a y spread u p w a r d s t o t h e v a l l e c u l a extend to postcricoid region, total laryngectomy and par-
a n d base o f t o n g u e ; downwards to postcricoid region; t i a l p h a r y n g e c t o m y is d o n e . R e m a i n i n g p h a i y n x c a n be
m e d i a l l y to a r y e p i g l o t t i c folds a n d ventricles. I t m a y i n f i l - p r i m a r i l y c l o s e d . T h i s is o f t e n c o m b i n e d w i t h e l e c t i v e or
trate i n t o the t h y r o i d cartilage, t h y r o i d g l a n d o r m a y pres- p r o p h y l a c t i c b l o c k dissection o f l y m p h nodes.
e n t as a s o f t tissue mass i n t h e n e c k . I f g r o w t h extends to p o s t c r i c o i d r e g i o n , total laryngec-
Lymphatic spread o c c u r s e a r l y . P y r i f o r m fossa has a r i c h t o m y a n d p h a r y n g e c t o m y is d o n e a l o n g w i t h b l o c k dissec-
lymphatic n e t w o r k . Seventy five percent o f the patients tion. Pharyngo-oesophageal s e g m e n t is r e c o n s t r u c t e d w i t h
h a v e c e r v i c a l n o d a l metastases w h e n f i r s t s e e n , w i t h h a l f o f m y o c u t a n e o u s flaps o r s t o m a c h pull-up.
them h a v i n g bilateral i n v o l v e m e n t . U p p e r a n d m i d d l e Planned post-operative radiotherapy can be given
g r o u p o f j u g u l a r c e r v i c a l n o d e s are o f t e n i n v o l v e d . S o m e t i m e s , r o u t i n e l y t o a l l cases. P a t i e n t s with no palpable nodes
n o d e s m a k e t h e i r appearance l o n g after t h e p r i m a r y has b e e n {N ( ) n e c k ) c a n also b e g i v e n r a d i o t h e r a p y a v o i d i n g b l o c k
eradicated. dissection.
 Tumours of the Hypopharynx and Pharyngeal Pouch

Spread
J 2. C a r c i n o m a Postcricoid Region ^
Growth is u s u a l l y e x o p h y t i c b u t m a y be ulcerative. It
This constitutes 30% o f laryngopharyngeal malignancies. r e m a i n s l o c a l i z e d u n t i l late a n d t h e n spreads t o t h e p r e v e r -
Paterson-Brown-Kelly (Plummer-Vinson) syndrome char- t e b r a l fascia, m u s c l e s a n d v e r t e b r a e .
acterised b y h y p o c h r o m i c m i c r o c y t i c anaemia is an i m p o r t a n t L y m p h a t i c s p r e a d is u s u a l l y b i l a t e r a l d u e t o m i d l i n e
aetiological f a c t o r as o n e - t h i r d o f patients o f postcricoid nature o f t h e lesion. 5 0 % o f the patients w i t h cancer o f
carcinoma may be suffering f r o m it. p o s t e r i o r p h a r y n g e a l w a l l h a v e n o d a l metastasis o n t h e i r
initial examination. Retropharyngeal nodes, though not
Spread
c l i n i c a l l y p a l p a b l e , m a y also b e i n v o l v e d .

U s u a l l y a n u l c e r a t i v e t y p e o f l e s i o n arises f r o m p o s t c r i c o i d
r e g i o n . L o c a l spread o f t e n occurs i n an annular fashion Clinical Features

causing m a r k e d dysphagia. G r o w t h s m a y invade cervical Dysphagia or spitting o f b l o o d may be the presenting

oesophagus, arytenoids, o r recurrent laryngeal nerve at s y m p t o m . S o m e m a y p r e s e n t w i t h a p a l p a b l e mass o f n o d e s
cricoarytenoid joint. i n the neck w i t h o u t any symptoms p o i n t i n g t o the pri-
Lymphatic spread involves paratracheal lymph nodes mary tumour.
a n d m a y be b i l a t e r a l d u e t o t h e m i d l i n e n a t u r e o f lesions.
T h e y m a y n o t be clinically palpable. Diagnosis

Clinical Features Indirect mirror examination o f t e n reveals t h e tumour.

L a t e r a l s o f t tissue r a d i o g r a p h y m a y s h o w v e r t i c a l extent
F e m a l e s are u s u a l l y a f f e c t e d , s o m e t i m e s i n the early age
and thickness o f the t u m o u r and any i n v o l v e m e n t o f cer-
g r o u p o f t w e n t i e s a n d t h i r t i e s . P r o g r e s s i v e d y s p h a g i a is t h e
v i c a l v e r t e b r a e . E n d o s c o p y is essential f o r b i o p s y a n d a c c u -
p r e d o m i n a n t p r e s e n t i n g s y m p t o m . T h i s m a y cause p r o -
r a t e assessment o f t h e t u m o u r a n d t o f i n d a n y s y n c h r o n o u s
gressive m a l n u t r i t i o n a n d w e i g h t loss. S o m e t i m e s , voice
p r i m a r y at a n y o t h e r site.
change and a p h o n i a m a y be p r o d u c e d due to i n f i l t r a t i o n
o f recurrent laryngeal nerve or posterior cricoarytenoid Treatment
muscles a f f e c t i n g v o c a l c o r d m o b i l i t y .
E a r l y lesions, particularly exophytic, can be treated by
Diagnosis radiotherapy w i t h preservation o f laryngeal f u n c t i o n . Early
s m a l l lesions c a n also b e e x c i s e d s u r g i c a l l y v i a l a t e r a l p h a r -
P o s t c r i c o i d g r o w t h s m a y n o t be visible o n indirect l a r y n -
y n g o t o m y a n d p r i m a r y r e p a i r w i t h e q u a l l y g o o d results.
goscopy. O e d e m a and erythema o f the postcricoid r e g i o n
A d v a n c e d lesions m a y r e q u i r e l a r y n g o p h a i y n g e c t o m y a n d
a n d p o o l i n g o f s e c r e t i o n s i n t h e h y p o p h a r y n x are s u g g e s -
b l o c k dissection o f n e c k w i t h repair o f the f o o d channel.
tive o f g r o w t h . Laryngeal crepitus, felt n o r m a l l y w h i l e
G r o s s 5 - y e a r c u r e rate is o n l y 19%.
m o v i n g l a r y n x o v e r t h e cervical spine, m a y b e lost.
L a t e r a l soft tissue r a d i o g r a p h o f t h e n e c k m a y s h o w a n
i n c r e a s e d p r e v e r t e b r a l s h a d o w . B a r i u m s w a l l o w is essential
PHARYNGEAL POUCH
t o f i n d t h e l o w e r e x t e n t o f t h e disease. E n d o s c o p y is a l w a y s
d o n e t o take b i o p s y a n d assess t h e e x t e n t o f l e s i o n .
Also called h y p o p h a r y n g e a l diverticulum or Zenker's
Treatment d i v e r t i c u l u m , i t is a p u l s i o n d i v e r t i c u l u m w h e r e p h a r y n -
geal m u c o s a herniates t h r o u g h t h e K i l l i a n ' s d e h i s c e n c e —
P r o g n o s i s is p o o r b o t h w i t h i r r a d i a t i o n a n d s u r g i c a l t r e a t -
a w e a k area b e t w e e n t w o parts o f t h e i n f e r i o r c o n s t r i c t o r
m e n t . S o m e p r e f e r t o g i v e r a d i o t h e r a p y i n i t i a l l y . I t has
(Figs 5 3 . 1 a n d 5 3 . 2 ) .
t h e a d v a n t a g e o f p r e s e r v i n g l a r y n g e a l f u n c t i o n . F a i l e d cases
are s u b j e c t e d t o l a r y n g o - p h a r y n g o - o e s o p h a g e c t o m y with
Aetiology
stomach pull-up or colon transposition to reconstruct
pharyngo-oesophageal segment. M a n y feel that i n i t i a l sur- E x a c t cause is n o t k n o w n . I t is p r o b a b l y d u e t o spasm of

g e r y , i f feasible, g i v e s b e t t e r results. c r i c o p h a r y n g e a l s p h i n c t e r o r its i n c o o r d i n a t e d c o n t r a c t i o n s

d u r i n g t h e act o f d e g l u t i t i o n . I t is u s u a l l y seen after 6 0 years
o f age.
3. Carcinoma Posterior Pharyngeal Wall

Pathology
T h i s is t h e least c o m m o n o f l a r y n g o p h a r y n g e a l m a l i g n a n c y
c o n s t i t u t i n g o n l y 1 0 % o f t h e m . T h e y are m o s t l y seen i n H e r n i a t i o n o f p o u c h starts i n t h e m i d l i n e . I t is at f i r s t
m a l e s a b o v e f i f t y years o f age. b e h i n d t h e o e s o p h a g u s a n d t h e n c o m e s t o l i e o n its l e f t .
Diseases of Pharynx

Thyropharyngeus

Thyropharyngeus Cricopharyngeus

Killian's
Killian's
dehiscence
dehiscence
Killian-Jamieson's
Cricopharyngeus area
Laimer's Outer longitudinal
Zenker's Circular and dehiscence fibres of oesophagus
diverticulum longitudinal
fibres of
oesophagus

Figure 53.1
Figure 53.2
Hypopharyngeal (Zenker's) diverticulum. Hypopharyngeal
Potential sites for hypopharyngeal diverticulum.
m u c o s a herniates t h r o u g h the Killian's dehiscence—a w e a k area

between t w o parts ofinferior constrictor muscle.

M o u t h o f t h e sac is w i d e r t h a n t h e o p e n i n g o f o e s o p h a g u s Diagnosis
a n d f o o d p r e f e r e n t i a l l y e n t e r s t h e sac.
B a r i u m s w a l l o w w i l l s h o w t h e sac a n d its size.

Clinical Features Treatment

D y s p h a g i a is t h e p r o m i n e n t f e a t u r e . I t appears after a f e w 1. Excision of pouch and cricopharyngeal myotomy.

s w a l l o w s w h e n t h e p o u c h gets f i l l e d w i t h f o o d , a n d presses T h i s is d o n e t h r o u g h c e r v i c a l a p p r o a c h .
o n t h e o e s o p h a g u s . G u r g l i n g s o u n d is p r o d u c e d o n s w a l - 2. Dohlman's procedure. The partition wall between
l o w i n g . U n d i g e s t e d f o o d m a y r e g u r g i t a t e at n i g h t , w h e n t h e o e s o p h a g u s a n d t h e p o u c h is d i v i d e d b y diathermy
p a t i e n t is r e c u m b e n t , c a u s i n g c o u g h a n d a s p i r a t i o n p n e u - through an endoscope. This is d o n e i n poor risk
m o n i a . P a t i e n t is o f t e n m a l n o u r i s h e d d u e t o dysphagia. debilitated patients.
P a t i e n t s w i t h p h a r y n g e a l p o u c h m a y h a v e associated h i a t u s 3. Endoscopic laser t r e a t m e n t . I t is s i m i l a r t o D o h l m a n ' s
hernia. Rarely carcinoma can d e v e l o p i n l o n g - s t a n d i n g p r o c e d u r e . P a r t i t i o n b e t w e e n t h e p o u c h a n d oesophagus
cases o f p h a r y n g e a l p o u c h . is d i v i d e d b y C O , laser u s i n g o p e r a t i n g m i c r o s c o p e .
S n o r i n g and Sleep A p n o e a

o f s o f t p a l a t e , t o n s i l l a r p i l l a r s a n d base o f t o n g u e p r o d u c i n g
SNORING s o u n d . S o u n d as l o u d as 9 0 d B has b e e n r e c o r d e d during
snoring.

I t is a n u n d e s i r a b l e d i s t u r b i n g s o u n d that occurs d u r i n g S n o r i n g m a y be p r i m a r y , i.e. w i t h o u t association with

sleep. I t is e s t i m a t e d t h a t 2 5 % o f a d u l t m a l e s a n d 1 5 % of o b s t r u c t i v e sleep a p n o e a ( O S A ) o r c o m p l i c a t e d , i . e . asso-

a d u l t f e m a l e s s n o r e . Its p r e v a l e n c e increases w i t h age. ciated w i t h O S A . P r i m a r y s n o r i n g is n o t associated w i t h

excessive d a y t i m e sleepiness a n d has a p n o e a — h y p n o e a index
o f less t h a n 5.
J Definition o f T e r m s

Aetiology
Sleep apnoea I t is c e s s a t i o n o f b r e a t h i n g t h a t last for
10 s e c o n d s o r m o r e d u r i n g sleep. Less t h a n f i v e s u c h e p i -
I n c h i l d r e n m o s t c o m m o n cause is a d e n o t o n s i l l a r hyper-
sodes is n o r m a l .
t r o p h y . I n a d u l t s cause o f s n o r i n g c o u l d b e i n t h e nose or
A p n o e a i n d e x I t is n u m b e r o f episodes o f apnoea i n 1 h o u r . nasopharynx s u c h as septal d e v i a t i o n , t u r b i n a t e h y p e r t r o -
Hypopnoea I t is r e d u c t i o n o f a i r f l o w . S o m e d e f i n e i t as phy, nasal v a l v e collapse, nasal p o l y p i o r t u m o u r s ; i n oral
d r o p o f 5 0 % o f a i r f l o w f r o m t h e base l i n e associated w i t h cavity a n d oropharynx s u c h as e l o n g a t e d soft palate a n d u v u l a ,
an E E G d e f i n e d arousal o r 4 % d r o p i n o x y g e n saturation. tonsillar enlargement, macroglossia, retrognathia, large
base o f t o n g u e ; o r its t u m o u r ; i n t h e larynx and laryngophar-
Respiratory disturbance index ( R D I ) Also called
ynx s u c h as l a r y n g e a l stenosis o r o m e g a - s h a p e d e p i g l o t t i s .
apnoea—hypopnoea i n d e x . I t is t h e n u m b e r o f a p n o e a a n d
O t h e r causes i n c l u d e o b e s i t y a n d t h i c k n e c k w i t h c o l l a r
h y p o p n o e a e v e n t s p e r h o u r . N o r m a l l y R D I is less t h a n 5.
size e x c e e d i n g 4 2 c m . U s e o f a l c o h o l , sedatives a n d h y p n o t -
B a s e d o n R D I , s e v e r i t y a p n o e a has b e e n classified as m i l d ,
ics aggravates s n o r i n g d u e t o m u s c l e r e l a x a t i o n .
5-14; m o d e r a t e , 1 5 - 3 0 ; a n d severe >30.

Arousal Transient a w a k e n i n g f r o m sleep as a r e s u l t of

apnoea o r respiratory efforts. Sites o f S n oring

Arousal index I t is n u m b e r o f a r o u s a l e v e n t s i n 1 h o u r .
S i t e o f s n o r i n g m a y b e soft palate, t o n s i l l a r p i l l a r s o r h y p o -
Less t h a n 4 is n o r m a l .
p h a r y n x . I t m a y vary f r o m patient to patient and even i n
Sleep efficiency M i n u t e s o f sleep d i v i d e d b y m i n u t e s i n
t h e same p a t i e n t t h u s m a k i n g s u r g i c a l c o r r e c t i o n a d i f f i c u l t
b e d a f t e r l i g h t s are t u r n e d o f f .
d e c i s i o n . S o m e t i m e s sites o f s n o r i n g are m u l t i p l e e v e n i n
Multiple sleep l a t e n c y test Patient undergoes f o u r or t h e same p a t i e n t .
f i v e s c h e d u l e d naps u s u a l l y i n t h e d a y t i m e . L a t e n c y p e r i o d
f r o m w a k e f u l n e s s t o t h e o n s e t o f sleep a n d R E M sleep are
Symptomatology
m e a s u r e d . I t is p e r f o r m e d w h e n n a r c o l e p s y is s u s p e c t e d o r
d a y t i m e sleepiness is e v a l u a t e d objectively.
E x c e s s i v e l o u d s n o r i n g is s o c i a l l y disruptive and forms

H^^^^^
s n o r i n g - s p o u s e s y n d r o m e a n d is t h e cause o f m a r i t a l d i s c o r d
sometimes leading to divorce. I n addition, a snorer w i t h
Mechanism of Snoring
o b s t r u c t i v e sleep a p n o e a m a y m a n i f e s t w i t h :

M u s c l e s o f p h a r y n x are r e l a x e d d u r i n g sleep a n d cause p a r t i a l • E x c e s s i v e d a y t i m e sleepiness

o b s t r u c t i o n . B r e a t h i n g against o b s t r u c t i o n causes v i b r a t i o n s • M o r n i n g headaches
Diseases of Pharynx

• General fatigue
Pathophysiology of O S A
8
M e m o r y loss
• I r r i t a b i l i t y a n d depression
A p n o e a d u r i n g sleep causes h y p o x i a a n d r e t e n t i o n o f c a r -
• Decreased libido
b o n d i o x i d e w h i c h leads t o p u l m o n a r y c o n s t r i c t i o n l e a d i n g
• Increased risk o f r o a d accidents
t o congestive heart failure, bradycardia a n d cardiac h y p o x i a
T a b l e 5 4 . 1 s h o w s a n E p w o r t h sleepiness scale. l e a d i n g t o left heart failure, a n d cardiac a r r h y t h m i a s s o m e -
t i m e s l e a d i n g t o s u d d e n d e a t h . D u r i n g sleep a p n o e a , t h e r e
are frequent arousals w h i c h cause sleep fragmentation,
J Treatment J
d a y t i m e sleepiness a n d o t h e r m a n i f e s t a t i o n s . T a b l e 5 4 . 2 lists
t h e c o n s e q u e n c e s o f o b s t r u c t i v e sleep a p n o e a .
1. A v o i d a n c e o f a l c o h o l , sedatives a n d h y p n o t i c s .
2. Reduction of weight.
3. S l e e p i n g o n t h e side r a t h e r t h a n o n t h e b a c k . Physiology of Sleep
4. R e m o v a l o f o b s t r u c t i n g lesion i n nose, nasopharynx,
oral cavity, h y p o p h a r y n x and larynx. R a d i o frequency A n o r m a l h e a l t h y a d u l t sleeps f o r 7—8 h o u r s . S l e e p o c c u r s
has b e e n u s e d f o r v o l u m e t r i c r e d u c t i o n o f tissues o f i n t w o phases: n o n - R E M ( n o n - r o l l i n g eye m o v e m e n t ) a n d
t u r b i n a t e s , soft palate a n d base o f t o n g u e . REM ( r o l l i n g eye m o v e m e n t ) . T h e t w o phases o c c u r i n
5. P e r f o r m i n g uvulopalatoplasty (UPP) surgically with semiregular cycles, each cycle lasting f o r 9 0 - 1 2 0 m i n u t e s .
c o l d k n i f e o r assisted w i t h r a d i o f r e q u e n c y ( R A U P ) or T h e r e are t h u s t h r e e o r f o u r c y c l e s o f sleep.
laser ( L A U P ) .
Non-REM Sleep

I t t o n u s 7 5 — 8 0 % o f sleep a n d o c c u r s i n f o u r stages:
SLEEP APNOEA
Stage I T r a n s i t i o n f r o m w a k e f u l n e s s t o sleep. I t c o n s t i -
t u t e s 2—5% o f sleep. E E G s h o w s decrease o f a l p h a
A p n o e a m e a n s n o b r e a t h i n g at a l l . T h e r e is n o movement
a n d increase o f t h e t a w a v e s . M u s c l e t o n e is less.
o f a i r at t h e l e v e l o f n o s e a n d m o u t h . I t is o f t h r e e t y p e s .
P e r s o n c a n b e easily a r o u s e d f r o m this stage.
1. Obstructive: T h e r e is collapse o f t h e u p p e r a i r w a y r e s u l t - Stage I I C h a r a c t e r i s e d b y sleep s p i n d l e s o r ' K ' c o m p l e x e s ,
i n g i n cessation o f air f l o w . O t h e r factors m a y be o b s t r u c - and decrease in muscle tone. It constitutes
tive conditions o f nose, nasopharynx, oral cavity and 4 5 - 5 5 % o f sleep.
o r o p h a r y n x , base o f t o n g u e o r l a r y n x . Stage I I I F o r m s 3-8% o f sleep, characterised by delta
2. Central: A i r w a y s are p a t e n t b u t b r a i n fails t o s i g n a l t h e w a v e s . I t is d e e p sleep.
muscles to breath. Stage I V Forms 10—15%) o f sleep, c h a r a c t e r i s e d b y delta
3. Mixed: I t is c o m b i n a t i o n o f b o t h t y p e s . w a v e s . I t is d e e p , m o s t r e s t f u l sleep.

REM Sleep
1 E p w o r t h sleepiness scale

Forms 2 0 — 2 5 % o f t o t a l sleep, c h a r a c t e r i s e d b y r a p i d eye

Situation S c o r e (0 to 3 )
m o v e m e n t s , increased a u t o n o m i c a c t i v i t y w i t h erratic car-
Sitting and reading diac a n d respiratory m o v e m e n t s . D r e a m i n g occurs i n this

Watching TV stage b u t m u s c u l a r a c t i v i t y is d e c r e a s e d so t h a t d r e a m s are

n o t enacted.
S i t t i n g i n a c t i v e in a p u b l i c place
(e.g. t h e a t r e o r in a m e e t i n g ) See T a b l e 5 4 . 3 f o r d i f f e r e n c e s b e t w e e n n o n - R E M and
REM sleep.
Being a passenger in a c a r f o r 1 h o u r
w i t h o u t break

Lying d o w n t o rest in t h e a f t e r n o o n w h e n Table 54.2 C o n s e q u e n c e s o f obstructive sleep a p n o e a

circumstances permit C o n g e s t i v e h e a r t failure/cor p u l m o n a l e

Sitting and talking to someone Polycythemia and hypertension
A t r i a l a n d v e n t r i c u l a r a r r h y t h m i a s a n d left h e a r t f a i l u r e
S i t t i n g q u i e t l y after a l u n c h w i t h o u t a l c o h o l
Attacks o f angina
S i t t i n g in a car w h i l e s t o p p e d in t r a f f i c f o r
Snoring spouse syndrome
a few minutes
Loss o f m e m o r y
0 = never d o z i n g off; 1 = slight c h a n c e o f d o z i n g off; 2 = moderate Decreased l i b i d o
c h a n c e o f d o z i n g off; 3 = high chance o f dozing. Traffic accidents
 Snoring and Sleep Apnoea

T a b l e 54.3 | M f e .• e n c e s between n o n - R E M and R E M sleep

Non-REM REM

Duration 7 5 - 8 0 % o f sleep 2 0 - 2 5 % o f sleep

Eye m o v e m e n t s N o eye rolling Rapid conjugate eye m o v e m e n t s

A u t o n o m i c activity Less a u t o n o m i c a c t i v i t y gives s l o w heart rate, Increased a u t o n o m i c activity with fluctuations in BP,

low BP, slow and steady respiration heart rate and respiration

Brain activity Minimal Brain is a c t i v e ( R E M s l e e p is a l s o c a l l e d activated

brain in a paralysed person)

M u s c u l a r activity Functional but less D e c r e a s e d . Since m u s c l e s are relaxed, snoring and

O S A o c c u r s in this stage.

EEG Passes f r o m alpha to delta waves from stage Mixed frequency, low voltage waves with occasional

1 to IV bursts o f saw-tooth waves

D r e a m i n g N o Yes

f o r c o l l a p s e o f t h e soft tissues at t h e l e v e l o f base o f

| Clinical Evaluation of a C a s e of Sleep A p n o e a |
t o n g u e a n d j u s t a b o v e t h e soft p a l a t e . L e v e l o f p h a -
ryngeal o b s t r u c t i o n can be f o u n d .
History

Patient's b e d p a r t n e r gives m o r e reliable i n f o r m a t i o n t h a n Systemic examination is d o n e t o l o o k f o r h y p e r t e n s i o n ,

t h e p a t i e n t h i m s e l f b e c a u s e l a t t e r does n o t k n o w w h a t congestive heart failure, pedal oedema, truncal obesity and

happened d u r i n g sleep. H i s t o r y s h o u l d i n c l u d e s n o r i n g any sign o f h y p o t h y r o i d i s m .

d u r i n g sleep, restless d i s t u r b e d sleep, g a s p i n g , c h o k i n g o r Cephalometric r a d i o g r a p h s are t a k e n f o r c r a n i o f a c i a l

a p n o e i c e v e n t s , a n d s w e a t i n g . I n t h e d a y t i m e , t h e r e is h i s - a n o m a l i e s a n d t o n g u e base o b s t r u c t i o n .
t o r y o f e x c e s s i v e d a y t i m e sleepiness ( E p w o r t h sleepiness
Polysomnography I t is t h e " g o l d s t a n d a r d " f o r d i a g n o -
scale is m o r e o f t e n u s e d , see T a b l e 5 4 . 1 ) and fatigue, i r r i -
sis o f sleep a p n o e a a n d r e c o r d s v a r i o u s p a r a m e t e r s which
t a b i l i t y , m o r n i n g h e a d a c h e s , m e m o r y loss a n d i m p o t e n c e .
include:
Also one s h o u l d elicit history o f b o d y position during
sleep, use o f a l c o h o l , sedatives a n d c a f f e i n e i n t a k e , m o u t h 3
E E G (electroencephalography)—to look for n o n - R E M
breathing and history o f menopause or h a v i n g h o r m o n a l o r R E M sleep a n d stages o f n o n - R E M sleep.
replacement therapy. 9
E C G ( e l e c t r o c a r d i o g r a p h y ) — f o r h e a r t rate a n d r h y t h m .
15
E O M ( e l e c t r o c u l o g r a m ) — f o r r o l l i n g eye movements.
9
E M G ( e l e c t r o m y o g r a p h y ) — r e c o r d e d from s u b m e n t a l a n d
Physical Examination
tibialis anterior muscle.
R i s k f a c t o r s i n c l u d e m a l e g e n d e r , o b e s i t y a n d age above • P u l s e o x i m e t r y — t o assess o x y g e n s a t u r a t i o n o f b l o o d t o
40 years. k n o w lowest S a 0 2 d u r i n g sleep.
s
Nasal a n d oral a i r f l o w — - f o r episodes o f apnoea and
I, Body m a s s i n d e x I t is c a l c u l a t e d b y d i v i d i n g b o d y
hypopnoea.
weight i n kilograms by height i n metres squared.
B
Sleep p o s i t i o n — h e l p s t o k n o w w h e t h e r a p n o e a / h y p o p n o e a
N o i m a l B M I (18.5-24.9); o v e r w e i g h t 2 5 - 2 9 % ; obesity
episodes o c c u r i n s u p i n e o r lateral r e c u m b e n t p o s i t i o n .
30—34.9. O b e s e p a t i e n t s n e e d t o r e d u c e w e i g h t .
• B l o o d pressure.
3. C o l l a r s i z e N e c k c i r c u m f e r e n c e at t h e l e v e l o f c r i c o -
• Oesophageal pressure. Not done i n all laboratories.
t h y r o i d m e m b r a n e is m e a s u r e d . C o l l a r size s h o u l d n o t
N e g a t i v e o e s o p h a g e a l pressure h e l p s t o k n o w d e g r e e o f
e x c e e d 42 c m i n males a n d 37.5 c m i n females.
b r e a t h i n g efforts m a d e b y the patient.
3. Complete h e a d a n d n e c k e x a m i n a t i o n L o o k for
tonsillar h y p e r t r o p h y , retrognathia, macroglossia, elon- Split-night polysomnography I n this study, the first
g a t e d soft palate a n d u v u l a , base o f t o n g u e t u m o u r s , p a r t o f n i g h t is u s e d i n u s u a l p o l y s o m n o g r a p h y w h i l e t h e
septal d e v i a t i o n , nasal p o l y p s , t u r b i n a t e h y p e r t r o p h y s e c o n d p a r t o f n i g h t is u s e d i n t i t r a t i o n o f pressures f o r
a n d nasal v a l v e c o l l a p s e . A l s o e x a m i n e nasopharynx c o n t i n u o u s p o s i t i v e a i r w a y pressure ( C P A P ) . I t is n o t r e c -
and larynx. o m m e n d e d b e c a u s e e p i s o d e s o f sleep a p n o e a o c c u r more
4. M u l l e r ' s m a n o e u v r e A f l e x i b l e e n d o s c o p e is passed o f t e n i n t h e s e c o n d h a l f o f n i g h t a n d are t h u s missed.
t h r o u g h t h e nose a n d the p a t i e n t asked to inspire v i g - T i t r a t i o n o f pressures f o r C P A P s h o u l d i d e a l l y b e d o n e o n
o r o u s l y w i t h nose and m o u t h c o m p l e t e l y closed. L o o k a second night.

c
Diseases o f Pharynx

Polysomnography can differentiate b e t w e e n primary pressure at t w o f i x e d l e v e l s — a h i g h e r i n s p i r a t o r y a n d a

s n o r i n g , p u r e O S A a n d c e n t r a l sleep a p n o e a . l o w e r e x p i r a t o r y pressure. N o w a n a u t o t i t r a t i n g P A P
( A P A P ) is also a v a i l a b l e w h i c h c o n t i n u o u s l y adjusts t h e
pressure. Their disadvantages are same as t h o s e o f
Treatment (Non-surgical)
CPAP.
1. Change i n lifestyle Those w i t h mild disease a n d
Surgery
m i n i m a l s y m p t o m s c a n b e t r e a t e d w i t h w e i g h t loss a n d
d i e t a r y changes b u t t h o s e w i t h c o r p u l m o n a l e as a result I t is i n d i c a t e d f o r f a i l e d o r n o n - c o m p l i a n t m e d i c a l t h e r a p y .
o f severe O S A m a y r e q u i r e p e r m a n e n t tracheostomy. P e r m a n e n t t r a c h e o s t o m y is t h e " g o l d s t a n d a r d " o f t r e a t -
• Use o f alcohol i n the evening aggravates O S A . m e n t b u t i t is n o t a c c e p t e d s o c i a l l y a n d has c o m p l i c a t i o n s
Sedatives/hypnotics t a k e n at n i g h t also h a v e t h e o f its o w n . I t is u s u a l l y n o t a p r e f e r r e d o p t i o n b y p a t i e n t s .
same effect. Surgical procedures used i n O S A i n c l u d e :
• S m o k i n g should be avoided.
Tonsillectomy and/or adenoidectomy
• R e d u c t i o n o f w e i g h t is h e l p f u l .
N a s a l s u r g e r y Nasal obstruction m a y be t h e p r i m a r y o r
2. Positional t h e r a p y P a t i e n t s h o u l d sleep o n t h e side
the aggravating factor f o r O S A . Septoplasty to correct
as s u p i n e p o s i t i o n m a y cause o b s t r u c t i v e a p n o e a . A
d e v i a t e d nasal s e p t u m , r e m o v a l o f nasal p o l y p s a n d r e d u c -
rubber ball can be f i x e d t o t h e back o f shirt t o prevent
tion o f t u r b i n a t e size h e l p t o r e l i e v e nasal obstruction.
a d o p t i n g supine position.
S o m e t i m e s nasal s u r g e r y is also i n d i c a t e d f o r e f f i c i e n t use o f
3. Intraoral d e v i c e s T h e y alter t h e p o s i t i o n o f m a n d i -
CPAP.
ble o r t o n g u e t o o p e n t h e a i r w a y a n d relieve s n o r i n g
and sleep apnoea. Mandible advancement device Oropharyngeal s u r g e r y U v u l o p a l a t o p l a s t y ( U P P ) is t h e

(MAD) keeps t h e m a n d i b l e f o r w a r d w h i l e tongue most c o m m o n procedure p e r f o r m e d for snoring and O S A .

retaining device ( T R D ) keeps tongue i n anterior I t is 80%> effective i n s n o r i n g b u t O S A is r e l i e v e d o n l y i n

p o s i t i o n d u r i n g sleep. T h e y h e l p i m p r o v e o r a b o l i s h 50%). S o m e patients o f O S A are k n o w n t o relapse i n l o n g -

s n o r i n g . M A D is also u s e f u l i n r e t r o g n a t h i c p a t i e n t s . t e r m studies b e c a u s e o f a n o t h e r site b e c o m i n g a c t i v e i n t h e

4. CPAP ( c o n t i n u o u s positive airway pressure) It cause o f o b s t r u c t i o n ( e . g . base o f t o n g u e ) . U P P c a n b e

p r o v i d e s p n e u m a t i c s p l i n t t o a i r w a y a n d increases its laser o r r a d i o f r e q u e n c y assisted.

c a l i b r e . O p t i m u m a i r w a y pressure f o r d e v i c e t o o p e n Advancement genioplasty with hyoid suspension It

t h e a i r w a y is d e t e r m i n e d d u r i n g sleep s t u d y a n d is
u s u a l l y k e p t at 5 - 2 0 c m o f H , 0 . A b o u t 4 0 % o f patients
f i n d t h e use o f C P A P d e v i c e c u m b e r s o m e and diffi-
cult t o carry w i t h t h e m w h e n t r a v e l i n g a n d thus stop
using i t .
W h e n C P A P is n o t t o l e r a t e d , a B i P A P ( b i l e v e l p o s -
i t i v e a i r w a y pressure) d e v i c e is used. I t d e l i v e r s p o s i t i v e
is d o n e i n p a t i e n t s w h e r e base o f t o n g u e also c o n t r i b u t e s t o
O S A . P a t i e n t s w i t h r e t r o g n a t h i a a n d m i c r o g n a t h i a are also
the candidates.
Procedure involves resection o f a rectangular p o r t i o n o f
the m a n d i b l e i n c l u d i n g genial tubercles a n d t h e attached
genioglossi muscles, its r o t a t i o n b y 9 0 ° , a n d f i x a t i o n b y
plates. I t helps t o p u l l t h e base o f t o n g u e a n t e r i o r l y . A l o n g

Table 54.4 Summary o f management o f OSA

N on-surgical Surgical

W e i g h t reduction Tonsil a n d adenoid surgery (children)

Avoidance o f alcohol, sedatives a n d s m o k i n g Nasal surgery: septoplasty, turbinate reduction, polypectomy

Positional therapy Palate surgery

Intraoral devices - Uvulopalatoplasty ( U P P )

- M a n d i b u l a r advancement device - Uvulopaiatopharyngoplasty (UPPP)

- T o n g u e retention device A d v a n c e m e n t pharyngoplasty

CPAP or BiPAP o r A P A P T o n g u e base surgery: Lingual tonsillectomy, laser m i d l i n e glossectomy

T o n g u e base radiofrequency reduction

M a n d i b u l a r o s t e o t o m y w i t h genioglossus a d v a n c e m e n t

Hyoid m y o t o m y a n d suspension

- Hyoid bone suspended t o lower border o f mandible

- Hyoid b o n e suspended t o upper border o f thyroid cartilage

Maxillomandibular o s t e o t o m y a n d advancement

Tracheostomy—the gold standard

 Snoring and Sleep A p n o e a

w i t h this p r o c e d u r e , t h e h y o i d b o n e is f r e e d f r o m its i n f e - Maxillomandibular advancement osteotomy Osteo-

r i o r m u s c u l a t u r e a n d suspended from lower border of t o m i e s are p e r f o r m e d o n m a n d i b u l a r r a m u s a n d m a x i l l a .
m a n d i b l e b y w i r e s . T h i s also h e l p s t o p u l l t h e base of O s t e o t o m y o f t h e m a x i l l a is l i k e a L e F o r t I p r o c e d u r e .
tongue anteriorly. T h e s e o s t e o t o m i e s are t h e n f i x e d i n a n t e r i o r p o s i t i o n w i t h
plates a n d s c r e w s . T h i s s u r g i c a l p r o c e d u r e is e f f e c t i v e i n
Tongue base radiofrequency Radiofrequency (RF) is
s e l e c t e d cases b u t has t h e d i s a d v a n t a g e o f c a u s i n g aesthetic
u s e d i n f i v e t o six s i t t i n g s t o r e d u c e t h e size o f t o n g u e . RF
facial changes.
n e e d l e is i n s e r t e d s u b m u c o s a l l y . I t c o a g u l a t e s tissue a n d
See T a b l e 5 4 . 4 f o r s u m m a r y o f m a n a g e m e n t o f O S A .
causes s c a r r i n g t h u s r e d u c i n g t h e size o f tissue.
D i s e a s e s o f Larynx a n d
Trachea
55. Anatomy and Physiology o f Larynx
56. Laryngotracheal Trauma
57. Acute and Chronic Inflammations o f Larynx
58. Congenital Lesions o f Larynx and Stridor
59. Laryngeal Paralysis
60. Benign Tumours o f Larynx
61. Cancer Larynx
62. Voice and Speech Disorders
63. Tracheostomy and Other Procedures for Airway Management
64. Foreign Bodies o f Air Passages
A n a t o m y a n d Physiology o f Larynx

m i d d l e o f t h y r o i d angle. M o s t o f laryngeal f o r e i g n
ANATOMY OF LARYNX b o d i e s are a r r e s t e d a b o v e t h e v o c a l c o r d s , i . e . a b o v e
t h e m i d d l e o f t h y r o i d cartilage a n d an effective a i r w a y

T h e l a r y n x lies i n f r o n t o f t h e h y p o p h a r y n x o p p o s i t e t h e c a n be p r o v i d e d b y p i e r c i n g t h e c r i c o t h y r o i d m e m -

t h i r d to sixth cervical vertebrae. I t moves vertically and i n b r a n e — a procedure called crkothyrotomy.

anteroposterior direction during s w a l l o w i n g and p h o n a - 2. Cricoid I t is t h e o n l y c a r t i l a g e f o r m i n g a c o m p l e t e

t i o n . I t c a n also b e passively m o v e d f r o m side t o side p r o - r i n g . Its p o s t e r i o r p a r t is e x p a n d e d t o f o r m a lamina

d u c i n g a characteristic g r a t i n g sensation called laryngeal w h i l e a n t e r i o r l y i t is n a r r o w f o r m i n g a n arch.

crepitus. I n a n a d u l t , t h e l a r y n x ends at t h e l o w e r b o r d e r o f Epiglottis I t is a l e a f - l i k e , y e l l o w , elastic cartilage

C, vertebra. f o r m i n g a n t e r i o r w a l l o f l a r y n g e a l i n l e t . I t is a t t a c h e d
6
to the b o d y o f h y o i d b o n e b y hyoepiglottic ligament
w h i c h divides it i n t o suprahyoid and i n f r a h y o i d e p i -
Laryngeal Cartilages glottis. A stalk-like process of epiglottis (petiole)
attaches t h e e p i g l o t t i s t o t h e t h y r o i d a n g l e . A n t e r i o r
L a r y n x has 3 u n p a i r e d a n d 3 p a i r e d cartilages. surface of e p i g l o t t i s is separated from thyrohyoid
Unpaired: T h y r o i d , cricoid, epiglottis. membrane a n d u p p e r p a r t o f t h y r o i d cartilage b y a
Paired: A r y t e n o i d , corniculate, c u n e i f o r m . potential space filled with fat—the pre-epiglottic
space. T h e space m a y b e i n v a d e d in carcinoma of
1. Thyroid I t is t h e largest o f all ( F i g . 5 5 . 1 ) . Its t w o alae
s u p r a g l o t t i c l a r y n x o r t h e base o f t o n g u e .
m e e t anteriorly f o r m i n g an angle o f 90° in males
4. Arytenoid cartilages They are paired. Each
a n d 1 2 0 ° i n f e m a l e s . V o c a l c o r d s are a t t a c h e d t o t h e
a r y t e n o i d c a r t i l a g e is p y r a m i d a l i n shape. I t has a base
Opening for w h i c h a r t i c u l a t e s w i t h c r i c o i d c a r t i l a g e ; a muscular pro-
superior loryngeol Epiglottis
cess, d i r e c t e d l a t e r a l l y t o g i v e a t t a c h m e n t t o i n t r i n s i c
laryngeal muscles; a vocal process directed anteriorly,
g i v i n g a t t a c h m e n t t o v o c a l c o r d ; a n d an apex which
supports t h e c o r n i c u l a t e cartilage.
Corniculate cartilages (of Santorini) They are
paired. E a c h articulates w i t h t h e apex o f a r y t e n o i d
cartilage.
Cuneiform cartilages (of Wrisberg) They are
r o d s h a p e d . E a c h is s i t u a t e d i n a r y e p i g l o t t i c f o l d i n
front o f corniculate cartilage and provides passive
supports to the fold.

T h y r o i d , c r i c o i d a n d m o s t o f t h e a r y t e n o i d cartilages are
h y a l i n e cartilages w h e r e a s e p i g l o t t i s , c o r n i c u l a t e , c u n e i f o r m
a n d t i p o f a r y t e n o i d near t h e c o r n i c u l a t e cartilage are f i b r o e l a s -
Figure 55.1 tic i n n a t u r e . H y a l i n e cartilages can u n d e r g o ossification; i t
begins at t h e age o f 25 years i n t h y r o i d , a l i t t l e later i n c r i c o i d
Laryngeal framework.
a n d a r y t e n o i d s , a n d is c o m p l e t e b y 65 years o f age.
Diseases of Larynx and Trachea

Laryngeal Joints
Hyoid bone

Cricoarytenoid joint I t is a s y n o v i a l j o i n t s u r r o u n d e d
by c a p s u l a r l i g a m e n t . I t is f o r m e d b e t w e e n t h e base o f
a r y t e n o i d a n d a facet, o n t h e u p p e r b o r d e r o f c r i c o i d l a m - Quadrangular
i n a . T w o t y p e s o f m o v e m e n t s o c c u r i n t h i s j o i n t : (a) rotatory, membrane
Thyroid
i n w h i c h a r y t e n o i d c a r t i l a g e m o v e s a r o u n d a v e r t i c a l axis, cartilage

thus a b d u c t i n g or a d d u c t i n g the v o c a l c o r d ; (b) gliding

Ventricle
movement, i n w h i c h o n e a r y t e n o i d glides t o w a r d s the o t h e r Poraglottic
cartilage o r a w a y f r o m i t , thus closing o r o p e n i n g the pos- space Cricovocal
membrane
terior part o f glottis. Cricoid
cartilage
Cricothyroid joint I t is also a s y n o v i a l j o i n t . E a c h is
f o r m e d b y the i n f e r i o r c o r n u a o f t h y r o i d cartilage w i t h a
facet o n t h e c r i c o i d c a r t i l a g e .

Figure 55.3

Laryngeal Membranes Coronal section o f larynx. L o w e r free edge o f the q u a d r a n g u -

lar m e m b r a n e lies in the false cord while upper free edge o f

1. Extrinsic Membranes (Fig. 55.1) the cricovocal m e m b r a n e forms the vocal ligament. Note for-

mation o f conus elasticus by the cricovocal m e m b r a n e s o f

(a) Thyrohyoid membrane Connects thyroid carti- t w o sides.

lage t o h y o i d b o n e . I t is p i e r c e d b y s u p e r i o r l a r y n g e a l
vessels a n d i n t e r n a l l a r y n g e a l n e r v e .
(b) Cricothyroid membrane Connects thyroid carti- Its l o w e r b o r d e r attaches t o t h e a r c h o f c r i c o i d c a r t i -
lage t o c r i c o i d c a r t i l a g e . l a g e . F r o m its l o w e r a t t a c h m e n t t h e m e m b r a n e pro-
(c) Cricotracheal membrane Connects cricoid carti- ceeds u p w a r d s a n d m e d i a l l y a n d t h u s , w i t h its f e l l o w
lage t o t h e f i r s t t r a c h e a l ring. o n t h e o p p o s i t e s i d e , f o r m s c o n u s elasticus ( F i g . 5 5 . 3 )
where subglottic foreign bodies sometimes get
2. Intrinsic Membranes
impacted.

(a) Cricovocal membrane I t is a t r i a n g u l a r f i b r o e l a s t i c (b) Quadrangular membrane I t lies d e e p t o mucosa

membrane. Its u p p e r b o r d e r is free and stretches of a r y e p i g l o t t i c folds and is n o t well defined. It

b e t w e e n m i d d l e o f t h y r o i d a n g l e t o t h e v o c a l process stretches b e t w e e n t h e e p i g l o t t i c a n d a r y t e n o i d c a r t i -

o f arytenoid and forms the vocal ligament (Fig. 55.2). lages. Its l o w e r b o r d e r f o r m s t h e v e s t i b u l a r l i g a m e n t
w h i c h lies i n t h e false c o r d .
Hyoepiglotiic
goment
Muscles of Larynx
Hyoid bone

Fat in pre-epiglottic
space T h e y are o f t w o t y p e s , i n t r i n s i c , w h i c h a t t a c h l a r y n g e a l
cartilages t o e a c h o t h e r , a n d e x t r i n s i c , w h i c h a t t a c h l a r y n x
Thyrohyoid membrane
Corniculate to the s u r r o u n d i n g structures.
Thyroid cartilage
cartilage
Quadrangular 1. Intrinsic muscles T h e y m a y act o n v o c a l c o r d s o r
Arytenoid membra no
cartilage laryngeal inlet.
Cricovocal
membrane (a) A c t i n g o n v o c a l c o r d s (Figs 5 5 . 4 a n d 55.5)
Abductors: Posterior cricoarytenoid
Adductors: Lateral c r i c o a r y t e n o i d
I n t e r a r y t e n o i d (transverse a r y t e n o i d )
T h y r o a r y t e n o i d (external part)
Tensors: Cricothyroid

Figure 55.2 Vocalis (internal part o f thyroarytenoid)

(b) A c t i n g o n l a r y n g e a l inlet (Fig. 55.5)
Sagittal section o f larynx s h o w i n g cricovocal a n d quadrangular
Openers of laryngeal inlet: T h y r o e p i g l o t t i c (part
m e m b r a n e s and boundaries o f the pre-epiglottic space.
of thyroarytenoid)
 Anatomy and Physiology of Larynx

Thyroarytenoid m. o f c r i c o i d c a r t i l a g e w h e r e i t is c o n t i n u o u s w i t h t h e l u m e n
Lamina of thyroid cart
(external part)
o f t r a c h e a . T w o pairs o f f o l d s — v e s t i b u l a r a n d v o c a l , d i v i d e
Vocol ligament Vocalis (internal part)
t h e c a v i t y i n t o t h r e e parts, n a m e l y t h e v e s t i b u l e , t h e v e n -

Arch of cricoid cort t r i c l e a n d t h e s u b g l o t t i c space.

Lateral
cricoarytenoid m. Inlet o f larynx I t is a n o b l i q u e o p e n i n g b o u n d e d a n t e r i -
Arytenoid cartilage
o r l y b y free m a r g i n o f e p i g l o t t i s ; o n t h e sides, b y a r y e p i g l o t t i c
Vocol process
Transverse folds a n d p o s t e r i o r l y b y i n t e r a r y t e n o i d f o l d ( F i g . 5 5 . 6 ) .
Muscular process arytenoid m.
Vestibule I t extends from laryngeal inlet to vestibular
Posterior
f o l d s . Its a n t e r i o r w a l l is f o r m e d b y p o s t e r i o r s u r f a c e o f
cricoarytenoid m.
e p i g l o t t i s ; sides b y t h e a r y e p i g l o t t i c f o l d s a n d p o s t e r i o r
Figure 55.4 wall by mucous membrane o v e r t h e a n t e r i o r surface o f
arytenoids.
Laryngeal muscles a n d their action.

Ventricle (sinus of larynx) is a d e e p e l l i p t i c a l space

b e t w e e n v e s t i b u l a r a n d v o c a l f o l d s , also e x t e n d i n g a s h o r t
d i s t a n c e a b o v e a n d l a t e r a l t o v e s t i b u l a r f o l d . T h e s a c c u l e is
a d i v e r t i c u l u m o f m u c o u s m e m b r a n e w h i c h starts f r o m t h e
anterior part o f ventricular cavity a n d extends upwards
b e t w e e n vestibular folds a n d l a m i n a o f t h y r o i d cartilage.
Aryepi glottic
W h e n abnormally enlarged a n d distended, i t m a y f o r m a
Thyroepiglottic
Transverse and laryngocele—an a i r c o n t a i n i n g sac w h i c h m a y p r e s e n t i n t h e
oblique arytenoid n e c k . T h e r e are m a n y m u c o u s glands i n t h e s a c c u l e .
Thyroarytenoid
Subglottic space (infraglottic larynx) I t extends from

Posterior v o c a l cords t o l o w e r b o r d e r o f c r i c o i d cartilage.

Cricovocal
cricoarytenoid
membrane Vestibular folds (false v o c a l cords) T w o i n number;
e a c h is a f o l d o f m u c o u s m e m b r a n e e x t e n d i n g a n t e r o p o s -
Lateral
cricoarytenoid t e r i o r l y across t h e l a r y n g e a l c a v i t y . I t c o n t a i n s vestibular
l i g a m e n t , a f e w fibres o f t h y r o a r y t e n o i d e u s muscle a n d
Figure 55.5 m u c o u s glands.

Intrinsic m u s c l e s o f l a r y n x as seen o n lateral view. V o c a l folds (true vocal c o r d s ) T h e y are t w o p e a r l y -

w h i t e sharp bands e x t e n d i n g f r o m t h e m i d d l e o f t h y r o i d

Closers of laryngeal inlet: Interarytenoid (oblique part)

Aryepiglottic (posterior oblique
part o f interarytenoids)

2. Extrinsic muscles T h e y connect the larynx to the

Laryngeal
n e i g h b o u r i n g s t r u c t u r e s a n d are d i v i d e d i n t o e l e v a t o r s inlet
Thyrohyoid
o r depressors o f l a r y n x . membrane
(a) E l e v a t o r s Primary elevators act d i r e c t l y as t h e y are Oblique
attached to the thyroid cartilage and include arytenoid m.
stylopharyngeus, salpingopharyngeus, palatopha-
Transverse
ryngeus a n d t h y r o h y o i d . arytenoid m.
Secondary elevators act i n d i r e c t l y as t h e y are
attached to the h y o i d bone and include m y l o h y o i d
(main), digastric, s t y l o h y o i d , g e n i o h y o i d . Posterior
cricoarytenoid m.
(b) D e p r e s s o r s They include sternohyoid, sterno-
thyroid andomohyoid.

Cavity o f the Larynx Figure 55.6

Laryngeal inlet and intrinsic muscles o f larynx as seen from

L a r y n g e a l c a v i t y starts at t h e l a r y n g e a l i n l e t w h e r e i t c o m -
behind.
m u n i c a t e s w i t h t h e p h a r y n x a n d ends at t h e l o w e r b o r d e r
Diseases of Larynx and Trachea

T h e r e are p r a c t i c a l l y n o l y m p h a t i c s i n v o c a l c o r d s , h e n c e
c a r c i n o m a o f t h i s site r a r e l y s h o w s l y m p h a t i c metastases.

Glottis
Nerve Supply (see p a g e 3 1 7 )

Spaces of the Larynx

1. P r e - e p i g l o t t i c s p a c e o f B o y e r (Figs 5 5 . 2 a n d 5 5 . 8 ) .
Figure 5 5 . 7 I t is b o u n d e d b y u p p e r p a r t o f t h y r o i d c a r t i l a g e a n d t h y -

R i m a glotcidis. N o t e a n t e r i o r 2/3 o f vocal c o r d is m e m b r a n o u s r o h y o i d membrane i nfront, hyoepiglottic ligament above

a n d p o s t e r i o r 1/3 c a r t i l a g i n o u s . and i n f r a h y o i d epiglottis a n d quadrangular membrane
b e h i n d . L a t e r a l l y , i t is c o n t i n u o u s w i t h p a r a g l o t t i c space. I t
is f i l l e d w i t h fat, a r e o l a r tissue a n d s o m e l y m p h a t i c s .

2. P a r a g l o t t i c s p a c e I t is b o u n d e d b y t h e t h y r o i d c a r t i -
a n g l e t o t h e v o c a l processes o f a r y t e n o i d s . E a c h v o c a l c o r d
lage l a t e r a l l y , c o n u s elasticus i n f e r o m e d i a l l y , t h e v e n t r i c l e
consists o f a v o c a l l i g a m e n t w h i c h is t h e t r u e u p p e r e d g e
and quadrangular membrane medially, and mucosa o f p y r i -
o f c r i c o v o c a l m e m b r a n e c o v e r e d b y closely b o u n d m u c o u s
f o r m fossa p o s t e r i o r l y (Figs 5 5 . 3 a n d 5 5 . 8 ) . I t is c o n t i n u o u s
m e m b r a n e w i t h scanty subepithelial c o n n e c t i v e tissue.
w i t h p r e - e p i g l o t t i c space. G r o w t h s w h i c h i n v a d e t h i s space
Glottis (rima glottidis) I t is t h e e l o n g a t e d space b e t -
c a n p r e s e n t i n t h e n e c k t h r o u g h c r i c o t h y r o i d space.
w e e n v o c a l c o r d s a n t e r i o r l y , a n d v o c a l processes a n d base
3. Reinke's space U n d e r t h e e p i t h e l i u m o f v o c a l c o r d s is
o f arytenoids posteriorly (Fig. 55.7).
a p o t e n t i a l space w i t h s c a n t y s u b e p i t h e l i a l c o n n e c t i v e tis-
A n t e r o p o s t e r i o r l y , g l o t t i s is a b o u t 2 4 m m i n m e n a n d
sues. I t is b o u n d e d a b o v e a n d b e l o w b y t h e a r c u a t e l i n e s ; i n
16 m m i n w o m e n . I t is t h e n a r r o w e s t p a r t o f l a r y n g e a l c a v -
f r o n t , b y a n t e r i o r c o m m i s s u r e , a n d b e h i n d b y v o c a l process
i t y . A n t e r i o r t w o - t h i r d s o f g l o t t i s are f o r m e d b y m e m b r a -
o f a r y t e n o i d . O e d e m a o f this space causes f u s i f o r m s w e l l -
n o u s c o r d s w h i l e p o s t e r i o r o n e - t h i r d b y v o c a l processes o f
i n g o f the m e m b r a n o u s cords ( R e i n k e ' s oedema).
a r y t e n o i d s . S i z e a n d shape o f g l o t t i s varies w i t h t h e m o v e -
ments o f vocal cords.

EMBRYOLOGICAL DEVELOPMENT

J| M u c o u s M e m b r a n e o f the Larynx
Laryngeal mucosa develops from the endoderm o f the
I t lines t h e l a r y n x a n d is l o o s e l y a t t a c h e d e x c e p t o v e r t h e c e p h a l i c p a r t o f f o r e g u t . L a r y n g e a l cartilages a n d m u s c l e s
p o s t e r i o r surface o f e p i g l o t t i s , t r u e vocal cords a n d c o r - develop f r o m the mesenchyme. Development o f other
n i c u l a t e a n d c u n e i f o r m cartilages. s t r u c t u r e s is as f o l l o w :
Epithelium o f t h e m u c o u s m e m b r a n e is c i l i a t e d c o l u m -
Epiglottis H y p o b r a n c h i a l eminence
nar type except o v e r the vocal cords and upper part o f the
v e s t i b u l e w h e r e i t is s t r a t i f i e d s q u a m o u s t y p e . U p p e r p a r t o f t h y r o i d cartilage 4 t h arch

Mucous glands are d i s t r i b u t e d a l l o v e r t h e m u c o u s l i n i n g Lower p a r t o f thyroid cartilage

a n d are p a r t i c u l a r l y n u m e r o u s o n t h e p o s t e r i o r surface o f Cricoid cartilage
epiglottis, posterior part o f the aryepiglottic folds a n d i n Corniculate cartilage 6th arch
t h e saccules. T h e r e are n o m u c o u s glands i n t h e v o c a l f o l d s . C u n e i f o r m cartilage
Intrinsic muscles o f larynx

| Lymphatic Drainage
Thyroid cart.
Pre-epiglottic space

S u p r a g l o t t i s l a r y n x above the vocal cords is d r a i n e d b y l y m - Epiglottis Paraglottic space

phatics w h i c h pierce t h e t h y r o h y o i d m e m b r a n e a n d g o t o Quadrangular
u p p e r deep cervical nodes.
Pyriform fosso
I n f f a g l o t t i c l a r y n x below the vocal cords is d r a i n e d b y l y m -
phatics w h i c h pierce cricothyroid membrane and go to
prelaryngeal a n d pretracheal nodes a n d thence t o l o w e r Figure 55.8
d e e p c e r v i c a l a n d m e d i a s t i n a l n o d e s . S o m e vessels p i e r c e
P a r a g l o t t i c a n d p r e - e p i g l o t t i c spaces c o m m u n i c a t e w i t h each
t h r o u g h cricotracheal membrane and drain directly i n t o
other.
l o w e r deep cervical nodes.
 Anatomy and Physiology of Larynx

Upper part o f body o f hyoid bone

Lesser c o r n u a o f hyoid bone 2nd arch PHYSIOLOGY OF LARYNX

Stylohyoid ligament

Lower part o f body o f hyoid bone 3 r d arch T h e larynx performs the f o l l o w i n g i m p o r t a n t functions:
a n d greater c o r n u a
1. P r o t e c t i o n o f l o w e r airways
S u p e r i o r l a r y n g e a l n e r v e , a b r a n c h o f v a g u s , is 4 t h a r c h 2. Phonation
n e r v e a n d supplies c r i c o t h y r o i d a n d c o n s t r i c t o r s o f p h a r y n x . 3. Respiration
R e c u r r e n t l a r y n g e a l n e r v e is 6 t h a r c h n e r v e a n d s u p p l i e s 4. F i x a t i o n o f t h e chest.
all the i n t r i n s i c muscles o f l a r y n x .

1. Protection of Lower Airways

PAED1ATRIC LARYNX

P h y l o g e n e t i c a l l y , t h i s is t h e earliest f u n c t i o n t o d e v e l o p ;

T h e l a r y n x o f an i n f a n t differs considerably f r o m that o f an v o i c e p r o d u c t i o n is s e c o n d a i y . The larynx protects the

a d u l t a n d has a g r e a t c l i n i c a l s i g n i f i c a n c e . l o w e r passages i n t h r e e d i f f e r e n t w a y s :

1. I n f a n t ' s l a r y n x is p o s i t i o n e d h i g h i n t h e n e c k o p p o s i t e (a) Sphincteric closure o f laryngeal o p e n i n g .

C 3 o r C 4 ( l e v e l o f v o c a l c o r d s ) at rest a n d reaches C I (b) Cessation o f respiration.

or C 2 d u r i n g s w a l l o w i n g . T h i s h i g h position allows (c) C o u g h reflex.

t h e e p i g l o t t i s t o m e e t soft p a l a t e a n d m a k e a n a s o p h a -
W h e n f o o d is s w a l l o w e d , its e n t r y i n t o a i r passage is
r y n g e a l c h a n n e l f o r nasal b r e a t h i n g d u r i n g s u c k l i n g .
p r e v e n t e d b y c l o s u r e o f t h r e e successive s p h i n c t e r s consist-
T h e m i l k f e e d passes s e p a r a t e l y over the dorsum o f
i n g o f (i) l a r y n g e a l i n l e t ( a r y e p i g l o t t i c f o l d s , t u b e r c l e of
t o n g u e a n d t h e side o f e p i g l o t t i s , t h u s a l l o w i n g b r e a t h -
epiglottis and arytenoids, approximately closing the l a r y n -
i n g and feeding t o go o n simultaneously.
g e a l i n l e t c o m p l e t e l y ) , ( i i ) false c o r d s , ( h i ) t r u e c o r d s , w h i c h
2. L a r y n g e a l cartilages are soft a n d collapse easily. E p i g l o t -
close t h e g l o t t i s . T h u s , n o f o r e i g n m a t t e r m e a n t t o b e s w a l -
tis is o m e g a - s h a p e d and arytenoids relatively large
l o w e d o r accidentally v o m i t e d can enter the l a r y n x .
c o v e r i n g significant p o r t i o n o f the posterior glottis.
R e s p i r a t i o n t e m p o r a r i l y ceases t h r o u g h a r e f l e x g e n e r -
3. T h y r o i d c a r t i l a g e i n a n i n f a n t is flat. I t also o v e r l a p s
ated b y afferent fibres o f n i n t h nerve, w h e n f o o d comes
t h e c r i c o i d c a r t i l a g e a n d is i n t u r n o v e r l a p p e d b y t h e
i n c o n t a c t w i t h p o s t e r i o r p h a r y n g e a l w a l l o r t h e base o f
h y o i d b o n e . T h u s c r i c o t h y r o i d a n d t h y r o h y o i d spaces
tongue.
are n a r r o w a n d n o t easily discernible as l a n d m a r k s
C o u g h is an i m p o r t a n t a n d p o w e r f u l m e c h a n i s m t o d i s -
w h e n p e r f o r m i n g tracheostomy.
lodge and expel a foreign particle w h e n it comes i n t o c o n -
4. I n f a n t ' s l a r y n x is s m a l l a n d conical. The diameter of
tact w i t h respiratory mucosa. L a r y n x is a p t l y c a l l e d the
c r i c o i d cartilage is s m a l l e r t h a n t h e size o f g l o t t i s ,
watch-dog of lungs as i t i m m e d i a t e l y ' b a r k s ' at t h e e n t r y o f
m a k i n g s u b g l o t t i s t h e n a r r o w e s t p a r t . I t has a b e a r i n g
any f o r e i g n i n t r u d e r .
i n the selection o f paediatric endotracheal tube.
I n a d u l t s , s u b g l o t t i c - g l o t t i c d i m e n s i o n s are a p p r o x -
i m a t e l y same a n d l a r y n x is cylindrical. £ 2. Phonation |
5. Submucosal tissues o f i n f a n t ' s l a r y n x are compara-
t i v e l y l o o s e a n d easily u n d e r g o oedematous change L a r y n x is l i k e a w i n d i n s t r u m e n t . V o i c e is p r o d u c e d b y t h e
w i t h trauma or i n f l a m m a t i o n leading to obstruction. f o l l o w i n g m e c h a n i s m (Aerodynamic myoelastic theory of voice
I n f a n t ' s l a r y n x shows t w o spurts i n g r o w t h . I n the first production):
t h r e e years o f l i f e l a r y n x g r o w s i n w i d t h a n d l e n g t h , a n d
(a) V o c a l c o r d s are k e p t a d d u c t e d .
thus obviates the n e e d f o r any a i r w a y surgery i n certain
(b) I n f r a g l o t t i c a i r pressure is g e n e r a t e d b y t h e e x h a l e d a i r
congenital anomalies. T h e second spurt i n g r o w t h occurs
f r o m the lungs due to contraction o f thoracic and
d u r i n g adolescence w h e n the t h y r o i d angle develops. The
a b d o m i n a l muscles.
length o f vocal cords then increases l e a d i n g to voice
(c) T h e a i r f o r c e o p e n t h e c o r d s a n d is r e l e a s e d as s m a l l
c h a n g e s associated w i t h p u b e r t y (see p u b e r p h o n i a ) . W i t h
puffs w h i c h vibrate the vocal cords and p r o d u c e s o u n d
g r o w t h o f t h e n e c k , l a r y n x g r a d u a l l y descends t o a d u l t ; t h e
which is a m p l i f i e d b y m o u t h , p h a r y n x , nose and
v o c a l c o r d s l y i n g o p p o s i t e C_.
chest.
I n c h i l d h o o d , v o c a l c o r d is 6 m m i n f e m a l e s a n d 8 m m
i n males. I t increases t o 15—19 m m i n a d u l t f e m a l e and T h i s s o u n d is c o n v e r t e d i n t o s p e e c h b y t h e m o d u l a t o r y
17—23 i n a d u l t m a l e . a c t i o n o f lips, t o n g u e , palate, p h a r y n x , a n d t e e t h .
Diseases of Larynx and Trachea
I n t e n s i t y o f s o u n d depends o n t h e air pressure p r o d u c e d
by the lungs w h i l e pitch depends o n the frequency w i t h
w h i c h the vocal cords vibrate.
3. Respiration
L a r y n x regulates f l o w o f air i n t o t h e lungs. V o c a l cords
abduct d u r i n g inspiration and adduct d u r i n g expiration.
4. Fixation o f the C h e s t
W h e n l a r y n x is c l o s e d , chest w a l l gets f i x e d a n d v a r i o u s
t h o r a c i c a n d a b d o m i n a l muscles can t h e n act best. T h i s
function is i m p o r t a n t i n d i g g i n g , p u l l i n g a n d c l i m b i n g .
C o u g h i n g , v o m i t i n g , defaecation, m i c t u r i t i o n and c h i l d -
b i r t h also r e q u i r e a f i x e d t h o r a c i c cage against a c l o s e d
glottis.
Laryngotracheal T r a u m a

false c o r d s . F r a c t u r e s o f l o w e r p a r t o f t h y r o i d c a r t i l a g e
Aetiology
m a y displace o r d i s r u p t t h e t r u e v o c a l cords.
7. Fractures o f c r i c o i d cartilage.
1. M o s t c o m m o n cause is a u t o m o b i l e a c c i d e n t s w h e n
8. Fractures o f u p p e r tracheal rings.
n e c k s t r i k e s against t h e s t e e r i n g w h e e l o r t h e i n s t r u -
9. T r a c h e a m a y separate f r o m t h e c r i c o i d c a r t i l a g e a n d
m e n t panel.
retract i n t o u p p e r m e d i a s t i n u m . I n j u r y t o recurrent
2. B l o w or k i c k o n the neck.
l a r y n g e a l n e r v e is o f t e n associated w i t h l a r y n g o t r a -
3. N e c k s t r i k i n g against a s t r e t c h e d w i r e o r c a b l e .
cheal separation.
4. Strangulation.
5. Penetrating injuries w i t h sharp i n s t r u m e n t s o r gun
shot w o u n d s .
^ Clinical Features J

Symptoms o f laryngotracheal i n j u r y w o u l d vary, greatly

Pathology d e p e n d i n g o n the structures damaged a n d the severity of
damage. T h e y i n c l u d e :
T h e degree and severity o f damage w i l l vary f r o m slight
1. Respiratory distress.
bruises e x t e r n a l l y o r t h e tear a n d l a c e r a t i o n of mucosa
2. Hoarseness o f v o i c e or a p h o n i a .
internally to a c o m m i n u t e d fracture o f the laryngeal frame-
3. P a i n f u l a n d d i f f i c u l t s w a l l o w i n g . T h i s is a c c o m p a n i e d
w o r k . T h e w o u n d m a y be c o m p o u n d e d externally, due to
by aspiration o f f o o d .
b r e a k i n t h e s k i n , o r i n t e r n a l l y b y m u c o s a l tears. L a r y n g e a l
4. Local p a i n i n the larynx. M o r e m a r k e d o n speaking or
f r a c t u r e s are c o m m o n after 4 0 years o f age b e c a u s e o f c a l -
swallowing.
cification o f the laryngeal f r a m e w o r k . I n children, carti-
5. H a e m o p t y s i s , u s u a l l y t h e r e s u l t o f tears i n l a r y n g e a l o r
lages are m o r e r e s i l i e n t a n d escape i n j u r y .
tracheal mucosa.
Pathological changes that may be seen in laryngeal
t r a u m a are: External signs i n c l u d e :

1. H a e m a t o m a and oedema o f supraglottic or subglottic 1. Bruises o r abrasions o v e r t h e s k i n .

region. 2. P a l p a t i o n o f t h e l a r y n g e a l area is p a i n f u l .
2. Tears i n laryngeal o r pharyngeal mucosa leading to 3. Subcutaneous emphysema due to mucosal tears. I t
subcutaneous emphysema. m a y increase o n c o u g h i n g .
3. D i s l o c a t i o n o f c r i c o a r y t e n o i d j o i n t s . T h e a r y t e n o i d car- 4. Flattening o f thyroid prominence and contour of
tilage m a y be displaced a n t e r i o r l y , d i s l o c a t e d o r avulsed. anterior cervical r e g i o n . T h y r o i d n o t c h m a y n o t be
4. Dislocation o f cricothyroid joint. This may cause palpable.
r e c u r r e n t l a r y n g e a l n e r v e paralysis w h i c h traverses j u s t 5. Fracture displacements o f t h y r o i d o r c r i c o i d cartilage
b e h i n d this j o i n t . o r h y o i d b o n e . G a p m a y be felt b e t w e e n the f r a c t u r e d
5. Fractures o f the h y o i d b o n e . fragments.
6. Fractures o f t h y r o i d cartilage. T h e y m a y be v e r t i c a l o r 6. B o n y crepitus b e t w e e n fragments o f h y o i d bone, t h y -
transverse. Fracture o f u p p e r p a r t o f t h y r o i d cartilage r o i d o r c r i c o i d cartilages, m a y s o m e t i m e s b e e l i c i t e d .
m a y result i n a v u l s i o n o f e p i g l o t t i s a n d o n e o r b o t h 7. Separation o f c r i c o i d cartilage f r o m l a r y n x o r trachea.
Diseases o f Larynx and Trachea

4. S t e r o i d t h e r a p y s h o u l d be started i m m e d i a t e l y a n d i n
Diagnostic Evaluation
f u l l dose. I t helps t o resolve o e d e m a a n d haematoma
a n d p r e v e n t s c a r r i n g a n d stenosis.
1. Indirect laryngoscopy I f patient's c o n d i t i o n p e r -
5. A n t i b i o t i c s are g i v e n t o p r e v e n t p e r i c h o n d r i t i s a n d
m i t s , t h i s is t h e m o s t v a l u a b l e e x a n r i n a t i o n . I t m a y
cartilage necrosis.
reveal l o c a t i o n a n d degree o f o e d e m a , haematoma,
mucosal lacerations, posterior displacement of epi- Surgical
glottis, exposed fragments o f cartilage, a s y m m e t r y o f
1. Tracheostomy Endotracheal intubation in cases of
glottis or laryngeal inlet.
laryngeal trauma may be difficult and hazardous.
2. Direct laryngoscopy I t is rarely informative in
T r a c h e o s t o m y is p r e f e r r e d i n these cases.
early p e r i o d f o l l o w i n g injury. I f performed, it may
2. Open reduction I d e a l l y , i t is d o n e 3 - 5 days after i n j u r y
p r e c i p i t a t e r e s p i r a t o r y distress a n d necessitate i m m e d i -
a n d i f p o s s i b l e s h o u l d n o t b e d e l a y e d b e y o n d 10 days.
ate tracheostomy. Fibre optic laryngoscopy gives
(a) Fractures o f h y o i d b o n e , t h y r o i d or c r i c o i d c a r t i -
i m p r o v e d v i s u a l i s a t i o n a n d has r e p l a c e d d i r e c t l a r y n -
lage c a n b e w i r e d a n d r e p l a c e d i n t h e i r a n a t o m i c
g o s c o p y i n r e c e n t years.
p o s i t i o n s . M i n i p l a t c s m a d e o f t i t a n i u m can b e u s e d
3. X-rays S o f t tissue lateral film o f t h e n e c k is v e r y u s e -
for i m m o b i l i s a t i o n o f cartilaginous fragments.
f u l and m a y reveal subcutaneous emphysema, swell-
(b) M u c o s a l l a c e r a t i o n s are r e p a i r e d w i t h c a t g u t a n d
i n g o f laryngeal mucosa, displacement o f epiglottis,
a n y loose fragments o f cartilage r e m o v e d .
fracture displacements o f hyoid bone, thyroid and
(c) E p i g l o t t i s is a n c h o r e d i n its n o r m a l p o s i t i o n a n d i f
c r i c o i d cartilages o r c h a n g e i n t h e c o n f i g u r a t i o n o f a i r
already avulsed, m a y be excised.
column.
(d) A r y t e n o i d cartilages c a n b e r e p o s i t i o n e d i n t h e i r
4. C T scan I t is v e r y v a l u a b l e i n assessing m o d e r a t e l y
n o r m a l p o s i t i o n o r m a y be r e m o v e d i f c o m p l e t e l y
severe o r severe i n j u r i e s o f l a r y n x . P r e s e n t l y three
avulsed.
dimensional CT is found more useful i n laryngeal
(e) I n laryngotracheal separation, e n d to e n d anasto-
trauma.
m o s i s c a n be d o n e .
5. Associated i n j u r i e s I t is essential to examine for
(f) I n t e r n a l s p l i n t a g e o f l a r y n g e a l s t r u c t u r e s m a y be
o t h e r i n j u r i e s l i k e i n j u r y t o head, cervical spine, chest,
r e q u i r e d . I t is d o n e w i t h a l a r y n g e a l stent, o r s i l i -
a b d o m e n a n d extremities. X - r a y chest f o r p n e u m o -
c o n e t u b e w h i c h m a y have t o be left f o r 2 to 6
t h o r a x a n d g a s t r o g r a f f i n s w a l l o w f o r o e s o p h a g e a l tears
w e e k s o n an average.
may be required.
(g) W e b b i n g o f a n t e r i o r c o m m i s s u r e c a n b e p r e v e n t e d
b y a silastic k e e l .

Treatment

Complications J
Conservative

1. Patient s h o u l d be hospitalised and observed f o r respi- 1. L a r y n g e a l stenosis, w h i c h m a y b e s u p r a g l o t t i s g l o t t i c

r a t o r y distress. or subglottic.
1. V o i c e rest is essential. 2. P e r i c h o n d r i t i s a n d l a r y n g e a l abscess.
3. H u m i d i f i c a t i o n o f i n s p i r e d a i r is essential. 3. V o c a l c o r d paralysis.
Acute and Chronic Inflammations
o f Larynx

o f v o c a l abuse, s u b m u c o s a l h a e m o r r h a g e s m a y b e seen i n
ACUTE LARYNGITIS the vocal cords.

A c u t e l a r y n g i t i s m a y be i n f e c t i o u s o r n o n - i n f e c t i o u s .
Treatment

1. Vocal rest. T h i s is t h e m o s t i m p o r t a n t s i n g l e f a c t o r . U s e
| Aetiology
o f voice d u r i n g acute laryngitis m a y lead t o i n c o m -
plete or delayed recovery.
The infectious type is m o r e c o m m o n a n d u s u a l l y f o l l o w s
2. Avoidance o f smoking and alcohol.
u p p e r r e s p i r a t o r y i n f e c t i o n . T o b e g i n w i t h , i t is v i r a l i n
3. Steam inhalations w i t h T r . Benzoin C o , o i l o f eucalyp-
o r i g i n b u t s o o n b a c t e r i a l i n v a s i o n takes p l a c e w i t h Strept.
tus o r p i n e are s o o t h i n g a n d l o o s e n v i s c i d s e c r e t i o n s .
pneumoniae, H. influenzae and haemolytic streptococci or
4. Cough sedative. T o suppress t r o u b l e s o m e i r r i t a t i n g c o u g h .
Staph, aureus. E x a n t h e m a t o u s fevers l i k e measles, c h i c k e n p o x
5. Antibiotics. When t h e r e is s e c o n d a r y infection w i t h
a n d w h o o p i n g c o u g h are also associated w i t h l a r y n g i t i s .
fever and toxaemia or p u r u l e n t expectoration.
The non-infectious type is d u e t o v o c a l abuse, a l l e r g y ,
6. Analgesics. T o relieve local pain and discomfort.
thermal or chemical burns to larynx due to inhalation or
7. Steroids. Useful i n laryngitis f o l l o w i n g thermal or
i n g e s t i o n o f v a r i o u s substances, o r l a r y n g e a l t r a u m a s u c h as
chemical burns.
endotracheal i n t u b a t i o n .
Acute membranous laryngitis T h i s c o n d i t i o n is s i m i -
l a r t o a c u t e m e m b r a n o u s t o n s i l l i t i s a n d is c a u s e d b y p y o -
genic non-specific organisms. It may b e g i n i n the larynx
Q Clinical Features
o r m a y be an extension f r o m the p h a r y n x . I t s h o u l d be
differentiated f r o m laryngeal d i p h t h e r i a .
Symptoms are u s u a l l y a b r u p t i n o n s e t a n d c o n s i s t o f :

1. H o a r s e n e s s w h i c h m a y l e a d t o c o m p l e t e loss o f v o i c e .
2. D i s c o m f o r t o r p a i n i n t h r o a t , p a r t i c u l a r l y after t a l k i n g .
ACUTE EPIGLOTTITIS
3. D r y , i r r i t a t i n g c o u g h w h i c h is u s u a l l y w o r s e at n i g h t .
(Syn. Supraglottic Laryngitis)
4. G e n e r a l s y m p t o m s o f h e a d , c o l d , r a w n e s s o r dryness
o f t h r o a t , m a l a i s e a n d f e v e r i f l a r y n g i t i s has f o l l o w e d
viral i n f e c t i o n o f u p p e r respiratory tract. I t is a n a c u t e i n f l a m m a t o r y c o n d i t i o n c o n f i n e d t o s u p r a -
glottic structures, i.e. epiglottis, a r y e p i g l o t t i c folds and
Laryngeal appearances v a r y w i t h s e v e r i t y o f disease. I n e a r l y arytenoids. T h e r e is m a r k e d o e d e m a o f these s t r u c t u r e s
stages, there is erythema and oedema o f epiglottis, w h i c h may obstruct the airway.
a r y e p i g l o t t i c folds, arytenoids a n d v e n t r i c u l a r bands, b u t
t h e v o c a l cords appear w h i t e a n d near n o r m a l a n d stand
out i n contrast to s u r r o u n d i n g mucosa, betraying the Aetiology
d e g r e e o f hoarseness p a t i e n t has. L a t e r , h y p e r a e m i a and
s w e l l i n g i n c r e a s e . V o c a l c o r d s also b e c o m e r e d a n d s w o l l e n . I t is a serious c o n d i t i o n a n d affects c h i l d r e n o f 2—7 years o f
S u b g l o t t i c r e g i o n also gets i n v o l v e d . S t i c k y s e c r e t i o n s are age b u t c a n also affect a d u l t s . H. influenzae B is t h e m o s t
seen b e t w e e n t h e c o r d s a n d i n t e r a r y t e n o i d r e g i o n . I n case c o m m o n o r g a n i s m responsible f o r this c o n d i t i o n i n c h i l d r e n .
Diseases of Larynx and Trachea

• Clinical Features
bacterial
Male children
infection
are more
by Gram
often affected.
positive
Secondary
cocci soon
supervenes.
1. O n s e t o f s y m p t o m s is a b r u p t w i t h r a p i d p r o g r e s s i o n .
2. S o r e t h r o a t a n d d y s p h a g i a are t h e c o m m o n presenting
s y m p t o m s i n adults.
| Pathology |
3. Dyspnoea and s t r i d o r are the common presenting
symptoms in children. They are r a p i d l y progressive
T h e l o o s e a r e o l a r tissue i n t h e s u b g l o t t i c r e g i o n swells u p
a n d m a y p r o v e fatal unless r e l i e v e d .
a n d causes r e s p i r a t o r y o b s t r u c t i o n a n d s t r i d o r . T h i s , cou-
4. Fever m a y go u p to 4 0 ° C . I t is d u e t o septicaemia.
p l e d w i t h t h i c k t e n a c i o u s s e c r e t i o n s a n d crusts, m a y com-
Patient's c o n d i t i o n may rapidly deteriorate.
pletely occlude the airway.

Examination
1 I Symptomatology

1. Depressing t h e t o n g u e w i t h a t o n g u e depressor m a y Disease starts as u p p e r r e s p i r a t o r y i n f e c t i o n w i t h h o a r s e -

s h o w red and swollen epiglottis. Indirect laryngoscopy
m a y s h o w oedema and congestion o f supraglottic struc-
t u r e . T h i s e x a m i n a t i o n is a v o i d e d f o r fear o f p r e c i p i t a t -
i n g c o m p l e t e o b s t r u c t i o n . I t is b e t t e r d o n e i n o p e r a t i o n
t h e a t r e w h e r e f a c i l i t i e s f o r i n t u b a t i o n are a v a i l a b l e .
2. L a t e r a l s o f t tissue X - r a y o f n e c k m a y s h o w swollen
epiglottis ( t h u m b sign).
ness a n d c r o u p y c o u g h . T h e r e is f e v e r o f 3 9 — 4 0 ° C . This
m a y be f o l l o w e d b y d i f f i c u l t y i n b r e a t h i n g and inspiratory
t y p e o f s t r i d o r . R e s p i r a t o r y d i f f i c u l t y m a y g r a d u a l l y increase
w i t h signs o f u p p e r a i r w a y o b s t r u c t i o n , i . e . suprasternal
a n d intercostal recession. Differences b e t w e e n acute e p i -
g l o t t i t i s a n d a c u t e l a r y n g o - t r a c h e o - b r o n c h i t i s are g i v e n i n
Table 57.1.

Treatment
1 I Treatment

1. Hospitalisation. Essential because o f the danger of 1. Hospitalisation is o f t e n essential b e c a u s e o f t h e i n c r e a s -

respiratory obstruction. ing difficulty i n breathing.

2. Antibiotics. Ampicillin or third generation cepha- 2. Antibiotics like ampicillin 50mg/kg/day in divided

l o s p o r i n are effective against H. influenzae and are doses is e f f e c t i v e against s e c o n d a r y i n f e c t i o n s d u e t o

g i v e n b y parenteral route ( i . m . o r i.v.) w i t h o u t w a i t - g r a m - p o s i t i v e c o c c i a n d H. influenzae.

i n g f o r results o f t h r o a t s w a b a n d b l o o d c u l t u r e . 3. Humidification helps to soften crusts a n d tenacious

3. Steroids. H y d r o c o r t i s o n e o r d e x a m e t h a s o n e is g i v e n i n secretions w h i c h b l o c k t r a c h e o b r o n c h i a l tree.

a p p r o p r i a t e doses i . m . o r i . v . T h e y relieve oedema 4. Parenteral fluids are essential t o c o m b a t d e h y d r a t i o n .

and may obviate need for tracheostomy. 5. Steroids, e.g. h y d r o c o r t i s o n e 100 m g i . v . m a y b e u s e f u l

4. Adequate hydration. Patient m a y require parenteral fluids. to relieve oedema.

5. Humidification and oxygen. Patient may require mist 6. Adrenaline, r a c e m i c adrenaline a d m i n i s t e r e d via a res-

tent or a croupette. p i r a t o r is a b r o n c h o d i l a t o r a n d m a y r e l i e v e dyspnoea

6. Intubation or tracheostomy m a y be r e q u i r e d f o r respira- and avert tracheostomy.

tory obstruction. 7. Intubation/tracheostomy is done, should respiratory

o b s t r u c t i o n increase i n spite o f the a b o v e measures.
T r a c h e o s t o m y is d o n e i f i n t u b a t i o n is r e q u i r e d b e y o n d

ACUTE LARYNGO-TRACHEO-BRONCHITIS 7 2 h o u r s . Assisted v e n t i l a t i o n m a y b e r e q u i r e d .

I t is an i n f l a m m a t o r y c o n d i t i o n o f t h e l a r y n x , t r a c h e a a n d
LARYNGEAL DIPHTHERIA
b r o n c h i ; m o r e c o m m o n than acute epiglottitis.

| Aetiology
M o s t l y , i t is v i r a l i n f e c t i o n ( p a r a i n f l u e n z a t y p e I a n d I I )
a f f e c t i n g c h i l d r e n b e t w e e n 6 m o n t h s t o 3 years o f age.
Aetiology
M o s t l y , i t is s e c o n d a r y t o f a u c i a l d i p h t h e r i a a f f e c t i n g c h i l -
d r e n b e l o w 10 years o f age. I n c i d e n c e o f d i p h t h e r i a i n g e n -
eral is d e c l i n i n g d u e t o w i d e - s p r e a d use o f i m m u n i s a t i o n .
 Acute and Chronic Inflammations of Larynx

M A I Differences between acute epiglottitis and a c u t e l a r y n g o - t r a c h e o - b r o n c h i t i s in children

Acute epiglottitis Acute laryngo-tracheo-bronchitis (or group)

• Causative organism Haemophilus influenzae t y p e B Parainfluenza virus type 1and II

• Age 2-7 years 3 m o n t h s to 3 years

• Pathology Supraglottic larynx Subglottic area

• Prodromal s y m p t o m s Absent Present

• Onset Sudden Slow

• Fever High L o w grade or no fever

• Patient's look Toxic Non-toxic

• C o u g h Usually absent Present, (Barking seal-like)

• Stridor Present and may be marked Present

• O d y n o p h a g i a Present, with drooling o f secretions Usually absent

• Radiology * T h u m b sign o n lateral view Steeple sign on anteroposterior view o f neck

• Treatment Humidified oxygen, third generation Humidified 0 2 tent, steroids

cephalosporin (ceftriaxone) or

amoxicillin

*Examinacion o f larynx and radiographs are avoided lest complete obstruction is precipitated. Examination is done in the operation theatre
where immediate intubation can be done.

Pathology
i I Treatment

E f f e c t s o f l a r y n g e a l d i p h t h e r i a are d u e t o : 1. Diphtheria antitoxin. Dose depends o n clinical severity

a n d d u r a t i o n o f illness, a n d varies from 20,000 to
t. F o r m a t i o n o f a t o u g h pseu d o m e m b r a n e o v e r t h e l a r y n x
1 0 0 , 0 0 0 u n i t s i . v . r o u t e as saline i n f u s i o n a f t e r a test
a n d trachea w h i c h m a y c o m p l e t e l y o b s t r u c t t h e a i r w a y .
d o s e . I t neutralises free t o x i n c i r c u l a t i n g i n t h e b l o o d .
2. E x o t o x i n liberated b y bacteria l e a d i n g t o m y o c a r d i t i s
2. Antibacterials. Benzylpenicillin, 500,000 units i.m.
and various neurological complications.
e v e r y 6 h o u r s f o r 6 days, is e f f e c t i v e against d i p h t h e r i a
b a c i l l i . E r y t h r o m y c i n can b e g i v e n t o t h o s e w h o are
| Clinical Features allergic to p e n i c i l l i n .
3. Maintenance of airway. Tracheostomy may become
General symptoms. O n s e t is i n s i d i o u s w i t h l o w g r a d e fever essential. D i r e c t l a r y n g o s c o p y , removal o f diphthe-
(100— 1 0 1 ° F ) , s o r e t h r o a t a n d m a l a i s e b u t p a t i e n t is v e r y ritic m e m b r a n e a n d i n t u b a t i o n c a n b e d o n e . I n t u b a t i o n
t o x a e m i c w i t h tachycardia a n d thready pulse. relieves respiratory o b s t r u c t i o n a n d can m a k e subse-
Laryngeal symptoms. Hoarse voice, croupy cough, inspira- q u e n t t r a c h e o s t o m y easy.
t o r y stridor, increasing dyspnoea w i t h m a r k e d u p p e r air- 4. Complete bed rest. C o m p l e t e b e d rest f o r 2 - 4 w e e k s is
way obstruction. essential t o g u a r d against effects o f m y o c a r d i t i s .
Membrane. G r e y i s h w h i t e m e m b r a n e is seen o n t h e t o n -
s i l , p h a r y n x a n d soft p a l a t e . I t is a d h e r e n t a n d its r e m o v a l
^ Complications j
leaves a b l e e d i n g s u r f a c e . S i m i l a r m e m b r a n e is seen o v e r
the l a r y n x and trachea.
1. A s p h y x i a and death due to airway o b s t r u c t i o n .
Cervical lymphadenopalhy. Characteristic " b u l l - n e c k " may
2. T o x i c myocarditis and circulatory failure.
be seen.
3. Palatal paralysis w i t h nasal r e g u r g i t a t i o n .
4. L a r y n g e a l a n d p h a r y n g e a l paralysis.
Diagnosis

OEDEMA OF LARYNX
L a r y n g e a l d i p h t h e r i a is m o s t l y s e c o n d a r y t o f a u c i a l d i p h -
t h e r i a . D i a g n o s i s is a l w a y s c l i n i c a l b u t c o n f i r m e d b y s m e a r
a n d c u l t u r e o f c o r y n e b a c t e r i u m d i p h t h e r i a e . T r e a t m e n t is O f t e n t e r m e d "oedema glottidis" i n t h e past, i t i n v o l v e s t h e
started o n c l i n i c a l suspicion. supraglottic and subglottic region w h e r e laryngeal mucosa
Diseases of Larynx and Trachea

is l o o s e . O e d e m a o f t h e v o c a l c o r d s o c c u r s r a r e l y because Aetiology
o f t h e sparse s u b e p i t h e l i a l c o n n e c t i v e tissue.
1. I t m a y f o l l o w i n c o m p l e t e l y resolved acute simple lar-
y n g i t i s o r its r e c u r r e n t attacks.
2. Presence o f c h r o n i c i n f e c t i o n i n paranasal sinuses,
Aetiology
t e e t h a n d tonsils a n d t h e chest are i m p o r t a n t c o n t r i b -
u t o r y causes.
Infections
3. O c c u p a t i o n a l f a c t o r s , e.g. e x p o s u r e t o d u s t a n d f u m e s
(i) Acute epiglottitis, laryngo-tracheo-bronchitis,
s u c h as i n m i n e r s , s t r o k e r s , g o l d o r i r o n s m i t h s a n d
tuberculosis o r syphilis o f larynx.
w o r k e r s i n chemical industries.
(ii) I n f e c t i o n i n n e i g h b o u r h o o d , e.g. p e r i t o n s i l l a r abscess,
4. S m o k i n g and alcohol.
r e t r o p h a r y n g e a l abscess a n d L u d w i g ' s a n g i n a .
5. Persistent t r a u m a o f c o u g h as i n c h r o n i c l u n g diseases.
2. Trauma Surgery o f tongue, floor o f m o u t h , laryn-
6. V o c a l abuse.
geal t r a u m a , f o r e i g n b o d y , e n d o s c o p y especially in
c h i l d r e n , i n t u b a t i o n , t h e r m a l o r caustic b u r n s o r i n h a -
Clinical Features
l a t i o n o r i r r i t a n t gases o r f u m e s .
3. Neoplasms Cancer of larynx or laryngopharynx 1. H o a r s e n e s s . T h i s is t h e c o m m o n e s t c o m p l a i n t . V o i c e
o f t e n associated w i t h d e e p u l c e r a t i o n . b e c o m e s easily t i r e d a n d p a t i e n t b e c o m e s a p h o n i c b y
4. Allergy A n g i o n e u r o t i c oedema, anaphylaxis. t h e e n d o f the day.
5. Radiation For cancer o f larynx or p h a r y n x . 2. C o n s t a n t h a w k i n g . T h e r e is dryness a n d i n t e r m i t t e n t
6. Systemic diseases Nephritis, heart failure, or t i c k l i n g i n t h e t h r o a t a n d p a t i e n t is c o m p e l l e d t o c l e a r
myxoedema. the throat repeatedly.
3. D i s c o m f o r t i n the throat.
4. C o u g h . I t is d r y a n d i r r i t a t i n g .
S y m p t o m s and Signs
Laryngeal examination T h e r e is h y p e r a e m i a o f l a r y n g e a l
s t r u c t u r e s . V o c a l c o r d s appear d u l l r e d a n d r o u n d e d . F l e c k s
1. Airway obstruction Degree o f respiratory distress
o f v i s c i d m u c u s are seen o n t h e v o c a l c o r d s a n d i n t e r -
varies. T r a c h e o s t o m y m a y b e c o m e essential.
arytenoid region.
1. Inspiratory stridor.
3. Indirect laryngoscopy shows oedema o f supra-
Treatment
glottic or subglottic region. C h i l d r e n may require
direct laryngoscopy. 1. Eliminate infection of upper or lower respira-
tory tract I n f e c t i o n i n t h e sinuses, t o n s i l s , t e e t h o r
chronic chest i n f e c t i o n (bronchitis, bronchiectasis,
Treatment t u b e r c u l o s i s , etc.) s h o u l d be t r e a t e d .
2. Avoidance of irritating factors, e.g. smoking,
I f t h e r e is a i r w a y o b s t r u c t i o n , i n t u b a t i o n o f l a r y n x o r t r a - a l c o h o l o r p o l l u t e d e n v i r o n m e n t , dust a n d fumes.
c h e o s t o m y w i l l be i m m e d i a t e l y r e q u i r e d . Less severe cases 3. Voice rest a n d speech t h e r a p y V o i c e rest has t o
are t r e a t e d c o n s e r v a t i v e l y a n d t r e a t m e n t w i l l d e p e n d o n be p r o l o n g e d for weeks or m o n t h s . Patient should
t h e cause. A n i n j e c t i o n o f a d r e n a l i n e ( 1 : 1 0 0 0 ) 0 . 3 - 0 . 5 m l r e c e i v e t r a i n i n g i n p r o p e r use o f v o i c e .
i . m . , r e p e a t e d i n 15 m i n u t e s i f necessary, is u s e f u l i n a l l e r g i c
4. Steam inhalations T h e y help to loosen secretions
o r a n g i o n e u r o t i c o e d e m a . S t e r o i d s are u s e f u l i n e p i g l o t t i t i s ,
and give relief.
laryngo-tracheo-bronchitis o r oedema due to traumatic
5. E x p e c t o r a n t s T h e y help t o loosen viscid secretions
a l l e r g i c o r p o s t - r a d i a t i o n causes.
and give relief f r o m h a w k i n g .

B. C h r o n i c Hypertrophic Laryngitis
CHRONIC LARYNGITIS
1 (Syn. C h r o n i c Hyperplastic Laryngitis) 1
A . C h r o n i c Laryngitis W i t h o u t Hyperplasia It m a y be e i t h e r a diffuse a n d s y m m e t r i c a l process or a

I ( C h r o n i c Hyperaemic Laryngitis) I localised one, the latter appearing like a t u m o u r o f the

l a r y n x . L o c a l i s e d v a r i e t y presents as d y s p h o n i a p l i c a v e n -
I t is a d i f f u s e i n f l a m m a t o r y c o n d i t i o n s y m m e t r i c a l l y i n v o l v - tricularis, vocal nodules, vocal p o l y p , R e i n k e ' s oedema and
i n g the w h o l e l a r y n x , i.e. t r u e cords, v e n t r i c u l a r bands, contact ulcer ( T h e y have b e e n described i n the relevant
interarytenoid region and root o f the epiglottis. sections).
 Acute and Chronic Inflammations of Larynx

Aetiology m i d d l e - a g e d m e n a n d w o m e n . T h i s is d u e t o o e d e m a o f
t h e s u b e p i t h e l i a l space ( R e i n k e ' s space) o f t h e v o c a l c o r d s .
Same as discussed under chronic laryngitis without
C h r o n i c i r r i t a t i o n o f v o c a l cords due t o misuse o f v o i c e ,
hyperplasia.
heavy smoking, chronic sinusitis a n d laryngopharyngeal

Pathology r e f l e x are t h e p r o b a b l e a e t i o l o g i c a l f a c t o r s . I t c a n also o c c u r

in myxoedema.
P a t h o l o g i c a l c h a n g e s start i n t h e g l o t t i c r e g i o n a n d later
m a y e x t e n d t o v e n t r i c u l a r b a n d s , base o f e p i g l o t t i s a n d e v e n
subglottis. M u c o s a , s u b m u c o s a , m u c o u s glands a n d i n later
stages i n t r i n s i c l a r y n g e a l muscles a n d j o i n t s m a y be a f f e c t e d . J Clinical Features
I n i t i a l l y , t h e r e is h y p e r a e m i a , o e d e m a a n d c e l l u l a r i n f i l -
tration i n the submucosa. T h e pseudostratified ciliated e p i - H o a r s e n e s s is t h e c o m m o n s y m p t o m . Patient uses false

t h e l i u m o f respiratory m u c o s a changes t o squamous type, c o r d s f o r v o i c e p r o d u c t i o n a n d t h i s gives h i m a l o w - p i t c h e d

and squamous e p i t h e l i u m o f the v o c a l cords to hyperplasia and r o u g h voice.

a n d k e r a t i n i s a t i o n . T h e m u c o u s glands suffer h y p e r t r o p h y O n i n d i r e c t l a r y n g o s c o p y , v o c a l c o r d s a p p e a r as f u s i f o r m

at first b u t l a t e r u n d e r g o a t r o p h y w i t h d i m i n i s h e d secre- swellings w i t h pale translucent l o o k . V e n t r i c u l a r bands m a y

t i o n a n d dryness o f l a r y n x . appear h y p e r a e m i c and hypertrophic and may hide the

v i e w o f the true cords.
Clinical Features

T h i s disease m o s t l y affects m a l e s (8:1) i n t h e age g r o u p o f

30—50 years.
Hoarseness, constant desire to clear t h e throat, dry
|P Treatment ^jj
c o u g h , tiredness o f v o i c e , a n d d i s c o m f o r t i n t h r o a t w h e n
t h e v o i c e has b e e n u s e d f o r an e x t e n d e d p e r i o d o f t i m e , are 1. D e c o r t i c a t i o n o f the v o c a l cords, i.e. r e m o v a l o f strip
the c o m m o n presenting symptoms. o f e p i t h e l i u m , is d o n e first o n o n e side a n d 3—4 w e e k s

Examination O n e x a m i n a t i o n , c h a n g e s are o f t e n d i f f u s e later o n the o t h e r .

and symmetrical. 2. V o i c e rest.

3. Speech therapy for proper voice p r o d u c t i o n .
1. L a r y n g e a l mucosa, i n general, is d u s k y r e d a n d t h i c k e n e d .
2. V o c a l c o r d s appear r e d a n d s w o l l e n . T h e i r edges l o s e
sharp d e m a r c a t i o n a n d a p p e a r r o u n d e d . I n late stages, PACHYDERMIA LARYNGIS
cords become b u l k y and irregular giving nodular
appearance.
I t is a f o r m o f c h r o n i c hypertrophic laryngitis affecting
3. V e n t r i c u l a r bands appear red a n d s w o l l e n a n d m a y be
posterior part o f larynx i n the region o f interarytenoid and
m i s t a k e n f o r prolapse o r eversion o f the v e n t r i c l e .
posterior part o f the v o c a l cords.
4. M o b i l i t y o f cords gets i m p a i r e d d u e t o o e d e m a a n d
C l i n i c a l l y , p a t i e n t presents w i t h hoarseness o r husky
infiltration, and later due to muscular atrophy or
voice and irritation i n the throat. Indirect laryngoscopy
arthritis o f the cricoarytenoid j o i n t .
reveals h e a p i n g u p o f r e d o r g r e y g r a n u l a t i o n tissue i n t h e

Treatment i n t e r a r y t e n o i d r e g i o n a n d posterior thirds o f v o c a l cords;

the latter sometimes s h o w i n g ulceration due to constant
Conservative Same as for chronic laryngitis without
h a m m e r i n g o f v o c a l processes as i n t a l k i n g , f o r m i n g w h a t
hyperplasia.
is c a l l e d t h e ' c o n t a c t u l c e r ' . T h e c o n d i t i o n is b i l a t e r a l a n d
Surgical S t r i p p i n g o f vocal cords, r e m o v i n g the h y p e r - symmetrical. It does not undergo malignant change.
plastic a n d o e d e m a t o u s m u c o s a , m a y b e d o n e i n s e l e c t e d H o w e v e r , b i o p s y o f t h e l e s i o n is essential t o d i f f e r e n t i a t e
cases. D a m a g e t o u n d e r l y i n g v o c a l l i g a m e n t should be the lesion f r o m carcinoma a n d t u b e r c u l o s i s . A e t i o l o g y is
c a r e f u l l y a v o i d e d . O n e c o r d is o p e r a t e d at a t i m e . u n c e r t a i n . I t is m o s t l y s e e n i n m e n w h o i n d u l g e i n e x c e s -
sive alcohol and smoking. Other factors are excessive
forceful talking and gastro-oesophageal reflux disease
POLYPOID DEGENERATION OF VOCAL w h e r e p o s t e r i o r p a r t o f l a r y n x is b e i n g c o n s t a n t l y bathed
C O R D S (REINKE'S O E D E M A ) w i t h acid juices f r o m the stomach.
T r e a t m e n t is r e m o v a l o f g r a n u l a t i o n tissue u n d e r o p e r -
It is bilateral symmetrical swelling of the whole of ating microscope w h i c h may require repetition, control o f
membranous p a r t o f t h e v o c a l c o r d s , m o s t o f t e n seen i n acid r e f l u x a n d speech therapy.
Diseases o f Larynx and T r a c h e a

Laryngeal Examination
ATROPHIC LARYNGITIS (LARYNGITIS SICCA)

1. H y p e r a e m i a o f t h e v o c a l c o r d i n its w h o l e e x t e n t o r
I t is c h a r a c t e r i s e d b y a t r o p h y o f l a r y n g e a l m u c o s a a n d c r u s t
c o n f i n e d t o posterior part w i t h i m p a i r m e n t o f adduc-
f o r m a t i o n . C o n d i t i o n is o f t e n seen i n w o m e n a n d is asso-
t i o n is t h e first s i g n .
ciated w i t h atrophic rhinitis and pharyngitis.
2. S w e l l i n g i n the interarytenoid region g i v i n g a m a m i l -
C o m m o n s y m p t o m s i n c l u d e hoarseness o f v o i c e w h i c h
lated appearance.
t e m p o r a r i l y i m p r o v e s o n c o u g h i n g a n d r e m o v a l o f crusts.
3. Ulceration of vocal cord giving mouse-nibbled
D r y irritating c o u g h a n d sometimes dyspnoea is d u e to
appearance.
obstmcting crusts.
4. Superficial ragged ulceration o n the arytenoids and
E x a m i n a t i o n shows atrophic mucosa covered w i t h f o u l -
interarytenoid region.
s m e l l i n g crusts. W h e n crusts h a v e b e e n e x p e l l e d , m u c o s a
5. G r a n u l a t i o n tissue i n i n t e r a r y t e n o i d r e g i o n o r vocal
m a y s h o w e x c o r i a t i o n a n d b l e e d i n g . C r u s t i n g m a y also b e
process o f a r y t e n o i d .
seen i n t h e t r a c h e a .
6. Pseudoedema o f the epiglottis " t u r b a n epiglottis".
Treatment is e l i m i n a t i o n o f t h e causative factor and
7. S w e l l i n g o f v e n t r i c u l a r bands a n d a r y e p i g l o t t i c folds.
h u m i d i f i c a t i o n . L a r y n g e a l sprays w i t h g l u c o s e i n g l y c e r i n e
8. M a r k e d pallor o f surrounding mucosa.
o r o i l o f p i n e are c o m f o r t i n g a n d h e l p t o l o o s e n t h e crusts.
A s s o c i a t e d nasal a n d p h a r y n g e a l conditions will require
attention. Expectorants containing a m m o n i u m chloride or Diagnosis
i o d i d e s also h e l p t o l o o s e n t h e crusts.

I n a d d i t i o n t o X - r a y chest a n d s p u t u m e x a m i n a t i o n , b i o p s y
o f l a r y n g e a l l e s i o n is essential t o e x c l u d e carcinoma and
TUBERCULOSIS OF LARYNX differentiate it f r o m other c o n d i t i o n .

Aetiology
Treatment

I t is a l m o s t a l w a y s s e c o n d a r y t o p u l m o n a r y tuberculosis,
T r e a t m e n t is t h e same as f o r p u l m o n a r y t u b e r c u l o s i s . Voice
m o s t l y a f f e c t i n g m a l e s i n m i d d l e age g r o u p . T u b e r c l e b a c i l l i
rest is i m p o r t a n t .
reach the l a r y n x b y b r o n c h o g e n i c o r haematogenous routes.

Pathology LUPUS OF THE LARYNX

Disease affects p o s t e r i o r p a r t o f l a r y n x m o r e t h a n a n t e r i o r . I t is a n i n d o l e n t t u b e r c u l a r i n f e c t i o n associated w i t h l u p u s

Parts a f f e c t e d are: (i) i n t e r a r y t e n o i d f o l d , ( i i ) v e n t r i c u l a r o f nose a n d p h a r y n x . U n l i k e tuberculosis o f l a r y n x w h i c h
bands, (iii) vocal cords a n d (iv) epiglottis, i n that o r d e r . m o s t l y affects p o s t e r i o r parts, l u p u s i n v o l v e s t h e anterior
T u b e r c l e bacilli, carried by s p u t u m f r o m the bronchi, p a r t o f l a r y n x . E p i g l o t t i s is i n v o l v e d f i r s t a n d m a y b e com-
settle a n d p e n e t r a t e t h e i n t a c t l a r y n g e a l m u c o s a p a r t i c u - p l e t e l y d e s t r o y e d b y t h e disease. T h e l e s i o n spreads t o a r y e p i -
larly i n the interarytenoid region (bronchogenic spread). glottic folds a n d sometimes t o v e n t r i c u l a r bands. L u p u s o f
This leads t o f o r m a t i o n o f s u b m u c o s a l tubercles w h i c h l a r y n x is a painless a n d o f t e n a n a s y m p t o m a t i c condition
m a y l a t e r caseate a n d u l c e r a t e . L a r y n g e a l m u c o s a appears a n d m a y be d i s c o v e r e d o n r o u t i n e l a r y n g e a l examination
r e d and s w o l l e n due t o cellular i n f i l t r a t i o n (pseudoedema). i n cases o f l u p u s o f n o s e . T h e r e is n o p u l m o n a r y t u b e r c u -
Stages o f p e r i c h o n d r i t i s a n d c a r t i l a g e n e c r o s i s are n o t c o m - losis. T r e a t m e n t is a n t i t u b e r c u l a r d r u g s . P r o g n o s i s is g o o d .
m o n l y seen these days.

SYPHILIS O F THE LARYNX

S y m p t o m s and Signs

T h e y w o u l d g r e a t l y d e p e n d o n t h e stage o f tuberculosis. I t is a r a r e c o n d i t i o n n o w . O n l y g u m m a o f t e r t i a r y stage is

Weakness o f voice is t h e earliest s y m p t o m f o l l o w e d b y s o m e t i m e s seen. I t m a y o c c u r i n a n y p a r t o f t h e l a r y n x a n d
hoarseness. U l c e r a t i o n i n t h e l a r y n x g i v e s rise t o s e v e r e p r e s e n t as a s m o o t h s w e l l i n g w h i c h m a y later ulcerate.
p a i n w h i c h m a y r a d i a t e t o t h e ears. S w a l l o w i n g is p a i n f u l D i a g n o s i s is o n l y o n b i o p s y a n d s e r o l o g i c a l tests. L a r y n g e a l
w i t h m a r k e d d y s p h a g i a i n l a t e r stages. stenosis is a f r e q u e n t complication.
 Acute and Chronic Inflammations of Larynx

w i t h o r w i t h o u t a nasal l e s i o n . T y p i c a l l y , i t presents as a
LEPROSY OF THE LARYNX
s m o o t h r e d s w e l l i n g i n t h e s u b g l o t t i c r e g i o n . Hoarseness o f
voice, w h e e z i n g and dyspnoea m a y be the presenting

I t is a r a r e c o n d i t i o n a n d is o f t e n associated w i t h l e p r o s y o f s y m p t o m s i n a d d i t i o n t o t h e nasal l e s i o n . D i a g n o s i s is m a d e

t h e s k i n a n d n o s e . I t p r e s e n t s as d i f f u s e n o d u l a r i n f i l t r a t i o n o n b i o p s y . T r e a t m e n t is b y s t r e p t o m y c i n o r t e t r a c y c l i n e ,

o f epiglottis, a r y e p i g l o t t i c folds and arytenoids. Lesions m a y o f t e n c o m b i n e d w i t h steroids t o p r e v e n t fibrosis. S u b g l o t t i c

u l c e r a t e . I t is associated w i t h nasal l e p r o s y . D i a g n o s i s is m a d e stenosis is a f r e q u e n t c o m p l i c a t i o n r e q u i r i n g s u b s e q u e n t

o n biopsy f r o m the lesion. D e f o r m i t y o f the laryngeal inlet reconstructive surgery.

a n d stenosis are t h e e n d results o f this disease after h e a l i n g .

LARYNGEAL MYCOSIS
SCLEROMA OF THE LARYNX

F u n g a l i n f e c t i o n s s u c h as c a n d i d i a s i s , histoplasmosis and
I t is a c h r o n i c i n f l a m m a t o r y c o n d i t i o n c a u s e d b y Klebsiella blastomycosis m a y rarely affect t h e l a r y n x . Diagnosis is
rhinosderomatis. N a s a l i n v o l v e m e n t is v e r y c o m m o n i n o u r usually made o n biopsy and o n f i n d i n g a similar lesion i n
c o u n t r y . L a r y n g e a l i n v o l v e m e n t m a y b e seen o c c a s i o n a l l y o t h e r parts o f t h e b o d y .
C o n g e n i t a l Lesions o f
Larynx and S t r i d o r

4. Laryngeal web ( F i g . 5 8 . 2 ) . I t is d u e t o i n c o m p l e t e
CONGENITAL LESIONS OF LARYNX r e c a n a l i s a t i o n o f l a r y n x . M o s d y , t h e w e b is seen b e t w e e n
t h e v o c a l c o r d s a n d has a c o n c a v e posterior margin. Pre-

* Laryngomalacia (congenital laryngeal stridor) s e n t i n g features are a i r w a y o b s t r u c t i o n , w e a k c r y o r a p h o n i a

* C o n g e n i t a l v o c a l c o r d paralysis dating from b i r t h . T r e a t m e n t depends o n the thickness o f

• C o n g e n i t a l s u b g l o t t i c stenosis t h e w e b . T h i n w e b s c a n b e c u t w i t h a k n i f e o r C O . , laser.

• Laryngeal w e b Thick ones m a y r e q u i r e e x c i s i o n v i a l a r y n g o fissure a n d

• Subglottic haemangioma placement o f a silicon keel a n d subsequent dilatations.

* Laryngo-oesophageal cleft 5. S u b g l o t t i c h a e m a n g i o m a T h o u g h congenital, patient

* Laryngocele is a s y m p t o m a t i c t i l l 3—6 m o n t h s o f age w h e n h a e m a n g i o m a
• L a r y n g e a l cyst

1. L a r y n g o m a l a c i a (congenital laryngeal stridor) It

is t h e m o s t c o m m o n c o n g e n i t a l a b n o r m a l i t y o f t h e l a r y n x .
I t is c h a r a c t e r i s e d b y excessive flaccidity o f supraglottic
l a r y n x w h i c h is s u c k e d i n d u r i n g i n s p i r a t i o n p r o d u c i n g
stridor and sometimes cyanosis. S t r i d o r is i n c r e a s e d on
c r y i n g b u t subsides o n p l a c i n g t h e c h i l d i n p r o n e p o s i t i o n ;
cry is n o r m a l . T h e c o n d i t i o n m a n i f e s t s at b i r t h o r s o o n
a f t e r , a n d u s u a l l y disappears b y 2 years o f age. D i r e c t l a r -
yngoscopy shows elongated epiglottis, curled u p o n itself
(omega-shaped ft), floppy a r y e p i g l o t t i c folds and pro-
m i n e n t a r y t e n o i d s . F l e x i b l e l a r y n g o s c o p e is v e r y u s e f u l t o
make the diagnosis. Mostly, t r e a t m e n t is conservative. Figure 58.1
T r a c h e o s t o m y m a y b e r e q u i r e d f o r s o m e cases o f severe
L a r y n g o m a l a c i a . N o t e : e p i g l o t t i s is f o l d e d longitudinally form-
respiratory obstruction (Fig. 58.1).
ing an omega.
2. C o n g e n i t a l vocal c o r d paralysis I t results f r o m b i r t h
t r a u m a w h e n r e c u r r e n t l a r y n g e a l n e r v e is s t r e t c h e d d u r i n g
b r e e c h o r forceps d e l i v e r y or can result f r o m anomalies o f
the central nervous system.

3. C o n g e n i t a l s u b g l o t t i c stenosis I t is d u e t o a b n o r m a l Web
t h i c k e n i n g o f c r i c o i d c a r t i l a g e o r f i b r o u s tissue seen b e l o w
the vocal cords. C h i l d may r e m a i n asymptomatic till upper
r e s p i r a t o r y i n f e c t i o n causes d y s p n o e a a n d s t r i d o r . C r y is
n o r m a l as i n l a r y n g o m a l a c i a . D i a g n o s i s is m a d e w h e n s u b -
g l o t t i c d i a m e t e r is less t h a n 4 m m in full-term neonate
(normal 4.5-5.5 m m ) or 3 m m i n premature neonate (nor- Figure 58.2
m a l 3 . 5 m m ) . M a n y cases o f c o n g e n i t a l stenosis i m p r o v e as
Laryngeal web.
the l a r y n x g r o w s b u t some m a y require surgery.
 Congenital Lesions of Larynx and Stridor

b e g i n s t o increase i n size. A b o u t 5 0 % o f t h e c h i l d r e n h a v e C o m m o n causes o f s t r i d o r i n i n f a n t s a n d c h i l d r e n are g i v e n

associated c u t a n e o u s haemangiomas. Patient m a y present below:
w i t h s t r i d o r b u t has a n o r m a l c r y . A g i t a t i o n o f t h e p a t i e n t o r
Stridor
c r y i n g m a y increase a i r w a y o b s t r u c t i o n d u e t o v e n o u s f i l l -
i n g . D i r e c t l a r y n g o s c o p y s h o w s r e d d i s h - b l u e mass b e l o w
Congenital Acquired
t h e v o c a l c o r d s . B i o p s y is s o m e t i m e s , n o t a l w a y s , associated Laryngomalocia
w i t h h a e m o r r h a g e . S o m e p a t i e n t s h a v e associated m e d i a s t i - Laryngeal web Afebrile Febrile
nal h a e m a n g i o m a . Subglottic stenosis » Papillomatosis Epiglottitis
D e p e n d i n g o n i n d i v i d u a l case, t h e t r e a t m e n t is: Haemangioma » Injury Acute laryngitis
Vocal cord paralysis
* Foreign body Laryngotracheitis
(a) Tracheostomy and observation, as many haeman- Tongue and jaw
» Laryngeal oedema Diphtheria
giomas i n v o l u t e spontaneously. abnormalities
• Adenotonsillar Retropharyngeal
(b) Steroid therapy. Dexamethasone 1 mg/kg/day for hypertrophy abscess
1 week and then prednisolone 3 m g / k g i n divided Infectious
mononucleosis
doses f o r o n e y e a r .
Peritonsillar
(c) C O , laser e x c i s i o n i f l e s i o n is s m a l l .
abscess

6. L a r y n g o - o e s o p h a g e a l c l e f t I t is d u e t o f a i l u r e o f t h e (a) Nose. C h o a n a l atresia i n n e w b o r n .

f u s i o n o f c r i c o i d l a m i n a . Patient presents w i t h repeated (b) Tongue. Macroglossia due to cretinism, haemangioma
aspiration and pneumonitis. Coughing, choking and o r l y m p h a n g i o m a , d e r m o i d at base o f t o n g u e , l i n g u a l
cyanosis are p r e s e n t at t h e t i m e o f f e e d i n g . thyroid.
(c) Mandible. Micrognathia, Pierre-Robin syndrome. In
7. L a r y n g o c e l e I t is d i l a t a t i o n o f l a r y n g e a l saccule a n d
these cases, s t r i d o r is d u e t o f a l l i n g b a c k o f t o n g u e .
extends between thyroid cartilage and the ventricle. It
(d) Pharynx. Congenital d e r m o i d , adenotonsillar h y p e r -
m a y b e i n t e r n a l , e x t e r n a l o r c o m b i n e d . T r e a t m e n t is e n d o -
t r o p h y , r e t r o p h a r y n g e a l abscess, t u m o u r s .
scopic or external excision.
(e) Larynx.
8. L a r y n g e a l cyst I t arises i n t h e a r y e p i g l o t t i c f o l d a n d
(i) Congenital: Laryngeal web, laryngomalacia,
appears as b l u i s h , f l u i d - f i l l e d s m o o t h s w e l l i n g i n t h e s u p r a -
cysts, v o c a l c o r d paralysis, s u b g l o t t i c stenosis.
glottic larynx. Respiratory obstruction may necessitate
Inflammatory: Epiglottitis, laryngotracheitis, d i p h -
tracheostomy. N e e d l e aspiration o r incision and drainage
theria, tuberculosis.
of cyst provides an emergency airway. Treatment is
in Neoplastic: Haemangioma and juvenile multiple
d e r o o f m g t h e c y s t o r e x c i s i o n w i t h C O , laser.
papillomas, carcinoma i n adults.
iv T r a u m a t i c : Injuries o f l a r y n x , f o r e i g n bodies, o e d e m a
f o l l o w i n g endoscopy, o r p r o l o n g e d i n t u b a t i o n .
STRIDOR
N e u r o g e n i c : L a r y n g e a l paralysis d u e t o a c q u i r e d
lesions.
S t r i d o r is n o i s y r e s p i r a t i o n p r o d u c e d b y t u r b u l e n t a i r f l o w M i s c e l l a n e o u s : T e t a n u s , t e t a n y , l a r y n g i s m u s stridulus.
t h r o u g h t h e n a r r o w e d a i r passages. I t m a y be h e a r d d u r i n g
inspiration, expiration or b o t h (Fig. 58.3). Pharynx &
supraglottis nspiratory stridor
• Inspiratory stridor is o f t e n p r o d u c e d i n o b s t r u c t i v e lesions
o f supraglottis o r p h a r y n x , e.g. l a r y n g o m a l a c i a o r r e t r o -
p h a r y n g e a l abscess.
Glottis, subglottis & cervica
• Expiratory stridor is p r o d u c e d i n lesions o f t h o r a c i c tra- trachea
chea, p r i m a r y a n d secondary b r o n c h i , e.g. b r o n c h i a l f o r -
e i g n b o d y , t r a c h e a l stenosis.
• Biphasic stridor is seen i n lesions o f g l o t t i s , s u b g l o t t i s a n d Thoracic trachea
& bronchi
c e r v i c a l trachea, e.g. l a r y n g e a l p a p i l l o m a s , v o c a l c o r d p a r a l -
ysis a n d s u b g l o t t i s stenosis.

^ Aetiology

Figure 58.3
Stridor may arise from lesions of nose, tongue,
Types o f stridor and their site o f origin.
mandible, pharynx, larynx or trachea and bronchi.
Diseases of Larynx and Trachea

(f) Trachea and bronchi (d) Associated fever indicates infective condition,
(i) C o n g e n i t a l : A t r e s i a , stenosis, tracheomalacia. e.g. acute laryngitis, epiglottitis, laryngo-tracheo-
(ii) Inflammatory: Tracheobronchitis. bronchitis or diphtheria.
(iii) N e o p l a s t i c : T u m o u r s o f trachea. (e) Stridor o f laryngomalacia, micrognathia, macroglossia
(iv) T r a u m a t i c : F o r e i g n b o d y , stenosis trachea (e.g. f o l - and i n n o m i n a t e artery compression disappears when
l o w i n g prolonged intubation or tracheostomy). b a b y lies i n p r o n e p o s i t i o n .
(g) Lesions outside respiratory tract (f) Sequential a u s c u l t a t i o n w i t h u n a i d e d ear a n d w i t h s t e t h o -
(i) C o n g e n i t a l : V a s c u l a r r i n g s (cause s t r i d o r a n d d y s - scope o v e r t h e n o s e , o p e n m o u t h , n e c k a n d t h e chest
p h a g i a ) , oesophageal atresia, tracheo-oesophageal h e l p s t o l o c a l i s e t h e p r o b a b l e site o f o r i g i n o f s t r i d o r .
f i s t u l a , c o n g e n i t a l g o i t r e , cystic h y g r o m a . (g) E x a m i n a t i o n o f nose, t o n g u e , j a w a n d p h a r y n x and
(ii) Inflammatory: Retropharyngeal and retro- l a r y n x c a n e x c l u d e l o c a l p a t h o l o g y i n t h e s e areas. I n
o e s o p h a g e a l abscess. a d u l t s , i n d i r e c t l a r y n g o s c o p y c a n b e d o n e easily w h i l e
(iii) Traumatic: FB oesophagus (secondary tracheal infants and c h i l d r e n require direct laryngoscopy.
compression).
(iv) T u m o u r s : Masses i n n e c k . Radiography

(a) X - r a y o f chest a n d soft tissue n e c k b o t h i n a n t e r o p o s -

Management t e r i o r a n d lateral v i e w s .
(b) Huoroscopy to see chest m o v e m e n t s both during

History inspiration and expiration.

(c) T o m o g r a p h y o f chest f o r m e d i a s t i n a l mass.
S t r i d o r is a p h y s i c a l s i g n a n d n o t a disease. A t t e m p t s h o u l d
(d) Oesophagogram w i t h l i p o i d a l f o r atresia o f o e s o p h a -
always be m a d e t o d i s c o v e r the cause. I t is i m p o r t a n t t o e l i c i t :
gus, t r a c h e o b r o n c h i a l f i s t u l a o r a b e r r a n t vessels.
(a) Time of onset t o f i n d w h e t h e r cause is c o n g e n i t a l or (e) A n g i o g r a p h y , i f a b e r r a n t vessels are s u s p e c t e d .
acquired. (f) X e r o r a d i o g r a p h y is u s e f u l t o s h o w s o f t tissue lesions
(b) Mode of onset. S u d d e n o n s e t ( f o r e i g n b o d y , oedema), i n the neck; n o w obsolete.
g r a d u a l a n d progressive ( l a r y n g o m a l a c i a , s u b g l o t t i c h a e - (g) CTscan/MRI.
mangioma, j u v e n i l e papillomas).
(c) Duration. Short (foreign body, oedema, infections), l o n g Direct Laryngoscopy Without Anaesthesia

(laryngomalacia, laryngeal stenosis, subglottic hae-

A q u i c k d i r e c t l a r y n g o s c o p y can be d o n e i n infants and
m a n g i o m a , anomalies o f tongue and j a w ) .
s m a l l c h i l d r e n w i t h o u t anaesthesia. H o w e v e r , resuscitative
(d) Relation to feeding. Aspiration i n laryngeal paralysis,
measures a n d t r a c h e o s t o m y t r a y s h o u l d be m a d e available.
o e s o p h a g e a l atresia, l a r y n g e a l c l e f t , vascular r i n g , f o r -
D i r e c t l a r y n g o s c o p y also g i v e s o p p o r t u n i t y t o see i f i n t u -
eign b o d y oesophagus.
b a t i o n w i l l be possible o r t r a c h e o s t o m y w i l l be required
(e) Cyanotic spells. Indicate need for airway maintenance. for f u r t h e r examination.
(f) Aspiration or ingestion of a foreign body.
(g) Laryngeal trauma. B l u n t injuries to larynx, i n t u b a t i o n , General Anaesthesia Followed by Bronchoscopy, Laryngoscopy
endoscopy. and Oesophagoscopy

Physical Examination A f t e r s l o w i n d u c t i o n , b r o n c h o s c o p y is d o n e f i r s t . I t is u s e -
f u l t o f i n d a n y o b s t r u c t i o n i n a i r passage f r o m s u b g l o t t i s t o
(a) S t r i d o r is always associated w i t h r e s p i r a t o r y distress. T h e r e
b r o n c h i , r e m o v a l o f t h e o b s t r u c t i o n , o b t a i n aspirate or
m a y b e recession i n suprasternal n o t c h , s t e r n u m , i n t e r -
b i o p s y . I f 3 . 5 m m size b r o n c h o s c o p e c a n b e passed, i n t u -
costal spaces a n d e p i g a s t r i u m d u r i n g i n s p i r a t o r y efforts.
b a t i o n o f t h e c h i l d is p o s s i b l e . A f t e r b r o n c h o s c o p y , c h i l d is
(b) N o t e w h e t h e r s t r i d o r is i n s p i r a t o r y , e x p i r a t o r y o r b i p h a -
intubated and detailed examination o f the larynx and
sic w h i c h indicates t h e p r o b a b l e site o f o b s t r u c t i o n .
oesophagus can t h e n be d o n e . L a r y n x s h o u l d again be
(c) N o t e associated c h a r a c t e r i s t i c s o f s t r i d o r .
e x a m i n e d w h e n p a t i e n t is c o m i n g o u t o f anaesthesia a n d
(i) Snoring or snorting sound—nasal or nasopha-
t h e t u b e has b e e n r e m o v e d t o see a c t i v e m o v e m e n t s of
r y n g e a l cause.
v o c a l c o r d s t o e x c l u d e l a r y n g e a l paralysis.
(ii) G u r g l i n g sound and muffled voice—pharyngeal
cause.
(iii) Hoarse cry or voice—laryngeal cause at vocal J Treatment
c o r d s . C r y is n o r m a l i n l a r y n g o m a l a c i a a n d s u b -
g l o t t i c stenosis. O n c e the diagnosis has b e e n m a d e , treatment o f exact
(iv) Expiratory wheeze—bronchial obstruction. cause c a n b e p l a n n e d .
Laryngeal Paralysis

Nerve Supply of Larynx

1 I Causes of Laryngeal Paralysis

Motor A l l the muscles which move the vocal cord I n t o p o g r a p h i c a l m a n n e r , t h e causes are:
( a b d u c t o r s , a d d u c t o r s o r tensors) are s u p p l i e d b y t h e r e c u r -
1. Supranuclear Rare.
rent laryngeal nerve except the c r i c o t h y r o i d muscle. The
2. Nuclear T h e r e is i n v o l v e m e n t o f n u c l e u s a m b i g u u s
l a t t e r r e c e i v e s its i n n e r v a t i o n f r o m t h e e x t e r n a l l a r y n g e a l
in the medulla. T h e causes are v a s c u l a r , neoplastic,
nerve—a branch o f superior laryngeal nerve.
m o t o r n e u r o n e disease, p o l i o , a n d s y r i n g o b u l b i a . I n
Sensory A b o v e the vocal cords, l a r y n x is s u p p l i e d b y n u c l e a r l e s i o n s , t h e r e w o u l d b e associated paralysis o f
internal laryngeal n e r v e — a branch o f superior laryngeal, o t h e r cranial nerves a n d n e u r a l p a t h w a y s .
and b e l o w the vocal cords b y recurrent laryngeal nerve. 3. H i g h vagal lesions Vagus nerve m a y be i n v o l v e d i n
the skull, at t h e exit f r o m jugular foramen or i n
Recurrent laryngeal nerve R i g h t recurrent laryngeal
p a r a p h a r y n g e a l space ( T a b l e 5 9 . 1 ) .
nerve arises f r o m the vagus at t h e l e v e l o f s u b c l a v i a n
a r t e r y , h o o k s a r o u n d i t a n d t h e n ascends b e t w e e n t h e t r a -
chea a n d oesophagus. T h e left recurrent laryngeal nerve
Superior ganglion
arises f r o m t h e v a g u s i n t h e m e d i a s t i n u m at t h e l e v e l o f of vagus
a r c h o f a o r t a , l o o p s a r o u n d i t a n d t h e n ascends i n t o the Jugular foramen
neck i n the tracheo-oesophageal groove. Thus, left recur-
Inferior ganglion
rent laryngeal nerve has a m u c h l o n g e r course which
of vagus
m a k e s i t m o r e p r o n e t o paralysis c o m p a r e d t o t h e right
Vagus nerve
one (Fig. 59.1).
Superior laryngeal
Superior laryngeal nerve I t arises f r o m i n f e r i o r g a n - nerve
g l i o n o f t h e v a g u s , descends b e h i n d i n t e r n a l c a r o t i d a r t e r y
Internal branch
Vagus nerve
a n d , at t h e l e v e l o f g r e a t e r c o r n u a o f h y o i d b o n e , d i v i d e s
i n t o external and i n t e r n a l branches. T h e external b r a n c h External branch
supplies c r i c o t h y r o i d muscle while the internal branch
pierces the t h y r o h y o i d membrane a n d supplies sensory Right recurrent Inferior thyroid artery
laryngeal nerve
i n n e r v a t i o n to the larynx and h y p o p h a r y n x .
Left recurrent
Subclavian aryngeal nerve
artery

Classification of Laryngeal Paralysis

L a r y n g e a l paralysis m a y b e u n i l a t e r a l o r b i l a t e r a l , a n d m a y Arch of aorto

involve:

1. R e c u r r e n t laryngeal nerve.
2. Superior laryngeal nerve. Figure 59.1
3. B o t h r e c u r r e n t a n d superior laryngeal nerves (com-
Recurrent and superior laryngeal nerves.
b i n e d o r c o m p l e t e paralysis).
D i s e a s e s o f Larynx and T r a c h e a

T h e a e t i o l o g y o f r e c u r r e n t l a r y n g e a l n e r v e paralysis is
T a b l e 59.1 Causes o f c o m b i n e d paralysis {high vagal
g i v e n i n T a b l e 5 9 . 3 . B r o n c h o g e n i c c a r c i n o m a is an i m p o r t a n t
lesions)
cause o f left recurrent paralysis a n d s h o u l d a l w a y s b e
Intracranial T u m o u r s o f posterior fossa
e x c l u d e d b y X - r a y chest, b r o n c h o s c o p y a n d b i o p s y unless
Basal meningitis (tubercular)
t h e o t h e r cause is o b v i o u s .
Skull base Fractures

Nasopharyngeal cancer
Clinical Features
G l o m u s t u m o u r

Neck Penetrating injury Unilateral r e c u r r e n t l a r y n g e a l paralysis m a y pass u n d e -

Parapharyngeal t u m o u r s t e c t e d as a b o u t o n e - t h i r d o f t h e p a t i e n t s are a s y m p t o m a t i c .
Metastatic nodes
Others have some change i n voice b u t n o problems o f
L y m p h o m a
aspiration o r airways obstruction. T h e voice i n unilateral
paralysis g r a d u a l l y i m p r o v e s d u e t o c o m p e n s a t i o n b y t h e
h e a l t h y c o r d w h i c h crosses t h e m i d l i n e t o m e e t t h e p a r a -
Low vagal or recurrent laryngeal nerve
lysed o n e .
(Table 59.2).
5. S y s t e m i c c a u s e s Diabetes, syphilis, d i p h t h e r i a , t y p h o i d ,
Treatment
s t r e p t o c o c c a l o r v i r a l i n f e c t i o n s , lead p o i s o n i n g .
6. Idiopathic I n about 3 0 % o f cases, cause remains G e n e r a l l y n o t r e a t m e n t is r e q u i r e d .
obscure.

R E C U R R E N T L A R Y N G E A L N E R V E PARALYSIS B. Bilateral (Bilateral A b d u c t o r Paralysis)

Aetiology
A. Unilateral
N e u r i t i s o r s u r g i c a l t r a u m a ( t h y r o i d e c t o m y ) are t h e m o s t
i m p o r t a n t causes. T h e c o n d i t i o n is o f t e n a c u t e .
U n i l a t e r a l i n j u r y t o r e c u r r e n t l a r y n g e a l n e r v e results i n
i p s i l a t e r a l paralysis o f all t h e i n t r i n s i c muscles e x c e p t t h e c r i -
c o t h y r o i d . T h e v o c a l c o r d t h u s assumes a m e d i a n o r p a r a m e - Position of Cords

d i a n p o s i t i o n a n d does n o t m o v e l a t e r a l l y o n d e e p i n s p i r a t i o n
As all t h e i n t r i n s i c muscles o f l a r y n x are paralysed, t h e
( T a b l e 5 9 . 2 ) . T h e r e are m a n y t h e o r i e s t o e x p l a i n t h e m e d i a n
v o c a l cords l i e i n m e d i a n o r paramedian p o s i t i o n d u e t o
o r p a r a m e d i a n p o s i t i o n o f t h e c o r d . O n e is Semen's law w h i c h
u n o p p o s e d a c t i o n o f c r i c o t h y r o i d muscles (Fig. 5 9 . 2 ) .
states t h a t , i n a l l p r o g r e s s i v e o r g a n i c l e s i o n s , a b d u c t o r f i b r e s
o f t h e n e r v e , w h i c h are p h y l o g e n e t i c a l l y n e w e r , are m o r e
Clinical Features
susceptible a n d thus t h e first t o b e paralysed c o m p a r e d t o
a d d u c t o r f i b r e s . T h e o t h e r e x p l a n a t i o n is Wagner and Grossman As b o t h t h e cords l i e i n m e d i a n o r paramedian p o s i t i o n ,
hypothesis which states t h a t c r i c o t h y r o i d muscle which t h e a i r w a y is i n a d e q u a t e c a u s i n g d y s p n o e a a n d s t r i d o r b u t
receives i n n e r v a t i o n f r o m s u p e r i o r l a r y n g e a l n e r v e keeps t h e t h e v o i c e is g o o d . D y s p n o e a a n d s t r i d o r b e c o m e w o r s e o n
c o r d i n p a r a m e d i a n p o s i t i o n d u e t o its a d d u c t o r f u n c t i o n . e x e r t i o n o r d u r i n g a n attack o f acute laryngitis.

Position o f the vocal cord in health a n d disease

Situation in

Position of the cord Location of the cord from midline Health Disease

M e d i a n Midline • Phonation RLN paralysis

Paramedian 1.5 m m • Strong whisper RLN paralysis

Intermediate 3.5 m m . T h i s is n e u t r a l position o f Paralysis o f b o t h recurrent

(cadaveric) cricoarytenoid joint. A b d u c t i o n a n d and superior laryngeal

a d d u c t i o n take place from this position nerves

Gentle a b d u c t i o n 7 m m Quiet respiration Paralysis o f a d d u c t o r s

Full abduction 9.5 m m Deep inspiration

 Laryngeal Paralysis

1 Causes o f recurrent laryngeal nerve paralysis (low vagal trunk or recurrent laryngeal nerve)

Right Left Both

• Neck t r a u m a 1. Neck

• Benign or malignant thyroid disease • Accidental t r a u m a

• Thyroid surgery • Thyroid disease (benign or malignant) Thyroid surgery

• C a r c i n o m a cervical oesophagus • Thyroid surgery C a r c i n o m a thyroid

• Cervicai l y m p h a d e n o p a t h y • C a r c i n o m a cervical oesophagus Cancer cervical oesophagus

• Cervical l y m p h a d e n o p a t h y Cervical l y m p h a d e n o p a t h y

II. Mediastinum

• A n e u r y s m o f subclavian artery • Bronchogenic cancer

• C a r c i n o m a apex right lung • C a r c i n o m a thoracic oesophagus

• Tuberculosis o f cervical pleura • Aortic aneurysm

• Idiopathic • Mediastinal l y m p h a d e n o p a t h y

• Enlarged left auricle

• Intrathoracic surgery

• Idiopathic

t r a c h e o s t o m y h o l e i n t h e neck. T h e latter relieves a i r w a y

o b s t r u c t i o n b u t at t h e e x p e n s e o f a g o o d v o i c e ; h o w e v e r
t h e r e is n o t r a c h e o s t o m y h o l e i n t h e n e c k .

LateraHsation o f the c o r d A i m is t o m o v e a n d f i x t h e
c o r d i n a lateral p o s i t i o n to i m p r o v e the a i r w a y . T h e v a r i -
ous p r o c e d u r e s are:

{a] Aiytenoidectomy. A r y t e n o i d c a r t i l a g e is e x c i s e d b y a n
external neck approach and the c o r d f i x e d i n a lateral
p o s i t i o n . A r y t e n o i d e c t o m y c a n also b e d o n e t h r o u g h
an endoscope.
(b) Vocal cord lateralisation through endoscope.
— Median (c) Thyroplasty type II. (See p h o n o s u r g e r y ) .

Paramedian (d) Cordectomy. T h i s can be a c c o m p l i s h e d t h r o u g h neck

i n c i s i o n . T h e s e days C O , laser has b e e n u s e d t o excise
Intermediate (cadaveric)
the c o r d t h r o u g h the endoscope.

Slight abduction (e) Nerve muscle implant. Sternohyoid muscle with its
n e r v e s u p p l y is t r a n s p l a n t e d i n t o t h e p a r a l y s e d p o s t e -
Full abduction
rior cricoarytenoid to b r i n g some m o v e m e n t to the
Figure 59.2 c o r d . T h i s o p e r a t i o n is n o t v e r y successful.

Position o f vocal cords.

Treatment PARALYSIS O F SUPERIOR

LARYNGEAL NERVE
Tracheostomy M a n y cases o f b i l a t e r a l a b d u c t o r paralysis
r e q u i r e t r a c h e o s t o m y as a n e m e r g e n c y p r o c e d u r e o r w h e n
they develop u p p e r respiratory tract infection. A. Unilateral
I n l o n g - s t a n d i n g cases, t h e c h o i c e is b e t w e e n a p e r m a -
nent tracheostomy w i t h a speaking valve o r a surgical Isolated lesions o f this n e r v e are rare; usual l y, i t is a p a r t o f
p r o c e d u r e t o lateralise t h e c o r d . T h e f o r m e r r e l i e v e s s t r i - combined paralysis. Paralysis o f superior laryngeal nerve
dor, p r e s e r v e s g o o d v o i c e b u t has t h e d i s a d v a n t a g e o f a causes paralysis of cricothyroid muscle and ipsilateral
Diseases of Larynx and Trachea

anaesthesia o f t h e l a r y n x a b o v e t h e v o c a l c o r d . Paralysis o f c r i - Aetiology

c o t h y r o i d can also o c c u r w h e n e x t e r n a l l a r y n g e a l n e r v e is
T h y r o i d s u r g e i y is t h e m o s t c o m m o n cause w h e n b o t h
i n v o l v e d i n t h y r o i d surgery, t u m o u r s , n e u r i t i s o r d i p h t h e r i a .
r e c u r r e n t a n d e x t e r n a l l a r y n g e a l n e r v e s o f o n e side m a y b e
involved.
Clinical Features I t m a y also o c c u r i n lesions o f n u c l e u s a m b i g u u s o r t h a t
o f the vagus nerve p r o x i m a l to the origin o f superior
V o i c e is w e a k a n d p i t c h c a n n o t b e r a i s e d . A n a e s t h e s i a of
laryngeal nerve. T h u s , lesion m a y lie i n the medulla, pos-
t h e l a r y n x o n o n e side m a y pass u n n o t i c e d o r cause o c c a -
terior cranial fossa, j u g u l a r f o r a m e n or paraphaiyngeal
sional aspiration. Laryngeal findings i n c l u d e :
space.
t. A s k e w p o s i t i o n o f g l o t t i s as a n t e r i o r c o m m i s s u r e is
r o t a t e d t o the h e a l t h y side. Clinical Features

2. S h o r t e n i n g o f c o r d w i t h loss o f t e n s i o n . T h e p a r a l y s e d A s a l l t h e m u s c l e s o f l a r y n x o n o n e side are p a r a l y s e d , v o c a l

c o r d appears w a v y d u e t o l a c k o f t e n s i o n . c o r d w i l l lie i n the cadaveric p o s i t i o n , i.e. 3.5 m m from
3. F l a p p i n g o f the paralysed c o r d . As t e n s i o n o f t h e c o r d the m i d l i n e (Table 5 9 . 2 ) . T h e h e a l t h y c o r d is u n a b l e to
is l o s t , i t sags d o w n d u r i n g i n s p i r a t i o n a n d b u l g e s u p approximate the paralysed cord, thus causing glottic
during expiration. i n c o m p e t e n c e . T h i s results i n hoarseness o f v o i c e a n d a s p i -
r a t i o n o f l i q u i d s t h r o u g h t h e g l o t t i s . C o u g h is i n e f f e c t i v e
d u e to air waste.
g B. Bilateral |
Treatment

T h i s is an u n c o m m o n c o n d i t i o n . B o t h t h e c r i c o t h y r o i d m u s -
1. Speech therapy. With proper speech therapy, the
cles are paralysed a l o n g w i t h anaesthesia o f u p p e r l a r y n x .
h e a l t h y c o r d m a y c o m p e n s a t e t h e loss o f f u n c t i o n o f
p a r a l y s e d v o c a l c o r d b y m o v i n g across t h e m i d l i n e .
Aetiology
2. Procedures to mediatise the cord. In uncompensated
I m p o r t a n t causes i n c l u d e s u r g i c a l o r a c c i d e n t a l trauma, cases, a i m is t o b r i n g t h e p a r a l y s e d c o r d t o w a r d s t h e
n e u r i t i s ( m o s t l y d i p h t h e r i t i c ) , pressure b y c e r v i c a l n o d e s o r midline so that healthy c o r d can meet it. This is
i n v o l v e m e n t i n a neoplastic process. achieved by:
(a) Injection of teflon paste l a t e r a l t o t h e p a r a l y s e d c o r d .
Clinical Features
T h i s is d o n e b y d i r e c t l a r y n g o s c o p y u n d e r l o c a l
P r e s e n c e o f b o t h paralysis a n d b i l a t e r a l anaesthesia causes anaesthesia.
i n h a l a t i o n o f f o o d a n d p h a r y n g e a l s e c r e t i o n s g i v i n g rise t o (b) Thyroplasty type I. (See phonosurgery vide infra).
c o u g h a n d c h o k i n g f i t s . V o i c e is w e a k a n d h u s k y . (c) Muscle or cartilage implant. L a r y n g o fissure is d o n e
a n d a b i p e d i c l e d muscle graft o r piece o f cartilage
Treatment
is i n s e r t e d b e t w e e n t h y r o i d c a r t i l a g e a n d its i n n e r
It depends o n cause. Cases d u e t o n e u r i t i s m a y recover p e r i c h o n d r i u m lateral to v o c a l c o r d , thus p u s h i n g
spontaneously. Patients with repeated aspiration may the c o r d medially.
r e q u i r e tracheostomy w i t h a cuffed tube and an oesopha- (d) Arthrodesis of cricoarytenoid joint. L a r y n x is o p e n e d
geal f e e d i n g t u b e . b y l a r y n g o f i s s u r e , a r y t e n o i d cartilage r o t a t e d m e d i -
E p i g l o t t o p e x y is an o p e r a t i o n t o close t h e laryngeal ally a n d f i x e d w i t h a screw.
inlet to protect the lungs from r e p e a t e d a s p i r a t i o n . I t is a
reversible procedure.
| B. Bilateral |

C O M B I N E D ( C O M P L E T E ) PARALYSIS
(RECURRENT AND
LARYNGEAL NERVE PARALYSIS)
B o t h r e c u r r e n t a n d s u p e r i o r l a r y n g e a l n e r v e s o n b o t h sides
SUPERIOR
are p a r a l y s e d . T h i s is a r a r e c o n d i t i o n . A s all t h e l a r y n g e a l
m u s c l e s are p a r a l y s e d , b o t h c o r d s l i e i n c a d a v e r i c p o s i t i o n .
T h e r e is also t o t a l anaesthesia o f t h e l a r y n x .

^ A. Unilateral
Clinical Features

T h i s causes paralysis o f a l l t h e m u s c l e s o f l a r y n x o n one 1. Aphonia. A s c o r d s d o n o t m e e t at a l l .

side e x c e p t t h e i n t e r a r y t e n o i d w h i c h also r e c e i v e s i n n e r v a - 2. Aspiration. This is d u e to incompetent glottis and
t i o n f r o m the o p p o s i t e side. l a r y n g e a l anaesthesia.
 Laryngeal Paralysis

3. Inability to cough. T h i s is d u e t o i n a b i l i t y o f t h e cords t o

Phonosurgery
m e e t . T h i s results i n r e t e n t i o n o f secretions i n t h e chest.
4. Bronchopneumonia. T h i s is d u e t o r e p e a t e d aspirations
Several surgical procedures have b e e n designed t o i m p r o v e
a n d r e t e n t i o n o f secretions.
the quality o f voice. T h e y i n c l u d e :

Treatment 1. E x c i s i o n o f b e n i g n o r m a l i g n a n t lesions b y m i c r o -
l a r y n g e a l s u r g e r y o r laser.
1. Tracheostomy. Essential t o r e m o v e p u l m o n a r y s e c r e -
2. I n j e c t i o n o f v o c a l c o r d w i t h t e f l o n paste o r g e l f o a m t o
tions and inhaled material.
a u g m e n t a n d m e d i a l i s e t h e p a r a l y s e d c o r d so t h a t t h e
2. Epigiottopexy. I t is a n o p e r a t i o n i n w h i c h e p i g l o t t i s is
o p p o s i t e h e a l t h y c o r d c a n easily a p p r o x i m a t e .
f o l d e d b a c k w a r d s a n d f i x e d t o t h e a r y t e n o i d s so as t o
3. Thyroplasty. Isshiki d i v i d e d thyroplasty procedures
p r e v e n t a s p i r a t i o n i n t o t h e l u n g s . I t is a r e v e r s i b l e
i n t o f o u r categories t o p r o d u c e f u n c t i o n a l a l t e r a t i o n o f
procedure.
vocal cords.
3. Vocal cord plication. L a r y n x is o p e n e d b y l a r y n g o f i s s u r e .
(a) T y p e I. I t is medial displacement o f v o c a l c o r d as is
M u c o s a o f t h e t r u e a n d false c o r d s is r e m o v e d a n d
a c h i e v e d i n t e f l o n paste i n j e c t i o n .
t h e n t h e y are a p p r o x i m a t e d w i t h s u t u r e s . T h i s p r o c e -
(b) T y p e I I . I t is lateral displacement o f vocal cord and
d u r e helps t o p r e v e n t aspiration a n d can be reversed
is u s e d t o i m p r o v e t h e a i r w a y .
w h e n required.
(c) T y p e I I I . I t is u s e d t o shorten (relax) the vocal c o r d .
4. Total laryngectomy. M a y b e n e e d e d i n those w h e r e cause is
R e l a x a t i o n o f vocal c o r d lowers the p i t c h . This
progressive a n d i r r e v e r s i b l e a n d speech is u n s e r v i c e a b l e .
p r o c e d u r e is d o n e i n m u t a t i o n a l falsetto o r i n those
5. Diversion procedures.
w h o have undergone gender transformation f r o m
female to male.
(d) T y p e IV. This procedure is used to lengthen
CONGENITAL V O C A L C O R D PARALYSIS
(tighten) t h e v o c a l c o r d a n d elevate the p i t c h . I t
converts male character o f voice to female and
I t m a y b e u n i l a t e r a l o r b i l a t e r a l . U n i l a t e r a l paralysis is m o r e has b e e n u s e d i n g e n d e r t r a n s f o r m a t i o n . I t is also
common. The cause m a y b e b i r t h t r a u m a o r c o n g e n i t a l u s e d w h e n v o c a l c o r d is l a x a n d b o w i n g d u e t o
a n o m a l y o f a g r e a t vessel o r h e a r t . B i l a t e r a l paralysis m a y b e a g i n g process o r t r a u m a .
due to hydrocephalus or A r n o l d - C h i a r i m a l f o r m a t i o n , 4. Laryngeal r e i n n e r v a t i o n procedures. I n this, a segment
intracerebral haemorrhage during birth, meningocoele, o f a n t e r i o r b e l l y o f o m o h y o i d m u s c l e , c a r r y i n g its n e r v e
o r c e r e b r a l o r n u c l e u s a m b i g u u s agenesis. T h e p a t i e n t o f {ansa h y p o g l o s s i ) a n d vessels, is i m p l a n t e d i n t o t h e t h y -
b i l a t e r a l paralysis presents w i t h features o f b i l a t e r a l a b d u c - r o a r y t e n o i d m u s c l e after m a k i n g a w i n d o w i n t h y r o i d
tor paralysis and respiratory obstruction necessitating c a r t i l a g e . I t is s u p p o s e d t o i n n e r v a t e t h e p a r a l y s e d t h y -
tracheostomy. roarytenoid muscle.
Benign T u m o u r s o f Larynx

B e n i g n t u m o u r s o f t h e l a r y n x are n o t as c o m m o n as t h e h i g h i n t e n s i t i e s . T h e y m o s t l y affect teachers, actors, ven-

m a l i g n a n t o n e s . T h e y are d i v i d e d i n t o : (a) N o n - n e o p l a s t i c d o r s o r p o p singers. T h e y are also seen i n s c h o o l going
a n d (b) N e o p l a s t i c t u m o u r s ( T a b l e 6 0 . 1 ) . c h i l d r e n w h o are t o o assertive a n d t a l k a t i v e .
Pathologically, trauma t o the vocal c o r d i n the f o r m o f
v o c a l abuse o r m i s u s e causes o e d e m a a n d h a e m o r r h a g e i n
NON-NEOPLASTIC
the submucosal space. T h i s u n d e r g o e s hyalinisation and
f i b r o s i s . T h e o v e r l y i n g e p i t h e l i u m also u n d e r g o e s hyper-
T h e y are n o t t r u e n e o p l a s m s b u t are t u m o u r - l i k e masses plasia f o r m i n g a n o d u l e . I n e a r l y stages, t h e n o d u l e s appear
w h i c h f o n n as a result o f i n f e c t i o n , t r a u m a o r d e g e n e r a t i o n . soft, r e d d i s h a n d o e d e m a t o u s s w e l l i n g s b u t later b e c o m e
T h e y are seen m o r e f r e q u e n t l y t h a n t r u e b e n i g n n e o p l a s m s . greyish o r w h i t e i n c o l o u r .
Patients with vocal nodules complain of hoarseness.
V o c a l fatigue and pain i n the neck o n p r o l o n g e d p h o n a -
^ A. Solid Non-neoplastic Lesions
t i o n , are o t h e r c o m m o n s y m p t o m s .
E a r l y cases o f v o c a l n o d u l e s can b e t r e a t e d conserva-
1. Vocal Nodules (Singer's or Screamer's Nodes)
t i v e l y b y e d u c a t i n g t h e p a t i e n t i n p r o p e r use o f v o i c e . W i t h
T h e y appear s y m m e t r i c a l l y o n t h e f r e e e d g e o f v o c a l c o r d , t h i s t r e a t m e n t , m a n y n o d u l e s i n c h i l d r e n disappear com-
at t h e j u n c t i o n o f a n t e r i o r o n e - t h i r d , w i t h t h e posterior p l e t e l y . S u r g e r y is r e q u i r e d f o r large n o d u l e s o r n o d u l e s o f
t w o - t h i r d s , as t h i s is t h e area o f m a x i m u m v i b r a t i o n o f l o n g - s t a n d i n g i n a d u l t s . T h e y are e x c i s e d w i t h precision
t h e c o r d a n d t h u s s u b j e c t t o m a x i m u m t r a u m a (Figs 6 0 . 1 under operating microscope a v o i d i n g any trauma to the
a n d 6 0 . 2 ) . T h e i r size varies f r o m t h a t o f p i n - h e a d t o h a l f a underlying vocal ligament.
pea. T h e y are the result o f vocal t r a u m a w h e n person Speech therapy and re-education i n voice p r o d u c t i o n
speaks i n u n n a t u r a l l o w t o n e s f o r p r o l o n g e d p e r i o d s o r at are essential t o p r e v e n t t h e i r r e c u r r e n c e .

Table 60.1 Benign t u m o u r s o f larynx

Non-neoplastic Neoplastic

Solid S q u a m o u s p a p i l l o m a

Vocal nodules juvenile type

Vocal polyp Adult-onset type

Reinke's o e d e m a C h o n d r o m a

C o n t a c t ulcer H a e m a n g i o m a

Intubation g r a n u l o m a G r a n u l a r cell t u m o u r

Leukoplakia Glandular t u m o u r s

A m y l o i d t u m o u r s R h a b d o m y o m a

Cystic L i p o m a
Figure 60.1
Ductal cysts Fibroma

Saccular cysts Vocal nodules. Typically, they form at the junction o f anterior

Laryngocele one-third with posterior two-thirds o f vocal cord.

 Benign T u m o u r s o f Larynx

2. Vocal Polyp u n i l a t e r a l o r bilateral ulcers w i t h c o n g e s t i o n o f a r y t e n o i d

cartilages. T h e r e m a y be g r a n u l o m a f o r m a t i o n .
I t is also t h e r e s u l t o f v o c a l abuse o r m i s u s e . O t h e r c o n t r i b -
u t i n g f a c t o r s are a l l e r g y a n d s m o k i n g . M o s t l y , i t affects
m e n in t h e age g r o u p o f 3 0 - 5 0 . I y p i c . i l l y . a v o c a l p o l y p is 5. Intubation Granuloma

u n i l a t e r a l a r i s i n g f r o m t h e same p o s i t i o n as v o c a l n o d u l e . I t results f r o m i n j u r y t o v o c a l processes o f a r y t e n o i d s d u e

I t is soft, s m o o t h a n d o f t e n p e d u n c u l a t e d . I t m a y flop up t o r o u g h i n t u b a t i o n , use o f l a r g e t u b e o r p r o l o n g e d p r e s -
and d o w n the glottis d u r i n g respiration or p h o n a t i o n . e n c e o f t u b e b e t w e e n t h e c o r d s . M u c o s a l u l c e r a t i o n is f o l -
H o a r s e n e s s is a c o m m o n s y m p t o m . L a r g e p o l y p m a y cause l o w e d b y granuloma f o r m a t i o n over the exposed cartilage.
dyspnoea, stridor o r i n t e r m i t t e n t c h o k i n g . S o m e patients U s u a l l y , t h e y are b i l a t e r a l i n v o l v i n g p o s t e r i o r t h i r d s o f t r u e
complain o f d i p l o p h o n i a (double voice) due to different c o r d s . T h e y p r e s e n t w i t h hoarseness a n d i f l a r g e , d y s p n o e a .
vibratory frequencies o f the t w o vocal cords. Treatment is v o i c e rest a n d e n d o s c o p i c r e m o v a l o f the
V o c a l p o l y p is c a u s e d b y s u d d e n s h o u t i n g r e s u l t i n g i n granuloma.
haemorrhage i n the vocal c o r d and subsequent submucosal
oedema. Treatment is s u r g i c a l e x c i s i o n u n d e r o p e r a t i n g
6. Leukoplakia or Keratosis
m i c r o s c o p e f o l l o w e d b y speech t h e r a p y .
T h i s is also a l o c a l i s e d f o r m o f e p i t h e l i a l h y p e r p l a s i a i n v o l v -
i n g u p p e r surface o f o n e o r b o t h v o c a l c o r d s . I t appears as
3. Reinke's Oedema (Bilateral Diffuse Polyposis)
a w h i t e plaque or w a r t y g r o w t h on the c o r d without
T h i s is d u e t o c o l l e c t i o n o f o e d e m a fluid i n t h e s u b e p i t h e - a f f e c t i n g its m o b i l i t y . I t is r e g a r d e d as a p r e c a n c e r o u s c o n -
lial space o f R e i n k e . U s u a l cause is v o c a l abuse a n d s m o k - d i t i o n because " c a r c i n o m a i n s i t u " f r e q u e n t l y supervenes.
i n g . B o t h v o c a l cords s h o w diffuse s y m m e t r i c a l swellings. H o a r s e n e s s is t h e c o m m o n p r e s e n t i n g s y m p t o m . T r e a t m e n t
Treatment is v o c a l cord stripping, preserving enough is s t r i p p i n g o f v o c a l c o r d s a n d s u b j e c t i n g t h e tissues t o h i s -
m u c o s a f o r e p i t h e l i a h s a t i o n . O n l y o n e c o r d is o p e r a t e d at t o l o g y for any malignant change. C h r o n i c laryngeal irritants
a t i m e . R e - e d u c a t i o n i n v o i c e p r o d u c t i o n a n d cessation o f as t h e a e t i o l o g i c a l factors s h o u l d b e s o u g h t a n d e l i m i n a t e d .
s m o k i n g are essential t o p r e v e n t recurrence.

7. Amyloid Tumour
4. Contact Ulcer
I t m o s t l y affects m e n i n t h e age g r o u p o f 50—70. The
T h i s is a g a i n due to faulty voice p r o d u c t i o n i n w h i c h t u m o u r presents as a s m o o t h p l a q u e o r a p e d u n c u l a t e d
v o c a l processes o f a r y t e n o i d s h a m m e r against e a c h o t h e r mass. D i a g n o s i s is o n l y o n h i s t o l o g y . T r e a t m e n t is e n d o -
resulting in ulceration and granuloma formation. Some scopic surgical excision.
cases are d u e t o gastric r e f l u x . C h i e f c o m p l a i n t s are h o a r s e
v o i c e , a c o n s t a n t d e s i r e t o clear t h e t h r o a t a n d p a i n i n t h e
t h r o a t w h i c h is w o r s e o n p h o n a t i o n . E x a m i n a t i o n r e v e a l s
B. Cystic Lesions

T h e y are o f t h r e e t y p e s :

1. D u c t a l c y s t s M o s t o f t e n t h e y are r e t e n t i o n cysts d u e
to blockage o f ducts o f s e r o m u c i n o u s glands o f laryngeal
m u c o s a . T h e y are seen i n t h e v a l l e c u l a , a r y e p i g l o t t i c f o l d ,
false c o r d s , v e n t r i c l e s a n d p y r i f o r m fossa. T h e y m a y r e m a i n
a s y m p t o m a t i c i f s m a l l , o r cause hoarseness, c o u g h , t h r o a t
p a i n a n d d y s p n o e a , i f large ( F i g . 6 0 . 3 ) .
S o m e t i m e s , a n i n t r a c o r d a l cyst m a y o c c u r o n t h e t r u e
c o r d . I t is s i m i l a r t o a n e p i d e r m o i d i n c l u s i o n c y s t .

2. S a c c u l a r c y s t s O b s t r u c t i o n t o t h e o r i f i c e o f saccule
causes r e t e n t i o n o f s e c r e t i o n and distension o f saccule
w h i c h presents as a cyst i n l a r y n g e a l v e n t r i c l e . Anterior sac-
cular cysts present i n the anterior part o f ventricle and
o b s c u r e p a r t o f v o c a l c o r d . Lateral saccular cysts, w h i c h are

Figure 60.2 l a r g e r , e x t e n d i n t o t h e false c o r d , a r y e p i g l o t t i c f o l d a n d

m a y e v e n appear i n the n e c k t h r o u g h t h y r o h y o i d m e m -
Vocal nodules.
b r a n e j u s t as l a r y n g o c e l e s d o .
Diseases of Larynx and Trachea

Figure 60.5

L a r y n g o c e l e left side as seen o n V a l s a l v a ( a r r o w ) .

A laryngocele is s u p p o s e d t o arise f r o m raised transglot-

tic air pressure as i n t r u m p e t players, glass-blowers o r

w e i g h t lifters.

A laryngocele presents w i t h hoarseness, c o u g h a n di f

large, o b s t r u c t i o n t o t h e airway. A n external laryngocele

p r e s e n t s as a r e d u c i b l e s w e l l i n g i n t h e n e c k w h i c h increases

in size o n c o u g h i n g o r p e r f o r m i n g Valsalva (Fig. 60.5).

Diagnosis c a n b e m a d e b y indirect laryngoscopy, a n d

Figure 60.3 soft t i s s u e A . P . a n dl a t e r a l v i e w s o fn e c k w i t h Valsalva. C T

scan helps t o f i n d t h e extent o f lesion.

(A) A r y e p i g l o t t i c cyst. I tc a u s e d intermittent laryngeal obstruc-
T r e a t m e n t is s u r g i c a l e x c i s i o n t h r o u g h a n external n e c k
tion. ( B )C y s t a f t e r removal.

incision. M a r s u p i a l i s a t i o n o fa n i n t e r n a l l a r y n g o c e l e c a n b e

d o n e b y laryngoscopy b u t there are chances o f recurrence.

A laryngocele i n a n adult m a y b e associated w i t h

c a r c i n o m a .

Thyrohyoid Laryngocele:
membrane
Externa!
component
NEOPLASTIC
nternal
component

E x c e p t f o r laryngeal papillomas w h i c h constitute about

80% o f t h e total occurrence o f neoplasms o f t h e larynx,

others are u n c o m m o n .

Figure 60.4
J 1. S q u a m o u s Papillomas |
Laryngocele mixed type with internal a n d external components.

T h e y c a n b e d i v i d e d i n t o (a) j u v e n i l e a n d (b) adult-onset

types.

(a) Juvenile papillomas T h e y are viral i n origin a n d

3. L a r y n g o c e l e I t is a n a i r - f i l l e d cystic s w e l l i n g d u e t o
m u l t i p l e , often i n v o l v i n g infants a n d y o u n g c h i l d r e n w h o
dilatation o ft h e saccule (Fig. 60.4). A laryngocele m a yb e :
present w i t h hoarseness a n d stridor. T h e y are m o s t l y seen

(i) Internal w h i c h is c o n f i n e d w i t h i n t h e l a r y n x a n d pres- on t h e true a n d false cords a n d t h e epiglottis, b u t they m a y

e n t s as d i s t e n s i o n o ffalse c o r d a n d aryepiglottic fold. i n v o l v e o t h e r sites i n t h e l a r y n x a n d trachea. Clinically,

(ii) External i nw h i c h distended saccule herniates t h r o u g h they appear as g l i s t e n i n g w h i t e i r r e g u l a r g r o w t h s , p e d u n c u -

the t h y r o i d m e m b r a n e a n d presents i n neck; o r lated o r sessile, f r i a b l e a n d b l e e d i n g easily (Fig. 60.6). T h e y

(iii) Combined or mixed i n w h i c h b o t h internal a n d exter- are k n o w n f o rr e c u r r e n c e after r e m o v a l a n d t h e r e f o r e m u l t i -

nal c o m p o n e n t s are seen. ple laryngoscopies m a yb e r e q u i r e d . T h e y tend t o disappear

 Benign T u m o u r s of Larynx

o u t w a r d f r o m t h e p o s t e r i o r p l a t e o f c r i c o i d a n d cause sense
o f l u m p i n t h r o a t a n d dysphagia. T h e y m o s t l y affect m e n
i n t h e age g r o u p o f 4 0 - 6 0 .

3. Haemangioma

Infantile haemangioma i n v o l v e s t h e s u b g l o t t i c area a n d

presents w i t h s t r i d o r i n t h e f i r s t 6 m o n t h s o f l i f e . About
5 0 % o f such c h i l d r e n have haemangiomas elsewhere i n the
b o d y p a r t i c u l a r l y i n t h e h e a d a n d n e c k area. T h e y t e n d t o
i n v o l u t e spontaneously b u t a tracheostomy m a y be needed
t o r e l i e v e r e s p i r a t o r y o b s t r u c t i o n i f a i r w a y is c o m p r o m i s e d .
M o s t o f t h e m are o f c a p i l l a r y t y p e a n d c a n be v a p o r i s e d
w i t h C O , laser.
Figure 60.6 A d u l t haemangiomas involve vocal cord or supraglottic
l a r y n x . T h e y are c a v e r n o u s t y p e a n d c a n n o t b e t r e a t e d w i t h
Supraglottic papillomatosis.
laser. T h e y are l e f t a l o n e i f a s y m p t o m a t i c . F o r l a r g e r ones
causing s y m p t o m s , steroid or radiation therapy m a y be
s p o n t a n e o u s l y after p u b e r t y . T h e y have b e e n t r e a t e d b y
employed.
endoscopic removal w i t h cup forceps, cryotherapy and
m i c r o electrocautery. T h e s e days, C O , laser is p r e f e r r e d
b e c a u s e o f t h e p r e c i s i o n i n r e m o v a l a n d less b l e e d i n g .
4. G r a n u l a r Cell T u m o u r
I n t e r f e r o n t h e r a p y is b e i n g t r i e d t o p r e v e n t r e c u r r e n c e a n d
has b e e n f o u n d successful.
It arises f r o m Schwann cells a n d is o f t e n submucosal.
(b) A d u l t - o n s e t p a p i l l o m a U s u a l l y , i t is s i n g l e , s m a l l e r Overlying epithelium shows pseudoepitheliomatous
i n size, less aggressive a n d does n o t r e c u r a f t e r s u r g i c a l hyperplasia, w h i c h m a y o n histology, resemble w e l l differ-
r e m o v a l . I t is c o m m o n i n m a l e s ( 2 : 1 ) i n t h e age g r o u p o f entiated carcinoma.
3 0 - 5 0 a n d u s u a l l y arises f r o m t h e a n t e r i o r h a l f o f v o c a l
c o r d o r a n t e r i o r c o m m i s s u r e . T r e a t m e n t is t h e s a m e as f o r
juvenile type. 5. Glandular Tumour

P l e o m o r p h i c a d e n o m a o r o n c o c y t o m a are rare g l a n d u l a r
P| 2. Chondroma tumours.
O t h e r rare b e n i g n laryngeal t u m o u r s i n c l u d e rhab-
M o s t o f t h e m arise f r o m c r i c o i d c a r t i l a g e a n d m a y p r e s e n t domyoma, neurofibroma, neurilemmoma, lipoma
in the s u b g l o t t i c area c a u s i n g dyspnoea or may grow or fibroma.
 asbestos, m u s t a r d gas a n d other c h e m i c a l o r p e t r o l e u m
Epidemiology
products has also b e e n related to the genesis o f laryngeal

cancer b u t w i t h o u t conclusive evidence.

C a n c e r l a r y n x constitutes 2 . 6 3 % o f all b o d y cancers i n

India. I t is 1 0 t i m e s m o r e c o m m o n i n males than in females

( 4 . 7 9 % versus 0.47%). Its incidence is 3.29 n e w cases i n T N M Classification a n d Staging

males a n d 0.42 n e w cases i n females per 1 0 0 , 0 0 0 p o p u l a -

t i o n ( N a t i o n a l C a n c e r R e g i s t r y , I C M R , A p r i l 2 0 0 5 report). A c c o r d i n g to A J C C (2002), l a r y n x has b e e n d i v i d e d i n t o

R e c e n t l y , its i n c i d e n c e i n females has increased i n western t h r e e sites ( o r r e g i o n s ) w i t h several subsites u n d e r each site

countries d u e to m o r e w o m e n t a k i n g to s m o k i n g . Disease (see T a b l e 61.1 a n d F i g . 61.1).

is m o s t l y s e e n i n the age g r o u p o f 4 0 - 7 0 years b u t y o u n g e r T u m o u r s arising f r o m these sites are further classified b y

people i n 30s m a y occasionally be affected. T N M system w h e r e :

T — i n d i c a t e s t u m o u r and its e x t e n t , e.g. T , , T „ T , , etc.

N — i n d i c a t e s regional l y m p h n o d e enlargement a n d its

Aetiology
size, e.g. N L N L N „ etc.

M — i n d i c a t e s distant metastasis. Absence o f metastasis is

B o t h tobacco a n d alcohol are w e l l established risk factors i n
M ( | w h i l e p r e s e n c e o f m e t a s t a s i s is M r D e p e n d i n g o n
laryngeal cancer. Cigarette s m o k e contains b e n z o p y r e n e
T N M , t u m o u r is f u r t h e r grouped into various stages.
a n d o t h e r h y d r o c a r b o n s w h i c h are carcinogenic i n m a n .
T h u s , each laryngeal cancer can be staged, d e p e n d i n g
C o m b i n a t i o n o f a l c o h o l a n d s m o k i n g increases the risk
u p o n the extent o f disease, n o d a l o r distant metastasis
15-folds c o m p a r e d to each factor alone (2—3 f o l d s ) . Previous
(Table 61.2). T h i s international staging o f disease helps to
radiation to n e c k for b e n i g n lesions o r laryngeal p a p i l l o m a

m a y i n d u c e laryngeal c a r c i n o m a . Japanese a n d Russian

w o r k e r s h a v e r e p o r t e d cases o f familial laryngeal m a l i g -

n a n c y i n c r i m i n a t i n g genetic factors. Occupational exposure to Pyriform fosso

False cord
T a b l e 61.1 Classification o f sites a n d v a r i o u s subsites under

e a c h site in l a r y n x ( A J C C classification 2002) Ventricle

True cord
Site Subsite

Supraglottis • Suprahyoid epiglottis ( b o t h lingual and

laryngeal surfaces)

•
Infrahyoid epiglottis

Aryepiglotticfolds (laryngeal aspect only) H

• Arytenoids F i g u r e 61.1
• Ventricular bands ( o r false cords)
A c c o r d i n g to AJCC, glottis extends from the horizontal plane
Glottis • True vocal cords including anterior and
passing t h r o u g h lateral m a r g i n o f ventricle at its j u n c t i o n with
posterior commissure
superior surface o f the vocal cord to 1 c m b e l o w it. S u b g l o t t i s

Subglottis • Subglottis up to lower border o f cricoid extends from lower limit o f glottis to lower border o f cricoid

cartilage cartilage.
 Cancer Larynx

c o m p a r e the results o f different modalities o f treatment b y

different w o r k e r s a n d assists i n t h e c h o i c e o f treatment a n d

prognosis o f disease.

H istopathology

A b o u t 90—95% o f laryngeal malignancies are s q u a m o u s

cell c a r c i n o m a w i t h various grades o f differentiation. C o r d a l

lesions are often well-differentiated w h i l e supraglottic ones

are anaplastic.

T h e rest 5 - 1 0 % o f lesions i n c l u d e verrucous c a r c i n o m a ,

spindle cell carcinoma, m a l i g n a n t salivary gland t u m o u r s

a n d sarcomas.
Figure 61.2

/. Supraglottic Cancer Cancer larynx ( A ) Supraglottic, (B) Glottic, ( C ) Subglottic.

Supraglottic cancer is less frequent than glottic cancer.

M a j o r i t y o f lesions are seen o n epiglottis, false cords fol-

l o w e d b y aryepiglottic folds, i n that order.

Increase i n size o f g r o w t h s w i t h a c c o m p a n y i n g o e d e m a
Spread C a n c e r o f supraglottic r e g i o n m a y spread locally
o r c o r d fixation m a y cause stridor a n d laryngeal obstruction.
a n d invade the a d j o i n i n g areas, i.e. v a l l e c u l a , base o f t o n g u e

a n d p y r i f o r m fossa. C a n c e r o f i n f r a h y o i d epiglottis a n d
3. Subglottic Cancer (1-2%)
anterior ventricular b a n d m a y e x t e n d i n t o pre-epiglottic

space a n d penetrate the t h y r o i d cartilage. Subglottic r e g i o n extends f r o m glottic area to l o w e r b o r -

N o d a l metastases o c c u r early. U p p e r a n d m i d d l e j u g u l a r der o f cricoid cartilage. Lesions o f this r e g i o n are rare.

nodes are often i n v o l v e d . Bilateral metastases m a y be seen

Spread G r o w t h starts o n o n e side o f subglottis and m a y
in cases o f e p i g l o t t i c cancer.
spread a r o u n d the anterior wall to the opposite side o r d o w n -

Symptoms S u p r a g l o t t i c g r o w t h s are often silent. H o a r s e - wards to the trachea. U p w a r d spread to the vocal cords is

n e s s is a l a t e s y m p t o m . T h r o a t pain, dysphagia a n d referred late a n d that is w h y hoarseness is n o t a n early s y m p t o m .

pain i n the ear o r mass o f l y m p h nodes i n the n e c k m a y be Subglottic g r o w t h s can invade c r i c o t h y r o i d m e m b r a n e ,

the presenting features. W e i g h t loss, respiratory obstruc- t h y r o i d g l a n d and r i b b o n muscles o f neck.

tion, halitosis are late features. L y m p h a t i c metastases g o to prelaryngeal, pretracheal,

paratracheal a n d l o w e r j u g u l a r nodes.

2. Glottic Cancer Symptoms T h e earliest presentation o f subglottic cancer

m a y be stridor o r laryngeal o b s t r u c t i o n b u t this is often

I n vast m a j o r i t y o f cases, l a r y n g e a l cancer originates i n the
late and b y this t i m e disease has already spread sufficiently
glottic r e g i o n . Free edge a n d u p p e r surface o f v o c a l c o r d
to encroach the a i r w a y .
i n its anterior a n d m i d d l e third is the m o s t frequent site
Hoarseness o f v o i c e indicates spread o f disease to the
(Fig. 61.2).
undersurface o f v o c a l cords, infiltration o f t h y r o a r y t e n o i d
Spread Locally, the lesion m a y spread anteriorly to ante-
muscle o r the i n v o l v e m e n t o f recurrent laryngeal nerve at
rior c o m m i s s u r e a n d t h e n to the opposite c o r d ; posteriorly
the c r i c o a r y t e n o i d j o i n t . Hoarseness o f v o i c e is a l a t e fea-
to v o c a l process a n d a r y t e n o i d region; u p w a r d to ventricle
ture o f subglottic g r o w t h .
a n d false c o r d ; a n d d o w n w a r d s to subglottic r e g i o n . V o c a l

c o r d m o b i l i t y is u n a f f e c t e d i n early stages.

F i x a t i o n o f vocal c o r d indicates spread o f disease t o t h y -

| D i a g n o s i s o f Laryngeal C a n c e r |
r o a r y t e n o i d m u s c l e a n d is a b a d prognostic sign.

T h e r e are f e w l y m p h a t i c s i n vocal cords a n d n o d a l m e t a -

1, History S y m p t o m a t o l o g y o f glottic, subglottic a n d
stasis are practically n e v e r seen i n cordal lesions unless the
supraglottic lesions w o u l d v a r y a n d is described u n d e r
disease spreads b e y o n d the r e g i o n o f m e m b r a n o u s c o r d .
appropriate h e a d s . I t is a d i c t u m that any patient in cancer

Symptoms Hoarseness o f voice is a n early sign because age group having persistent or gradually increasing hoarseness of
lesions o f c o r d affect its v i b r a t o r y c a p a c i t y . I t is b e c a u s e o f voice for 3 weeks must have laryngeal examination to exclude
this that glottic cancer is d e t e c t e d early. cancer.
Diseases of Larynx and T r a c h e a

I T N M classification o f cancer larynx (American Joint C o m m i t t e e o n Cancer, 2 0 0 2 )

Supraglottis
T, T u m o u r limited to one subsite o f supraglottis with normal vocal cord mobility

T 2 T u m o u r invades m u c o s a o f more than one adjacent subsite o f supraglottis or glottis or region outside the

supraglottis (e.g., m u c o s a o f base o f tongue, vallecula, medial wall o f pyriform sinus) w i t h o u t fixation o f the larynx

T 3 T u m o u r limited to larynx with vocal cord fixation a n d / o r invades any o f the following: postcricoid area, pre-epiglottic

tissues, paraglottic space a n d / o r m i n o r thyroid cartilage invasion

T 4 a T u m o u r invades through the thyroid cartilage a n d / o r invades tissues b e y o n d the larynx (e.g., trachea, soft tissues o f

neck i n c l u d i n g deep extrinsic muscle o f tongue, strap muscles, thyroid or oesophagus)

T d b T u m o u r invades prevertebral space, encases carotid artery or invades mediastinal structures

Glottis
T., T u m o u r limited to vocal cord(s) ( m a y involve anterior or posterior commissures) with normal mobility

T a T u m o u r limited to one vocal cord

T ^ T u m o u r involves b o t h vocal cords

T 2 T u m o u r extends to supraglottis a n d / o r subglottis, a n d / o r with impaired vocal cord mobility

T 3 T u m o u r limited to the larynx with vocal cord fixation a n d / o r invades paraglottic space a n d / o r m i n o r thyroid

cartilage erosion

T 4 a T u m o u r invades through thyroid cartilage a n d / o r invades tissues b e y o n d the larynx (e.g., trachea, soft tissues o f neck

including deep extrinsic muscles o f the tongue, strap muscles, thyroid, or oesophagus)

T^b T u m o u r invades prevertebral space, encases carotid artery or invades mediastinal structures

Subglottis
T 5 T u m o u r limited to the subglottis

T 2 T u m o u r extends to vocal cord(s) with n o r m a l or impaired mobility

T 3 T u m o u r limited to larynx with vocal cord fixation

T 4 a T u m o u r invades cricoid or thyroid cartilage a n d / o r invades tissues b e y o n d the larynx (e.g., trachea, soft tissues o f

neck i n c l u d i n g deep extrinsic muscle o f tongue, strap muscles, thyroid or oesophagus)

T 4 b T u m o u r invades prevertebral space, encases carotid artery or invades mediastinal structures

Source: Greene FL, Page DL, Fleming I D , et at. (editors). American Joint Committee on Cancer Staging Manual, 6th edition, New York:

Springer-Verlag, 2002.

Regional l y m p h nodes ( N ) Stage g r o u p i n g

N x Regional l y m p h nodes c a n n o t be assessed

0 T N

IS o
N 0 N o regional l y m p h node metastasis

N , Metastasis in a single ipsilateral l y m p h node, 3 c m

1
T, N
o K
or less i n g r e a t e s t dimension II
N 0
M
o
N 3 Metastasis in a single ipsilateral l y m p h node, more
III N M
o o
than 3 c m but not more than 6 c m in greatest

dimension, or multiple ipsilateral l y m p h nodes,

T, ft M
n

T 2
N
1 M
o
none more than 6 c m in greatest dimension, or

bilateral or contralateral l y m p h nodes, none % N

, Mo

m o r e than 6 c m in greatest dimension. IVA

N 0
M
o

N 2 a Metastasis in a single ipsilateral l y m p h node more N , M

o

than 3 c m but not more than 6 c m in greatest

% N 2 Mo
M
dimension N
; 0
N
N 2 b Metastasis in m u l t i p l e ipsilateral l y m p h nodes, ,
N M
none more than 6 c m in greatest dimension 3
D

N c ? M e t a s t a s i s in bilateral o r c o n t r a l a t e r a l l y m p h 1VB A n y N M
o
nodes, none more than 6 c m in greatest A n y T
N 3 M 0

dimension
IVC A n y T A n y N M ,
N 3 Metastasis in a l y m p h node more than 6 c m in

greatest dimension
Histopathologic grade (G)
Distant metastasis ( M )
Grade 1: Well-differentiated
M x Distant metastasis c a n n o t be assessed
Grade 2: Moderately differentiated
M Q N o distant metastasis

M , Distant metastasis G r a d e 3: Poorly differentiated

2. I n d i r e c t laryngoscopy not b e c l e a r l y seen b y m i r r o r e x a m i n a t i o n m a k i n g d i r e c t
laryngoscopy essential.
(a) Appearance of lesion. Appearance o f lesion w i l l vary
w i t h t h e site o f o r i g i n . 6. M i c r o l a r y n g o s c o p y F o r s m a l l lesions o f v o c a l c o r d s ,
(i) Lesions o f s u p r a h y o i d e p i g l o t t i s are usually exo- l a r y n g o s c o p y is d o n e u n d e r m i c r o s c o p e t o b e t t e r visualise
phytic while those of i n f r a h y o i d epiglottis are t h e l e s i o n a n d take m o r e a c c u r a t e b i o p s y s p e c i m e n s w i t h -
ulcerative. out damaging the c o r d .
(ii) L e s i o n o f v o c a l c o r d m a y appear as raised n o d u l e ,
7. Supravital staining and biopsy T o l u i d i n e b l u e is
ulcer or t h i c k e n i n g .
a p p l i e d t o t h e l a r y n g e a l l e s i o n a n d t h e n w a s h e d w i t h saline
(iii) L e s i o n o f anterior commissure may appear as
and e x a m i n e d u n d e r the operating microscope. Carcinoma-
g r a n u l a t i o n tissue.
i n - s i t u and superficial carcinomas take u p the d y e w h i l e
(iv) L e s i o n o f s u b g l o t t i c r e g i o n appears as a raised s u b -
l e u k o p l a k i a does n o t . T h u s , i t h e l p s t o select t h e area f o r
m u c o s a l n o d u l e , m o s t l y i n v o l v i n g t h e a n t e r i o r half.
biopsy in a leukoplakic patch.
(b) Vocal cord mobility. I m p a i r m e n t or f i x a t i o n o f vocal
c o r d indicates deeper i n f i l t r a t i o n i n t o t h y r o a r y t e n o i d
muscle, cricoarytenoid j o i n t or invasion o f recurrent
Treatment of Laryngeal Cancer
l a r y n g e a l n e r v e , a n d is an i m p o r t a n t s i g n .
(c) Extent of disease. S p r e a d o f disease t o v a l l e c u l a , base o f
I t d e p e n d s u p o n t h e site o f l e s i o n , e x t e n t o f l e s i o n , p r e s -
t o n g u e , p y r i f o r m fossa s h o u l d b e n o t i c e d .
e n c e o r absence o f n o d a l a n d d i s t a n t metastases. T r e a t m e n t

3. E x a m i n a t i o n of neck I t is d o n e t o f i n d (i) e x t r a l a - consists o f :

r y n g e a l s p r e a d o f disease, a n d (ii) n o d a l metastasis. G r o w t h s

1. Radiotherapy
of anterior commissure and subglottic region spread
2. S u r g e r y , (a) c o n s e r v a t i o n l a r y n g e a l s u r g e i y , (b) t o t a l
t h r o u g h c r i c o t h y r o i d m e m b r a n e and may produce a m i d -
laryngectomy
l i n e s w e l l i n g . T h e y m a y also i n v a d e t h e t h y r o i d c a r t i l a g e
3. C o m b i n e d therapy.
and cause p e r i c h o n d r i t i s w h e n c a r t i l a g e w i l l b e t e n d e r o n
p a l p a t i o n . T h y r o i d g l a n d a n d strap m u s c l e s m a y also b e 1. R a d i o t h e r a p y C u r a t i v e r a d i o t h e r a p y is r e s e r v e d for

invaded. e a r l y lesions w h i c h n e i t h e r i m p a i r c o r d m o b i l i t y n o r i n v a d e

Search s h o u l d be made f o r metastatic lymph nodes, cartilage or cervical nodes. C a n c e r o f the v o c a l c o r d w i t h -

t h e i r size a n d n u m b e r ; a n d also i f t h e y are m o b i l e o r f i x e d , out i m p a i r m e n t o f its m o b i l i t y g i v e s a 9 0 % c u r e rate after

unilateral, bilateral or contralateral. irradiation and has the advantage o f preservation of

v o i c e . S u p e r f i c i a l e x o p h y t i c lesions, especially o f the t i p o f
4. Radiography e p i g l o t t i s , a n d a r y e p i g l o t t i c folds g i v e 70—90% cure rate.
R a d i o t h e r a p y does n o t g i v e g o o d results i n lesions with
(a) X-ray chest is essential f o r c o - e x i s t e n t l u n g disease ( e . g .
f i x e d cords, subglottic extension, cartilage i n v a s i o n , a n d
tuberculosis), p u l m o n a r y metastasis or mediastinal
n o d a l metastases. T h e s e lesions r e q u i r e s u r g e i y .
nodes.
(b) Soft tissue lateral view neck. E x t e n t o f lesions o f e p i - 2. Surgery
glottis, aryepiglottic folds, arytenoids and i n v o l v e m e n t (a) Conservation surgery Earlier total laryngectomy was
o f p r e - e p i g l o t t i c space m a y b e seen. D e s t r u c t i o n of d o n e f o r m o s t o f the l a r y n g e a l cancers a n d the p a t i e n t was
t h y r o i d c a r t i l a g e m a y b e seen. T h i s is n o w superceded left w i t h n o voice and a permanent tracheostome. Lately,
b y C T scan a n d M R I . t h e r e has b e e n a t r e n d f o r c o n s e r v a t i o n l a r y n g e a l s u r g e i y
(c) Contrast laryngograms. Radio-opaque d y e , d i o n o s i l , is w h i c h c a n p r e s e r v e v o i c e a n d also a v o i d a p e r m a n e n t t r a -
instilled into the larynx. Laryngograms outline the c h e a l o p e n i n g . H o w e v e r , f e w cases w o u l d b e s u i t a b l e f o r
s u r f a c e e x t e n t o f t u m o u r s . T h i s i n v e s t i g a t i o n has n o w this t y p e o f surgery a n d t h e y s h o u l d be c a r e f u l l y selected.
b e e n r e p l a c e d b y C T scan. C o n s e r v a t i o n surgery includes:
(d) C T scan. I t is a v e r y u s e f u l i n v e s t i g a t i o n t o f i n d t h e
(i) E x c i s i o n o f v o c a l c o r d after s p l i t t i n g t h e l a r y n x ( c o r -
extent o f t u m o u r , invasion o f pre-epiglottic or paraepi-
d e c t o m y via laryngofissure),
g l o t t i c space, d e s t r u c t i o n o f c a r t i l a g e a n d l y m p h n o d e
{ifi Excision o f vocal cord and anterior commissure
involvement.
r e g i o n (partial f r o n t o l a t e r a l l a r y n g e c t o m y ) ,
5. D i r e c t l a r y n g o s c o p y I t is d o n e t o see (a) t h e h i d d e n (iii) E x c i s i o n o f supraglottis, i.e. epiglottis, a r y e p i g l o t t i c
areas o f l a r y n x a n d (b) e x t e n t o f disease. f o l d s , false c o r d s a n d v e n t r i c l e — a s o r t o f transverse
H i d d e n areas o f t h e l a r y n x i n c l u d e i n f r a h y o i d e p i g l o t t i s , section o f l a r y n x above t h e v o c a l cords (partial h o r i -
anterior commissure, subglottis and ventricle, w h i c h m a y zontal laryngectomy).
Diseases of Larynx and Trachea

(b) Total laryngectomy T h e entire larynx including t h e T2NQ cancer

h y o i d b o n e , p r e - e p i g l o t t i c space, strap muscles, a n d o n e o r

m o r e rings o f trachea are r e m o v e d . Pharyngeal wall is Cord mobile

1
Cord mobility impaired
repaired

breathing.
a n d l o w e r tracheal s t u m p sutured t o t h e skin f o r
I or
Involvement of anterior
Radiotherapy to the commissure or arytenoid
L a r y n g e c t o m y m a y be c o m b i n e d w i t h b l o c k dissection , primary including
for nodal metastasis.
radiation to upper
neck nodes
T o t a l l a r y n g e c t o m y is indicated i n t h e f o l l o w i n g
Failure
conditions:

" T , lesions ( i . e .w i t h c o r d fixed)

Conservation Conservation
• A l l T 4 lesions laryngectomy laryngectomy
• Invasion o f t h y r o i d o r cricoid cartilage
Failure Failure
• Bilateral a r y t e n o i d cartilage i n v o l v e m e n t

• Lesions o f posterior c o m m i s s u r e
Total laryngectomy Total laryngectomy
Failure after radiotherapy o r conservation surgery
± neck dissection ± neck dissection
• Transglottic cancers, i.e. t u m o u r s i n v o l v i n g supraglottis

a n d glottis across t h e ventricle, causing fixation o f t h e

Figure 61.3
vocal cord.
Algorithm fortreatment o f T 2 N glottic cancer.
It is c o n t r a i n d i c a t e d i n patients w i t h distant metastasis.

3. C o m b i n e d therapy Surgical ablation m a y b e c o m -

b i n e d w i t h p r e - o r post-operative radiation t o decrease t h e

ii. Is t h e r e i n v o l v e m e n t o f anterior c o m m i s s u r e
incidence o f recureence. Pre-operative radiation m a y also
a n d / o r arytenoid?
r e n d e r fixed nodes resectable.

I f c o r d is m o b i l e a n d anterior c o m m i s s u r e a n d a r y t e n o i d

is n o t i n v o l v e d , radiotherapy gives g o o d results. S u c h

Glottic Carcinoma
patients are k e p t u n d e r regular f o l l o w - u p . I fdisease recurs,

total l a r y n g e c t o m y is p e r f o r m e d . S o m e surgeons w i l l still

Carcinoma-in-situ I t is b e s t treated b y transoral e n d o -

consider partial vertical l a r y n g e c t o m y t o preserve v o i c e i n

scopic C O , l a s e r . I fl a s e r is n o t a v a i l a b l e , stripping o f vocal

such radiation-failed cases.

c o r d is d o n e u n d e r m i c r o s c o p e a n d tissue subjected t o
I f anterior c o m m i s s u r e a n d / o r a r y t e n o i d is i n v o l v e d o r

biopsy. I f b i o p s y s h o w s invasive carcinoma, give r a d i o -

c o r d m o b i l i t y is i m p a i r e d , radiotherapy is n o t preferred

therapy. I fb i o p s y c o n f i r m s o n l y c a r c i n o m a i n situ, treat-

because o f t h e possibility o f d e v e l o p i n g perichondritis

m e n t is r e g u l a r f o l l o w - u p .
w h i c h w o u l d entail total l a r y n g e c t o m y . I n such cases, s o m e

Invasive c a r c i n o m a f o r m o fconservation surgery such as v e r t i c a l h e m i l a r y n g e -

T.—carcinoma—Radiotherapy is t h e treatment o f c t o m y o r frontolateral l a r y n g e c t o m y is d o n e t o p r e s e r v e t h e

choice. I fradiotherapy is r e f u s e d o r n o t available, voice. S u c h patients are also k e p t u n d e r regular f o l l o w - u p

excision o f c o r d b y e n d o s c o p i c C O , laser o r l a r y n - a n d c o n v e r t e d t o total l a r y n g e c t o m y i fdisease recurs.

gofissure is p e r f o n n e d . In M L neck, i n T , c a r c i n o m a , chances o f occult nodal

T —carcinoma
( with extension to anterior commissure. metastasis a r e less t h a n 2 5 % , therefore prophylactic neck

R a d i o t h e r a p y is t h e best choice. I n t h e absence o f dissection is n o t d o n e . H o w e v e r , i fr a d i a t i o n is considered

this, frontolateral partial l a r y n g e c t o m y is d o n e w i t h the m o d e o f treatment, f o r t h e p r i m a r y , u p p e r n e c k nodes

regular f o l l o w - u p . I f i t fails, total l a r y n g e c t o m y is are i n c l u d e d i n t h e radiation field.

p e r f o r m e d . C o r d m o b i l i t y is i m p o r t a n t i n d e t e r m i n i n g t h e o u t -

T —carcinoma
s with extension to arytenoid. T r e a t m e n t is c o m e o fT , lesions. N o r m a l c o r d m o b i l i t y suggests g r o w t h

same as a b o v e b u t surgery is preferred. is o n l y l i m i t e d t o t h e surface. I m p a i r e d m o b i l i t y indicates

T , l N \ — I t implies t u m o u r o ft h e glottic region, i.e. vocal deeper invasion i n t o intrinsic laryngeal muscles o r para-

cord(s), anterior c o m m i s s u r e a n d / o r vocal p r o - glottic space a n d thus p o o r response t o radiation. Invasion

cess o f t h e a r y t e n o i d w i t h extension t o supra- o f paraglottic o r subglottic space is also associated w i t h

glottic o r subglottic regions b u t w i t h n o l y m p h u n d e t e c t e d invasion o flaryngeal cartilages a n d h e n c e p o o r

n o d e i n v o l v e m e n t . T r e a t m e n t depends o n t w o survival results. W i t h radiation, cure rate o fT , lesions, w i t h

factors (see F i g . 61.3). n o r m a l c o r d m o b i l i t y , is 8 6 % ) a n d i t d r o p s t o 6 3 % i f c o r d

i. Is m o b i l i t y o fvocal c o r d n o r m a l o r impaired? m o b i l i t y is i m p a i r e d .
 T 3 and T 4 g l o t t i c c a r c i n o m a s are best t r e a t e d b y t o t a l
J M e t h o d s o f c o m m u n i c a t i o n in laryngecto-
l a r y n g e c t o m y . I t is c o m b i n e d w i t h n e c k d i s s e c t i o n i f n o d e s
I mised patients
are palpable. More advanced T 4 l e s i o n s are t r e a t e d by
c o m b i n e d therapy, i.e. surgery w i t h post-operative r a d i o - • W r i t t e n language (Pen and paper)

• A p h o n i c lip speech (By t r a p p i n g air in buccal cavity;

therapy or only palliative treatment.
often c o m b i n e d with sign language)
Subglottic cancer E a r l y l e s i o n s T j a n d T , are t r e a t e d b y • Oesophageal speech
radiotherapy. T 3 and T 4 lesions r e q u i r e t o t a l l a r y n g e c t o m y • Electrolarynx

a n d p o s t - o p e r a t i v e r a d i a t i o n . R a d i a t i o n p o r t a l s h o u l d also • Transoral p n e u m a t i c device

include superior mediastinum. • Tracheo-oesophageai speech

- Biom-Singer prosthesis
Supraglottic cancer F o l l o w i n g f a c t o r s are c o n s i d e r e d i n
- Panje prosthesis
the treatment o p t i o n :

(i) Status o f c e r v i c a l l y m p h n o d e s
(ii) Mobility of cord j Vocal Rehabilitation After T o t a l Laryngectomy j
(iii) A g e o f the patient
(iv) Status o f l u n g f u n c t i o n s A f t e r l a r y n g e c t o m y , p a t i e n t loses his s p e e c h completely.
(v) Cartilage invasion V a r i o u s m e t h o d s b y w h i c h c o m m u n i c a t i o n can be estab-
(vi) Subsite o f supraglottis i n v o l v e d l i s h e d are l i s t e d i n T a b l e 61.3.
(vii) Status o f p r e - e p i g l o t t i c space i n v o l v e m e n t 1. Oesophageal speech I n t h i s , p a t i e n t is t a u g h t to

T , l e s i o n s r e s p o n d w e l l t o r a d i a t i o n . T h e y c a n also b e s w a l l o w air a n d h o l d i t i n the u p p e r oesophagus a n d t h e n

e x c i s e d w i t h C O , laser. s l o w l y eject i t f r o m the oesophagus i n t o the pharynx.

T , l e s i o n s are t r e a t e d b y s u p r a g l o t t i c l a r y n g e c t o m y w i t h P a t i e n t can speak 6 - 1 0 w o r d s b e f o r e r e - s w a l l o w i n g air.

o r w i t h o u t n e c k d i s s e c t i o n i f l u n g f u n c t i o n is g o o d . I f l u n g V o i c e is r o u g h b u t l o u d a n d understandable.

f u n c t i o n is p o o r , r a d i o t h e r a p y c a n b e g i v e n t o t h e p r i m a r y 2. A r t i f i c i a l l a r y n x I t is u s e d i n t h o s e w h o f a i l t o l e a r n
and the nodes. oesophageal speech.
T 3 and T 4 lesions o f t e n r e q u i r e t o t a l l a r y n g e c t o m y w i t h (a) Electrolarynx. I t is a t r a n s i s t o r i s e d , b a t t e r y operated
n e c k dissection and post-operative radiotherapy to neck. p o r t a b l e d e v i c e . Its v i b r a t i n g disc is h e l d against t h e soft

(A) Electrolarynx. (B) A laryngectomised patient using the electrolarynx to produce sound.
Diseases of Larynx and Trachea

tissues o f t h e n e c k a n d a l o w p i t c h e d s o u n d is p r o d u c e d i n 3. T r a c h e o - o e s o p h a g e a l s p e e c h H e r e a t t e m p t is m a d e
t h e h y p o p h a r y n x w h i c h is f u r t h e r m o d u l a t e d i n t o s p e e c h t o carry air f r o m trachea to oesophagus o r h y p o p h a r y n x b y
b y the t o n g u e , lips, t e e t h a n d palate (Fig. 6 1 . 4 A . B ) . the creation o f s k i n - l i n e d fistula o r b y p l a c e m e n t o f an
(b) Transoral pneumatic device. A n o t h e r type o f artificial artificial prosthesis. T h e v i b r a t i n g c o l u m n o f air e n t e r i n g
l a r y n x is a t r a n s o r a l d e v i c e . H e r e v i b r a t i o n s p r o d u c e d i n a t h e p h a r y n x is t h e n m o d u l a t e d i n t o s p e e c h . T h i s tech-
r u b b e r d i a p h r a g m are c a r r i e d b y a plastic t u b e i n t o the n i q u e has t h e d i s a d v a n t a g e o f f o o d e n t e r i n g the trachea.
back o f the oral cavity w h e r e s o u n d is c o n v e r t e d into T h e s e days prosthesis (Blom-Singer o r P a n j e ) are being
s p e e c h b y m o d u l a t o r s . T h i s is a p n e u m a t i c t y p e o f d e v i c e u s e d t o s h u n t air f r o m t r a c h e a t o t h e o e s o p h a g u s . They
a n d uses e x p i r e d air f r o m t h e t r a c h e o s t o m e t o v i b r a t e t h e have i n b u i l t valves w h i c h w o r k o n l y i n o n e d i r e c t i o n thus
diaphragm. p r e v e n t i n g problems o f aspiration.
Voice a n d Speech Disorders

2. Indirect laryngoscopy. M a n y o f the local laryngeal

Hoarseness
causes c a n b e d i a g n o s e d .
3. E x a m i n a t i o n o f n e c k , chest, c a r d i o v a s c u l a r a n d n e u -
H o a r s e n e s s is d e f i n e d as r o u g h n e s s o f v o i c e r e s u l t i n g f r o m
r o l o g i c a l s y s t e m w o u l d h e l p t o f i n d cause f o r l a r y n -
variations o f periodicity and/or intensity o f consecutive
geal p a r a l y s i s .
sound waves.
4. Laboratory investigations and radiological examina-
F o r p r o d u c t i o n o f n o r m a l v o i c e , vocal cords s h o u l d :
t i o n s h o u l d b e d o n e as p e r d i c t a t e s o f t h e cause sus-
1. B e able t o a p p r o x i m a t e p r o p e r l y w i t h each o t h e r . pected o n clinical examination.
2. H a v e a p r o p e r size a n d stiffness.
3. H a v e a n a b i l i t y t o vibrate r e g u l a r l y i n response t o air
column. I Causes o f hoarseness

A n y c o n d i t i o n that interferes w i t h the above functions 1 . Inflammations

causes hoarseness. Acute Acute laryngitis usually following

cold, influenza, exanthematous

(a) Loss of approximation m a y b e seen i n v o c a l c o r d p a r a l y - fever, laryngo-tracheo-bronchitis,

sis o r f i x a t i o n o r a t u m o u r c o m i n g i n b e t w e e n t h e diphtheria

vocal cords. Chronic (i) Specific. Tuberculosis, syphilis,

(b) Size of the cord m a y i n c r e a s e i n o e d e m a o f t h e c o r d o r scleroma, fungal infections

a t u m o u r ; t h e r e is a decrease i n p a r t i a l s u r g i c a l e x c i - (ii) Non-specific. Chronic laryngitis,

sion or fibrosis. atrophic laryngitis

(c) Stiffness m a y decrease i n paralysis, i n c r e a s e i n spastic 2 . Tumours

d y s p h o n i a or fibrosis. Benign Papilloma (solitary and

multiple), h a e m a n g i o m a ,
C o r d s m a y n o t be able t o v i b r a t e p r o p e r l y i n t h e p r e s - c h o n d r o m a , fibroma, leukoplakia
ence o f congestion, submucosal haemorrhages, n o d u l e o r a Malignant Carcinoma

polyp. Tumour4ike masses Vocal nodule, vocal polyp,

angiofibroma, amyloid tumour,

contact ulcer, cysts, laryngocele

Aetiology
3 . Trauma Submucosal haemorrhage,

H o a r s e n e s s is a s y m p t o m a n d n o t a disease p e r se. The laryngeal t r a u m a (blunt and

causes o f hoarseness are s u m m a r i s e d i n T a b l e 6 2 . 1 . sharp), foreign bodies, intubation

4. Paralysis Paralysis o f recurrent, superior

laryngeal or both nerves

Investigations
5. Fixation of cords Arthritis or fixation o f
I. History. Mode o f onset and duration of illness, cricoarytenoid joints

p a t i e n t ' s o c c u p a t i o n , h a b i t s a n d associated c o m p l a i n t s
6 . Congenital Laryngeal web, cyst, laryngocele
are i m p o r t a n t a n d w o u l d o f t e n h e l p t o e l u c i d a t e t h e
7 . Miscellaneous Dysphonia plica ventricularis,
cause. Any hoarseness persisting for more than three weeks
m y x o e d e m a , gout
deserves examination of larynx. Malignancy should be
8 . Functional Hysterical a p h o n i a
excluded in patients above 40 years.
Diseases of Larynx and Trachea

D i r e c t laryngoscopy and m i c r o l a r y n g o s c o p y help in t h o u g h their physical a n d sexual d e v e l o p m e n t is n o r m a l .

detailed e x a m i n a t i o n , biopsy o f the lesions a n d assess- T r e a t m e n t is t r a i n i n g the b o d y to p r o d u c e l o w - p i t c h e d

m e n t o f the m o b i l i t y o f c r i c o a r y t e n o i d joints. voice. Pressing the t h y r o i d p r o m i n e n c e i n a b a c k w a r d a n d

6. B r o n c h o s c o p y and o e s o p h a g o s c o p y m a y be r e q u i r e d d o w n w a r d d i r e c t i o n relaxes the overstretched cords a n d

in cases o f paralytic lesions o f the c o r d to exclude l o w tone v o i c e can be p r o d u c e d ( G u t z m a n n ' s pressure

m a l i g n a n c y . test). T h e patient pressing o n his l a r y n x learns to p r o d u c e

l o w tone v o i c e and t h e n trains h i m s e l f to p r o d u c e syllables,

w o r d s and n u m b e r s . Prognosis is g o o d .
D y s p h o n i a Plica Ventricularis

I (Ventricular D y s p h o n i a )
1
( Q ^ ^ ^ ^ ^ Phonasthenia
H e r e v o i c e is p r o d u c e d b y ventricular folds (false cords)

w h i c h have taken o v e r the f u n c t i o n o f true cords. V o i c e is I t is w e a k n e s s o f v o i c e d u e to fatigue o f p h o n a t o r y muscles.

r o u g h , l o w - p i t c h e d and unpleasant. V e n t r i c u l a r v o i c e m a y T h y r o a r y t e n o i d a n d interarytenoids o r b o t h m a y be

be secondary to i m p a i r e d f u n c t i o n o f the true c o r d such as affected. I t is s e e n i n abuse o r misuse o f v o i c e o r f o l l o w i n g

paralysis, fixation, surgical excision, o r t u m o u r s . V e n t r i c u l a r laryngitis. Patient c o m p l a i n s o f easy-fatiguability o f voice.

bands i n these situations try to c o m p e n s a t e o r assume p h o - Indirect l a r y n g o s c o p y s h o w s three characteristic findings:

natory f u n c t i o n o f true cords.

(i) Elliptical space b e t w e e n the cords i n weakness o f
F u n c t i o n a l type o f ventricular d y s p h o n i a occurs i n n o r -
t h y r o a r y t e n o i d .
m a l larynx. H e r e cause is p s y c h o g e n i c . I n this type, v o i c e
(ii) T r i a n g u l a r gap near the posterior c o m m i s s u r e i n
begins n o r m a l l y b u t soon b e c o m e s r o u g h w h e n false cords
weakness o f interarytenoid.
usurp the f u n c t i o n o f true cords. Diagnosis is m a d e o n
(iii) K e y - h o l e appearance o f glottis w h e n b o t h t h y -
indirect laryngoscopy; the false cords are seen to a p p r o x i -
roarytenoid and interarytenoids are i n v o l v e d (Fig. 62.1).
m a t e partially o r c o m p l e t e l y a n d obscure the v i e w o f true

cords o n p h o n a t i o n . V e n t r i c u l a r d y s p h o n i a secondary to T r e a t m e n t is v o i c e rest a n d vocal hygiene, emphasising

laryngeal disorders is difficult to treat b u t the functional o n periods o f v o i c e rest after excessive use o f voice.

type can b e h e l p e d t h r o u g h v o i c e therapy a n d p s y c h o l o g i -

cal counselling.

| Hyponasality (Rhinolalia C l a u s a )

Functional A p h o n i a (Hysterical A p h o n i a ) I t is l a c k o f nasal resonance f o r w o r d s w h i c h are resonated

in the nasal c a v i t y , e.g. m , n , ng.

I t is a f u n c t i o n a l d i s o r d e r m o s t l y seen i n e m o t i o n a l l y labile It is d u e to blockage o f the nose o r nasopharynx.

females i n the age g r o u p o f 1 5 - 3 0 . A p h o n i a is u s u a l l y sud- I m p o r t a n t causes are listed i n T a b l e 62.2.

d e n a n d u n a c c o m p a n i e d b y other laryngeal s y m p t o m s .

Patient c o m m u n i c a t e s w i t h whisper. O n e x a m i n a t i o n ,

vocal cords are seen i n a b d u c t e d p o s i t i o n a n d fail t o adduct

o n p h o n a t i o n ; h o w e v e r a d d u c t i o n o f v o c a l cords can be

seen o n c o u g h i n g , i n d i c a t i n g n o r m a l a d d u c t o r f u n c t i o n .

E v e n t h o u g h patient is a p h o n i c , s o u n d o f c o u g h is g o o d .

T r e a t m e n t g i v e n is t o r e a s s u r e t h e patient o f n o r m a l l a r y n -

geal f u n c t i o n and psychotherapy.

P u b e r p h o n i a (Mutational Falsetto Voice)

N o r m a l l y , c h i l d h o o d v o i c e has a h i g h e r pitch. W h e n the

l a r y n x matures at puberty, v o c a l cords lengthen, a n d the

v o i c e changes to one o f l o w e r p i t c h . T h i s is a f e a t u r e e x c l u -

sive to males. Failure o f this c h a n g e leads to persistence o f

F i g u r e 62.1
c h i l d h o o d h i g h - p i t c h e d v o i c e a n d is c a l l e d p u b e r p h o n i a . I t
Appearances o f glottis in phonasthenia. (A) Weakness o f
is s e e n i n b o y s w h o are e m o t i o n a l l y i m m a t u r e , feel inse-
thyroarytenoid, (B) Interarytenoid, (C) thyroarytenoid and
cure a n d s h o w excessive fixation to their m o t h e r .
interarytenoid.
Psychologically, they s h u n to assume male responsibilities
 Voice and Speech Disorders

c o m m u n i c a t i o n b e t w e e n the oral a n d nasal cavities. T h e

1 C a u s e s o f h y p o n a s a l i t y and hypernasality
causes are listed i n T a b l e 62.2.

Hyponasality Hypernasality

C o m m o n cold Velopharyngeal insufficiency

Nasal allergy Congenitally short soft palate [P Stuttering

Nasal polypi S u b m u c o u s palate
I t is a d i s o r d e r o f f l u e n c y o f speech a n d consists o f hesita-
Nasal g r o w t h Large nasopharynx

Adenoids Cleft o f soft palate t i o n to start, repetitions, p r o l o n g a t i o n s o r blocks i n the

Nasopharyngeal mass Paralysis o f soft palate f l o w o f speech. W h e n well-established, a stutterer m a y

Familial speech pattern Post-adenoidectomy d e v e l o p secondary m a n n e r i s m s such as facial g r i m a c i n g ,

Habitual Oronasal fistula eye b l i n k a n d a b n o r m a l head m o v e m e n t s . N o r m a l l y , m o s t

Familial speech pattern o f the c h i l d r e n have dysfluency o f speech b e t w e e n 2 - 4

Habitual speech pattern

years. I f t o o m u c h attention is g i v e n o r child r e p r i m a n d e d

b y parents a n d peers, this b e h a v i o u r pattern m a y b e c o m e

fixed a n d c h i l d m a y d e v e l o p i n t o an adult stutterer.

IH Hypernasality (Rhinolalia Aperta) Stuttering can be p r e v e n t e d b y p r o p e r e d u c a t i o n o f the

parents, n o t to overreact to child's dysfluency i n early stages

It is s e e n w h e n certain w o r d s w h i c h h a v e littie nasal res- o f speech d e v e l o p m e n t . T r e a t m e n t o f an established stut-

o n a n c e are resonated t h r o u g h nose. T h e d e f e c t is i n f a i l u r e o f terer is s p e e c h therapy a n d p s y c h o t h e r a p y to i m p r o v e his

the n a s o p h a r y n x to cut o f f f r o m o r o p h a r y n x or a b n o r m a l i m a g e as a s p e a k e r a n d reduce his fear o f dysfluency.

T r a c h e o s t o m y a n d O t h e r Procedures
for Airway Management

(). T o a d m i n i s t e r a n a e s t h e s i a I n cases w h e r e e n d o t r a -
T R A C H E O S T O M Y
c h e a l i n t u b a t i o n is d i f f i c u l t o r i m p o s s i b l e as i n l a r y n -
gopharyngeal g r o w t h s or trismus.

T r a c h e o s t o m y is m a k i n g a n o p e n i n g i n t h e a n t e r i o r w a l l
o f trachea a n d c o n v e r t i n g it i n t o a stoma o n t h e s k i n sur-
face. Sometimes, the t e r m Tracheotomy has b e e n inter- Indications of Tracheostomy

changeably used b u t the latter actually means o p e n i n g the

t r a c h e a , w h i c h is a step i n t h e t r a c h e o s t o m y o p e r a t i o n . T h e r e are t h r e e m a i n i n d i c a t i o n s ( T a b l e 63.1)

A. Respiratoiy obstruction.

Functions of Tracheostomy B. R e t a i n e d secretions.

C. Respiratory insufficiency.

1. Alternative pathway for breathing This circum-

vents any o b s t r u c t i o n i n the u p p e r a i r w a y f r o m lips t o
Types of Tracheostomy
the tracheostome.
2. Improves a l v e o l a r v e n t i l a t i o n I n cases o f r e s p i r a -
t o r y i n s u f f i c i e n c y , a l v e o l a r v e n t i l a t i o n is i m p r o v e d b y : • Emergency tracheostomy
• Elective or tranquil tracheostomy
(a) D e c r e a s i n g t h e d e a d space b y 3 0 - 5 0 % ( n o r m a l
Permanent tracheostomy
d e a d space is 150 m l ) .
(b) R e d u c i n g t h e resistance t o a i r f l o w . • Percutaneous dilatational tracheostomy

3. Protects the airways B y using cuffed tube, tracheo- • M i n i t r a c h e o s t o m y (eric o t h y r o i d o t o m y )

b r o n c h i a l t r e e is p r o t e c t e d against a s p i r a t i o n o f : 1. E m e r g e n c y tracheostomy I t is e m p l o y e d w h e n a i r -
(a) P h a r y n g e a l s e c r e t i o n s , as i n case o f b u l b a r paralysis w a y o b s t r u c t i o n is c o m p l e t e o r a l m o s t c o m p l e t e a n d t h e r e
or coma. is a n u r g e n t n e e d t o est ab l i sh t h e a i r w a y . I n t u b a t i o n o r
(b) B l o o d , as i n h a e m o r r h a g e f r o m p h a r y n x , l a r y n x o r l a r y n g o t o m y are e i t h e r n o t p o s s i b l e o r feasible i n s u c h
maxillofacial injuiies. W i t h tracheostomy, pharynx cases.
a n d l a r y n x c a n also b e p a c k e d t o c o n t r o l b l e e d i n g .
2. Elective t r a c h e o s t o m y (syn. tranquil, orderly or
4. Permits removal of tracheobronchial secretions
routine tracheostomy) T h i s is a p l a n n e d , unhurried
W h e n p a t i e n t is u n a b l e t o c o u g h as i n c o m a , h e a d i n j u -
p r o c e d u r e . A l m o s t a l l o p e r a t i v e s u r g i c a l f a c i l i t i e s are a v a i l -
ries, r e s p i r a t o r y paralysis; o r w h e n c o u g h is p a i n f u l , as i n
able, endotracheal t u b e can b e p u t a n d local o r general
chest i n j u r i e s o r u p p e r a b d o m i n a l o p e r a t i o n s , t h e t r a -
anaesthesia c a n b e g i v e n . I t is o f t w o t y p e s :
c h e o b r o n c h i a l a i r w a y c a n b e k e p t c l e a n o f secretions b y
repeated suction t h r o u g h the tracheostomy, thus a v o i d - (a) Therapeutic, to relieve respiratory o b s t r u c t i o n , r e m o v e
i n g need for repeated b r o n c h o s c o p y or intubation t r a c h e o b r o n c h i a l secretions o r g i v e assisted v e n t i l a t i o n .
w h i c h is n o t o n l y t r a u m a t i c b u t r e q u i r e s e x p e r t i s e . (b) Prophylactic, t o g u a r d against a n t i c i p a t e d r e s p i r a t o r y
5. Intermittent positive pressure respiration ( I P P R ) obstruction or aspiration o f b l o o d or pharyngeal
I f I P P R is r e q u i r e d b e y o n d 7 2 h o u r s , t r a c h e o s t o m y is s e c r e t i o n s s u c h as i n e x t e n s i v e s u r g e r y o f t o n g u e , f l o o r
superior to intubation. o f m o u t h , m a n d i b u l a r resection or laryngofissure.

i
 T r a c h e o s t o m y & O t h e r P r o c e d u r e s for A i r w a y M a n a g e m e n t

this site c a n cause p e r i c h o n d r i t i s o f t h e c r i c o i d cartilage a n d

Table 63.1 Indications for t r a c h e o s t o m y
s u b g l o t t i c stenosis a n d is always a v o i d e d . O n l y i n d i c a t i o n f o r
A. Respiratory obstruction h i g h t r a c h e o s t o m y is c a r c i n o m a o f l a r y n x because i n s u c h
1. Infections
cases, t o t a l l a r y n x a n y w a y w o u l d u l t i m a t e l y b e r e m o v e d a n d
- Acute laryngo-tracheo-bronchitis, acute epiglottitis,
a fresh t r a c h e o s t o m e m a d e i n a c l e a n area l o w e r d o w n . A
diphtheria
m i d t r a c h e o s t o m y is t h e p r e f e r r e d o n e a n d is d o n e t h r o u g h
- Ludwig's angina, peritonsillar, retropharyngeal or
t h e II o r I I I rings a n d w o u l d e n t a i l d i v i s i o n o f d i e t h y r o i d
parapharyngeal abscess, tongue abscess
i s t h m u s o r its r e t r a c t i o n u p w a r d s o r d o w n w a r d s t o expose
2. T r a u m a
this part o f trachea. A l o w t r a c h e o s t o m y is d o n e b e l o w t h e
- External injury o f larynx and trachea
l e v e l o f i s t h m u s . T r a c h e a is deep at t h i s l e v e l a n d close t o
- T r a u m a due to endoscopies, especially in infants
several large vessels; also t h e r e are d i f f i c u l t i e s w i t h tracheos-
and children
t o m y t u b e w h i c h i m p i n g e s o n suprasternal n o t c h .
- Fractures o f mandible or maxillofacial injuries

3. N e o p l a s m s

- Benign and malignant neoplasms o f larynx,

pharynx, upper trachea, tongue and thyroid J| Technique J

4. Foreign b o d y larynx
Whenever possible, endotracheal intubation s h o u l d be
5. O e d e m a larynx due to steam, irritant fumes or gases, d o n e b e f o r e t r a c h e o s t o m y . T h i s is s p e c i a l l y i m p o r t a n t i n
allergy ( a n g i o n e u r o t i c or d r u g sensitivity), radiation
infants a n d c h i l d r e n .
6. Bilateral a b d u c t o r paralysis
Position Patient lies s u p i n e w i t h a pillow under the
7. Congenita! anomalies
s h o u l d e r s so t h a t n e c k is e x t e n d e d . T h i s b r i n g s t h e t r a c h e a
- Laryngeal web, cysts, t r a c h e o - o e s o p h a g e a l fistula
forward.
- Bilateral choanal atresia
Anaesthesia N o anaesthesia is r e q u i r e d i n u n c o n s c i o u s
B . Retained secretions
p a t i e n t s o r w h e n i t is a n e m e r g e n c y p r o c e d u r e . I n c o n -
1. Inability to c o u g h
s c i o u s p a t i e n t s , 1 - 2 % l i g n o c a i n e w i t h e p i n e p h r i n e is i n f i l -
- C o m a o f any c a u s e , e.g. head injuries, cerebro-
t r a t e d i n t h e l i n e o f i n c i s i o n a n d t h e area o f d i s s e c t i o n .
vascular accidents, narcotic overdose
S o m e t i m e s , g e n e r a l anaesthesia w i t h i n t u b a t i o n is u s e d .
- P a r a l y s i s o f r e s p i r a t o r y m u s c l e s , e.g. spinal injuries,

polio, Guillain-Barre syndrome, myasthenia gravis

- Spasm o f respiratory muscles, tetanus, eclampsia,

strychnine poisoning Steps of Operation

2. Painful c o u g h

- Chest injuries, multiple rib fractures, p n e u m o n i a

1. A v e r t i c a l i n c i s i o n is m a d e i n t h e m i d l i n e o f n e c k ,
extending from cricoid cartilage t o j u s t a b o v e the
3. Aspiration o f pharyngeal secretions
s t e r n a l n o t c h . T h i s is t h e m o s t f a v o u r e d i n c i s i o n a n d
- Bulbar polio, polyneuritis, bilateral laryngeal

paralysis
c a n b e used i n e m e r g e n c y a n d e l e c t i v e p r o c e d u r e s . I t
g i v e s r a p i d access w i t h m i n i m u m o f b l e e d i n g a n d t i s -
C. Respiratory insufficiency
sue d i s s e c t i o n . A transverse i n c i s i o n , 5 c m l o n g , m a d e
- Chronic lung c o n d i t i o n s , viz. e m p h y s e m a , chronic

bronchitis, bronchiectasis, atelectasis

2 fingers' b r e a d t h above the sternal n o t c h can b e used

- Conditions listed in A and B i n e l e c t i v e p r o c e d u r e s . I t has t h e a d v a n t a g e o f a c o s -

m e t i c a l l y b e t t e r scar ( F i g . 6 3 . 1 ) .
2. A f t e r i n c i s i o n , tissues are d i s s e c t e d i n t h e midline.
D i l a t e d v e i n s are e i t h e r d i s p l a c e d o r l i g a t e d .
3. S t r a p m u s c l e s are separat ed i n t h e m i d l i n e a n d r e t r a c t e d
E l e c t i v e t r a c h e o s t o m y is o f t e n t e m p o r a r y a n d is c l o s e d
laterally.
w h e n i n d i c a t i o n is o v e r .
4. Thyroid i s t h m u s is d i s p l a c e d u p w a r d s o r divided
3. P e r m a n e n t tracheostomy T h i s m a y be r e q u i r e d f o r b e t w e e n the clamps, and suture-ligated.
cases o f b i l a t e r a l a b d u c t o r paralysis o r l a r y n g e a l stenosis. I n 5. A f e w d r o p s o f 4 % l i g n o c a i n e are i n j e c t e d i n t o t h e
l a r y n g e c t o m y o r l a r y n g o p h a r y n g e c t o m y , l o w e r tracheal t r a c h e a t o suppress t h e c o u g h w h e n t r a c h e a is i n c i s e d .
s t u m p is b r o u g h t t o s ur f ace a n d s t i t c h e d t o t h e s k i n . 6. T r a c h e a is f i x e d w i t h a h o o k a n d o p e n e d w i t h a v e r t i -
T r a c h e o s t o m y has also b e e n d i v i d e d i n t o h i g h , m i d o r cal i n c i s i o n i n t h e r e g i o n o f 3 r d a n d 4 t h o r 3 r d a n d 2 n d
l o w . A h i g h t r a c h e o s t o m y is d o n e a b o v e t h e l e v e l o f rings. T h i s is t h e n c o n v e r t e d i n t o a c i r c u l a r o p e n i n g .
t h y r o i d i s t h m u s ( i s t h m u s lies against I I , I I I a n d I V t r a c h e a l T h e f i r s t t r a c h e a l ring is never d i v i d e d as p e r i c h o n d r i t i s
r i n g s ) . I t v i o l a t e s t h e 1st r i n g o f t r a c h e a . T r a c h e o s t o m y at o f c r i c o i d c a r t i l a g e w i t h stenosis c a n r e s u l t ( F i g . 6 3 . 2 ) .
Diseases of Larynx and Trachea

C o m m o n indications o f tracheostomy in

• infants and children

Infants b e l o w 1 year (mostly congenital lesions)

• Subglottic h a e m a n g i o m a

• Subglottic stenosis

• Laryngeal cyst

• Glottic web

• Bilateral vocal cord paralysis

Children (mostly inflammatory or t r a u ni a t i c lesions)

• Acute laryngo-tracheo-bronchitis

• Epiglottitis

• Diphtheria
1
• Laryngeal o e d e m a (chemical/therma injury)

• External laryngeal t r a u m a

Figure 63.1 • Prolonged intubation

• Juvenile laryngeal papillomatosis

Skin incisions in tracheostomy. (A) Vertical midline incision.

(B) Transverse incision.

G r e a t care a n d c a u t i o n is r e q u i r e d w h e n d o i n g t r a c h e o -
s t o m y i n i n f a n t s a n d c h i l d r e n lest i t is a t t e n d e d w i t h c o m -
p l i c a t i o n s t h a t are a v o i d a b l e .

t. T r a c h e a o f i n f a n t s a n d c h i l d r e n is s o f t a n d c o m p r e s s -
i b l e a n d its i d e n t i f i c a t i o n m a y b e c o m e d i f f i c u l t a n d
t h e s u r g e o n m a y easily d i s p l a c e i t a n d g o d e e p o r l a t -
eral t o i t i n j u r i n g r e c u r r e n t l a r y n g e a l n e r v e o r e v e n
t h e c a r o t i d . I t is a l w a y s u s e f u l t o h a v e an e n d o t r a c h e a l
t u b e o r a b r o n c h o s c o p e inserted i n t o trachea before
operation. Tracheostomy i n i n f a n t s a n d c h i l d r e n is
...,J
p r e f e r a b l y d o n e u n d e r g e n e r a l anaesthesia.

U
2. D u r i n g positioning, do not extend the neck too m u c h

i< as t h i s p u l l s s t r u c t u r e s f r o m chest i n t o t h e n e c k a n d
t h u s i n j u r y m a y o c c u r t o p l e u r a , i n n o m i n a t e vessels
and t h y m u s or the tracheostomy opening may be
m a d e t o o l o w near suprasternal n o t c h .
3. B e f o r e i n c i s i n g t r a c h e a , s i l k s u t u r e s are p l a c e d i n t h e
t r a c h e a , o n e i t h e r side o f m i d l i n e .
Figure 63.2
4. T r a c h e a l l u m e n is s m a l l , d o n o t i n s e r t k n i f e t o o d e e p ;
M i d tracheostomy. Thyroid i s t h m u s is d i v i d e d and ligated. it w i l l i n j u r e posterior tracheal w a l l o r even oesopha-
gus c a u s i n g t r a c h e o - o e s o p h a g e a l fistula.
5. T r a c h e a is s i m p l y i n c i s e d , w i t h o u t e x c i s i n g a c i r c u l a r
piece o f tracheal w a l l .
T r a c h e o s t o m y t u b e o f a p p r o p r i a t e size is i n s e r t e d a n d
6. A v o i d i n f o l d i n g o f anterior tracheal w a l l w h e n insert-
s e c u r e d b y tapes (see p a g e 4 7 3 f o r d i f f e r e n t t y p e s a n d
i n g the tracheostomy tube.
size o f t r a c h e o s t o m y t u b e s ) .
7. S e l e c t i o n o f t u b e is i m p o r t a n t . I t s h o u l d b e o f p r o p e r
8. S k i n i n c i s i o n s h o u l d n o t be s u t u r e d o r p a c k e d t i g h t l y as i t
diameter, length and curvature. A l o n g tube impinges
m a y lead t o d e v e l o p m e n t o f subcutaneous e m p h y s e m a .
o n t h e c a r i n a o r right b r o n c h u s . W i t h h i g h c u r v a t u r e ,
9. G a u z e d r e s s i n g is p l a c e d b e t w e e n t h e s k i n a n d f l a n g e
l o w e r e n d o f t u b e i m p i n g e s o n a n t e r i o r tracheal w a l l
o f the tube a r o u n d the stoma.
w h i l e u p p e r part compresses t h e tracheal rings o r c r i -
c o i d (see A p p e n d i x I I , page 463).
8. U s e s o f t silastic o r p o r t e x t u b e . M e t a l l i c t u b e s cause

J Tracheostomy in I n f a n t s a n d C h i l d r e n J more trauma.

9. T a k e a p o s t - o p e r a t i v e X - r a y o f t h e n e c k a n d chest t o
I m p o r t a n t c o n d i t i o n s r e q u i r i n g t r a c h e o s t o m y i n t h i s age
ascertain the p o s i t i o n o f the t r a c h e o s t o m y t u b e .
g r o u p are l i s t e d i n T a b l e 63.2.
 Tracheostomy & O t h e r Procedures for Airway Management

tracheobronchial infections, tracheal ulceration, granula-

Post-operative Care
t i o n s , stenosis a n d u n s i g h t l y scars.
T o d e c a n n u l a t e a p a t i e n t , t r a c h e o s t o m y t u b e is p l u g g e d
1. Constant supervision. After tracheostomy, constant
a n d the p a t i e n t closely observed. I f t h e patient can tolerate
supervision o f the patient for bleeding, displacement
i t f o r 2 4 h o u r s , t u b e c a n b e safely r e m o v e d . I n c h i l d r e n ,
o r b l o c k i n g o f t u b e a n d r e m o v a l o f s e c r e t i o n s is essen-
t h e a b o v e p r o c e d u r e is d o n e u s i n g a s m a l l e r t u b e . A f t e r
tial. A nurse or patient's relative s h o u l d be i n atten-
t u b e r e m o v a l , w o u n d is t a p e d a n d p a t i e n t a g a i n closely
d a n c e . P a t i e n t is g i v e n a b e l l o r a p a p e r p a d a n d a p e n c i l
o b s e r v e d . H e a l i n g o f t h e w o u n d takes p l a c e w i t h i n a f e w
to communicate.
days o r a w e e k . R a r e l y a s e c o n d a i y c l o s u r e o f w o u n d m a y
2. Suction. D e p e n d i n g on the a m o u n t o f secretion, suc-
be r e q u i r e d .
t i o n m a y b e r e q u i r e d e v e r y h a l f a n h o u r o r so; use
Observe the f o l l o w i n g principles w h e n decannulating
sterile catheters w i t h a Y - c o n n e c t o r t o break s u c t i o n
an i n f a n t o r a y o u n g c h i l d :
f o r c e . S u c t i o n i n j u r i e s t o t r a c h e a l m u c o s a s h o u l d be
a v o i d e d . T h i s is d o n e b y a p p l y i n g s u c t i o n t o t h e c a t h - 1. Decannulate i n t h e o p e r a t i o n t h e a t r e w h e r e services
eter o n l y w h e n w i t h d r a w i n g i t (Fig. 63.3). o f a t r a i n e d n u r s e a n d a n anaesthetist are a v a i l a b l e .
3. Prevention of crusting and tracheitis. T h i s is a c h i e v e d b y : 2. Equipment for re-intubation should be available
(a) Proper humidification, by use of humidifier, i m m e d i a t e l y . I t consists o f a g o o d h e a d l i g h t , l a r y n g o -
steam tent, ultrasonic nebulizer o r k e e p i n g a b o i l - s c o p e , p r o p e r - s i z e d e n d o t r a c h e a l tubes a n d a t r a c h e o s -
i n g ketde i n the r o o m . t o m y tray.
(b) I f crusting occurs, a f e w drops o f n o r m a l or h y p o - 3. A f t e r d e c a n n u l a t i o n , w a t c h t h e c h i l d f o r several h o u r s
t o n i c saline o r R i n g e r ' s l a c t a t e are i n s t i l l e d i n t o for respiratory distress, tachycardia and colour
t h e t r a c h e a e v e r y 2—3 h o u r s t o l o o s e n crusts. A O x y m e t r y is v e r y u s e f u l t o m o n i t o r o x y g e n s a t u r a t i o n .
m u c o l y t i c a g e n t s u c h as a c e t y l c y s t e i n e s o l u t i o n , It may require blood gas determinations. When
can be instilled to l i q u i f y tenacious secretions o r a t t e m p t s at d e c a n n u l a t i o n are n o t successful, l o o k f o r
t o l o o s e n t h e crusts. t h e cause. I t m a y b e :
4. Care of tracheostomy tube. Inner cannula should be (i) Persistence o f the c o n d i t i o n f o r w h i c h tracheo-
r e m o v e d a n d c l e a n e d as a n d w h e n i n d i c a t e d f o r t h e s t o m y was d o n e .
f i r s t 3 days. O u t e r t u b e , unless b l o c k e d o r d i s p l a c e d , (ii) O b s t r u c t i n g granulations a r o u n d the stoma or
s h o u l d n o t b e r e m o v e d f o r 3—4 days t o a l l o w a t r a c k b e l o w i t w h e r e tip o f the tracheostomy tube had
t o b e f o r m e d w h e n t u b e p l a c e m e n t w i l l b e c o m e easy. been impinging.
After 3—4 days, outer tube can be removed and ( i i i ) T r a c h e a l o e d e m a o r s u b g l o t t i c stenosis.
cleaned every day. ( i v ) I n c u r v i n g o f t r a c h e a l w a l l at t h e site o f t r a c h e o -
stome.
I f c u f f e d t u b e is u s e d , i t s h o u l d b e p e r i o d i c a l l y d e f l a t e d
(v) Tracheomalacia.
t o p r e v e n t pressure necrosis o r d i l a t a t i o n o f trachea.
(vi) Psychological dependence o n tracheostomy and
Decannulation Tracheostomy tube s h o u l d n o t be kept
i n a b i l i t y t o t o l e r a t e t h e resistance o f t h e upper
longer t h a n necessaiy. P r o l o n g e d use o f t u b e leads to
airways.

A case o f d i f f i c u l t d e c a n n u l a t i o n may require endo-

scopic e x a m i n a t i o n o f the l a r y n x , trachea a n d bronchi
p r e f e r a b l y u n d e r m a g n i f i c a t i o n u s i n g telescopes o r a f l e x -
ible endoscope.

| Complications

A. Immediate (at t h e t i m e o f o p e r a t i o n ) :

1. Haemorrhage.
2. A p n o e a . T h i s f o l l o w s o p e n i n g o f trachea i n a patient
w h o had p r o l o n g e d respiratory obstruction. T h i s is

Figure 63.3 due to sudden w a s h i n g o u t o f C O , w h i c h was acting

as a r e s p i r a t o r y s t i m u l u s . T r e a t m e n t is t o a d m i n i s t e r
Tracheotomised patient o f laryngeal cancer with suction-aid
5 % C O , i n o x y g e n o r assisted v e n t i l a t i o n .
tracheostomy tube and receiving oxygen t h r o u g h a side port.
3. P n e u m o t h o r a x due to i n j u r y to apical pleura.
Diseases o f Larynx and T r a c h e a

L I n j u r y to recurrent laryngeal nerves.

5. Aspiration o f blood.
6, I n j u i y to oesophagus. T h i s can o c c u r w i t h t i p o f k n i f e
w h i l e i n c i s i n g the trachea a n d m a y result i n t r a c h e o -
oesophageal fistula.

B. Intermediate ( d u r i n g f i r s t f e w h o u r s o r days):

1. Bleeding, reactionary or secondary.

2. Displacement o f tube.
Figure 63.4
3. B l o c k i n g o f tube.
4. Subcutaneous emphysema. Laryngeal mask airway.

5. Tracheitis and tracheobronchitis with crusting in

trachea.
(Fig. 63.4). O x y g e n can be delivered d i r e c t l y i n t o the t r a -
6. A t e l e c t a s i s a n d l u n g abscess.
chea. T h o u g h m o s t c o m m o n l y used f o r non-emergent
7. Local w o u n d infection and granulations.
a i r w a y c o n t r o l , i t c a n b e u s e d as a n a l t e r n a t i v e i f s t a n d a r d

C . Late ( w i t h p r o l o n g e d use o f t u b e f o r w e e k s a n d m o n t h s ) : m a s k v e n t i l a t i o n is i n a d e q u a t e a n d i n t u b a t i o n unsuccessful

(see A p p e n d i x I I o n I n s t r u m e n t s ) .
H a e m o r r h a g e , d u e t o e r o s i o n o f m a j o r vessel.
2. L a r y n g e a l stenosis, due to perichondritis o f cricoid 5. T r a n s t r a c h e a l j e t v e n t i l a t i o n I t is a n i n v a s i v e p r o c e -

cartilage. d u r e . A n i n t r a v e n o u s c a t h e t e r o f 1 2 o r 14 g a u g e w i t h a

3. Tracheal stenosis, due to tracheal ulceration and s y r i n g e a t t a c h e d is i n s e r t e d i n t o t h e c r i c o t h y r o i d m e m -

infection. brane and directed caudally. O n c e i n t r a l u m i n a l placement

4. Tracheo-oesophageal f i s t u l a , d u e t o p r o l o n g e d use o f is c o n f i r m e d b y a s p i r a t i o n , n e e d l e is w i t h d r a w n l e a v i n g

cuffed tube or erosion o f trachea b y the t i p o f t r a c h e o - the catheter i n p o s i t i o n a n d j e t v e n t i l a t i o n started. I n t h i n

stomy tube. i n d i v i d u a l s w h e r e trachea can be palpated, catheter can

5. P r o b l e m s o f d e c a n n u l a t i o n . Seen c o m m o n l y i n infants be i n s e r t e d easily. E x p i r a t i o n o f a i r s h o u l d b e insured

and children. otherwise pulmonary barotrauma with pneumothorax,

(>. Persistent tracheocutaneous fistula. p n e u m o m e d i a s t i n u m a n d surgical e m p h y s e m a can result.

7. P r o b l e m s o f t r a c h e o s t o m y scar. K e l o i d o r u n s i g h t l y 6. Endotracheal intubation This is t h e most rapid

scar. method. L a r y n x is v i s u a l i s e d w i t h a laryngoscope and
8. C o r r o s i o n o f t r a c h e o s t o m y t u b e a n d a s p i r a t i o n o f its e n d o t r a c h e a l t u b e o r a b r o n c h o s c o p e i n s e r t e d . N o anaes-
fragments i n t o the t r a c h e o b r o n c h i a l tree. thesia is r e q u i r e d . T h i s h e l p s t o a v o i d a h u r r i e d t r a c h e o s -
t o m y i n w h i c h c o m p l i c a t i o n rate is h i g h e r . A f t e r i n t u b a t i o n ,
an o r d e r l y t r a c h e o s t o m y can be p e r f o r m e d .
| Procedures for Immediate A i r w a y M a n a g e m e n t [
7. Cricothyrotomy or laryngotomy or mini tra-

W h e n a i r w a y o b s t r u c t i o n is so m a r k e d as t o a l l o w n o t i m e cheostomy T h i s is a p r o c e d u r e f o r o p e n i n g t h e a i r w a y

t o d o a n o r d e r l y t r a c h e o s t o m y , f o l l o w i n g measures are t a k e n : through the c r i c o t h y r o i d m e m b r a n e . Patient's head and

n e c k is e x t e n d e d , l o w e r b o r d e r o f t h y r o i d c a r t i l a g e a n d
1. J a w t h r u s t L i f t i n g the j a w f o r w a r d and e x t e n d i n g the
c r i c o i d r i n g are i d e n t i f i e d . S k i n i n t h i s area is i n c i s e d v e r t i -
n e c k i m p r o v e s t h e a i r w a y b y d i s p l a c i n g t h e soft tissues.
cally a n d t h e n c r i c o t h y r o i d m e m b r a n e c u t w i t h a trans-
N e c k extension s h o u l d be a v o i d e d i n spinal injuries.
verse i n c i s i o n . T h i s space c a n b e k e p t o p e n w i t h a s m a l l
2. O r o p h a r y n g e a l airway I t displaces t h e t o n g u e a n t e - tracheostomy tube or b y inserting the handle o f k n i f e and
r i o r l y a n d r e l i e v e s s o f t tissue o b s t r u c t i o n . V e n t i l a t i o n can b e t u r n i n g i t at right angles i f t u b e is n o t a v a i l a b l e . I t is e s s e n -
c a r r i e d o u t b y face m a s k p l a c e d s n u g l y o v e r t h e face a n d t i a l t o p e r f o r m a n o r d e r l y t r a c h e o s t o m y as s o o n as p o s s i b l e
c o v e r i n g b o t h nose a n d m o u t h . A m b u b a g can b e u s e d f o r because p e r i c h o n d r i t i s , s u b g l o t t i c o e d e m a and laryngeal
i n f l a t i o n o f air o r o x y g e n . stenosis can f o l l o w p r o l o n g e d l a r y n g o t o m y .
3. Nasopharyngeal airway (trumpet) I t is i n s e r t e d " M i n i t r a c h e o s t o m y is a n e m e r g e n c y p r o c e d u r e t o b u y
transnasally into the posterior h y p o p h a r y n x and relieves t i m e to a l l o w patient t o be carried to o p e r a t i o n theatre.
s o f t tissue o b s t r u c t i o n c a u s e d b y t h e t o n g u e a n d p h a r y n x . C o m m e r c i a l e m e r g e n c y k i t s are also a v a i l a b l e f o r t h i s . A s
I t is b e t t e r t o l e r a t e d t h a n o r o p h a r y n g e a l a i r w a y i n a w a k e a n e l e c t i v e p r o c e d u r e i t has b e e n d o n e t o c l e a r t h e b r o n -
patients. chial secretions f o l l o w i n g thoracic s u r g e r y . "

4. L a r y n g e a l m a s k a i r w a y I t is a d e v i c e w i t h a t u b e a n d 8. E m e r g e n c y tracheostomy Technique o f emergency

a t r i a n g u l a r distal e n d w h i c h f i t s o v e r t h e l a r y n g e a l i n l e t tracheostomy is as f o l l o w s : Patient's neck is extended,

trachea i d e n t i f i e d a n d f i x e d b e t w e e n surgeon's left t h u m b
a n d i n d e x f i n g e r . A v e r t i c a l i n c i s i o n is m a d e f r o m l o w e r
b o r d e r o f t h y r o i d t o suprasternal n o t c h c u t t i n g through
skin and subcutaneous tissues. Lower border o f cricoid
c a r t i l a g e is i d e n t i f i e d a n d a transverse incision made i n
p r e t r a c h e a l fascia. T h e t h y r o i d i s t h m u s d i s s e c t e d d o w n t o
expose u p p e r three tracheal rings. V e r t i c a l tracheal i n c i s i o n
is m a d e i n 2 n d a n d 3 r d r i n g s , o p e n e d w i t h a h a e m o s t a t a n d
the t u b e inserted, b l e e d i n g can be c o n t r o l l e d by p a c k i n g
w i t h gauze.
Emergency tracheostomy o n a struggling patient w i t h
i n a d e q u a t e l i g h t i n g , s u c t i o n a n d i n s t r u m e n t s is f r a u g h t w i t h
m a n y c o m p l i c a t i o n s . I f possible, an e n d o t r a c h e a l t u b e s h o u l d
b e p u t f o r a m o r e o r d e r l y p r o c e d u r e t o be c a r r i e d o u t .
PERCUTANEOUS DILATATIONAL
TRACHEOSTOMY
T h i s t y p e o f t r a c h e o s t o m y is d o n e i n I C U w h e r e p a t i e n t is
a l r e a d y i n t u b a t e d a n d b e i n g m o n i t o r e d . I t is d o n e u n d e r
s e d a t i o n . N e c k is e x t e n d e d w i t h a p a d u n d e r t h e s h o u l d e r s .
T r a c h e o s t o m y & O t h e r P r o c e d u r e s for A i r w a y M a n a g e m e n t
N e c k is p r e p a r e d a n d d r a p e d a n d 1 . 5 - 2 c m i n c i s i o n is
m a d e 2 c m b e l o w t h e l o w e r b o r d e r o f c r i c o i d . T r a c h e a is
e x p o s e d b y d i s s e c t i o n a n d p a l p a t i o n . T h y r o i d i s t h m u s is
pushed d o w n . N o w a small caliber flexible bronchoscope,
t o w h i c h a c a m e r a has b e e n a t t a c h e d , is passed t h r o u g h t h e
e n d o t r a c h e a l t u b e t o m o n i t o r t h e passage o f t h e needle,
g u i d e w i r e a n d d i l a t o r / s . I t is i m p o r t a n t t o e n t e r t h e t r a -
chea i n t h e m i d l i n e a n d a v o i d any lateral e n t r y . E n t r y i n t o
t h e t r a c h e a is m a d e b e t w e e n s e c o n d a n d t h i r d rings. A f t e r
d i l a t a t i o n t r a c h e o s t o m y t u b e is i n s e r t e d .
A d v a n t a g e s o f t h e p r o c e d u r e i n c l u d e : (i) N o n e e d t o
transport the p a t i e n t t o o p e r a t i o n theatre, (ii) a v o i d i n g O T
e x p e n s e s , ( i i i ) a v o i d i n g I C U n o s o c o m i a l i n f e c t i o n s t o be
carried to O T a n d earlier discharge o f patient.
T h e p r o c e d u r e is a v o i d e d i n p a t i e n t s w h o are o b e s e ,
h a v e a n e c k mass, d i f f i c u l t t o i n t u b a t e , d i f f i c u l t t o e x t e n d
t h e n e c k , l a r y n x a n d t r a c h e a are n o t easily p a l p a b l e o r h a v e
uncorrectable coagulopathies.
Complication o f the procedure include paratracheal
entry o f dilator or tracheostomy tube i n t o the l u m e n , hae-
m o r r h a g e , damage t o posterior tracheal w a l l and surgical
emphysema.
Foreign Bodies o f A i r Passages

A foreign b o d y aspirated into air passage can lodge i n the

Clinical Features
larynx, trachea, o r bronchi. Site o f l o d g e m e n t w o u l d d e p e n d

o n the size a n d nature o f the foreign b o d y .

S y m p t o m a t o l o g y o f foreign b o d y is d i v i d e d into 3 stages:
A large foreign b o d y , unable to pass t h r o u g h t h e glottis,

w i l l l o d g e i n the supraglottic area w h i l e the smaller o n e

1. I n i t i a l p e r i o d o f c h o k i n g , g a g g i n g a n d w h e e z i n g
T h i s lasts f o r a s h o r t time. F o r e i g n b o d y m a y be c o u g h e d
w i l l pass d o w n t h r o u g h the l a r y n x into the trachea o r

out or i t m a y lodge i n the l a r y n x o r further d o w n i n the

b r o n c h i . F o r e i g n bodies w i t h sharp points, e.g. pins, n e e -

t r a c h e o b r o n c h i a l tree.
dles, fish bones, etc. can stick a n y w h e r e i n the larynx, or

t r a c h e o b r o n c h i a l tree. 2. S y m p t o m l e s s i n t e r v a l T h e respiratory mucosa adapts

to the presence o f foreign b o d y a n d initial s y m p t o m s dis-

appear. S y m p t o m l e s s interval w i l l v a r y w i t h the size a n d

| Aetiology nature o f the foreign b o d y .

3. Later symptoms T h e y are caused b y obstruction to

C h i l d r e n are m o r e often affected; m o r e t h a n half o f t h e m
the airway, i n f l a m m a t i o n o r t r a u m a i n d u c e d b y the foreign
are b e l o w 4 years. A c c i d e n t s o c c u r w h e n t h e y s u d d e n l y
b o d y a n d w o u l d d e p e n d o n the site o f its l o d g e m e n t .
inspire d u r i n g play o r fight w h i l e h a v i n g s o m e t h i n g i n the

m o u t h . I n children, peanut is t h e m o s t c o m m o n vegetable (a) Laryngeal foreign body. A large f o r e i g n b o d y m a y

foreign b o d y ; others i n c l u d e a l m o n d seed, peas, beans, totally obstruct the a i r w a y leading to sudden death

g r a m o r w h e a t seed, w a t e r m e l o n seed, pieces o f carrot unless resuscitative measures are t a k e n u r g e n t l y . A

or apple. N o n v e g e t a b l e matters i n c l u d e plastic whistle, partially obstructive foreign b o d y w i l l cause d i s c o m -

plastic toys, safety pins, nails, all-pin, t w i s t e d wires o r ball fort o r p a i n i n the throat, hoarseness o f voice, c r o u p y

bearings. c o u g h , aphonia, dyspnoea, w h e e z i n g a n d haemoptysis.

In adults, foreign bodies are aspirated d u r i n g c o m a , deep (Fig. 64.1).

sleep or alcoholic intoxication. L o o s e teeth o r d e n t u r e m a y (b) Tracheal foreign body. A sharp foreign b o d y w i l l o n l y

be aspirated d u r i n g anaesthesia. p r o d u c e c o u g h a n d haemoptysis. A loose foreign b o d y

like seed m a y m o v e u p a n d d o w n the trachea b e t w e e n

the carina a n d the undersurface o f v o c a l cords causing

Nature of Foreign Bodies " a u d i b l e slap" a n d "palpatory t h u d " . A s t h m a t o i d

w h e e z e m a y also b e present. I t is b e s t h e a r d a t patient's

(a) Non-irritating type. Plastic, glass o r metallic foreign o p e n m o u t h .

bodies are relatively n o n - i r r i t a t i n g a n d m a y r e m a i n (c) Bronchial foreign body. M o s t foreign bodies enter the

s y m p t o m l e s s for a l o n g t i m e . right b r o n c h u s because i t is w i d e r a n d m o r e i n line

(b) Irritating type. Vegetable o r foreign bodies like peanuts, w i t h the tracheal l u m e n . A foreign b o d y m a y totally

beans, seeds, etc. set u p a diffuse v i o l e n t reaction lead- obstruct a lobar o r segmental b r o n c h u s causing atelecta-

ing t o c o n g e s t i o n a n d o e d e m a o f the t r a c h e o b r o n - sis o r i t m a y p r o d u c e a check valve o b s t r u c t i o n - a l l o w i n g

chial m u c o s a — a c o n d i t i o n called "vegetal b r o n c h i t i s " . o n l y ingress o f air but, n o t egress, l e a d i n g t o obstruc-

T h e y also s w e l l u p w i t h t i m e causing airway obstruction tive e m p h y s e m a . F o r pathogenesis a n d clinical picture

a n d later s u p p u r a t i o n i n the l u n g . o f b r o n c h i a l foreign b o d y see F i g . 64.2.

 Foreign Bodies of Air Passages

Diagnosis

It can be m a d e b y detailed h i s t o r y o f the f o r e i g n b o d y

" i n g e s t i o n " , p h y s i c a l e x a m i n a t i o n o f t h e n e c k a n d chest. A
history o f sudden onset o f c o u g h i n g , w h e e z i n g and d i m i n -
ished e n t r y o f air i n t o t h e lungs o n auscultations f o r m s a
classical t r i a d . R a d i o l o g y is v e r y h e l p f u l .

1. S o f t tissue p o s t e r o a n t e r i o r a n d l a t e r a l v i e w o f t h e n e c k
i n its e x t e n d e d p o s i t i o n . T h i s c a n s h o w radio-opaque
and sometimes even the r a d i o l u c e n t f o r e i g n bodies i n
t h e l a r y n x a n d t r a c h e a (Figs 6 4 . 3 t o 6 4 . 5 ) .
2. P l a i n X - r a y chest i n p o s t e r o a n t e r i o r a n d lateral v i e w s ,
0 11 12 113 14 15 116 17 18 1
(a) It may s h o w the radio-opaque foreign b o d y — i t s
size, shape a n d l o c a t i o n .

(b) L o b a r o r s e g m e n t a l atelectasis ( c o m p l e t e obstruc-

Laryngeal foreign bodies. (1) Safety pin, (2) A n a l l p i n , ( 3 , 4) A tion by foreign body).
twisted wire, (5) A fruit seed. Unilateral hyperinflation o f lobe or segment o r
entire l u n g (if ball valve obstruction). Mediastinal
s h i f t t o o p p o s i t e side is seen i n h y p e r i n f l a t i o n .
Fluoroscopy or X-rays taken d u r i n g inspiration
a n d e x p i r a t i o n are h e l p f u l .

(d) P e n u m o m e d i a s t i n u m or p n e u m o t h o r a x .

(e) A normal X-ray chest. I n e a r l y cases w i t h i n 24

hours o r f o r e i g n b o d y causing partial obstruction
w i t h f u l l ingress a n d egress o f a i r does n o t p r o -
duce any sign.

(f) Pneumonitis/bronchiectasis. P r o l o n g e d stay o f f o r -

eign b o d y may cause aletelectasis, pneumonitis
or bronchiectasis.

Figure 64.2
Types o f bronchial obstruction by a foreign body. (A) Partial

obstruction. Air can pass in and out, causing only wheeze.

(B) One way obstruction. Air can go in (during inspiration)

but not out, causing e m p h y s e m a o f lungs. (C) Total obstruc-

tion. Air can neither go in nor out, causing obstructive

atelectasis. ( D ) One way obstruction (reverse o f B). Air can

only go out, causing atelectasis. D a r k pink shows n o r m a l size

o f lung while lighter p i n k indicates effect o f obstruction.

E m p h y s e m a t o u s bulla may r u p t u r e causing spontaneous

pneumothorax. A f o r e i g n b o d y m a y also s h i f t f r o m one Figure 64.3
side t o t h e o t h e r c a u s i n g c h a n g e i n t h e p h y s i c a l signs. A
A radioiucent fruit seed (Chiku) seen in subglottic region o f
retained f o r e i g n b o d y i n the l u n g m a y later give rise to
larynx (arrow). P a t i e n t has a tracheostomy (double arrows).
p n e u m o n i t i s , b r o n c h i e c t a s i s o r l u n g abscess.
Diseases of Larynx and Trachea

Figure 64.6

Heimlich's manoeuvre. Sudden thrust directed upwards a n d

backwards, below the epigastrium, squeezes the air f r o m the

Figure 64.4
lungs, sufficient to dislodge a foreign body.

P.A. view chest s h o w i n g a nail in the right bronchus.

unable to cry for help. H e m a y die o f asphyxia unless

i m m e d i a t e first a i d m e a s u r e s are taken. T h e measures c o n -

sist o f p o u n d i n g o n the back, t u r n i n g the patient upside

d o w n a n d f o l l o w i n g H e i m l i c h m a n o e u v r e . T h e s e measures

s h o u l d n o t be d o n e i f patient is o n l y partially obstructed,

for fear o f causing total o b s t r u c t i o n .

Heimlich's manoeuvre. Stand b e h i n d the person, a n d place

y o u r arms a r o u n d his l o w e r chest a n d give four a b d o m i n a l

thrusts. T h e residual air i n the lungs m a y dislodge the for-

eign b o d y p r o v i d i n g s o m e a i r w a y { F i g . 64.6).

C r i c o t h y r o t o m y o r e m e r g e n c y t r a c h e o s t o m y s h o u l d be

d o n e i fH e i m l i c h ' s m a n o e u v r e fails. O n c e acute respiratoiy

e m e r g e n c y is o v e r , f o r e i g n b o d y can be r e m o v e d b y direct

laryngoscopy o r b y laryngofissure, i f f o u n d i m p a c t e d .

Tracheal and bronchial foreign bodies can be r e m o v e d

Figure 64.5
by b r o n c h o s c o p y w i t h full preparation a n d u n d e r general

P.A. view chest s h o w i n g a b r o k e n piece o f Fuller's tracheostomy anaesthesia. E m e r g e n c y r e m o v a l o f these foreign bodies is

tube in the left bronchus. not i n d i c a t e d unless there is a i r w a y o b s t r u c t i o n o r they are

o f the vegetable nature (e.g. seeds) a n d likely to swell up.

X - r a y chest at the e n d o f inspiration a n d e x p i r a t i o n . M e t h o d s to r e m o v e t r a c h e o b r o n c h i a l foreign b o d y :

Atelectasis a n d obstructive e m p h y s e m a can be seen.

\. C o n v e n t i o n a l rigid b r o n c h o s c o p y .
T h e y also give indirect evidence o f r a d i o l u c e n t for-
2. R i g i d b r o n c h o s c o p y w i t h telescopic aid.
e i g n bodies.
3. B r o n c h o s c o p y w i t h C - a r m f l u o r o s c o p y .
F l u o r o s c o p y / v i d e o f l u o r o s c o p y . E v a l u a t i o n d u r i n g
4. U s e o f D o r m i a basket o r Fogarty's b a l l o o n for r o u n d e d
inspiration a n d e x p i r a t i o n can be m a d e .
objects.
C T chest.
5. T r a c h e o s t o m y first a n d t h e n b r o n c h o s c o p y t h r o u g h

the tracheostome.

6. T h o r a c o t o m y a n d b r o n c h o t o m y for peripheral for-

|H Management
eign bodies.

Laryngeal foreign body A large bolus o f f o o d obstructed 7. Flexible fibre optic b r o n c h o s c o p y i n selected adult

above the cords m a y m a k e the patient totally aphonic, patients.

Diseases of Oesophagus

65. Anatomy and Physiology o f Oesophagus

66. Disorders o f Oesophagus
67. Dysphagia
68. Foreign Bodies o f Food Passage
A n a t o m y and Physiology o f
Oesophagus

Applied A n a t o m y
1 • Applied Physiology

I t is a f i b r o m u s c u l a r t u b e , a b o u t 2 5 c m l o n g i n a n a d u l t . I t M a n o m e t r i c studies h a v e s h o w n t w o h i g h p r e s s u r e z o n e s
extends f r o m t h e l o w e r e n d o f p h a r y n x ( C J t o t h e cardiac i n oesophagus and they f o r m the physiological sphincters.
end o f stomach (T ) n (Fig. 6 5 . 1 ) . I t runs vertically b u t T h e upper oesophageal sphincter starts at t h e u p p e r b o r d e r
i n c l i n e s t o t h e l e f t f r o m its o r i g i n t o t h o r a c i c inlet and o f o e s o p h a g u s a n d is a b o u t 3—5 c m i n l e n g t h a n d f u n c t i o n s
again f r o m T t o oesophageal o p e n i n g i n the diaphragm. I t d u r i n g t h e act o f s w a l l o w i n g .
shows three n o r m a l constrictions a n d i t is i m p o r t a n t t o T h e lower oesophageal sphincter is s i t u a t e d at l o w e r p o r t i o n
k n o w t h e i r l o c a t i o n at o e s o p h a g o s c o p y . T h e y are: o f o e s o p h a g u s . I t is also 3—5 c m i n l e n g t h a n d f u n c t i o n s t o
p r e v e n t oesophageal r e f l u x .
1. A t p h a r y n g o - o e s o p h a g e a l j u n c t i o n (C ( )—15 cm from
the u p p e r incisors.
2. A t crossing o f arch o f aorta a n d left m a i n bronchus
( T ) — 2 5 c m f r o m u p p e r incisors.
4

3. Where i t pierces the d i a p h r a g m ( T | Q )—40 cm from

Pharynx- Vertebral level Distance
u p p e r incisors.
from
incisors
F o r e i g n b o d i e s i n t h e o e s o p h a g u s c a n b e h e l d u p at
these c o n s t r i c t i o n s . Pharyngo-oesophagea C6- - -15 cm
The wall o f o e s o p h a g u s consists o f f o u r layers. From junction
w i t h i n o u t w a r d s , t h e y are: Trachea

(a) Mucosa, which is lined by stratified squamous

epithelium.
(b) Submucosa, w h i c h connects m u c o s a t o muscular layer. Arch of aorta
(c) Muscular layer, w h i c h has i n n e r c i r c u l a r a n d o u t e r l o n - 25 cm

g i t u d i n a l f i b r e s . C i r c u l a r f i b r e s at t h e l o w e r e n d are
thickened to f o r m a cardiac sphincter. The upper
t h i r d o f o e s o p h a g u s has striated, t h e l o w e r t h i r d s m o o t h , Left bronchus
a n d the m i d d l e t h i r d b o t h striated and s m o o t h muscle
Oesophagus
fibres (Fig. 65.2).
(d) Fibrous layer, w h i c h forms loose c o v e r i n g o f oesophagus.
Right crus of diaphragm
Nerve Supply

Parasympathetic fibres c o m e f r o m vagus nerves ( X ) and Gastro-

sympathetic fibres f r o m the sympathetic t r u n k . oesophageal
i unction
Lymphatic Drainage
Figure 65.1
The c e r v i c a l , t h o r a c i c a n d a b d o m i n a l parts d r a i n r e s p e c -
A n a t o m y o f oesophagus and levels o f normal constrictions
t i v e l y i n t o d e e p c e r v i c a l , p o s t e r i o r m e d i a s t i n a l a n d gastric
from the upper incisors.
nodes.
Diseases of Oesophagus

(b) P h a r y n g e a l phase I t is i n i t i a t e d w h e n t h e b o l u s o f
Pharynx
f o o d c o m e s i n t o c o n t a c t w i t h p h a r y n g e a l m u c o s a . A series
Upper sphincter o f r e f l e x a c t i o n s t a k e p l a c e c a r r y i n g t h e f o o d past o r o - a n d
( 3 - 5 cm)
l a r y n g o p h a r y n x i n t o the oesophagus. The communica-
t i o n s i n t o n a s o p h a r y n x , o r a l c a v i t y a n d l a r y n x are c u t o f f .
Striated muscle
(i) C l o s u r e o f n a s o p h a r y n x : S o f t palate c o n t r a c t s against
t h e Passavant's r i d g e o n t h e p o s t e r i o r p h a r y n g e a l w a l l

Mixed smooth and striated muscle a n d c o m p l e t e l y cuts o f f t h e n a s o p h a r y n x f r o m the

oropharynx.
(ii) Closure o f oropharyngeal isthmus: T h e entry o f f o o d

Smooth mi b a c k i n t o o r a l c a v i t y is p r e v e n t e d b y c o n t r a c t i o n o f
Lower sphincter t o n g u e against t h e palate a n d s p h i n c t e r i c a c t i o n of
( 3 - 5 cm) palatoglossal muscles.
Diaphragm
(iii) C l o s u r e o f l a r y n x : A s p i r a t i o n i n t o t h e l a r y n x is p r e -
v e n t e d b y t e m p o r a r y cessation o f r e s p i r a t i o n , c l o s u r e
o f laryngeal inlet b y c o n t r a c t i o n o f aryepiglottic folds,
closure o f false a n d t r u e cords, a n d r i s i n g o f l a r y n x u n d e r
Figure 65.2 t h e base o f t o n g u e . T h e r o l e o f e p i g l o t t i s i n p r o v i d i n g

Oesophagus and its sphincters.

p r o t e c t i o n t o l a r y n x is n o t clear b u t i t is seen t o d e f l e c t
b a c k w a r d s w h e n f o o d passes i n t o t h e p y r i f o m i fossae.
(iv) C o n t r a c t i o n o f p h a r y n g e a l muscles a n d r e l a x a t i o n o f
cricopharyngeus: Relaxation o f cricopharyngeus m u s -
M i d d l e p o r t i o n o f oesophagus s h o w s a c t i v e peristalsis. cles is so t i m e d a n d s y n c h r o n o u s t h a t f o o d passes f r o m
T h e w a v e s are w e a k e r i n t h e u p p e r p a r t , b e c o m i n g g r a d u - p h a r y n x i n t o t h e oesophagus during contraction o f
ally stronger t o w a r d s the l o w e r p o r t i o n . p h a r y n g e a l muscles.

(c) O e s o p h a g e a l phase A f t e r f o o d enters t h e o e s o p h a g u s ,

Physiology of Swallowing the c r i c o p b a r y n g e a l s p h i n c t e r closes a n d t h e p e r i s t a l t i c

m o v e m e n t s o f oesophagus t a k e t h e b o l u s d o w n t h e s t o m a c h .

T h e act o f s w a l l o w i n g is d i v i d e d i n t o t h r e e phases: Gastro-oesophageal s p h i n c t e r at t h e l o w e r e n d o f o e s o p h a -

gus relaxes w e l l b e f o r e p e r i s t a l t i c w a v e reaches a n d p e r m i t s
(a) O r a l or buccal
fluids t o pass. B o l u s o f f o o d is passed b y c o n t r a c t i o n o f
(b) Pharyngeal
p e r i s t a l t i c w a v e s a n d t h e n t h e s p h i n c t e r closes.
(c) Oesophageal
R e g u r g i t a t i o n o f f o o d back f r o m stomach i n t o oesopha-
(a) O r a l o r b u c c a l p h a s e T h e f o o d w h i c h is p l a c e d i n gus is p r e v e n t e d b y (i) t o n e o f g a s t r o - o e s o p h a g e a l sphinc-
t h e m o u t h is c h e w e d , l u b r i c a t e d w i t h saliva, c o n v e r t e d ter, (ii) n e g a t i v e i n t r a t h o r a c i c pressure, (iii) p i n c h - c o c k
i n t o a bolus and t h e n p r o p e l l e d i n t o the p h a r y n x b y eleva- e f f e c t o f d i a p h r a g m , ( i v ) m u c o s a l f o l d s , (v) oesophagogas-
t i o n o f t h e t o n g u e against t h e p a l a t e . t r i c a n g l e , a n d (vi) s l i g h t p o s i t i v e i n t r a - a b d o m i n a l pressure.
Disorders o f O e s o p h a g u s

signs o f s h o c k , s u r g i c a l e m p h y s e m a i n t h e n e c k , c r u n c h i n g
ACUTE OESOPHAGITIS s o u n d o v e r t h e h e a r t ( H a m m a n ' s s i g n , because o f a i r i n t h e
mediastinum) and pneumothorax.

I t is a c u t e i n f l a m m a t i o n o f t h e o e s o p h a g u s a n d c a n b e d u e X-rays o f t h e chest a n d n e c k are essential. They may

t o (a) i n g e s t i o n o f h o t l i q u i d s ; (b) i n g e s t i o n o f caustic o r r e v e a l w i d e n i n g o f t h e m e d i a s t i n u m a n d r e t r o v i s c e r a l space,

c o r r o s i v e agents; (c) l a c e r a t i o n d u e t o s w a l l o w e d f o r e i g n s u r g i c a l e m p h y s e m a , p n e u m o t h o r a x , p l e u r a l e f f u s i o n o r gas

b o d y , o r t r a u m a o f o e s o p h a g o s c o p y ; (d) m o n i l i a l i n f e c t i o n o f u n d e r the diaphragm.

o e s o p h a g u s f r o m t h r u s h i n t h e o r a l c a v i t y a n d (e) systemic
disorder, like pemphigus.
Treatment
Patient complains o f dysphagia, retrosternal b u r n i n g o r
haematemesis. Diagnosis can be made f r o m history, X - r a y
A l l o r a l feeds are s t o p p e d i m m e d i a t e l y . N u t r i t i o n is m a i n -
studies a n d o e s o p h a g o s c o p y .
t a i n e d t h r o u g h i . v . r o u t e . M a s s i v e doses o f a n t i b i o t i c s are
given i.v. to combat infection.

PERFORATION OF OESOPHAGUS E a r l y p e r f o r a t i o n s o f c e r v i c a l o e s o p h a g u s can b e man-

a g e d b y c o n s e r v a t i v e m e a s u r e s ; d r a i n a g e is r e q u i r e d o n l y
i f s u p p u r a t i o n d e v e l o p s . R e t r o v i s c e r a l space a n d / o r u p p e r
Aetiology m e d i a s t i n u m can be d r a i n e d t h r o u g h the neck.
Rupture o f thoracic o e s o p h a g u s is m o r e s e r i o u s and
P e r f o r a t i o n o r t h e r u p t u r e o f o e s o p h a g u s results f r o m : c o n s e r v a t i v e t r e a t m e n t r a r e l y succeeds. I f d i a g n o s i s is m a d e
e a r l y ( w i t h i n 6 h o u r s ) , p e r f o r a t i o n is s u r g i c a l l y r e p a i r e d
(a) Instrumental trauma, i . e . o e s o p h a g o s c o p y o r d i l a t a t i o n o f
a n d p l e u r a l c a v i t y d r a i n e d . I f d i a g n o s i s is d e l a y e d , r e p a i r is
s t r i c t u r e s w i t h b o u g i e s . T h e c o m m o n site o r r u p t u r e
n o t p o s s i b l e ; s u r g e r y is t h e n r e s t r i c t e d t o d r a i n a g e o f t h e
i n t h e s e cases is j u s t a b o v e t h e u p p e r s p h i n c t e r ; s o m e -
i n f e c t e d area.
t i m e s i t is t h e l o w e r o e s o p h a g u s n e a r t h e h i a t u s .
(b) Spontaneous rupture. T h i s usually f o l l o w s v o m i t i n g and
involves mostly the l o w e r t h i r d oesophagus. Post-
CORROSIVE BURNS OF OESOPHAGUS
e m e t i c r u p t u r e o f a l l t h e layers o f o e s o p h a g u s is c a l l e d
Boerhaave's syndrome.
Aetiology

Diagnosis
A c i d s , alkalies o r o t h e r c h e m i c a l s m a y b e s w a l l o w e d a c c i -
dentally i n c h i l d r e n or taken w i t h the purpose o f suicide i n
E a r l y d i a g n o s i s is i m p e r a t i v e , as m e d i a s t i n i t i s , r e s u l t i n g f r o m
adults.
r u p t u r e , can r a p i d l y p r o v e fatal. A l l patients c o m p l a i n i n g
o f p a i n i n the neck o r interscapular r e g i o n , f o l l o w i n g an
oesophagoscopy, s h o u l d be suspected o f a p e r f o r a t i o n . Pathology
T h e features of cervical oesophageal rupture are p a i n , f e v e r ,
d i f f i c u l t y t o s w a l l o w a n d l o c a l t e n d e r n e s s , a l o n g w i t h signs Severity o f oesophageal burns depends o n t h e nature of
o f surgical emphysema i n the neck. corrosive substance, its quantity and concentration and the dura-
T h e features of thoracic oesophageal rupture are p a i n , r e f e r r e d tion of its contact w i t h t h e o e s o p h a g e a l w a l l . A l k a l i e s are
t o the interscapular r e g i o n , fever 102—104°F (39—40°C), m o r e d e s t r u c t i v e a n d p e n e t r a t e d e e p i n t o t h e layers o f t h e
Diseases of Oesophagus

oesophagus. W i t h l y e b u r n s , e n t i r e o e s o p h a g u s a n d s t o m a c h
m a y s l o u g h o f f c a u s i n g fatal m e d i a s t i n i t i s a n d p e r i t o n i t i s .
BENIGN STRICTURES OF OESOPHAGUS

O e s o p h a g e a l b u r n s r u n t h r o u g h t h r e e stages:

(i) Stages o f a c u t e n e c r o s i s . Aetiology

(ii) Stage o f g r a n u l a t i o n s : S l o u g h separates l e a v i n g g r a n -
ulating ulcer. The strictures usually o c c u r w h e n muscular coat o f the
( i i i ) Stage o f s t r i c t u r e : S t r i c t u r e f o n n a t i o n b e g i n s at 2 w e e k s o e s o p h a g u s is d a m a g e d . T h e c o m m o n causes are:
and continues for 2 months or longer.
(a) B u m s d u e t o c o r r o s i v e substances o r h o t fluids.
(b) T r a u m a to oesophageal wall due to impacted f o r e i g n
Evaluation of Patients bodies or instrumentation or external injuries.
(c) U l c e r a t i o n s due to r e f l u x oesophagitis.
Evaluate the patient and determine the t y p e o f caustic (d) Ulcerations due to diphtheria, typhoid.
ingested, signs and symptoms o f shock, upper airway (e) Sites o f s u r g i c a l anastomosis.
o b s t r u c t i o n , mediastinitis, p e r i t o n i t i s , acid-base imbalance, (f) C o n g e n i t a l , usually i n the l o w e r t h i r d .
a n d associated b u r n s o f face, l i p s a n d o r a l c a v i t y . T a k e X - r a y
o f t h e chest a n d soft tissue l a t e r a l v i e w o f n e c k .
Clinical Features and Diagnosis

Management
D y s p h a g i a , f i r s t t o solids a n d t h e n t o l i q u i d s , is t h e c o m m o n
complaint. W h e n o b s t r u c t i o n is c o m p l e t e , r e g u r g i t a t i o n
(a) Hospitalise the patient.
a n d c o u g h m a y o c c u r . P a t i e n t is m a l n o u r i s h e d .
(b) T r e a t s h o c k a n d a c i d - b a s e i m b a l a n c e b y i . v . fluids a n d
B a r i u m s w a l l o w establishes t h e d i a g n o s i s . Oesophago-
electrolytes. M o n i t o r u r i n e o u t p u t f o r renal failure.
s c o p y is r e q u i r e d t o e x c l u d e m a l i g n a n c y .
(c) Relieve pain.
(d) Relieve airway obstruction. Tracheostomy may be
required. Treatment

(e) Neutralisation o f the corrosive b y appropriate w e a k

a c i d o r a l k a l i , g i v e n b y m o u t h , c a n b e d o n e b u t is (a) P r o g r a d e d i l a t a t i o n w i t h b o u g i e s I t s h o u l d be d o n e

effective o n l y i f d o n e w i t h i n first 6 hours. u n d e r direct v i s i o n t h r o u g h oesophagoscope. Dilatations

(f) Parenteral antibiotics s h o u l d be started i m m e d i a t e l y m a y be r e q u i r e d f r e q u e n t l y .

and c o n t i n u e d f o r 3 - 6 weeks d e p e n d i n g o n the degree (b) G a s t r o s t o m y I t helps t o f e e d t h e patients a n d g i v e rest

of bums. t o t h e i n f l a m e d area a b o v e t h e s t r i c t u r e s . A f t e r a f e w days,
(g) Pass a nasogastric t u b e . I t is u s e f u l t o f e e d t h e p a t i e n t w h e n i n f l a m m a t i o n subsides, l u m e n m a y b e c o m e v i s i b l e
and t o m a i n t a i n oesophageal l u m e n . a n d p r o g r a d e d i l a t a t i o n can b e r e s t o r e d . P a t i e n t can b e g i v e n
(h) Oesophagoscopy. S o m e a d v o c a t e a n early o e s o p h a g o - a t h r e a d t o s w a l l o w , w h i c h is r e c o v e r e d f r o m t h e s t o m a c h ,
s c o p y w i t h i n 2 days t o k n o w i f b u r n s i n t h e oesophagus a n d p r o g r a d e o r r e t r o g r a d e b o u g i n a g e can b e d o n e .
h a v e o c c u r r e d a n d i f so, t h e i r d e g r e e a n d e x t e n t so as t o
(c) S u r g e r y Excision o f strictured segment and reconstruc-
p l a n f u r t h e r t r e a t m e n t . O e s o p h a g o s c o p e is n o t passed
t i o n o f f o o d passage u s i n g s t o m a c h , c o l o n o r j e j u n u m .
b e y o n d t h e f i r s t severe c i r c u m f e r e n t i a l b u r n .
(i) Steroids s h o u l d b e s t a r t e d w i t h i n 48—96 h o u r s and
c o n t i n u e d f o r 4—6 w e e k s t o p r e v e n t s t r i c t u r e . HIATUS HERNIA
(j) F o l l o w the patient w i t h oesophagogram and oesopha-
g o s c o p y e v e r y t w o w e e k s , t i l l h e a l i n g is c o m p l e t e , f o r
It is d i s p l a c e m e n t o f stomach into the chest t h r o u g h
the d e v e l o p m e n t o f any stricture.
o e s o p h a g e a l o p e n i n g o f t h e d i a p h r a g m . M o s t p a t i e n t s are
(k) I f stricture develops it can be treated b y :
e l d e r l y , past 4 0 years. T h i s d i s o r d e r is o f t w o t y p e s :
(i) Oesophagoscopy and prograde dilatations, if
permeable, (a) Sliding. S t o m a c h is p u s h e d i n t o t h e t h o r a x , i n l i n e w i t h
(ii) G a s t r o s t o m y and retrograde dilatation, if t h e o e s o p h a g u s . R e f l u x o e s o p h a g i t i s is c o m m o n a n d
impermeable, m a y g i v e rise t o u l c e r a t i o n a n d stenosis. H a e m a t e m e s i s
(iii) O e s o p h a g e a l r e c o n s t r u c t i o n o r by-pass, i f d i l a t a - may occur. I t is c a u s e d b y raised intra-abdominal
t i o n s are i m p o s s i b l e . pressure.
(1) Patients o f c o r r o s i v e i n j u r i e s o f o e s o p h a g u s m a y r e q u i r e (b) Paraoesophageal. A p a r t o f t h e s t o m a c h a l o n g w i t h its
life-long follow-up. p e r i t o n e a l c o v e r i n g passes u p i n t o t h e t h o r a x b y t h e
 Disorders of Oesophagus

side o f o e s o p h a g u s . T h e g a s t r o - o e s o p h a g e a l j u n c t i o n
still r e m a i n s b e l o w t h e d i a p h r a g m a n d the angle b e t w e e n
oesophagus a n d s t o m a c h is m a i n t a i n e d . T h e r e is n o
r e f l u x oesophagitis i n this type o f hernia. T h e main
s y m p t o m is d y s p n o e a o n e x e r t i o n d u e t o p o s i t i o n o f
stomach i n the thorax, and sometimes bleeding.
f e e l i n g o f l u m p is m o r e m a r k e d b e t w e e n t h e m e a l s r a t h e r
t h a n d u r i n g a m e a l . S u c h a p a t i e n t m a y h a v e fear o f cancer
in the throat. Clinical examination o f the pharynx, larynx
a n d base o f t o n g u e is n o r m a l .
Treatment is reassurance t o t h e p a t i e n t w h e n n o cause
has b e e n f o u n d .

Diagnosis o f b o t h types o f hiatus h e r n i a can b e m a d e b y

barium swallow.
MOTILITY DISORDERS OF
OESOPHAGUS

H Treatment £ T h e y can be d i v i d e d i n t o :

M a i n l y i t is s u r g i c a l ; t h e h e r n i a is r e d u c e d a n d d i a p h r a g m a t i c (a) H y p e r m o t i l i t y d i s o r d e r , e . g . c r i c o p h a r y n g e a l spasm,

o p e n i n g r e p a i r e d . E a r l y cases a n d those u n f i t f o r s u r g e r y m a y d i f f u s e o e s o p h a g e a l spasm, n u t c r a c k e r oesophagus.

be treated conservatively t o reduce r e f l u x oesophagitis b y (b) H y p o m o t i l i t y d i s o r d e r s , e . g . c a r d i a c achalasia, gastro-

m e a s u r e s s u c h as (i) s l e e p i n g w i t h h e a d a n d chest r a i s e d ; oesophageal r e f l u x , s c l e r o d e r m a , a m y o t r o p h i c lateral

(ii) a v o i d a n c e o f s m o k i n g ; ( i i i ) use o f d r u g s t h a t r e d u c e sclerosis.

a c i d i t y (antacids a n d p r o t o n p u m p i n h i b i t o r s ) ; (iv) r e d u c - T h e y m a y i n v o l v e the u p p e r sphincter, l o w e r sphincter

t i o n o f o b e s i t y ; a n d (v) a t t e n t i o n t o t h e causes w h i c h raises
or t h e b o d y o f oesophagus.
i n t r a - a b d o m i n a l pressure.

PLUMMER-VINSON Cricopharyngeal Spasm

(PATTERSON BROWN-KELLY) SYNDROME

I t is caused b y f a i l u r e o f t h e u p p e r o e s o p h a g e a l sphincter
t o r e l a x p r o p e r l y . T h e r e is i n c o o r d i n a t i o n b e t w e e n r e l a x -
Classical f e a t u r e s o f t h i s s y n d r o m e i n c l u d e d y s p h a g i a , i r o n -
a t i o n o f the u p p e r oesophageal sphincter a n d simultaneous
d e f i c i e n c y a n a e m i a , glossitis, a n g u l a r s t o m a t i t i s , k o i l o n y c h i a
c o n t r a c t i o n o f t h e p h a r y n x . T h e c o m m o n causes are c e r e -
( s p o o n i n g o f nails) a n d a c h l o r h y d r i a . T h e r e is a t r o p h y o f
brovascular accidents, Parkinson's disease, b u l b a r p o l i o ,
the m u c o u s m e m b r a n e o f the alimentary tract.
m u l t i p l e sclerosis a n d m u s c u l a r d y s t r o p h i e s .
P r e d o m i n a n t l y , i t affects f e m a l e s past 4 0 years. B a r i u m
swallow shows a w e b i n the post-cricoid region and the
s a m e c a n b e seen o n o e s o p h a g o s c o p y . I t is d u e t o s u b e p i -
thelial fibrosis i n this r e g i o n .
g Diffuse Oesophageal S p a s m Jj
A b o u t 1 0 % o f t h e cases w i t h t h i s s y n d r o m e w i l l d e v e l o p
p o s t - c r i c o i d c a r c i n o m a . I t also predisposes t o t h e d e v e l o p -
I t is c h a r a c t e r i s e d b y s t r o n g n o n - p e r i s t a l t i c c o n t r a c t i o n s o f
m e n t o f carcinoma i n the tongue, buccal mucosa, p h a r y n x ,
t h e b o d y o f oesophagus w h i l e s p h i n c t e r i c r e l a x a t i o n is
oesophagus a n d the stomach.
n o r m a l . T h e symptoms consist o f dysphagia o r o d y n o p h a g i a
with substernal chest p a i n , simulating angina pectoris.
B a r i u m s w a l l o w m a y s h o w s e g m e n t e d o e s o p h a g e a l spasms
Treatment
g i v i n g a rosary, bead or a cork-screw type o f o e s o p h a g u s , t h o u g h
it m a y be n o n n a l i n some. M a n o m e t r y shows normal
(i) To connect a n a e m i a b y o r a l / p a r e n t e r a l i r o n . Serum
r e l a x a t i o n o f t h e s p h i n c t e r o n s w a l l o w i n g . T h e treatment is
levels o f i r o n are m o r e i m p o r t a n t t h a n h a e m o g l o b i n
d i l a t a t i o n o f l o w e r o e s o p h a g u s . S e v e r e cases m a y r e q u i r e
level. Associated B 1 2 and B ( [ d e f i c i e n c y s h o u l d also b e
m y o t o m y o f oesophagus f r o m the arch o f aorta t o l o w e r
corrected;
sphincter.
(ii) d i l a t a t i o n o f t h e w e b b e d area b y oesophageal b o u g i e s .

J Nut-cracker Oesophagus J
GLOBUS (HYSTERICUS) PHARYNGEUS
T h e s e are s t r o n g , h i g h a m p l i t u d e o e s o p h a g e a l c o n t r a c t i o n s
b u t the contractions r e m a i n peristaltic ( c o m p a r e diffuse
I t is a f u n c t i o n a l d i s o r d e r w h e r e t h e p a t i e n t c o m p l a i n s o f
o e s o p h a g e a l spasm w h e r e c o n t r a c t i o n s are n o n - p e r i s t a l t i c ) .
" l u m p " i n t h e t h r o a t . T h e r e is n o t r u e d y s p h a g i a . I n fact,
I t causes d y s p h a g i a a n d s u b s t e r n a l p a i n .
Diseases of Oesophagus

• Barrett's oesophagus ( n o r m a l s q u a m o u s e p i t h e l i u m
Cardiac Achalasia
o f oesophagus is r e p l a c e d b y c o l u m n a r e p i t h e l i u m

as a result o fc o n t i n u o u s i n f l a m m a t i o n ) . I t is a p r e -
It is c h a r a c t e r i s e d b y t h e absence o fperistalsis i n t h e b o d y
cancerous c o n d i t i o n
o f oesophagus a n d h i g h resting pressure i n l o w e r o e s o p h -
I I . L u n g
geal sphincter; t h e latter also does n o t relax d u r i n g
• A s p i r a t i o n p n e u m o n i a
s w a l l o w i n g .
• A s t h m a
T h e symptoms o f cardiac achalasia i n c l u d e dysphagia,
• Bronchiectasis
w h i c h is m o r e t o liquids than solids (reverse o ft h a t s e e n i n
I I I . L a r y n x
m a l i g n a n c y o r strictures) a n d regurgitation o f s w a l l o w e d
8
Posterior laryngitis causing vague p a i n i n throat,
f o o d particularly at night.
hoarseness a n d repeated throat clearing
T h e diagnosis i s m a d e b y : (a) r a d i o g r a p h y ( b a r i u m s w a l l o w
• P a c h y d e r m i a laryngis
s h o w s dilated oesophagus w i t h n a r r o w e d rat tail lower end),
• C o n t a c t ulcers a n d g r a n u l o m a s
sometimes also c a l l e d b i r d - b e a k a p p e a r a n c e ; ( b ) m a n o m e t r i c
• Posterior glottic stenosis
studies ( l o w pressure i n t h e b o d y o foesophagus a n d h i g h
0
P a r o x y s m a l laryngospasm
pressure at l o w e r sphincter a n d failure o ft h e sphincter t o
• C a r c i n o m a l a r y n x
relax); (c) e n d o s c o p y ( t o exclude b e n i g n stricture o r a n y
I V . E a r
d e v e l o p m e n t o f c a r c i n o m a w h i c h is a c o m m o n c o m p l i c a t i o n
• Otitis m e d i a w i t h effusion
o f this disorder.
V. Miscellaneous
T h e treatment o f choice is t h e m o d i f i e d Heller's operation
• G l o b u s hystericus
( m y o t o m y o ft h e n a r r o w e d l o w e r p o r t i o n o ft h e o e s o p h a -

gus). Forceful p n e u m a t i c d i l a t a t i o n o ft h e l o w e r oesophagus

can b e d o n e i n those unfit f o r surgery.

[ Scleroderma [

It is a s y s t e m i c collagen disorder primarily neural, b u t second-

[ G a s t r o - o e s o p h a g e a l Reflux J
arily w e a k e n i n g t h e s m o o t h muscles o f t h e l o w e r t w o -

thirds o fo e s o p h a g u s a n d t h e l o w e r o e s o p h a g e a l sphincter.
It is d u e t o d e c r e a s e d f u n c t i o n o f l o w e r oesophageal sphinc-
D y s p h a g i a m a y precede cutaneous lesions. B a r i u m s w a l l o w
ter thus p e r m i t t i n g r e g u r g i t a t i o n o f gastric contents i n t o
s h o w s absence o f peristalsis i n distal t w o - t h i r d s o f t h e
oesophagus. O t h e r causes o f gastro-oesophageal reflux
oesophagus. M a n y o fthese patients h a v e hiatus hernia, o r
are pregnancy, hiatus hernia, scleroderma, excessive use
reflux oesophagitis a n dm a yd e v e l o p stricture i n distal part
o f tobacco a n d alcohol, a n d drugs that relax t h e s m o o t h
o f the oesophagus d u e t o recurrent i n f l a m m a t i o n .
muscle (anticholinergic, beta-adrenergic drugs a n dc a l c i u m -

channel blockers).

symptoms
T h e o foesophageal reflux i n c l u d e substernal
[ Schatzki's Ring [
pain, heartburn, a n d regurgitation.

T h e treatment consists o f :
It occurs at t h ej u n c t i o n o fs q u a m o u s a n d c o l u m n a r e p i -

t h e l i u m a t t h e l o w e r e n d o fo e s o p h a g u s a n d h a s also b e e n
(a) E l e v a t i o n o ft h e head o fb e d at n i g h t .
called lower oesophageal ring. U s u a l l y seen i n patients above
( b ) A v o i d i n g f o o d a t least 3 h o u r s before b e d t i m e .
50 years o fage. Cause is u n k n o w n . S y m p t o m a t i c patients
(c) Antacids.
c o m p l a i n o f i n t e r m i t t e n t dysphagia a n d s o m e m a y e v e n
( d ) D r u g s that increase tone o f l o w e r oesophageal sphinc-
present w i t h bolus obstruction. I t m a yb e associated w i t h
ter, e.g. m e t o c l o p r a m i d e .
hiatus hernia. T r e a t m e n t is o e s o p h a g e a l dilatation.
(e) H 3 receptor antagonists, e.g. c i m e t i d i n e a n d

ranitidine.

(f) A v o i d i n g s m o k i n g , alcohol, caffeine, chocolates, mints

NEOPLASMS O F OESOPHAGUS
a n d carbonated drinks.

( g ) A n t i r e f l u x surgery, e.g.Nissen's f u n d o p l i c a t i o n .

Benign N e o p l a s m s
Complications of Gastro-oesophageal Reflux

B e n i g n neoplasms are rare c o m p a r e d t o m a l i g n a n t ones.

I . O e s o p h a g u s

Oesophagitis, oesophageal m u c o s a l erosion a n d Leiomyoma is t h e m o s t c o m m o n a n d accounts for t w o -

h a e m o r r h a g e t h i r d s o f all t h eb e n i g n neoplasms. I tarises f r o m t h e s m o o t h

- B e n i g n oesophageal stricture m u s c l e a n dg r o w s i n t h e wall o foesophagus. D y s p h a g i a is

 Disorders of Oesophagus

p r o d u c e d w h e n t u m o u r exceeds t h e d i a m e t e r o f 5 c m . Clinical Features

B a r i u m s w a l l o w shows an o v o i d filling defect. E n d o s c o p y

1. Early symptoms i n c l u d e substernal d i s c o m f o r t a n d p r e f -
reveals a s u b m u c o s a l s w e l l i n g . B i o p s y s h o u l d n o t b e t a k e n .
erence f o r soft o r l i q u i d f o o d .
T r e a t m e n t is e n u c l e a t i o n o f t h e t u m o u r b y t h o r a c o t o m y .
2. Progressive dysphagia and emaciation. D y s p h a g i a first t o

Mucosal polyps, lipomas, fibromas and haeman- s o l i d s a n d t h e n t o l i q u i d s . P a t i e n t loses w e i g h t a n d

giomas are other benign tumours. They are often becomes emaciated.

pedunculated and present in the oesophageal lumen. 3. Pain. U s u a l l y signifies e x t e n s i o n o f t u m o u r b e y o n d

E n d o s c o p i c r e m o v a l is a v o i d e d b e c a u s e o f t h e d a n g e r o f t h e w a l l s o f o e s o p h a g u s . I t is r e f e r r e d t o t h e b a c k .

o e s o p h a g e a l p e r f o r a t i o n . T r e a t m e n t is s u r g i c a l e x c i s i o n b y 4. Aspiration problem. S p r e a d o f c a n c e r m a y cause l a r y n g e a l

oesophagotomy. paralysis o r fistulae f o r m a t i o n l e a d i n g t o c o u g h , h o a r s e -

ness o f v o i c e , a s p i r a t i o n p n e u m o n i a a n d m e d i a s t i n i t i s .

Diagnosis
Carcinoma Oesophagus J
1. Barium swallow s h o w s n a r r o w a n d i r r e g u l a r o e s o p h a g e a l
Incidence
l u m e n , w i t h o u t p r o x i m a l d i l a t a t i o n o f t h e oesophagus.
I n c i d e n c e o f o e s o p h a g e a l c a r c i n o m a is h i g h i n C h i n a , J a p a n ,
2. Oesophagoscopy. U s e f u l t o see t h e site o f i n v o l v e m e n t ,
U S S R a n d S o u t h A f r i c a . I n I n d i a , i t c o n s t i t u t e s 3 . 6 % o f all
extent o f t h e lesion, a n d to take biopsy. F l e x i b l e fibre
b o d y cancers i n t h e r i c h a n d 9 . 1 3 % o f t h o s e i n t h e p o o r .
optic oesophagoscopy obviates the n e e d f o r general
anaesthesia a n d g i v e s a m a g n i f i e d v i e w .
Aetiology
3. Bronchoscopy helps to exclude extension of growth
S m o k i n g a n d a l c o h o l c o n s u m p t i o n are h i g h r i s k factors a n d i n t o t h e trachea a n d b r o n c h i .
so are s o m e p a r t i c u l a r d i e t a r y h a b i t s . I n I n d i a , h i g h i n c i - 4. C T scan is u s e f u l t o assess t h e e x t e n t o f disease a n d
d e n c e is associated w i t h t o b a c c o c h e w i n g a n d s m o k i n g . n o d a l metastases.
A b o u t 5 % o f o e s o p h a g e a l cancers arise i n t h e p r e - e x i s t i n g
p a t h o l o g i c a l lesions, s u c h as b e n i g n s t r i c t u r e s , h i a t u s h e r n i a , Treatment
cardiac achalasia a n d d i v e r t i c u l a . P l u m m e r - V i n s o n s y n d r o m e
S u r g e r y o f u p p e r t w o - t h i r d s o f o e s o p h a g u s is d i f f i c u l t d u e
is a n o t h e r p r e d i s p o s i n g f a c t o r .
to g r e a t vessels a n d i n v o l v e m e n t o f m e d i a s t i n a l nodes.

Pathology R a d i o t h e r a p y is t h e t r e a t m e n t o f c h o i c e .
S u r g e r y is t h e p r e f e r r e d m e t h o d o f t r e a t m e n t f o r c a n c e r
S q u a m o u s c e l l c a r c i n o m a is t h e m o s t c o m m o n ( 9 3 % ) . A d e n o -
o f l o w e r one t h i r d . T h e affected segment, with a wide
c a r c i n o m a (3%) is also seen, b u t i n t h e l o w e r o e s o p h a g u s ,
m a r g i n o f oesophagus p r o x i m a l l y , and the f u n d u s o f s t o m -
a n d m a y b e a n u p w a r d e x t e n s i o n o f t h e gastric c a r c i n o m a .
ach distally, can be excised w i t h p r i m a r y r e c o n s t r u c t i o n o f
O t h e r t y p e s are r a r e .
the f o o d channel.
I n a d v a n c e d l e s i o n s , o n l y p a l l i a t i o n is p o s s i b l e . A n a l t e r -
Spread of Carcinoma
native f o o d c h a n n e l can be p r o v i d e d b y :
(a) Direct. T h e l e s i o n m a y fill t h e l u m e n a n d i n f i l t r a t e t h e
(i) A by-pass o p e r a t i o n .
w a l l o f o e s o p h a g u s . I t m a y also s p r e a d t o t h e a d j o i n -
(ii) Oesophageal intubation w i t h Celestin or Mousseau-
i n g s t r u c t u r e s s u c h as t h e t r a c h e a , l e f t b r o n c h u s , a o r t a
Barbin or a similar tube.
or pericardium. I n v o l v e m e n t o f the recurrent l a r y n -
(Hi) Permanent gastrostomy or a feeding j e j u n o s t o m y .
geal n e r v e s causes a s p i r a t i o n p r o b l e m s .
(iv) Laser s u r g e r y : O e s o p h a g e a l g r o w t h is b u r n t w i t h N d :
(b) Lymphatic. D e p e n d i n g o n t h e site i n v o l v e d , c e r v i c a l ,
YAG laser t o p r o v i d e a f o o d c h a n n e l . C h e m o t h e r a p y
mediastinal or coeliac nodes m a y be i n v o l v e d . C e r v i c a l
is u s e d o n l y as a p a l l i a t i v e m e a s u r e i n the locally
a n d t h o r a c i c lesions also spread t o s u p r a c l a v i c u l a r n o d e s .
a d v a n c e d o r d i s s e m i n a t e d disease.
" S k i p l e s i o n s " m a y also o c c u r d u e t o s p r e a d t h r o u g h
the submucosal lymphatics.
Prognosis
(c) Blood borne. Metastases m a y d e v e l o p i n t h e l i v e r , l u n g s ,
bone and brain. F i v e - y e a r s u r v i v a l is n o t m o r e t h a n 5 - 1 0 % .
Dysphagia

Dysphagia is d i f f i c u l t y i n s w a l l o w i n g . T h e t e r m odynophagia is (i) Obstructive lesions of pharynx, e.g. t u m o u r s o f t o n s i l , soft

used w h e n s w a l l o w i n g causes p a i n . T h e latter is m o r e m a r k e d p a l a t e , p h a r y n x , base o f t o n g u e , s u p r a g l o t t i c l a r y n x ,
i n u l c e r a t i v e a n d i n f l a m m a t o r y lesions o f f o o d passages- o r even o b s t r u c t i v e h y p e r t r o p h i c tonsils.
oral cavity, o r o p h a r y n x and oesophagus. (ii) Inflammatory conditions, e.g. acute tonsillitis, p e r i t o n -
sillar abscess, r e t r o o r p a r a - p h a r y n g e a l abscess, a c u t e
epiglottitis, oedema larynx.
(iii) Spasmodic conditions, e . g . t e t a n u s , rabies.
^ Aetiology J (iv) Paralytic conditions. Paralysis o f soft p a l a t e d u e t o d i p h -

T h e cause o f d y s p h a g i a m a y b e pre-oesophageal (i.e. due to t h e r i a , b u l b a r palsy, c e r e b r o v a s c u l a r accidents. They

d i s t u r b a n c e i n t h e o r a l o r p h a r y n g e a l phase o f d e g l u t i t i o n ) , cause r e g u r g i t a t i o n i n t o t h e n o s e .

o r oesophageal ( w h e n d i s t u r b a n c e is i n o e s o p h a g e a l p h a s e ) .
Paralysis of larynx-lesions of vagus and bilateral
T h i s c l a s s i f i c a t i o n is c l i n i c a l l y u s e f u l as m o s t o f t h e p r e -
s u p e r i o r l a r y n g e a l n e r v e s cause a s p i r a t i o n o f f o o d i n t o t h e
o e s o p h a g e a l causes c a n b e easily e x c l u d e d b y p h y s i c a l e x a m -
larynx.
i n a t i o n w h i l e oesophageal ones r e q u i r e i n v e s t i g a t i o n .

Pre-oesophageal Causes
Oesophageal Causes

(a) O r a l p h a s e . N o r m a l l y , f o o d m u s t be m a s t i c a t e d , l u b r i -
T h e lesions m a y l i e i n t h e l u m e n , i n t h e w a l l o r o u t s i d e t h e
c a t e d w i t h saliva, c o n v e r t e d i n t o a b o l u s b y m o v e m e n t s of
w a l l o f oesophagus.
tongue and then pushed into the pharynx b y elevation o f
t h e t o n g u e against t h e h a r d p a l a t e . A n y d i s t u r b a n c e i n these (a) Lumen. O b s t r u c t i o n t o l u m e n c a n o c c u r i n atresia, f o r -
e v e n t s w i l l cause d y s p h a g i a . T h u s cause m a y b e : eign b o d y , strictures, b e n i g n or m a l i g n a n t t u m o u r s .
(b) Wall. I t c a n b e a c u t e o r c h r o n i c o e s o p h a g i t i s , o r m o t i l -
(i) Disturbance in mastication: trismus, fractures o f m a n d i -
i t y d i s o r d e r s . T h e l a t t e r are:
ble, t u m o u r s o f the u p p e r o r l o w e r j a w , disorders o f
(i) H y p o m o t i l i t y disorders, e.g. achalasia, s c l e r o d e n n a ,
temporomandibular joints.
a m y o t r o p h i c l a t e r a l sclerosis.
(ii) Disturbance in lubrication: xerostomia f o l l o w i n g radio-
(ii) H y p e r m o t i l i t y disorders, e.g. c r i c o p h a r y n g e a l spasm,
t h e r a p y , M i k u l i c z disease.
d i f f u s e o e s o p h a g e a l spasm.
(iii) Disturbance in mobility of tongue: paralysis o f t o n g u e ,
(c) Outside the wall. T h e lesions cause o b s t r u c t i o n b y press-
p a i n f u l u l c e r s , t u m o u r s o f t o n g u e , l i n g u a l abscess, t o t a l
i n g o n the oesophagus f r o m outside:
glossectomy.
(i) H y p o p h a r y n g e a l d i v e r t i c u l u m (see p a g e 290).
(iv) Defects of palate: cleft palate, oronasal fistula.
(ii) Hiatus hernia.
(v) Lesions of buccal cavity and floor of mouth: s t o m a t i t i s , u l c e r -
(iii) C e r v i c a l osteophytes.
ative lesions, L u d w i g ' s angina.
(iv) Thyroid lesions, e.g. enlargement, tumours,
(b) P h a r y n g e a l phase. For a normal swallow, f o o d should Hashimoto's thyroiditis.
e n t e r t h e p h a r y n x a n d t h e n be d i r e c t e d t o w a r d s o e s o p h a g e a l (v) M e d i a s t i n a l lesions, e . g . t u m o u r s o f m e d i a s t i n u m ,
o p e n i n g . A l l u n w a n t e d c o m m u n i c a t i o n s i n t o the nasophar- l y m p h n o d e e n l a r g e m e n t , a o r t i c a n e u r y s m , cardiac
y n x , l a r y n x , oral cavity s h o u l d be closed. Disturbances i n enlargement.
t h i s phase c a n arise f r o m : (vi) Vascular rings (dysphagia lusoria).
 4. R a d i o g r a p h y

(a) X-ray chest: T o exclude cardiovascular, p u l m o n a r y a n d

J Investigations ^
mediastinal diseases.
1. H i s t o r y . A d e t a i l e d h i s t o r y is o f p a r a m o u n t i m p o r t a n c e .
( b ) Lateral view neck: T o exclude cervical osteophytes a n d
Ascertain, i f dysphagia is of:
any soft tissue lesions o f p o s t - c r i c o i d or r e t r o p h a r y n -
(i) S u d d e n onset (foreign b o d y o r i m p a c t i o n o f f o o d o n
geal space.
a preexisting stricture o r m a l i g n a n c y , n e u r o l o g i c a l
(c) Barium swallow: I t is u s e f u l i n the diagnosis o f m a l i g -
disorders),
nancy, cardiac achalasia, strictures, diverticula, hiatus
(ii) Progressive (malignancy),
hernia o r oesophageal spasms. C o m b i n e d w i t h fluo-
(iii) I n t e r m i t t e n t (spasms o r spasmodic episodes o v e r an
roscopic c o n t r o l o r cineradiography, it can help i n the
organic lesion),
diagnosis o f m o t i l i t y disorders o f oesophageal wall o r
(iv) M o r e to liquids (paralytic lesions),
sphincters.
(v) M o r e to solids a n d progressing even to liquids ( m a l i g -
5. M a n o m e t r i c a n d p H s t u d i e s A pressure transducer
n a n c y o r stricture),
a l o n g w i t h a p H electrode a n d an o p e n - t i p p e d catheter is
(vi) Intolerance to acid f o o d o r fruit juices (ulcerative
i n t r o d u c e d i n t o the oesophagus to measure the pressures
lesions).
in the oesophagus a n d at its sphincters. A c i d reflux i n t o

N o t e a n y associated s y m p t o m s , e.g. regurgitation a n d the oesophagus is m e a s u r e d b y p H electrode. It also m e a -

heart b u r n (hiatus hernia); regurgitation o f undigested f o o d sures the effectiveness o f oesophagus to clear the acid l o a d

w h i l e l y i n g d o w n , w i t h c o u g h at n i g h t ( h y p o p h a r y n g e a l after acid solution is p u t i n the oesophagus. T h e s e studies

d i v e r t i c u l u m ) ; aspiration i n t o lungs (laryngeal paralysis); help i n m o t i l i t y disorders, gastro-oesophageal reflux a n d

aspiration i n t o the nose (palatal paralysis). to f i n d w h e t h e r oesophageal spasms are spontaneous o r

a c i d - i n d u c e d .
2. Clinical examination E x a m i n a t i o n o f oral cavity,

o r o p h a r y n x , and larynx and h y p o p h a r y n x can exclude m o s t 6. O e s o p h a g o s c o p y It gives direct e x a m i n a t i o n o f oesoph-

o f the pre-oesophageal causes o f dysphagia. E x a m i n a t i o n o f ageal m u c o s a a n d permits biopsy specimens. Flexible fibre-

the neck, chest a n d nervous system, i n c l u d i n g cranial nerves optic or rigid scopes can be used.

s h o u l d also be undertaken.
7. Other investigations B r o n c h o s c o p y (for b r o n c h i a l

3. B l o o d e x a m i n a t i o n H a e m o g r a m is i m p o r t a n t i n the carcinoma), cardiac catheterisation (for vascular a n o m a -

diagnosis and treatment o f P l u m m e r - V i n s o n s y n d r o m e a n d lies), t h y r o i d scan (for m a l i g n a n t t h y r o i d ) m a y be required,

to k n o w the n u t r i t i o n a l status o f the patient. d e p e n d i n g o n the case.

Foreign Bodies o f Food Passage

A n ingested foreign b o d y ( F B ) m a y lodge i n : 4. Narrowed oesophageal lumen. Pieces o f f o o d m a y b e

h e l d u p i n cases o f o e s o p h a g e a l s t r i c t u r e o r carcinoma.
1. T h e tonsil.
T h e first s y m p t o m o f c a r c i n o m a oesophagus m a y b e
2. T h e base o f tongue/vallecula.
s u d d e n o b s t r u c t i o n f r o m a foreign b o d y such as a
3. T h e p y r i f o r m fossa.
piece o f meat, fruit o r vegetable.
4. T h e oesophagus.
5. Psychotics. F o r e i g n b o d y m a y b e s w a l l o w e d w i t h a n

Tonsil Usually, i t is a s h a r p fish b o n e o r a needle i n o n e attempt t o c o m m i t suicide.

o f the tonsillar crypts. I t c a n b e easily o b s e r v e d b y o r o p h a -

ryngeal e x a m i n a t i o n a n d r e m o v e d .
Site o f L o d g e m e n t o f Foreign Body
Base o f tongue or vallecula H e r e again i t is u s u a l l y t h e

fish b o n e o r a needle. I t c a n b e o b s e r v e d b y m i r r o r e x a m i - B y far t h e c o m m o n e s t site is at o r j u s t b e l o w the c r i c o p h a -

nation. I t c a n b e r e m o v e d as a n office p r o c e d u r e b y asking ryngeal sphincter. Flat objects like coins are h e l d u p at the

the patient t o h o l d his o w n t o n g u e w h i l e e x a m i n e r holds sphincter w h i l e others are h e l d i n the u p p e r oesophagus

a large laryngeal m i r r o r i n o n e h a n d a n d a c u r v e d forceps just b e l o w t h e sphincter d u e t o p o o r peristalsis. F o r e i g n

in t h e other. b o d i e s w h i c h pass t h e s p h i n c t e r c a n b e held u p at t h e n e x t

n a r r o w i n g at b r o n c h o - a o r t i c constriction o r at t h e cardiac
Pyriform fossa Fish b o n e , c h i c k e n b o n e , needle o r a
end. Sharp o r p o i n t e d objects lodge a n y w h e r e i n t h e
d e n t u r e m a y lodge i n the p y r i f o r m fossa. Small foreign
oesophagus.
bodies c a n b e r e m o v e d u n d e r local anaesthetic w i t h a

c u r v e d forceps as d e s c r i b e d above. Large i m p a c t e d f o r e i g n

bodies o r those i n c h i l d r e n s h o u l d b e r e m o v e d b y e n d o s -
Clinical F e a t u r e s [j
c o p y u n d e r general anaesthesia.

Oesophagus U s u a l f o r e i g n bodies that get l o d g e d i n t h e

Symptoms

oesophagus are a c o i n , piece o f meat, chicken b o n e , denture,

1. History o f initial c h o k i n g o r gagging.
safety p i n , o r a marble.
2. Discomfort or pain located just a b o v e t h e clavicle o n t h e

l i g h t o r left o f trachea. D i s c o m f o r t increases o n attempts

to swallow. Local discomfort m a y p o i n t t o t h e site o f F B

£ Aetiology ^ in cervical oesophagus b u t n o t so i n l o w e r oesophagus.

3. Dysphagia. O b s t r u c t i o n t o s w a l l o w i n g m a y b e partial

1. Age. C h i l d r e n are m o r e often affected. T h e y h a v e a o r total. Partial o b s t r u c t i o n b e c o m e s total w i t h time

t e n d e n c y t o p u t a n y t h i n g i n t h e m o u t h . P l a y i n g w h i l e due t o o e d e m a .

eating is a n o t h e r factor. 4. Drooling of saliva. I t is s e e n i n cases o f t o t a l obstruction.

2. Loss of protective mechanism. U s e o f u p p e r d e n t u r e Saliva m a y b e aspirated causing p n e u m o n i t i s .

prevents tactile sensation a n d a f o r e i g n b o d y is s w a l - 5. Respiratory distress. I m p a c t e d foreign b o d y i n the u p p e r

l o w e d u n d e t e c t e d . Loss o f consciousness, epileptic oesophagus compresses posterior wall o f trachea caus-

seizures, d e e p sleep o r a l c o h o l i c i n t o x i c a t i o n are other i n g respiratory o b s t r u c t i o n especially i n children.

factors. Laryngeal o e d e m a c a n develop.

3. Carelessness. P o o r l y prepared f o o d , i m p r o p e r mastica- 6. Substernal or epigastric pain m a y o c c u r d u e t o o e s o p h a -

tion, hasty eating a n d d r i n k i n g . geal spasm o r i n c i p i e n t perforation.

 Foreign Bodies of F o o d Passage

Signs 3. T r a n s t h o r a c i c o e s o p h a g o t o m y For i m p a c t e d f o r -

eign bodies of thoracic oesophagus, chest IS o p e n e d at the

! - T e n d e r n e s s i n the l o w e r part o f neck o n the right o r
appropriate level.
left o f trachea.

2. P o o l i n g o f secretions i n the p y r i f o r m fossa o n indirect A foreign b o d y w h i c h has reached the s t o m a c h m a y

laryngoscopy. T h e y d o n o t disappear o n s w a l l o w i n g . pass t h r o u g h the rest o f gastrointestinal tract w i t h o u t dif-

3. S o m e t i m e s a foreign b o d y m a y be seen p r o t r u d i n g f r o m ficulty; stools s h o u l d be carefully e x a m i n e d every day.

the oesophageal o p e n i n g i n the postcricoid region. Patient s h o u l d take a n o r m a l diet, a n d n o purgatives s h o u l d

be administrated to hasten the passage. Operative interference

m a y be required w h e n :
[ Investigations J
(i) Patient complains o f p a i n a n d tenderness i n

1. Plain X-rays. Soft tissue lateral v i e w o f neck, poster- a b d o m e n .

oanterior, and lateral v i e w o f chest m a y s h o w the (ii) F o r e i g n b o d i e s are n o t s h o w i n g any progress o n serial

presence and l o c a t i o n o f a r a d i o - o p a q u e foreign b o d y X - r a y s taken at a f e w days interval.

(Fig. 68.1). C h i l d r e n should be X - r a y e d f r o m nasophar- (lit) F o r e i g n b o d y is 5 c m or longer (e.g. hair pin) i n a

y n x to the r e c t u m as m u l t i p l e f o r e i g n b o d i e s m a y have child b e l o w 2 years. I t is u n l i k e l y t o pass t h r o u g h the

b e e n ingested. turns o f the d u o d e n u m .

2. Fluoroscopy. R a d i o l u c e n t foreign bodies are n o t seen ( i v ) Presence o f p y l o r i c stenosis.

o n plain X - r a y s . T h e y can be diagnosed o n fluoros-

copy, w h e n the patient is g i v e n a piece o f c o t t o n

soaked i n b a r i u m o r b a r i u m filled capsule to s w a l l o w

| C o m p l i c a t i o n s o f O e s o p h a g e a l Foreign B o d y |
a n d i t s p a s s a g e is o b s e r v e d t h r o u g h the oesophagus.

L. Respiratory obstruction. T h i s is d u e to tracheal c o m p r e s -

Management sion b y the F B i n the oesophagus, or laryngeal o e d e m a

especially in infants a n d children.

1. O e s o p h a g o s c o p i c r e m o v a l M o s t o f the foreign b o d - 2. Periesophageal cellulitis and abscess i n the n e c k .

ies i n oesophagus can be r e m o v e d b y o e s o p h a g o s c o p y

3. Perforation. Sharp objects m a y perforate the oesopha-

u n d e r general anaesthesia.
geal wall, setting u p mediastinitis, pericarditis o r e m p y -

2. Cervical oesophagotomy I m p a c t e d foreign bodies ema. T h e y m a y perforate the aorta a n d p r o v e fatal.

or those w i t h sharp h o o k s such as p a r t i a l dentures located 4. Tracheo-oesophagealfistula. Rare.

a b o v e thoracic inlet m a y require r e m o v a l t h r o u g h an i n c i - Ulceration and stricture. O v e r l o o k e d foreign bodies m a y

sion i n the n e c k a n d o p e n i n g o f cervical oesophagus. cause s l o w ulceration a n d stricture.

F i g u r e 68.1

Foreign body food passage. ( A ) P.A. v i e w s h o w i n g 5 0 paisa coin. (B) Lateral view o f the same.
Recent Advances

69. Laser Surgery 361

70. Cryosurgery 364
71. Radiotherapy in Head and Neck Cancer 366
72. Chemotherapy for Head and Neck Cancer 370
73. HIV Infection/AIDS and ENT Manifestations 373
L A S E R is a n a c r o n y m for Light Amplification by Stimulated 3. N d : Y A G ( N e o d y m i u m - y t t r i u m a l u m i n i u m garnet)

Emission of Radiation . 4. C O ,

Principle N o r m a l l y , an a t o m is i n a s t a b l e f o r m , i.e. the

T h e clinical applications o f these lasers d e p e n d o n their
electrons equal to the n u m b e r o f protons, are r e v o l v i n g
w a v e l e n g t h a n d special absorptive p o w e r s o f the tissues
a r o u n d the nucleus i n a fixed orbit. W h e n g i v e n energy,
o n w h i c h they are used. T h e f u n c t i o n o f the laser b e a m s is
electrons change their orbits a w a y f r o m the nucleus a n d the
three folds ( i ) t o vaporise, ( i i ) t o cut o r ( i i i ) t o coagulate the
atoms are t h e n called 'excited' b u t this e x c i t e d state o f atoms
tissue.
does n o t last long. T h e atoms s o o n release their absorbed
A r g o n a n d K T P - 5 3 2 lasers fall i n the visible s p e c t r u m
energy automatically {spontaneous emission) and return to
(400—700nm) a n d d o n o t require a separate b e a m to focus
t h e i r o r i g i n a l state. I f p h o t o n s are m a d e t o strike these excited
t h e m (Fig. 69.1). T h e y are, therefore, ideal for m i d d l e ear
atoms, the decay o f the atoms is a c c e l e r a t e d and b o t h the
surgery.
incident a n d the absorbed photons are released (stimulated

emission). T h i s stimulated radiation is amplified w i t h the

help o f mirrors. T h u s , lasers are electromagnetic radiations Properties of Different Lasers a n d

w i t h specific w a v e

m e d i u m such
length d e p e n d i n g

as a r g o n , carbon
u p o n

d i o x i d e or
the type o f lasing

N d : Y A G .
I Their Surgical U s e

1. A r g o n laser, w a v e l e n g t h 4 8 8 - 5 1 4 n m , blue i n colour,

passes t h r o u g h clear fluid b u t gets absorbed b y p i g -

Types o f Lasers
m e n t e d tissues. I t is m a i n l y u s e d for p h o t o c o a g u l a t i o n

such as o f p o r t w i n e stain, h a e m a n g i o m a , telangiecta-

F o u r types o f laser are generally used i n surgery. T h e y are:
sia. I t is also used for retinal lesions and m i c r o s u r g e r y

1. A r g o n o f the ear (stapedotomy, lysis o f m i d d l e ear adhesions,

2. K T P - 5 3 2 (Potassium titanyl phosphate) spot w e l d i n g o f t y m p a n o p l a s t y grafts).

Helium neon Nd:YAG co

KTP-532 2
Argon
(1060 nm) (10600 nm)
-514 nm

400 nm 700 nm
Visible spectrum

Invisible spectrum Invisible spectrum

F i g u r e 69.1

Argon and K T P - 5 3 2 fall u n d e r visible z o n e o f s p e c t r u m while Nd:YAG and C 0 2 lasers are in invisible z o n e a n d require another visible

source ( H e - N e o n ) to focus them.

2. KTP-532 laser, w a v e f u n c t i o n 5 3 2 n m , falls i n optical density o f 6; for A r g o n laser use o r a n g e -

visible s p e c t r u m (blue—green), a n d is selectively y e l l o w glasses.

absorbed b y p i g m e n t . I t is used f o r m i c r o s u r g e r y o f Patient's eyes s h o u l d also b e p r o t e c t e d b y a d o u b l e

the ear. layer o f saline-moistened eye pads.

3. N d : Y A G laser, w a v e length 1060 n m ; invisible; can (c) Protection of other exposed areas. A l l exposed parts o f

b e t r a n s m i t t e d b y flexible endoscopes; has effective skin a n d m u c o u s m e m b r a n e s o f the patient, n o t i n

coagulative properties. It can b e used w i t h C O , laser surgical field, s h o u l d be p r o t e c t e d b y saline soaked

in the treatment o f tracheal a n d e n d o b r o n c h i a l towels, pads o r sponges w h i c h are k e p t w e t b y m o i s t -

t u m o u r s . e n i n g t h e m periodically. T e e t h s h o u l d also be

4. C 0 2 laser, w a v e l e n g t h 1 0 6 0 0 n m ; invisible; requires protected.

a i m i n g b e a m o f h e l i u m — n e o n laser. It c a n n o t pass (d) Evacuation of smoke. T w o separate suctions, o n e for

t h r o u g h the flexible fibrescope. I t is v e r y effective t o the b l o o d a n d the o t h e r f o r s m o k e a n d steam

v a p o r i s e tissues a n d give a bloodless field. I t is t h e m o s t w h i c h is p r o d u c e d b y vaporisation o f tissues, s h o u l d

c o m m o n l y used laser i n E N T surgery. be used.

(e) Anaesthetic gases and equipment. O n l y n o n - i n f l a m m a b l e

Uses ofC0 2 Laser in ENT gases like halothane or enflurane s h o u l d be used.

W h e n u s i n g C O , laser, r e d r u b b e r o r silicone tube

(a) Nose, e.g. papillomas, r h i n o p h y m a , telangiectasias,
s h o u l d be w r a p p e d b y reflective metallic foil. C u f f
nasal p o l y p i , choanal atresia, t u r b i n e c t o m y . I t is v e r y
s h o u l d be inflated w i t h m e t h y l e n e - b l u e c o l o u r e d
beneficial i n patients w i t h b l e e d i n g dyscrasias a n d
saline a n d p r o t e c t e d w i t h saline soaked cottonoids.
coagulopathies.

(b) O r a l cavity, e.g. m u l t i p l e areas o f l e u k o p l a k i a , erythro-

T h e safest endotracheal tube to use w i t h N d : Y A G laser
plakia, small superficial cancers, d e b u l k i n g o f large,
is colourless o r w h i t e p o l y v i n y l o r silicone tube that does
r e c u r r e n t o r inoperable t u m o u r s . Advantages are t r a n -
not have a n y b l a c k o r dark lettering or a lead lined m a r k -
soral approach, precision surgery, haemostasis a n d less
ing a l o n g the side. N e g l i g e n c e i n these precautions can
post-operative o e d e m a a n d pain.
cause endotracheal tube fires.
(c) Oropharynx, e.g. tonsillar a n d p h a r y n g e a l t u m o u r s .

Laser t o n s i l l e c t o m y is d o n e i n those w i t h c o a g u l o p a -

thies or hypertension.
Photodynamic Therapy

(d) Larynx, e.g. p a p i l l o m a larynx, laryngeal w e b , sub-

It is an u p c o m i n g n e w e r m o d a l i t y o f treating cancer o f
glottic stenosis, capillary h a e m a n g i o m a . I n adults, i t

skin, larynx, nasopharynx, t u m o u r o f aerodigestive tract

has b e e n used for vocal n o d u l e , l e u k o p l a k i a o f c o r d ,

a n d e n d o b r o n c h i a l t u m o u r s . I t is b a s e d o n the principle o f
p a p i l l o m a , p o l y p o i d d e g e n e r a t i o n o f c o r d , endoscopic

injecting a photosensitising agent w h i c h is t a k e n u p

laser a r y t e n o i d e c t o m y , m a l i g n a n t T ( lesions o f the

preferentially b y the t u m o u r s cells a n d t h e n e x p o s i n g the

vocal c o r d .

(e) Trachea and bronchi, e.g. recurrent papillomatosis,

site t o s p e c i f i c w a v e l e n g t h o f laser. Laser activates the p h o -

tosensitising agent w h i c h brings a b o u t destruction o f c a n -

tracheal stenosis, g r a n u l a t i o n tissue a n d b r o n c h i a l ade-

cer cells b u t spares the n o r m a l tissues. P h o t o d y n a m i c

n o m a , d e b u l k i n g o f obstructive m a l i g n a n t lesions o f

therapy has also b e e n used for recurrences after surgery,

trachea o r b r o n c h i .

(t) Plastic surgery, e.g. b e n i g n a n d m a l i g n a n t t u m o u r s

radiation o r c h e m o t h e r a p y . Photosensitising agents used

intravenously i n c l u d e h a e m a t o p o r p h y r i n derivative (for

o f skin, vaporisation o f naevi a n d tattoos,

(g) Neuro-otology, e.g. r e m o v a l o f acoustic n e u r o m a s .

head a n d n e c k cancers) a n d p h o t o s a n - 3 (for e n d o b r o n -

chial t u m o u r s ) . T o p i c a l sensitiser, delta a m i n o l e v u l i n i c

acid, has b e e n used f o r skin cancers (basal cell c a r c i n o m a

Safety Precautions in the U s e o f Laser a n d B o w e n ' s disease).

Laser o f t e n used is a r g o n tunable dye laser w i t h a w a v e -

(a) Education of staff. T h e surgeon, anaesthesiologist, nursing l e n g t h o f 6 3 0 n m . I t also has the advantage o f d e l i v e r y

a n d o p e r a t i o n theatre personnel s h o u l d b e educated t h r o u g h flexible fibres. Also, b y c h a n g i n g the dye, lasers

i n safety measures w h i l e u s i n g laser. w i t h different w a v e l e n g t h s can be p r o d u c e d . Patients

(b) Protection of eye. Protective eye glasses, specific for the r e c e i v i n g p h o t o d y n a m i c therapy s h o u l d a v o i d exposure t o

w a v e l e n g t h o f laser b e i n g u s e d , s h o u l d be w o r n b y the sunlight a n d use sun-protective c l o t h i n g to a v o i d p h o t o -

personnel to prevent accidental b u m s to the cornea sensitive s k i n reactions w h i c h m a y c o n t i n u e for several

or retina. F o r N d : Y A G laser, w e a r green glasses w i t h weeks.

 Laser Surgery

d i f f u s i o n o f o x y g e n t o c o c h l e a r a n d v e s t i b u l a r cells a n d
R A D I O F R E Q U E N C Y S U R G E R Y IN ENT
other ischaemic cells.

R a d i o w a v e s have been used surgically t o reduce the v o l u m e

Procedure
o f tissues. I t has b e e n u s e d o n i n f e r i o r t u r b i n a t e s t o r e l i e v e
nasal o b s t r u c t i o n ; o n soft p a l a t e t o r e l i e v e p r i m a r y s n o r i n g ,
P a t i e n t is p l a c e d i n h y p e r b a r i c o x y g e n c h a m b e r w h e r e h e /
u p p e r a i r w a y resistance a n d sleep a p n o e a ; a n d o n t h e base
she inhales 1 0 0 % o x y g e n f o r 1 h o u r at 2 . 4 a t m o s p h e r i c p r e s -
o f t o n g u e t o r e l i e v e sleep a p n o e a . I t has also b e e n u s e d f o r
s u r e . P a t i e n t c a n sit o r l i e d o w n o n t h e b e d . C o m p r e s s i o n
the treatment o f lingual t h y r o i d .
t i m e f o r t h e c h a m b e r is 10 m i n u t e s w h i l e decompression
T h e r a d i o f r e q u e n c y ( R F ) d e v i c e generates e l e c t r o m a g -
is 15 m i n u t e s . T h i s is i n a d d i t i o n t o 1 h o u r o f o x y g e n
netic waves o f v e r y h i g h frequency b e t w e e n 350 k H z and
i n h a l a t i o n u n d e r pressure. P a t i e n t r e c e i v e s o n e s i t t i n g p e r
4 M H z . U s u a l l y 4 6 0 k H z is u s e d . R F is d e l i v e r e d t h r o u g h
d a y ( u s u a l l y six p e r w e e k ) f o r a t o t a l o f 10 t o 2 0 s i t t i n g s .
v a r i o u s p r o b e s a c c o r d i n g t o t h e site o f a b l a t i o n . T h e p r o b e ,
i n s e r t e d i n t o t h e tissues, causes i o n i c a g i t a t i o n , heats u p t h e
tissues w h i c h r e s u l t i n p r o t e i n c o a g u l a t i o n a n d tissue n e c r o -
Results
sis b u t n o c h a r r i n g . L a t e r scar f o r m a t i o n o c c u r s i n 3 w e e k s
w i t h r e d u c t i o n i n size o f tissue. U s u a l l y t h e t e m p e r a t u r e is
I n s u d d e n deafness, a r e c o v e i y o f 1 0 - 2 0 d B has b e e n n o t i c e d
c o n t r o l l e d b e t w e e n 8 0 a n d 8 5 ° C . T h e essential parameters
i n 32.6%) o f p a t i e n t s i n t w o f r e q u e n c i e s after 15 s i t t i n g s .
o f r a d i o f r e q u e n c y are t h e p o w e r ( i n W a t t s ) , t e m p e r a t u r e
T i n n i t u s loudness was decreased b y h a l f (visual analogue
(degrees o f C e l s i u s ) , resistance ( i n O h m s ) , t r e a t m e n t t i m e
scale) i n 45%> o f p a t i e n t s . L a t e a p p l i c a t i o n o f H B O , with
(in seconds) and total energy delivered i n joules (i.e.
delay m o r e t h a n 3 m o n t h s reduces the beneficial o u t c o m e .
W a t t X seconds) a n d can be c o n t r o l l e d i n the d e v i c e .
I n another r a n d o m i s e d prospective trial o f p r i m a r y HB0 2

U s i n g d i f f e r e n t types o f electrodes, r a d i o f r e q u e n c y has also

versus p r i m a r y c o n s e r v a t i v e t r e a t m e n t i n G e r m a n y s h o w s a
been used t o p e r f o r m t o n s i l l o t o m y , microlaryngeal sur-
better o u t c o m e i n the H B O , g r o u p w i t h recovery i n 8 0 %
g e i y ( t o r e m o v e g r a n u l o m a s , p a p i l l o m a s , cysts), m y r i n g o -
o f patients. I n still a n o t h e r trial u s i n g H B O , therapy w h e r e
tomy, uvulopalatoplasty, correction o f r h i n o p h y m a and
c o n s e r v a t i v e t r e a t m e n t ( i n c l u d i n g cortisone) h a d f a i l e d s h o w e d
c o s m e t i c r e m o v a l o f s k i n l e s i o n s . R a d i o f r e q u e n c y is u s e d
i m p r o v e m e n t i n 3 0 % o f cases e v e n a f t e r 3 m o n t h s d e l a y .
t o c u t a n d c o a g u l a t e tissues w i t h m i n i m a l lateral tissue d a m -
T i n n i t u s is r e d u c e d t o 5 0 % i n t e n s i t y i n 7 0 % o f cases i f
age a n d c h a r r i n g . I t is m i n i m a l l y i n v a s i v e t e c h n i q u e , a n d
treated w i t h i n 3 m o n t h s o f onset; 3 0 % m a y be t o t a l l y c u r e d
s u r g e r y can b e p e r f o r m e d as a n o u t d o o r p r o c e d u r e . C o m -
o f tinnitus.
p l i c a t i o n s are f e w . T h e p r o c e d u r e s are cost e f f e c t i v e .
B o t h i n s u d d e n deafness a n d t i n n i t u s , results o f t r e a t m e n t
are b e t t e r i f t h e H B O , t h e r a p y is s t a r t e d e a r l i e r t h a n i n
t h o s e s t a r t e d late a f t e r 3 m o n t h s .
H y p e r b a r i c o x y g e n t h e r a p y is also b e i n g u s e d f o r several
HYPERBARIC OXYGEN
o t h e r c o n d i t i o n s , s u c h as:
T H E R A P Y IN ENT
I. N o n - h e a l i n g u l c e r s a n d c o m p r o m i s e d s k i n grafts a n d

T h e role o f hyperbaric oxygen therapy ( H B O , ) i n some flaps

d i s o r d e r s o f E N T is w e l l e s t a b l i s h e d a n d is b e i n g u s e d i n II. Gas gangrene

E u r o p e , Japan and C h i n a . Disorders like sudden idiopathic III. N e c r o t i s i n g soft tissue infections o f subcutaneous

s e n s o r i n e u r a l h e a r i n g loss, a c o u s t i c t r a u m a , n o i s e - i n d u c e d tissues, m u s c l e s a n d fascia

h e a r i n g loss a n d t i n n i t u s h a v e b e e n t r e a t e d s u c c e s s f u l l y b y IV. Burns

t h i s m o d a l i t y . I t has also b e e n u s e d t o t r e a t m a l i g n a n t o t i t i s V. O c u l a r ischaemic p a t h o l o g y

e x t e r n a a n d m u c o n n y c o s i s o f paranasal sinuses a n d s k i n flaps VL C a r b o n - m o n o x i d e poisoning or smoke inhalation

w i t h c o m p r o m i s e d b l o o d supply. D u r i n g H B O , therapy, VII. A i r o r gas e m b o l i s m

p a r t i a l pressure o f o x y g e n rises i n t h e p e r i l y m p h a n d e n d o - V I I I . N o n - h e a l i n g w o u n d s — d i a b e t i c or venous

l y m p h , w h i c h t h e n diffuses a n d s u p p l i e s o x y g e n t o s e n s o r y IX. C h r o n i c osteomyelitis

cells o f t h e i n n e r ear. D u r i n g H B O , t h e r a p y p O , increases

e v e n u p t o 4 6 0 % i n l a b y r i n t h i n e fluids a n d is still 60%) a b o v e J C o s t of Treatment J
n o r m a l a f t e r 1 h o u r o f t e r m i n a t i o n o f t h e r a p y . H B O , also
causes r e d u c t i o n o f h a e m a t o c r i t a n d decrease i n t h e b l o o d E a c h s i t t i n g o f t h e r a p y costs a b o u t R s . 1 8 0 0 . H o w e v e r , s p e -
viscosity a n d thus can have a r h e o l o g i c effect improving c i a l p a c k a g e s are also a v a i l a b l e f o r 5 , 10, 2 0 a p p l i c a t i o n s .
Cryosurgery

R a p i d f r e e z i n g o f tissues t o t e m p e r a t u r e s of —30°C and 5. Cryoimmunisation A u t o a n t i b o d i e s , specific to the

b e l o w a n d t h e i r s l o w t h a w i n g causes d e s t r u c t i o n . T h i s fact tissues f r o z e n , h a v e b e e n seen e x p e r i m e n t a l l y . T h i s is s u p -
has b e e n u s e d t o t r e a t v a r i o u s l e s i o n s o f t h e h e a d a n d n e c k p o s e d t o p r o v i d e tissue s p e c i f i c i m m u n i t y t o s u b s e q u e n t
i n c l u d i n g benign, premalignant and malignant neoplasms. c h a l l e n g e s w i t h t h e same t u m o u r .

Agents used i n freezing t h e tissue are u s e d e i t h e r b y a n

o p e n m e t h o d ( l i q u i d n i t r o g e n spray o r c a r b o n d i o x i d e s n o w )
Technique ~J
o r t h r o u g h a c l o s e d s y s t e m s u c h as a c r y o p r o b e . A c r y o -
p r o b e is based o n J o u l e - T h o m s o n effect, i.e. r a p i d e x p a n s i o n
C r y o t h e r a p y can be a p p l i e d u n d e r local o r l i g h t general
o f c o m p r e s s e d gas t h r o u g h a s m a l l h o l e p r o d u c e s cooling.
anaesthesia. S o m e t i m e s , n o anaesthesia is u s e d as f r e e z i n g
P r o b e s i n c u r r e n t use p r o d u c e a t i p t e m p e r a t u r e o f — 7 0 ° C
i t s e l f causes n u m b n e s s . The area t o b e f r o z e n s h o u l d b e
o r b e l o w a n d are a v a i l a b l e i n d i f f e r e n t sizes a n d d e s i g n s t o
i n s u l a t e d . A s u i t a b l e c r y o p r o b e is a p p l i e d i n t o o r u p o n t h e
s u i t t h e area o f c r y o a p p l i c a t i o n . S o m e p r o b e s also h a v e
tissues a n d t h e l a t t e r f r o z e n q u i c k l y f o r 3 - 8 minutes and
thermocouples w h i c h c a n b e i n s e r t e d i n t o t h e tissue t o
t h e n a l l o w e d t o t h a w s l o w l y . T h e p r o c e d u r e is repeated
m o n i t o r the temperature. The clinically available closed
once or twice. Area frozen should include a margin of
systems e m p l o y l i q u i d n i t r o g e n , n i t r o u s o x i d e o r carbon
n o r m a l tissue. A t h e r m o c o u p l e c a n b e i m p l a n t e d t o e n s u r e
dioxide.
f r e e z i n g at an a d e q u a t e d e p t h . A f t e r c r y o t h e r a p y , t h e area
is a l l o w e d t o h e a l b y s e c o n d a r y i n t e n t i o n . T h e necrotic
s l o u g h falls o f f i n 3 - 6 w e e k s . R e p e a t c y c l e s o f c r y o t h e r a p y
m a y be r e q u i r e d to achieve t h e desired result.
Mechanism of Tissue Destruction J
F r e e z i n g causes c e l l d e a t h t h r o u g h s e v e r a l mechanisms:
1. D e h y d r a t i o n T h e p u r e water inside and outside the J Uses of Cryotherapy J
c e l l crystallises w i t h c o n s e q u e n t rise i n t h e concentration
o f e l e c t r o l y t e s . T h e p H o f t h e m e d i u m also c h a n g e s as t h e 1. B e n i g n v a s c u l a r t u m o u r s C r y o t h e r a p y has b e e n f o u n d
b u f f e r i n g substances crystallise o u t . U r e a a n d d i s s o l v e d gases useful to treat h a e m a n g i o m a s i n v o l v i n g s k i n , oral cavity or
also r e a c h t o x i c c o n c e n t r a t i o n s a n d cause c e l l d e a t h . o r o p h a r y n x . I t has also b e e n u s e d as a n a d j u n c t t o t r e a t
2. D e n a t u r a t i o n C e l l m e m b r a n e s are m a d e u p o f l i p o - vascular t u m o u r s s u c h as a n g i o f i b r o m a a n d g l o m u s t u m o u r .
proteins. T h e i r denaturation makes cell m e m b r a n e perme- 2. Premalignant lesions Leukoplakia, involving the
able t o c a t i o n s . T h a w i n g o f cells, n o w e n g o r g e d w i t h c a t i o n s c h e e k , t o n g u e , f l o o r o f m o u t h , has b e e n e f f e c t i v e l y t r e a t e d
r e s u l t , i n c e l l lysis. b y c r y o t h e r a p y . I t is p r e f e r r e d t o e l e c t r o s u r g e r y because o f
3. Thermal s h o c k T h i s arrests t h e r e s p i r a t o r y f u n c t i o n less s c a r r i n g , b e t t e r q u a l i t y o f r e g e n e r a t e d epithelium, and

o f cell. n o r e c u r r e n c e o f l e s i o n . I t is also u s e d t o t r e a t solar k e r a t o -

sis, a p r e c a n c e r o u s c o n d i t i o n o f s k i n .
4 . V a s c u l a r stasis B o t h arterial a n d v e n o u s s u p p l y o f b l o o d
is o c c l u d e d l e a d i n g t o i s c h a e m i c i n f a r c t . M i c r o t h r o m b o s i s 3. Malignant lesions S k i n c a n c e r s l i k e B o w e n ' s disease
o f c a p i l l a r i e s is seen w i t h i n a f e w h o u r s o f c r y o a p p l i c a t i o n . (intraepithelial carcinoma) a n d basal c e l l c a r c i n o m a have
I t is b e c a u s e o f t h i s m e c h a n i s m t h a t c r y o s u r g e r y is u s e f u l t o b e e n t r e a t e d successfully w i t h a c u r e rate o f 9 4 - 9 7 % . C r y o -
t r e a t v a s c u l a r t u m o u r s , e.g. h a e m a n g i o m a , angiofibroma t h e r a p y is p a r t i c u l a r l y u s e f u l w h e n t u m o u r o v e r l i e s t h e c a r -
or glomus tumours. t i l a g e as t h e l a t t e r does n o t u n d e r g o n e c r o s i s w i t h f r e e z i n g .
It is also useful f o r s k i n cancers w h i c h are m u l t i p l e . 2. U s e f u l i n patients w i t h b l e e d i n g disorders o r

R e c u r r e n t skin cancers o r lesions w h i c h d o n o t h a v e w e l l - coagulopathies.

d e f m e d margins s h o u l d n o t be treated b y this m e t h o d . 3. C a n be used i n m u l t i p l e cancers, palliation o f recurrent

M a j o r role o f c r y o t h e r a p y has b e e n i n the palliation o f cancers w h e r e second course o f radiation is n o t

advanced cancers o r recurrent or residual t u m o u r s . I n these advisable.

c a s e s , a i m is t o d e b u l k the t u m o u r mass to facilitate d e g l u t i - 4. Causes m i n i m a l post-treatment d i s c o m f o r t o r pain.

t i o n o r respiration, to reduce t e n d e n c y o f t u m o u r s to bleed, 5. Causes m i n i m a l scarring. C a n b e u s e d at sites, n o t o r i -

a n d to relieve pain. ous f o r k e l o i d f o r m a t i o n , e.g. presternal r e g i o n .

R o l e o f curative cryotherapy i n p r i m a r y m a l i g n a n t lesion 6. I t is a n out-patient procedure.

o f the oral cavity a n d o r o p h a r y n x is l i m i t e d t h o u g h s o m e

s u c c e s s is r e p o r t e d i n early lesions ( T l N O ) i n v o l v i n g floor

J Disadvantages of Cryotherapy
o f m o u t h , t o n g u e a n d palate. F o r this, c r y o t h e r a p y s h o u l d

be used v e r y selectively, i n patients w h o are otherwise h i g h

1. N o tissue is available for biopsy i n case o f small
risk groups and h a v e a short expectancy o f life d u e to other
lesions.
c o n c u r r e n t disease.
2. N o t possible to assess m a r g i n s o f t u m o u r to k n o w
4. O t h e r uses C r y o t h e r a p y has b e e n applied to nasal t u r -
w h e t h e r free o f m a l i g n a n t cells.
binates to reduce their size and i m p r o v e the airway. It has
3. N o c o n t r o l o n d e p t h o f freezing.
also b e e n used i n allergic rhinitis to c o n t r o l sneezing a n d
4. W h e n used for skin lesions, c r y o t h e r a p y causes d e p i g -
r h i n o r r h o e a . C r y o d e s t r u c t i o n o f tonsils has b e e n d o n e i n
m e n t a t i o n a n d loss o f hair d u e to destruction o f hair
p o o r risk patients.
follicles.

5. Anaesthesia o f the p a r t is r e q u i r e d w h e n l e s i o n is near

the nerve, e.g. ulnar or digital.

J Advantages of Cryotherapy W i t h the advent o f laser therapy, m a n y o f the i n d i -

cations f o r c r y o t h e r a p y w i l l be reduced; h o w e v e r , its l o w e r

1. U s e f u l i n p o o r risk patients a n d can be applied w i t h -
cost w i l l be an i m p o r t a n t factor i n d e v e l o p i n g countries.
o u t anaesthesia o r u n d e r local anaesthesia.
R a d i o t h e r a p y in Head a n d
Neck Cancer

R a d i o t h e r a p y f o r m s a n i m p o r t a n t m o d a l i t y t o treat head
Types o f Radiation
and neck malignancies. I t m a yb e used:

1. P h o t o n b e a m s These are t h e most c o m m o n forms o f

(a) A l o n e , to cure early cancers a n d thus preserve t h e func-
radiation, b o t h X - r a y s a n dg a m m a rays fall i n this category
t i o n o ft h e o r g a n , e.g.glottic cancer.
(Fig. 71.1). A p h o t o n is c o n s i d e r e d a " p a c k e t " o f electro-
( b ) As an adjuvant t o surgery o r c h e m o t h e r a p y , t o increase
m a g n e t i c radiations. X - r a y s are p r o d u c e d b y X - r a y
the survival rate i n m o r e a d v a n c e d lesions.
machines w h e n h i g h energy electrons b o m b a r d a metallic
(c) As a palliative measure, i n advanced lesions, t o c o n t r o l
target. G a m m a rays are e m i t t e d b y radioactive sources,
local s y m p t o m s o f pain, b l e e d i n g o r o b s t r u c t i o n t oa i r
e.g. cobalt 6 0 .
a n d f o o d channels, w h e n t o t a l c o n t r o l o fd i s e a s e c a n -

n o t b e anticipated. 2. E l e c t r o n b e a m s These are second m o s t c o m m o n fonns

o f radiation. T h e i r m a i n characteristic is r a p i d d o s e build u p

It has also b e e n used i n t h e treatment o f certain benign
a n d s h a r p d o s e fall o f f w i t h v e r y little scatter. T h e y areused t o
vascular lesions w h e r e risks o f surgery are great, e.g. a n g i o -
boost u p t h eradiation dose t o t h e target area a v o i d i n g radia-
f i b r o m a o r g l o m u s t u m o u r a n d also t o c o n t r o l excessive
t i o n t o a d j o i n i n g vital structures, e.g. spinal cord. T h e y are
scar f o r m a t i o n i n keloids.
p r o d u c e d b y linear accelerator, betatron a n dm i c r o t r o n .

B
o
E
E
C

Visible
spectrum

/ \

400 nm
1
Y

1
700 nm

F i g u r e 71.1

Electromagnetic spectrum.
 R a d i o t h e r a p y in H e a d a n d N e c k C a n c e r

3. Particle radiation, e.g. n e u t r o n s , p r o t o n s o r p i o n s .

T h e y are s t i l l u n d e r i n v e s t i g a t i o n .
J S o u r c e s o f R a d i a t i o n ( T a b l e 71.1) H

H i g h e r t h e e n e r g y o f radiations, deeper d o t h e y p e n e t r a t e .
J Modes of Radiotherapy Earlier, X - r a y m a c h i n e s p r o d u c e d e n e r g y i n k i l o v o l t s ( k V )
a n d c o u l d be used f o r superficial t u m o u r s o f d i e s k i n o r l i p .
1. E x t e r n a l b e a m t h e r a p y o r t e l e t h e r a p y I t uses p h o t o n N o w , m a c h i n e s can p r o d u c e radiations o f h i g h e n e r g y i n m i l -
o r e l e c t r o n b e a m s w h i c h are p r o j e c t e d t o t h e t a r g e t area l i o n v o l t s ( M V ) . T h e y h a v e greater p e n e t r a t i n g p o w e r a n d can
t h r o u g h the skin. be used f o r deep-seated t u m o u r s s p a r i n g u n t o w a r d effects o n
2. B r a c h y t h e r a p y I t uses r a d i o a c t i v e m a t e r i a l w h i c h are t h e s k i n a n d b o n e . T h e various sources used f o r r a d i a t i o n are:
p l a c e d i n close c o n t a c t w i t h t h e t u m o u r tissue. T h e r a d i o - 1. Kilovoltage machines They produce X-rays of
a c t i v e m a t e r i a l is a p p l i e d i n t h e f o r m o f : 50—400 k V . T h e y w e r e the earliest m a c h i n e s used and
can be d i v i d e d i n t o superficial 5 - 1 5 0 k V or o r t h o voltage
(i) A mould
2 0 0 - 4 0 0 k V X - r a y machines.
(ii) Interstitial implant. Radioactive material i n the f o r m o f
2. Cobalt 60 machine I t is t h e m o s t c o m m o n l y u s e d
n e e d l e s , w i r e s , r i b b o n s o r seeds, are i n s e r t e d i n t o t h e
s o u r c e f o r h e a d a n d n e c k c a n c e r . I t uses r a d i o a c t i v e c o b a l t
t u m o u r tissue. B e c a u s e o f s h o r t e r h a l f - l i f e , t h e y are
s o u r c e w h i c h p r o d u c e s g a m m a rays o f 1.17 a n d 1.33MeV.
s o m e t i m e s p e r m a n e n t l y l e f t i n t h e tissues.
T h e s o u r c e has its n a t u r a l d e c a y t i m e a n d n e e d s r e p l a c e -
(iii) Intracavitary implant. H e r e , r a d i o a c t i v e m a t e r i a l is p l a c e d
m e n t after e v e r y 5 years.
i n a h o l l o w c a v i t y n e x t t o t h e t u m o u r , e.g. nasophar-
3. L i n e a r accelerator, betatron or microtron They
y n x , m a x i l l a r y a n t r u m , f o r a specific p e r i o d o f m i n u t e s ,
are m e g a v o l t a g e m a c h i n e s w h i c h w o r k o n e l e c t r i c i t y a n d
h o u r s o r days.
p r o d u c e r a d i a t i o n o f 4 - 2 5 M V . T h e y can p r o d u c e b o t h
Availability o f after-loading techniques, development p h o t o n o r electron beams d e p e n d i n g o n w h e t h e r an i n t e r -
o f safer r a d i o n u c l i d e s a n d c o m p u t e r i s e d d o s i m e t r y h a v e v e n i n g m e t a l l i c t a r g e t is u s e d i n m a c h i n e o r n o t .
r e n e w e d the interest i n brachytherapy w h i c h had been 4. R a d i o a c t i v e material Earlier, r a d i u m 226 was used
p r a c t i c a l l y a b a n d o n e d e a r l i e r d u e t o hazards t o r a d i a t i o n t o i n t h e f o r m o f n e e d l e s b u t n o w its use has b e e n r e p l a c e d b y
t h e p h y s i c i a n , nurses a n d o t h e r p e r s o n n e l . safer r a d i o n u c l i d e s , e . g . C e s i u m 137 ( i n t h e f o n n o f p e l l e t s ) ,
Advantages o f brachytherapy over external beam radi- I r i d i u m 192 ( i n t h e f o r m o f w i r e ) , G o l d 198 a n d I o d i n e
a t i o n are: 125 ( i n t h e f o r m o f seeds o r g r a i n ) .

(a) G r e a t e r dose c a n be d e l i v e r e d t o t h e t u m o u r a n d lesser U n i t of radiation E a r l i e r , rad ( r a d i a t i o n a b s o r b e d dose) was

t o t h e s u r r o u n d i n g n o r m a l tissues a n d t h u s b e t t e r l o c a l
control and fewer complications.
(b) R a d i a t i o n is d e l i v e r e d t o t h e t u m o u r c o n t i n u o u s l y at
a l o w dose. T h i s is m o r e e f f e c t i v e t h a n i n t e r m e d i a t e o r
h i g h dose r a d i a t i o n i n t r e a t m e n t o f h y p o x i c o r s l o w l y
proliferating tumours.
t h e u n i t o f radiation. N o w i t has b e e n replaced b y a n i n t e r n a -
t i o n a l u n i t — G r a y . O n e G r a y ( G y ) is e q u i v a l e n t t o o n e j o u l e o f
energy deposited per k i l o g r a m o f material.
O n e G y equals 100 rads o r 100 c e n t i g r a y s ( c G y ) .
T a b l e 7 1 . 1 gives the e n e r g y range a n d t y p e o f r a d i a t i o n
i n d i f f e r e n t types o f r a d i o t h e r a p y .

B r a c h y t h e r a p y m a y b e u s e d as t h e sole t r e a t m e n t o f t h e
t u m o u r d e l i v e r i n g a t o t a l o f 70—80 G y o r i t is c o m b i n e d 1 Energy range, type o f r a d i a t i o n in different

I types o f radiotherapy
with teletherapy d e l i v e r i n g 40—50 G y with teletherapy
f o l l o w e d b y 30—40 G y w i t h b r a c h y t h e r a p y . Types of therapy Radiation Voltage

3. Intensity m o d u l a t e d r a d i a t i o n t h e r a p y ( I M R T ) I t is Superficial therapy X-rays 5 0 - 1 5 0 kV

a r e c e n t d e v e l o p m e n t i n d e l i v e r y o f r a d i o t h e r a p y a n d has Orthovoltage therapy X-rays 2 0 0 - 4 0 0

b e e n possible b y (a) b e t t e r d e l i n e a t i o n o f target tissue b y C T Megavoltage therapy X-rays k V > I M V

o r M R I a n d (b) c o m p u t e r - c o n t r o l l e d d e l i v e r y o f r a d i a t i o n . I n y-rays or electrons

this w a y m a x i m u m dose can be d e l i v e r e d t o t h e t u m o u r b u t L o w energy X-rays electron up to 6 M V

s a v i n g i m p o r t a n t n o r m a l s t m c t u r e s . I t is a f o r m o f conformal beam

radiotherapy because dose o f r a d i a t i o n c o n f o r m s t o t h e a m o u n t

M e d i u m energy Same 6-15 M V
o f target tissue i n t h r e e d i m e n s i o n s . I n t h e m a x i l l a r y a n t r u m ,
High energy Same > 1 5 M V
I M R T helps t o l i m i t the dose t o visual p a t h w a y s , spinal c o r d
Cobalt 60 therapy y-rays 1.17 or 1.33
a n d salivary glands. S i m i l a r l y i n t h e n a s o p h a r y n x , salivary
M e V (fixed)
glands, s k u l l b o n e a n d spinal c o r d can be p r o t e c t e d b y u n n e c -
k V = Kilovolts, M e V = M i llion electron voltage, M V = Million volts
essary i r r a d i a t i o n t h u s a v o i d i n g c o m p l i c a t i o n s .
 (ii) E x t e n t o f t u m o u r has b e e n defined a n d radiation can

J Types of Radiotherapy ( T a b l e 71.2) be g i v e n t o s u s p e c t e d areas o f residual disease o r areas

o f positive margins.
1. Curative radiotherapy. S m a l l cancerous lesions can
(iii) Surgical resection is t e c h n i c a l l y e a s i e r a n d postopera-
be c u r e d b y radiotherapy alone. Surgery also gives
tive healing better.
equally g o o d results i n t h e s e cases b u t r a d i a t i o n has the
(iv) T h e r e are f e w c o m p l i c a t i o n o f flap necrosis a n d
advantage o f preserving the f u n c t i o n . T h e total dose
infection, i f surgeiy is d o n e i n n o n - r a d i a t e d tissues.
o f curative radiation i n h e a d a n d n e c k cancer ranges

from 6 5 0 0 to 7 5 0 0 rads.
Generally, post-operative radiotherapy s h o u l d be g i v e n

2. Palliative radiotherapy. W h e n c a n c e r is t o o advanced, to all cases o f c a n c e r w h e n :

has distant metastases, o r the c o n d i t i o n o f the patient

(i) M a r g i n s or g r o w t h are reported t o o close o r positive,
is t o o p o o r to u n d e r g o surgery d u e to p o o r n u t r i t i o n
(n) W h e n b o n e o r cartilage is invaded.
o r other factors such as heart, l u n g , liver, or k i d n e y
(Hi) L y m p h nodes s h o w extracapsular invasion,
disease, o n l y palliative treatment is possible.
(iv) N e c k n o d e s are m u l t i p l e or the size o f a n o d e is
3. Combination therapy. R a d i o t h e r a p y can be c o m -
greater t h a n 3 c m .
b i n e d w i t h b o t h surgery a n d c h e m o t h e r a p y .

Disadvantages. After surgeiy, b l o o d supply to the tissues

/. Radiotherapy and Surgery
interfered w i t h , a n d the h y p o x i c cells w i l l n o t r e s p o n d

R a d i o t h e r a p y can be g i v e n before o r after surgery to w e l l t o radiation.

achieve better c o n t r o l o f disease. E a c h m o d a l i t y aims to

o v e r c o m e the deficiency o f the other. 2. Radiotherapy and Chemotherapy

Preoperative radiation
C h e m o t h e r a p y can be used either before, d u r i n g or after
Advantages
radiotherapy. W h e n u s e d before r a d i o t h e r a p y ( i n d u c t i o n che-

motherapy), it reduces the b u l k o f t u m o u r , w h i l e its vascular-

(i) I t reduces the t u m o u r b u l k m a k i n g questionably res-

i t y is m a i n t a i n e d o r has b e e n enhanced b y decrease i n size o f

pectable t u m o u r to o n e that is d e f i n i t e l y respectable.

(ii) O x y g e n a t i o n o f tissues has n o t b e e n t a m p e r e d w i t h

the t u m o u r . W h e n used concomitantly w i t h radiotherapy, che-

m o t h e r a p y acts as a radiosensitizer to i m p r o v e the effect o f

a n d therefore the response to treatment is better.

radiation o n the t u m o u r cells. M e t h o t r e x a t e and b l e o m y c i n

(iii) L y m p h a t i c s are b l o c k e d b y radiation a n d thus dis-

are b o t h radiosensitizers. C o n c o m i t a n t chemotherapy and

s e m i n a t i o n o f t u m o u r cells d u r i n g s u r g e r y is less.

radiation has b e e n used i n head and neck cancers. Cells resis-

(iv) Eliminates microscopic spread b e y o n d palpable t u m o u r

tant to one m o d a l i t y m a y respond to the other. C h e m o t h e r a p y

mass o r o c c u l t metastasis to l y m p h nodes.

shrinks the t u m o u r decreasing its i n t e r s t i t i a l p r e s s u r e a n d thus

Disadvantages. Preoperative radiation reduces the vitality o f
i m p r o v i n g b l o o d supply and oxygenation w h e r e radiation
tissues thereby delaying healing process. It also increases
can n o w w o r k m o r e effectively. T h o u g h chemoradiotherapy
chances o f flap necrosis, fistulae f o r m a t i o n , carotid b l o w - o u t s
has b e e n u s e d i n u n r e s e c t a b l e h e a d a n d n e c k tumours, its role
in post-operative p e r i o d .
has been investigated i n stage I I I or I V resectable t u m o u r s

Postoperative radiation w i t h added advantage o f preservation o f organ and its func-

Advantages tion, e.g. l a r y n g e a l o r h y p o p h a r y n g e a l cancers. H o w e v e r , the

side effects o f c o n c o m i t a n t radiation and c h e m o t h e r a p y are

(i) M o r e effective, as b u l k o f t u m o u r mass h a d b e e n
m o r e . C h e m o t h e r a p y can be used after radiation, b u t is less
r e m o v e d b y surgeiy.
likely to penetrate the affected tissue due to p o o r b l o o d

supply.

T a b l e 71.2 Types o f radiotherapy

1. R a d i a t i o n alone ^ f ~ ~ " Planning of Radiotherapy

Effective in early cases; preserves function

2. C o m b i n e d surgery and radiation

T h e f o l l o w i n g points are considered w h e n a patient is to
• Pre-operative radiation
receive radiotherapy:
• Post-operative radiation

Used in advanced cases 1. Types o f radiotherapy, w h e t h e r i t is c u r a t i v e , pal-

3. C o m b i n e d with c h e m o t h e r a p y liative, o r c o m b i n a t i o n type o f therapy.

Neoadjuvant chemoradiation
2. Site o f t u m o u r a n d its l y m p h a t i c field T h e p r i -
4. Palliative radiotherapy
m a r y t u m o u r a n d its d r a i n i n g l y m p h nodes h a v e to b e
Massive cancers with distant metastases
i n c l u d e d i n the radiation field.
 Radiotherapy in Head and Neck Cancer

Table 71.3 Complications o f radiotherapy

Early Late
1. R a d i a t i o n sickness (loss o f appetite and nausea) 1. P e r m a n e n t xerostomia

2. Mucositis 2. Skin changes (atrophy o f skin, subcutaneous fibrosis)

3. Dryness o f m u c o u s m e m b r a n e s 3. Decaying o f teeth

4. Skin reactions (erythema, dry or w e t desquamation) 4. Osteoradionecrosis

5. Laryngeal o e d e m a 5. Trismus (fibrosis o f T M joint and muscles)

6. Candida i n f e c t i o n s 6. T r a n s v e r s e myelitis

7. H a e m a t o p o i e t i c suppression 7. R a d i a t i o n retinopathy and cataract

8. A c u t e t r a n s v e r s e m y e l i t i s (rare) 8. Endocrinal deficit (thyroid, pituitary)

9. Radiation induced malignancy (thyroid cancer, osteosarcoma

o f orbit)

3. Extent of tumour It can be f o u n d b y clinical e x a m i - evaluation a n d get all questionable teeth extracted before radi-

n a t i o n (palpation u n d e r anaesthesia is i m p o r t a n t ) , a t i o n . W o u n d m u s t h e a l b e f o r e r a d i a t i o n is s t a r t e d . Xerostomia

r o u t i n e X - r a y s , C T scan o r m a g n e t i c resonance i m a g - adds to caries o f teeth. Osteoradionecrosis o f the mandible

ing. Smaller the t u m o u r b u l k , b e t t e r is t h e response to m a y follow extraction o f teeth i n an irradiated mandible.

radiation. Field o f radiation is p l a n n e d a c c o r d i n g to

3. C a r e o f skin S k i n reactions are c o m m o n w i t h o r t h o v o l t -
the extent o f t u m o u r .
age or electron b e a m therapy to skin b u t the m o d e m m e g a -
4. Histology of tumour T u m o u r s o f l y m p h o i d tissues
voltage therapy has a s k i n - s p a r i n g effect. D u r i n g radiotherapy,
are v e r y sensitive a n d respond q u i c k l y . Anaplastic
patient is a d v i s e d in the care o f irradiated skin. H e should:
t u m o u r s a n d those o f e m b r y o n a l o r i g i n are also r a d i o -

sensitive b u t recur early. S q u a m o u s c a r c i n o m a also (i) k e e p the area d r y a n d a v o i d w a s h i n g w i t h soap and

responds w e l l b u t s l o w l y . A d e n o c a r c i n o m a s are less water.

sensitive. Sarcomas a n d b o n e t u m o u r s also have l o w (ii) a v o i d exposure to sunlight.

sensitivity. (iii) a v o i d w e t shaving.

5. Dose of radiation and fractionation G e n e r a l l y , (iv) n o t use adhesive plaster for dressings; it peels o f f the

the curative dose is 6 5 0 0 — 7 5 0 0 c G y . C o n v e n t i o n a l l y , skin at the t i m e o f r e m o v a l .

it is delivered i n fractions o f 2 0 0 c G y per day for 5 (v) c o v e r the area w i t h soft c l o t h , like silk, w h i c h s h o u l d

days i n a w e e k ( M o n d a y s to Fridays) a n d thus it takes p r o v i d e free aeration o f the skin, a n d

l
6A to IVi w e e k s to c o m p l e t e the treatment. (vi) n o t use abrasive dressing o r c l o t h i n g .

F o r m o i s t desquamation, an antibiotic o i n t m e n t is use-

ful. T o p i c a l steroid creams can be used to relieve i t c h i n g

J Complications of Radiotherapy J a n d pain.

4. C a r e of oral cavity M u c o s i t i s and xerostomia are

C o m p l i c a t i o n s o f radiotherapy d e p e n d o n the site o f radia-
c o m m o n complications. T h e y also interfere w i t h feeding.
tion, total dose delivered and the daily fraction o f radiation
Patient s h o u l d a v o i d alcohol, tobacco or h i g h l y spiced
used. H i g h total dose and larger daily fractions cause m o r e
f o o d to lessen further trauma. Irritating m o u t h washes
complications.
w h i c h c o n t a i n a l c o h o l s h o u l d n o t be used. M i l k o f m a g -
C o m p l i c a t i o n s f o l l o w i n g radiation can be d i v i d e d i n t o
nesia can be applied to the area o f mucositis to give p r o -
early o r late (Table 71.3).
tective coating. I t also neutralises the acid p H a n d prevents

caries o f teeth. Pain a n d d i s c o m f o r t o f mucositis can be

J Care of Patient During Radiotherapy J relieved b y use o f lignocaine 1 0 % to enable the patient to

eat. A c u t e radiation mucositis usually persists 8—12 w e e k s

1. N u t r i t i o n T h i s is p a r t i c u l a r l y i m p o r t a n t i n cancers o f after radiation.

oral cavity a n d p h a r y n x . D i e t , rich i n p r o t e i n , v i t a m i n s

5. C a r e against i n f e c t i o n Patients r e c e i v i n g radiother-
a n d i r o n s h o u l d be g i v e n . Nasogastric t u b e m a y be used
apy are generally debilitated a n d easily develop Candida
w h e r e necessary. B l o o d transfusions m a y be required, i f
infection o f the oral cavity and p h a r y n x . I t can be treated
h a e m o g l o b i n l e v e l is l o w .
b y topical application o f nystatin o r clotrimazole. M y c e l i a

2. C a r e o f teeth A n y patient w h o is a c a n d i d a t e f o r irradia- m a y lie protected b e n e a t h organic debris a n d m a y require

tion particularly i n the area o f mandible should have dental antifungal systemic therapy.
C h e m o t h e r a p y f o r Head a n d
Neck Cancer M B

C h e m o t h e r a p y m a y b e used alone o r i n c o m b i n a t i o n w i t h W h e n used before surgery o r radiation, i t is called

o t h e r modalities o f treatment. M o s t o f the h e a d a n d n e c k induction or anterior chemotherapy. I t helps to reduce

malignancies are s q u a m o u s cell cancers a n d the drugs t u m o u r b u r d e n a n d micrometastases that can o c c u r

f o u n d effective are methotrexate, cisplatin, b l e o m y c i n a n d at the t i m e o f surgery o r i n the p e r i o d before

5-fluorouracil. A d r i a m y c i n has b e e n used for certain n o n - radiation.

s q u a m o u s carcinomas (e.g. a d e n o i d cystic carcinoma), a n d W h e n used simultaneously w i t h radiotherapy, it

dacarbazine for m e l a n o m a s . L y m p h o m a s o f the h e a d and a c t s as a r a d i o s e n s i t i z e r to cells w h i c h are otherwise

neck, b o t h H o d g k i n a n d n o n - H o d g k i n types, are also radioresistant.

treated b y c h e m o t h e r a p y because o f their m u l t i f o c a l origin W h e n used after surgery o r radiation, it is called

a n d w i d e - s p r e a d i n v o l v e m e n t . posterior chemotherapy and is aimed to cure

micrometastases.

Types of Chemotherapy

Single A g e n t vs Multidrug
1. Palliative c h e m o t h e r a p y
in c o m b i n a t i o n are used to
C y t o t o x i c drugs,

treat advanced,
singly

recurrent
o r
I Combination Therapy
1
o r metastatic disease w i t h a n a i m to relieve the s y m p - M e t h o t r e x a t e , cisplatin, b l e o m y c i n a n d 5 - f l u o r o u r a c i l

t o m s a n d to p r o l o n g life i n s o m e o f t h e m . have b e e n used as single agents i n various dosage forms.

2. A d j u v a n t c h e m o t h e r a p y H e r e c h e m o t h e r a p y is u s e d T h e y have also b e e n used i n c o m b i n a t i o n w i t h other

before, d u r i n g o r after t r e a t m e n t w i t h other modalities. drugs w i t h the object to i m p r o v e overall response rate and

1 C o m m o n l y used anticancer drugs and their side effects

Drugs Type of neoplasm Conventional dose * Side effects Remarks

2
1. Methotrexate S q u a m o u s eel 40 m g / m i.v. Bone m a r r o w suppression Excreted via urine. Hydration

cancer. Acute weekly, high dose mucositis o f oral and G.I. and alkalinisation o f and

leukaemia can be given mucosa. M a c u l o p a p u l a r urine before after d r u g

l y m p h o m a s with leucovorin rash. Renal and hepatic administration reduces the

rescue toxicity risk o f c o m p l i c a t i o n s . Liver

function tests before use

2. 5-F!uorouracil S q u a m o u s cell 10-15 m g / k g i.v. Myelosuppression (Neutro- N o t given in poorly

(5-Fu) cancers. N o n - daily. N o t m o r e penia thrombocytopenia at nourished patients

s q u a m o u s t u m o u r s t h a n 1 g in single 1 to 2 weeks). Mucositis

o f breast and G.I. bolus for 4-5 (nausea and vomiting,

tract days. Repeated at stomatitis and diarrhoea).

weekly intervals Skin (alopecia, hyperpig-

mentation, maculopapular

rash, h a n d - f o o t syndrome)

(Continued)
 Chemotherapy for Head and Neck Cancer

(Continued)

Drugs Type o f neoplasm Conventional d o s e * Side effects Remarks

3. Cyclophos- S q u a m o u s cancer 6 0 - 1 2 0 m g / m 2
i.v Haemorrhagic cystitis Hydrate the patient well

p h a m i d e L y m p h o m a s daily X 5 days for Nausea and vomiting before and after

Leukaemia 3 weeks Alopecia drug administration. Avoid

N e u r o b l a s t o m a Neutropenia at 1- 2 weeks barbiturates during therapy

Multiple m y e l o m a with recovery at

2-3 weeks. Cessation

o f menses. Permanent

infertility

4. Dacarbazine M e l a n o m a 250 m g / m 2
X 5 days Severe nausea and

Sarcomas every 3 weeks vomiting

Myeiosuppression

Flu-like s y m p t o m s (fever,

malaise, myalgia) for

several weeks

Alopecia

5. Bleomycin S q u a m o u s cell 10-20 m g / m 2

once Pneumonitis (dry cough Weekly X-ray chest. Use with

cancer, or twice weekly, and rales) and p u l m o n a r y care in patients o f p u l m o n a r y

L y m p h o m a i.m. or i.v. fibrosis Fever a n d chills and renal disease. D o not

in first 2 4 h. (give exceed total dose o f 400

antipyretics) Anaphylactic units, as it causes. Pulmonary

reaction fibrosis. (1 u n i t = 1 m g )

Alopecia

Erythema,

hyperpigmentation

Stomatitis

6. Adriamycin L y m p h o m a 6 0 - 9 0 m g / m 2
i.v. Cardiotoxic C a r d i o t o x i c i t y is s e e n in

(Doxorubicin) Sarcomas every 3 weeks. Alopecia E.C.C.

Esthesioneuro- C a r d i o m y o p a t h y if Stomatitis, nausea, Urine m a y be red

blastomas. total dose exceeds v o m i t i n g and diarrhoea for 1-2 days

2
Salivary (500 m g / m ) Neutropenia,

gland cancer thrombocytopenia which

Paediatric recovers by 3 weeks

malignancy

7. A c t i n o m y c i n - D R h a b d o m y o - 0.5 m g / m 2
i.v. X Myeiosuppression Avoid extravasation into

sarcoma 5 days Nausea and vomiting soft tissue at the time

Mucositis and diarrhoea o f injection

Alopecia

M a c u l o p a p u l a r rash

8. Avoid extravasation into

2
Vincristine L y m p h o m a 1.5 m g / m i.v. Neurotoxic (sensory

(Oncovin) S q u a m o u s cell once or twice and m o t o r neuropathy) tissues

cancer R h a b d o - monthly. Single Constipation (give

m y o s a r c o m a dose should not stool softeners)

exceed 2 m g Alopecia

9. Cisplatin S q u a m o u s cell 8 0 - 1 2 0 m g / m 2
i.v. G.l.T. (nausea, vomiting) Adequate prehydration

cancer infusion every Renal toxicity M a n n i t o l diuresis. D o not

3 weeks Haematologic (anaemia, use drug if creatinine

neutropenia, c l e a r a n c e is below

thrombocytopenia) 40 m l / m i n

Neurologic (peripheral

neuropathy)

Ototoxicity (4-8 kHz)

*Follow instructions given with drug literature. Most o f the drugs are given according t o surface area o f the body which is calculated according
to weight and height o f a person.
Recent Advances

d u r a t i o n o f response. A trend is e m e r g i n g that c o m b i n a t i o n •(. Biochemistry:

o f t w o o r m o r e drugs i m p r o v e s the response rate a n d defi- • B l o o d urea n i t r o g e n ( M e t h o t r e x a t e a n d

nitely i m p r o v e s the quality o f patient's life but it has failed • Creatinine cisplatin are

to i m p r o v e the d u r a t i o n o f response. • L i v e r f u n c t i o n tests n e p h r o t o x i c )

5. Radiology:
X - r a y chest ( B l e o m y c i n causes interstitial p u l m o n a r y
D r u g s U s e d in C a n c e r T h e r a p y
fibrosis)

C T scan o r M R I w h e r e indicated 1 F o r extent o f

C o m m o n l y used anticancer drugs a n d t h e i r side effects are
U l t r a s o u n d o f liver/spleen J disease
listed i n T a b l e 7 2 . 1 .
6. Pulmonary function tests ( F o r B l e o m y c i n )
7. E.C.G. (For Adriamycin)

8. Audiogram (Cisplatin causes h i g h frequency hearing loss)

P| Pretreatment W o r k - u p of the Patient ~J
9. Nutritional status

Patient w h o is a c a n d i d a t e f o r c a n c e r c h e m o t h e r a p y s h o u l d

be w o r k e d u p i n the f o l l o w i n g m a n n e r :

J Toxicity of Anticancer Drugs ^|

1. History and clinical examination (exclude k i d n e y , heart

and l u n g disease) M o s t o f the d r u g s act o n r a p i d l y d i v i d i n g cells a n d therefore

2. H a e m a t o l o g i c a l tests: include n o r m a l cells as t h o s e o f h a i r f o l l i c l e s , gastrointestinal

• H a e m o g l o b i n ] (As a baseline, as m a n y m u c o s a and b o n e m a r r o w causing alopecia, stomatitis, nau-

• T o t a l a n d I o f the drugs are sea, v o m i t i n g , diarrhoea, anaemia, leukopenia and t h r o m b o -

differential c o u n t myelosuppressive) cytopenia. S o m e drugs have selective action o n k i d n e y

• Platelet c o u n t (methotrexate, cisplatin), nerves (vincristine a n d cisplatin),

3. Urine exam heart (adriamycin) and bladder (cyclophosphamide).

HIV Infection/AIDS and ENT
Manifestations

A c q u i r e d i m m u n o - d e f i c i e n c y is caused b y retroviruses. 1986. N a t i o n a l A I D S C o n t r o l Organisation ( N A C O )

T h o s e infecting the h u m a n beings are o f t w o types: (a) H I V reports that o f a total o f 31,47,598 persons screened till

T y p e I — w h i c h is t h e m o s t c o m m o n and very pathogenic J u l y 1997, 6 6 , 3 1 5 w e r e f o u n d seropositive (seropositivity

and (b) H I V T y p e I I - — w h i c h is less c o m m o n a n d less patho- o f 21.07 per thousands).

genic. O n c e virus enters the body, it attacks T - l y m p h o c y t e s States h a v i n g h i g h seropositivity rates per t h o u s a n d per-

a n d other cells w h i c h have C D 4 surface marker. C D 4 sons are M a n i p u r (169.62), Maharashtra (103.03), N a g a l a n d

T - l y m p h o c y t e s are n o r m a l l y associated w i t h helper-inducer (55.48), Punjab (43.68), a n d D a m a n a n d D i u (32.0). I n

function o f the i m m u n e system. W i t h the fall i n C D 4 l y m - D e l h i , seropositivity rate is n e a r l y 4 per thousand.

3 3
phocytes b e l o w 500 cells/nun , (normal 6 0 0 - 1 5 0 0 cells/mm )

the i m m u n e s y s t e m starts b r e a k i n g d o w n w i t h the appearance

P A I D S Patients [j
o f opportunistic infections and unusual malignancies w h e n it

is c a l l e d A I D S . W h e n C D 4 - c e l l c o u n t falls b e l o w 200cells/

3
T i l l 31st January 2 0 0 3 , 4 3 , 5 4 2 cases o f A I D S h a v e b e e n
m m , death occurs w i t h i n 2—3 years.
r e p o r t e d to N A C O . T a b l e 73.1 gives the d i s t r i b u t i o n o f

A I D S c a s e s as reported to N A C O . M a x i m u m n u m b e r o f
Modes of Transmission A I D S cases w e r e detected i n T a m i l N a d u (18,276), fol-

l o w e d b y Maharashtra (10,797), Gujarat (2,141) and

H I V i n f e c t i o n is t r a n s m i t t e d t h r o u g h :
A n d h r a Pradesh (2,565).

(a) Sexual c o n t a c t — h o m o s e x u a l or heterosexual. O u t o f a total o f 43,542, 8 4 . 2 4 % w e r e d u e to sexual

( b ) U s e o f non-sterile needles, syringes o r o t h e r s k i n - relationship alone w h i l e nearly 3%) w e r e due to b l o o d and

p i e r c i n g instruments. b l o o d products and 2 . 6 % d u e to perinatal transmission.

(c) B l o o d and b l o o d products.

( d ) Infected m o t h e r to i n f a n t — D u r i n g birth, perinatally

Course of Disease
a n d via breast m i l k .

H i g h risk groups include: (i) h e t e r o s e x u a l l y p r o m i s c u - After exposure, the disease runs t h r o u g h the f o l l o w i n g

ous i n d i v i d u a l s (ii) h o m o s e x u a l s (iii) prostitutes a n d t r u c k - stages:

drivers (iv) I . V . d r u g users (v) recipients o f b l o o d and

(a) Initial viraemia: P r i m a r y infection w i t h H I V , first
b l o o d products (haemophilics, thalassaemia patients and
causes viraemia w h i c h p r o d u c e s m i l d clinical disease
those u n d e r g o i n g dialysis a n d (vi) c h i l d r e n b o r n to H I V
like fever, headache, b o d y aches a n d pains, m a c u l a r
infected mothers.
skin rash a n d l y m p h nodes enlargement. T h i s picture
M a j o r hazard to health care w o r k e r s is from b l o o d and b o d y
resembles infections like m o n o n u c l e o s i s a n d subsides
fluids like amniotic, pleural, peritoneal or pericardial fluid.
in 1-2 weeks. T h e v i r u s is t h e n taken u p b y l y m p h o i d
R i s k o f acquiring infection f r o m specimens o f urine, stool,
organs like l y m p h nodes, tonsils a n d adenoids. Initial
saliva, s p u t u m , tears, s w e a t a n d v o m i t u s is n e g l i g i b l e .
plasma viraemia lasts for a f e w w e e k s a n d t h e n n o

virus can be detected i n plasma.

Epidemiology (b) Latent period: This is t h e asymptomatic period a n d

m a y last f o r a v a r i a b l e period, o n an average 10 years.

T h e first case o f A I D S was seen i n India i n the year 1986. D u r i n g this p e r i o d n o virus is detectable i n plasma

Surveillance o f H I V i n f e c t i o n / A I D S cases was started i n t h o u g h it is replicating i n the l y m p h o i d tissue a n d

 becomes susceptible to opportunistic infections.
T a b l e 73.1 A I D S Cases in India (Reported t o N A C O )
T h e r e a r e c l i n i c a l signs a n d s y m p t o m s o f A I D S a n d
S. no. State/ Union A I D S cases
d e a t h m a y o c c u r w i t h i n 2 years.
territory A s on 31st As on 30th
July, April,
1997 2003
| E N T Manifestations ofAIDS |
1. A n d h r a Pradesh 27 2,565

2. Assam 14 149
T h e y are c a u s e d b y o p p o r t u n i s t i c i n f e c t i o n s d u e t o v i r u s e s ,
3. Arunachal Pradesh 0 0 bacteria, f u n g i a n d protozoa a n d d u e t o activation o f t h e

4. A n d a m a n & Nicobar 0 24 n e o p l a s t i c process, e . g . K a p o s i ' s s a r c o m a a n d n o n - H o d g -

Island kin's l y m p h o m a . M o r e than 5 0 % o f t h e patients with

5. Bihar 2 148 A I D S p r e s e n t w i t h s y m p t o m s o r signs i n t h e h e a d a n n e c k

region.
6. Chandigarh (U.T.) V; ; vx
; .665

7. Punjab 100 227

Ear
8. Delhi 737 • Otitis media
9. D a m a n & D i u (U.T.) 1 1 • Kaposi's sarcoma o f p i n n a

10. D a d r a & N a g a r Haveli 0 0

• Sensorineural h e a r i n g loss ( u s u a l l y d u e t o cytomega-
l o v i r u s a f f e c t i n g i n n e r ear o r C N V I I I )
11. G o a 12 139
• F a c i a l paralysis ( v i r a l o r i g i n )
13. Gujarat 133 2,408

14. H a r y a n a 1 247 Nose

15. H i m a c h a l Pradesh 9 106 • Sinusitis ( d u e to b o t h aerobic a n d anaerobic infections)

16. Karnataka 97 1,617

• F u n g a l sinusitis d u e t o aspergillus o r m u c o n n y c o s i s . I t is
r a p i d l y i n v a s i v e a n d extends i n t r a c r a n i a l l y
17. Kerala 105 267

18. Lakshadweep (U.T.) 0 0 O r a l cavity

19. M a d h y a Pradesh 119 949 • Candida infection

20. M a h a r a s h t r a 2 , 3 5 4 10,797 • A n g u l a r cheilitis

• R e c u r r e n t a p h t h o u s ulcers
21. O n s s a 2 82
• H a i r y l e u k o p l a k i a ( i t is c a u s e d b y E . B . v i r u s a n d appears
22. Nagaland 4 298
as w h i t e p a t c h e s o n t h e l a t e r a l b o r d e r o f t o n g u e . Occurs
23. M a n i p u r
HE9B 1,238
early i n H I V i n f e c t i o n )
24. M i z o r a m 5 34
• Kaposi's sarcoma (can o c c u r a n y w h e r e i n t h e oral cavity
25. Meghalaya 8 8 b u t is m o s t c o m m o n i n t h e palate)
26. Pondicherry 128 157 • Non-Hodgkin's lymphoma

27. Rajasthan 54 630

Parotid
28. Sikkim 1 6
• P a r o t i d cysts a n d p a r o t i t i s
29. Tamil N a d u 1,080 18,276

30. Tripura 0 5 Oesophagus

3 1 . Uttar Pradesh 112 830

• C a n d i d a i n f e c t i o n o f oesophagus c a u s i n g severe dysphagia
32. W e s t Bengal 57 930

Total 4,828 4 3 , 5 4 2 Neck

• Cervical l y m p h a d e n o p a t h y . I t can be secondary infec-

t i o n , l y m p h o m a , tuberculosis o r carcinoma o r Kaposi's
sarcoma. F N A C o r biopsy m a y be indicated.

C D 4 T - h e l p e r c e l l n u m b e r a n d f u n c t i o n is d e t e r i o r a t -
i n g . A n t i b o d y test b e c o m e s p o s i t i v e i n 2—4 m o n t h s o f Non-Hodgkin's Lymphoma
infection.
(c) Advanced disease: I t starts a f t e r several years; T h e C D 4 N o n - H o d g k i n ' s l y m p h o m a c a n o c c u r i n 10—30% o f A I D S
T - c e l l c o u n t falls b e l o w 2 0 0 c e l l s / m m 3
a n d patient p a t i e n t s . I t t e n d s t o b e aggressive a n d o c c u r s i n l a t e stages
 HIV Infection/AIDS and E N T Manifestations

o f disease w h e n C D 4 c o u n t s falls b e l o w 2 0 0 / n i m . B o t h 3

n o d a l a n d e x t r a n o d a l l y m p h o m a s m a y b e seen. C N S lym-
HIV I N F E C T I O N AND

p h o m a s are also c o m m o n i n p a t i e n t s w i t h A I D S .
HEALTH CARE WORKERS

D o c t o r s , p a r t i c u l a r l y t h e s u r g e o n s , nurses a n d l a b o r a t o r y
Kaposi's Sarcoma
staff h a n d l i n g t h e b l o o d , b l o o d - s t a i n e d b o d y fluids and
o t h e r s e c r e t i o n s m a y c o n t r a c t t h e disease as o c c u p a t i o n a l
I t is a m u l t i c e n t r i c n e o p l a s m w h i c h may involve skin,
hazard. T h e y s h o u l d f o l l o w the universal precautions (vide
m u c o s a o r v i s c e r a . T h e r e is e x c e s s i v e p r o l i f e r a t i o n o f s p i n -
i n f r a ) c o n s i d e r i n g t h a t e v e r y s a m p l e t h e y h a n d l e is p o t e n -
d l e cells o f v a s c u l a r o r i g i n . I t is n o n - i n v a s i v e a n d respects
t i a l l y i n f e c t e d . T h e r i s k is d u e t o :
t h e fascial p l a n e s . I n t h e o r a l c a v i t y , K a p o s i ' s s a r c o m a is
m o s t l y seen i n t h e p a l a t e , b u t m a y o c c u r o n t h e t o n g u e o r 1. Needle-stick injury. H o l l o w n e e d l e (e.g. i n j e c t i o n n e e -
g i n g i v a o r t h e p o s t e r i o r w a l l o f p h a r y n x . I t appears pur- d l e ) is m o r e d a n g e r o u s t h a n s o l i d n e e d l e ( e . g . s u t u r e
plish i n c o l o u r and m a y need to be differentiated f r o m n e e d l e ) , T h e risk is 1 : 2 5 0 .
a n g i o m a o r p y o g e n i c g r a n u l o m a . I t c a n o c c u r at a n y stage 2. Cuts with contaminated knife or other sharp
o f H I V i n f e c t i o n , even i n those w i t h n o r m a l C D 4 counts. instruments.
S i z e o f t h e t u m o u r m a y v a r y f r o m a f e w m m t o several 3. Exposure of open wound t o i n f e c t e d b l o o d o r b o d y f l u i d .
c e n t i m e t r e s . D i a g n o s i s is based o n b i o p s y w h i c h m a y s h o w Entry o f virus can also occur through a n area of
p r o l i f e r a t i o n o f s p i n d l e cells, e n d o t h e l i a l cells, e x t r a v a s a t i o n dermatitis.
o f r e d b l o o d cells a n d h a e m o s i d e r i n l a d e n macrophages.
4. Large mucous membrane exposure, e.g. b y splatter of
T r e a t m e n t includes localised radiation, intralesional v i n -
blood, amniotic fluid, etc.
blastine o r c r y o t h e r a p y . Single agent systemic chemother-
5. Exposure of skin t o i n f e c t e d b l o o d a n d b o d y f l u i d s . U s e
apy m a y be g i v e n i n those w i t h m u l t i p l e lesions.
o f g l o v e s a n d g o w n / c o a t is p r o t e c t i v e .

Management of Needle-stick Injury

| Diagnosis of H I V Infection J I n case o f n e e d l e - s t i c k i n j u r y o r c u t , w a s h t h e area t h o r -

o u g h l y w i t h w a t e r a n d a p p l y an a n t i s e p t i c . E L I S A test is
1. ELISA t e s t ( E n z y m e - l i n k e d i m m u n o s o r b e n t assay):
d o n e as s o o n as p o s s i b l e t o establish n e g a t i v e b a s e l i n e f o r
I t is a s c r e e n i n g test w i t h h i g h s e n s i t i v i t y o f 9 9 . 9 % .
worker's compensation. Test s h o u l d be repeated at 6
W h e n p o s i t i v e , i t is c o n f i r m e d b y W e s t e r n b l o t test.
weeks, 3 m o n t h s and 6 m o n t h s for any seroconversion.
2. W e s t e r n b l o t t e s t : C o n f i r m a t i o n test f o r H I V i n f e c -
Z i d o v u d i n e t h e r a p y f o r 6 w e e k s as s o o n as p o s s i b l e a f t e r
t i o n . T h e s p e c i f i c i t y o f p o s i t i v e results b y E L I S A a n d
e x p o s u r e c a n b e o f f e r e d . I t is s h o w n t o decrease t h e r a t e o f
W e s t e r n b l o t reaches 100%.
s e r o c o n v e r s i o n a f t e r n e e d l e - s t i c k i n j u r y . H o w e v e r , t h e side
3. B l o o d tests: M a y i n d i c a t e anaemia, l e u k o p e n i a espe-
effects o f d r u g a n d also t h e fact t h a t s e r o c o n v e r s i o n can still
cially l y m p h o p e n i a a n d t h r o m b o c y t o p e n i a i n advanced
o c c u r i n s p i t e o f d r u g t h e r a p y , s h o u l d be b o r n e i n m i n d .
disease.
4. C D 4 T-cell count: Normal count 600-1500/mm . 3

F a l l i n g c o u n t s i n d i c a t e p r o g r e s s i o n o f disease. C o u n t Universal Precautions

<200/mm 3
indicates risk o f A I D S .
CD4 l y m p h o c y t e percentage is m o r e reliable t h a n • W a s h hands b e f o r e a n d after p a t i e n t o r s p e c i m e n c o n t a c t .
CD-4 c o u n t . R i s k o f p r o g r e s s i o n t o A I D S is h i g h • H a n d l e t h e b l o o d o f all patients as p o t e n t i a l l y i n f e c t i o u s .
w i t h c o u n t o f ,20%). • W e a r gloves f o r p o t e n t i a l contact w i t h b l o o d a n d b o d y
5. B..-Microglobulin level: I t is i n d i c a t i v e o f mac- fluids.
r o p h a g e - m o n o c y t e s t i m u l a t i o n . L e v e l s o f this p r o t e i n • Place used syringes i m m e d i a t e l y i n n e a r b y i m p e r m e a b l e
rise at s e r o c o n v e r s i o n a n d c o n t i n u e t o rise w i t h p r o - c o n t a i n e r ; D O N O T recap o r m a n i p u l a t e needle i n any
g r e s s i o n o f disease. T h i s test is u s e f u l f o r p r o g n o s i s . way!
6. P-24 a n t i g e n : P - 2 4 is c o r e p r o t e i n o f t h e A I D S v i r u s . • W e a r p r o t e c t i v e e y e w e a r a n d mask i f splatter w i t h b l o o d o r
P r e s e n c e o f this a n t i g e n i n d i c a t e s a c t i v e H I V r e p l i c a - b o d y fluids is possible (e.g. b r o n c h o s c o p y , o r a l s u r g e i y ) .
t i o n . T e s t is p o s i t i v e e v e n p r i o r t o s e r o c o n v e r s i o n . • W e a r g o w n s w h e n splash w i t h b l o o d o r b o d y fluids is
7. P C R ( p o l y m e r a s e c h a i n r e a c t i o n ) : I t is a q u a n t i t a t i v e anticipated.
test w h i c h measures v i r a l l o a d a n d t h u s c o r r e l a t e s w i t h " H a n d l e all l i n e n soiled w i t h b l o o d a n d / o r b o d y secre-
p r o g r e s s i o n o f disease. t i o n s as p o t e n t i a l l y i n f e c t i o u s .
Recent Advances

• Process all laboratory specimens as potentially D i d a n o s i n e (ddl)

infectious. Zalcitabine ( d d C )

• W e a r m a s k for T B a n d other respiratory organisms ( H I V Stavudine (d4T)

is n o t airborne). L a m i v u d i n e (3TC) (reverse transcriptase i n h i b i t o r )

(b) Protease inhibitors

J Antiretroviral Drugs [ Saquinavir

Pvitonavir

(a) Nucleoside analogues I n d i n a v i r

Z i d o v u d i n e ( A Z T ) (c) Combination of drugs

Clinical Methods in E N T a n d
Neck M a s s e s
Clinical M e t h o d s in ENT

2. Head mirror. I t is a c o n c a v e m i r r o r u s e d t o r e f l e c t l i g h t
EQUIPMENT, HISTORY TAKING AND
f r o m t h e B u l l ' s eye l a m p o n t o t h e p a r t b e i n g e x a m i n e d .
GENERAL SETUP
I t has a f o c a l l e n g t h o f a p p r o x i m a t e l y 25 c m . T h e e x a m -
i n e r sees t h r o u g h t h e h o l e i n t h e c e n t r e o f t h e m i r r o r .

E v a l u a t i o n o f t h e p a t i e n t w i t h disease o f ear, nose a n d D i a m e t e r o f t h e m i r r o r is 8 9 m m (3M>") a n d t h a t o f t h e

throat requires skill i n e l i c i t i n g a m e a n i n g f u l history a n d c e n t r a l h o l e is 1 9 m m (3/4").

masterly d e x t e r i t y i n the e x a m i n a t i o n o f d a r k e r cavities o f 3. Tongue depressors. D i f f e r e n t sizes f o r children and

t h e ear, n o s e , p h a r y n x a n d l a r y n x . A s t u d e n t is e x p e c t e d t o a d u l t s s h o u l d b e available. I t is u s e d i n t h e e x a m i n a t i o n
learn this b y regular practice i n E N T clinics. o f oral cavity and o r o p h a r y n x ,
4. Nasal specula. T w o types are c o m m o n l y u s e d , n a m e l y
t h e T h u d i c u m a n d V i e n n a t y p e s . T h e size o f t h e nasal
E q u i p m e n t for E N T Examination ( F i g . 7 4 . 1 )
s p e c u l u m is s e l e c t e d a c c o r d i n g t o t h e age o f t h e p a t i e n t
a n d size o f t h e n o s t r i l .
T h e requirements o f equipment i n a clinic may vary b u t
5. Laryngeal mirrors. T h e y are u s e d t o e x a m i n e t h e l a r y n x
t h e essential i n s t r u m e n t s f o r r o u t i n e e x a m i n a t i o n are l i s t e d
a n d l a r y n g o p h a r y n x . V a r i o u s sizes, f r o m 6 t o 3 0 m m
here.
d i a m e t e r , are a v a i l a b l e . T o p r e v e n t f o g g i n g , a m i r r o r is
1, Bull's eye lamp. I t provides a p o w e r f u l source o f light. always w a r m e d over a spirit l a m p or b y d i p p i n g i t i n
The l a m p can be t i l t e d , r o t a t e d , raised o r l o w e r e d h o t w a t e r a n d t h e n tested o n t h e back o f h a n d before
a c c o r d i n g to the needs. insertion into the m o u t h .

Left t o r i g h t ( 1 ) T u n i n g f o r k , ( 2 ) Siegle's s p e c u l u m , ( 3 ) O t o s c o p e , ( 4 ) H e a d m i r r o r , ( 5 ) Barany's noise box.

Clinical Methods in E N T and Neck Masses

F i g u r e 74.1 B

(1) Jobson-Horne p r o b e , ( 2 )V i e n n a nasal s p e c u l u m , ( 3 ) H a r t m a n n ' s packing forceps, ( 4 ) Wilde's packing forceps, ( 5 ) Eustachian tube

catheter, ( 6 ) T h u d i c u m nasal speculum, ( 7 )L a r y n g e a l m i r r o r , ( 8 ) Post-nasal m i r r o r , ( 9 )B l u n t probe, ( 1 0 ) E a rspecula, ( 1 1 ) Lacks

tongue depressor.

6. Postnasal mirror. I t is u s e d t o e x a m i n e t h e n a s o p h a r y n x engages o n t h e posterior free b o r d e r o ft h e nasal sep-

a n d p o s t e r i o r part o f nasal cavity. L i k e l a r y n g e a l mirror, t u m . A t this p o i n t , i t is r o t a t e d 1 8 0 ° laterally t ol i e

it is also w a r m e d a n d tested o n t h e back o f h a n d against t h e o p e n i n g o f eustachian tube. A b u l b is

before use. attached a n d air insufflated. I f t h e tube is patent, a i r

7. Ear specula. V a r i o u s sizes a r e a v a i l a b l e t o s u i t different enters t h em i d d l e ear a n dc a nb e detected b y a n aus-

sizes o f t h e e a r c a n a l . T h e largest s p e c u l u m w h i c h c a n cultation t u b e w h i c h connects patient's ear t o that o f

be c o n v e n i e n t l y inserted i n t h e ear canal s h o u l d b e the e x a m i n e r (seep a g e 6 5 ) .

used. 14. Otoscope. I t is a n electric o r battery operated device

8. Siegle's speculum. Essential i n e x a m i n a t i o n o f tympanic w i t h a m a g n i f y i n g glass. S o m e t i m e s i t hasa n arrange-

m e m b r a n e ; i t gives m a g n i f i e d v i e w o f t y m p a n i c m e n t t o attach a b u l b t o f u n c t i o n as S i e g l e ' s specu-

m e m b r a n e a n dh e l p s t o test its m o b i l i t y . I tis also used l u m . I t is u s e f u l f o r d e t a i l e d e x a m i n a t i o n o f t h e e a r . I t

to elicit t h e fistula sign. is a n essential i n s t r u m e n t t o e x a m i n e t h e ear o fa n

9. Tuning forks. C o m m o n l y used t u n i n g fork has a fre- infant, a child o r a b e d r i d d e n patient.

q u e n c y o f 5 1 2 H z . F o r k s o f o t h e r frequencies, e.g. 15. Spirit lamp. I t is used t o w a r m t h e laryngeal o r post-

2 5 6 a n d 1 0 2 4H z s h o u l d also b e available. nasal m i r r o r (Fig. 74.2).

10. Johson—Home's probe. O n e e n d o f t h e p r o b e is u s e d t o 16. Gloves. T h e y are essential f o r intraoral palpation.

f o r m a c o t t o n b u dt o clean t h e ear o fdischarge a n d 17. Spray. I t is u s e d t o apply local anaesthetic t o abolish

the o t h e r e n d ( w i t h r i n g curette) is u s e d t o r e m o v e the g a greflex.

the w a x . 18. Suction apparatus. T o clear t h e ear o r nose o f discharge

1 1 . Blunt probe. I t is used f o r p a l p a t i o n i n t h e nasal cavity or b l o o d f o r detailed e x a m i n a t i o n .

o r ear canal.

12. Tilley's or Hart man's forceps. I t is u s e d i n p a c k i n g o f ear

canal o r nasal cavity. History Taking

13. Eustachian catheter. I t is u s e d t o test p a t e n c y o f the eusta-

chian tube a n d c a n also b e u s e d t o r e m o v e foreign b o d - 1. History of present illness. A patient presents w i t h cer-

ies f r o m t h e nose. T o test t h e patency o f eustachian tain presenting complaints. T h e y are asked i n detail,

tube, t h enose is f i r s t a n a e s t h e t i s e d , t h ecatheter is t h e n w i t h particular reference t o t h e d u r a t i o n o f s y m p -

passed a l o n g t h e floor o fnose into t h e nasopharynx, t o m s , their onset, progression, severity a n d o t h e r

t u r n e d m e d i a l l y a n d then slightly w i t h d r a w n till i t a c c o m p a n y i n g complaints. I n q u i r y s h o u l d also b e

 Clinical Methods i n ENT

left at t h e level o fhis s h o u l d e r . T h ee x a m i n e r uses a h e a d

m i r r o r t o reflect light f r o m t h e Bull's e y e l a m p o n t o t h e

area o f e x a m i n a t i o n .

A head m i r r o r gives g o o d illumination a n d permits free-

d o m t o useb o t h hands for other activities. S o m e prefer t ouse

a head light i n place o f Bull's eyel a m p a n da h e a d mirror.

I. E X A M I N A T I O N O F E A R

Sy m pto m atol ogy

A patient w i t h e a rdisease presents w i t h o n eo r m o r e o f the

f o l l o w i n g complaints:

1. H e a r i n g loss.

2. T i n n i t u s .

3. Dizziness o r vertigo.

4. E a r discharge.

Figure 74.2 5. Earache.

6. I t c h i n g i n t h ee a r .
W a r m i n g a laryngeal m i r r o r over a spirit lamp. W a r m only the
glass side o f t h e m i r r o r . 7. D e f o r m i t y o ft h e pinna.

8. S w e l l i n g a r o u n d t h e ear.

T h e details o fhistory o f these s y m p t o m s particularly i n

m a d e o fa n y systemic disease t h e patient m a yb e suf-

reference t o t h e onset, duration, progression a n d severity s h o u l d

be noted.
fering from, e.g. diabetes, hypertension, c o r o n a r y

artery disease, liver o r k i d n e y disease, o r a b l e e d i n g

disorder. A l s o f i n d o u t a b o u t t h e treatment patient

Examination
has t a k e n o r is still t a k i n g f o rt h e present ailment.

2. History of past illness. I t includes history o f similar

It includes b o t h physical a n dfunctional e x a m i n a t i o n .
c o m p l a i n t s i n t h e past, t r e a t m e n t taken, history o f any

o p e r a t i o n w h i c h t h ep a t i e n t h a s u n d e r g o n e a n d allergy
A. Physical Examination
to a n y d r u g .

3. Personal history. I n q u i r e a b o u t t h e patient's profession It includes e x a m i n a t i o n o f :

a n d nature o f j o b , personal habits ( s m o k i n g , c h e w i n g

1. P i n n a a n dt h e s u r r o u n d i n g area.

0
p a n o r tobacco, u s e o f a l c o h o l ) a n df o o d habits (exces-
External a u d i t o r y canal:
s i v e u s e o ftea o r coffee). I t is also i m p o r t a n t t o k n o w
(i) W i t h o u t s p e c u l u m
a b o u t hisactivities, exercise, o r sedentary habits.
(ii) W i t h s p e c u l u m
4. Family history. S o m e diseases h a v e a genetic basis, e . g .
3. T y m p a n i c m e m b r a n e .
otospongiosis, certain types o f sensorineural hearing
4. M i d d l e ear.
loss a n d a u t o i m m u n e disorders w h i l e others are t h e
5. M a s t o i d .
result o fclose contact b e t w e e n different m e m b e r s o f
6. Eustachian tube.
the family, e.g.tuberculosis, syphilis, pediculosis, sca-
7. Facial nerve a n do t h e r cranial nerves.
bies, etc.
1. P i n n a and the s u r r o u n d i n g area T h e p i n n a is e x a m -

i n e d b y i n s p e c t i o n a n dp a l p a t i o n . B o t h o fits surfaces, t h e

G e n e r a l Setup a n d Position o f Patient lateral a n dt h e m e d i a l , s h o u l d b e e x a m i n e d .

L o o k for size (microtia, macrotia); shape (abnormalities

T h e p a t i e n t is e x a m i n e d i na s e m i - d a r k r o o m . H e is s e a t e d o f c o n t o u r , cauliflower ear); position ( b a tear). Also l o o k

o n a stool o r chair opposite t h e e x a m i n e r , a n d is m a d e t o for redness (furuncle o r abscess); swelling ( h a e m a t o m a ,

sit e r e c t leaning slightly f o r w a r d t o w a r d s t h ee x a m i n e r . H e abscess); vesicles in concha a n d retroauricular groove (herpes

s h o u l d n o ts l u m p i n t h e seat. B u l l ' s e y el a m p is k e p t o nt h e zoster); scars (trauma o r operation); ulceration or neoplasm.

C l i n i c a l M e t h o d s in E N T a n d N e c k M a s s e s

Also e x a m i n e t h earea above, i nfront, b e l o w a n d b e h i n d ( b ) Position. T y m p a n i c m e m b r a n e m a y b e retracting o r

the p i n n a a n d l o o k f o r a swelling { m a s t o i d o r z y g o m a t i c b u l g i n g . General retraction is s e e n i n t u b a l occlusion,

abscess, n e o p l a s m o r l y m p h nodes); sinus (preauricular retraction pockets are seen i n attic o r posterosuperior

sinus); fistula (mastoid fistula) scar (endaural o r postaural r e g i o n a n d m a y collect epithelial flakes. S o m e t i m e s ,

scar d u e t o p r e v i o u s operation). t y m p a n i c m e m b r a n e is v e r y t h i n , deeply retracted a n d

Palpation o f pinna is essential t o l o o k for raised temperature is f i x e d t o p r o m o n t o r y as i n adhesive otitis media.

(perichondritis o r abscess); thickness of tissues (perichondritis); B u l g i n g t y m p a n i c m e m b r a n e is s e e n i n a c u t e otitis

fluctuation (seroma o r abscess) a n d tenderness. M o v e m e n t o f media, h a e m o t y m p a n u m o r n e o p l a s m o f m i d d l e ear

pinna is p a i n f u l i n f u r u n c u l o s i s o f the external canal. w h i c h has n o ty e tperforated t h e d r u m .

2. E x a m i n a t i o n o fexternal a u d i t o r y canal (c) Suface of tympanic membrane. It m a y s h o w vesicles o r b u l -

lae (herpes zoster o r myringitis bullosa), a perforation

(a) Examination without a speculum. T h i s is a n i m p o r t a n t
(acute o r chronic otitis media). A perforation m a y b e
part o ft h e e x a m i n a t i o n a n d precedes i n t r o d u c t i o n o f
central ( i npars tensa) o r attic ( i np a r s f l a c c i d a ) o r m a r -
s p e c u l u m . T h e p i n n a is p u l l e d u p w a r d s a n d b a c k -
ginal (at t h e p e r i p h e r y i n v o l v i n g t h e annulus). A central
wards w h i l e t h e tragus is p u l l e d forwards t o spread
perforation m a yb e small, m e d i u m , subtotal o r total.
o p e n t h e meatus. L o o k for t h e size of meatus ( n a r r o w
(d) Mobility. I t is tested w i t h a Siegle's s p e c u l u m
o r w i d e ) , contents of lumen (wax, debris, discharge o r
(Fig. 74.5). A n o r m a l t y m p a n i c m e m b r a n e is m o b i l e .
p o l y p ) o r swelling of its wall (furuncle, neoplasm).

(b) Examination with a speculum. O n c e t h e size o f t h e

m e a t u s is k n o w n , p r o p e r s p e c u l u m is selected a n d

i n t r o d u c e d (Fig. 74.3). U s e t h e largest s p e c u l u m that

can easily enter t h e canal. L o o k f o rw a x , debris, dis-

charge, p o l y p , granulations, exostosis, b e n i g n o r

m a l i g n a n t neoplasm, sagging o f posterosuperior area

(coalescent mastoiditis).

3. Examination o f tympanic membrane Normal

tympanic m e m b r a n e is p e a r l y w h i t e i n colour a n d semi-

transparent, a n do b l i q u e l y set at t h em e d i a l e n do f the meatus.

It has t w op a r t s — p a r s tensa a n d pars flaccida, b o t h o f w h i c h

should b e carefully examined. Its v a r i o u s l a n d m a r k s are s h o w n

in Fig. 74.4. A t y m p a n i c m e m b r a n e is e x a m i n e d for:

(a) Colour. Red a n d congested i n acute otitis media, bluish Figure 74.4
in secretory otitis m e d i a o r h a e m o t y m p a n u m . A chalky
Landmarks o f a n o r m a l t y m p a n i c m e m b r a n e (right side).
plaque is s e e n i n tympanosclerosis.

A B

Figure 74.3

E x a m i n a t i o n o f ear w i t h a s p e c u l u m : ( A ) R i g h t ear. ( B ) Left ear.

 C l i n i c a l M e t h o d s in E N T

Restricted m o b i l i t y is s e e n i n t h e presence o f fluid o r f r o m the ear w h e n patient tries to b l o w w i t h m o u t h a n d

adhesions i n the m i d d l e ear. A n atrophic s e g m e n t o f nose closed.

t y m p a n i c m e m b r a n e m a y be h y p e r m o b i l e .
7. E x a m i n a t i o n o f f a c i a l n e r v e Paralysis o f facial nerve

4. E x a m i n a t i o n of middle ear N o r m a l l y , m i d d l e ear m a y co-exist w i t h disease o f the ear, e.g. acute or chronic

c a n n o t be e x a m i n e d directly. W h e n t y m p a n i c m e m b r a n e suppurative otitis media, herpes zoster oticus, malignant otitis

is semi-transparent, s o m e structures can be seen t h r o u g h externa, t u m o u r s o f external or m i d d l e ear and trauma. I t is

it. I n the presence o f a perforation, i t is p o s s i b l e to k n o w essential to test f o r facial n e r v e i n eveiy case o f ear disease.

the c o n d i t i o n o f m i d d l e ear m u c o s a a n d any i n - g r o w t h o f

s q u a m o u s e p i t h e l i u m f r o m the edges o f the p e i f o r a t i o n . 6. Functional Examination

5. E x a m i n a t i o n o f m a s t o i d L o o k for a swelling (abscess 1. A u d i t o r y f u n c t i o n

o r enlarged nodes), obliteration of retroauricular groove ( f u r u n - (a) V o i c e test

cle), fistula (burst abscess), scar (previous operation). (b) T u n i n g f o r k tests

N o n n a l l y , mastoid surface feels irregular o n palpation. R i n n e test

T h e s e irregularities are " i r o n e d o u t " a n d surface feels s m o o t h W e b e r test

in periosteal i n f l a m m a t i o n as i n s u b p e r i o s t e a l abscess. S c h w a b a c h test

T e n d e r n e s s o f m a s t o i d is s e e n i n m a s t o i d i t i s . I t is e l i c i t e d A b s o l u t e b o n e c o n d u c t i o n test.

b y p r e s s u r e at three sites:
2. V e s t i b u l a r f u n c t i o n

(a) O v e r the a n t r u m (just a b o v e a n d b e h i n d the meatus) (a) S p o n t a n e o u s n y s t a g m u s

(b) O v e r the tip (b) Fistula test (page 47)

(c) O v e r the part b e t w e e n the m a s t o i d tip a n d m a s t o i d (c) Positional tests ( p a g e 47).

a n t r u m .

6. E x a m i n a t i o n o f e u s t a c h i a n t u b e T y m p a n i c orifice

o f eustachian t u b e can be seen i n the anterior part o f m i d d l e

II. E X A M I N A T I O N OF NOSE AND
e a r i f t h e r e is p e r f o r a t i o n o f t y m p a n i c m e m b r a n e . Pharyngeal
PARANASAL SINUSES
o p e n i n g o f tube can be seen b y posterior rhinoscopy.

F u n c t i o n o f t u b e can be tested b y Valsalva m a n o e u v r e .

I n the presence o f a perforation, air can be felt to escape Symptomatology

A patient w i t h disease o f the nose a n d paranasal sinuses

presents w i t h o n e o r m o r e o f the f o l l o w i n g complaints:

1. Nasal obstruction.

2. Nasal discharge.

3. Post-nasal drip.

4. Sneezing.

5. Epistaxis.

6. H e a d a c h e o r facial pain.

7. S w e l l i n g o r d e f o r m i t y .

8. Disturbances o f smell.

9. S n o r i n g .

10. C h a n g e i n v o i c e (hyper- o r hyponasality).

A detailed history o f these s y m p t o m s w i t h special regard to

their onset, duration, progression, severity should be asked.

T h e y are discussed i n the relevant sections o f the b o o k .

A. Examination of Nose

F i g u r e 74.5
Nasal e x a m i n a t i o n includes:

Use o f Siegle's speculum to see mobility o f tympanic

1. E x a m i n a t i o n o f external nose.
membrane.
2. E x a m i n a t i o n o f vestibule.
Clinical Methods in ENT and Neck Masses

3. A n t e r i o r r h i n o s c o p y . w h i l e i n t r o d u c i n g a n d partially o p e n w h e n r e m o v i n g f r o m

4. Posterior rhinoscopy. the nose t o a v o i d catching t h e hair. L i g h t is focussed at

5. F u n c t i o n a l e x a m i n a t i o n o f nose. different sites i n t h e nose t o e x a m i n e t h e nasal septum,

roof, floor a n d t h elateral w a l l . F o r this, patient's h e a d m a y

/. External Nose n e e d t o t h etilted i n different directions. L o o k f o rt h e f o l -

l o w i n g points:
E x a m i n e t h e skin a n d osteocartilaginous f r a m e w o r k o f

nose b o t h b y inspection a n d palpation.

(i) Nasal passage. N a r r o w (septal d e v i a t i o n o r h y p e r t r o -
Skin is e x a m i n e d f o r signs o f inflammation (furuncle, sep-
p h y o ft u r b i n a t e s , g r o w t h ) , w i d e (atrophic rhinitis).
tal abscess), scars (operation o r trauma), sinus (congenital
(ii) Septum. D e v i a t i o n o r spur, ulcer, perforation, s w e l l -
d e r m o i d ) , swelling ( d e r m o i d o r g l i o m a ) o r a neoplasm (basal
i n g ( h a e m a t o m a o rabscess), g r o w t h (rhinosporidiosis,
cell o r s q u a m o u s cell c a r c i n o m a ) .
h a e m a n g i o m a ) .
Osteocartilaginous framework is e x a m i n e d f o r d e f o r m i t y ,
(iii) Floor of nose. D e f e c t (cleft palate o r fistula), s w e l l i n g
e.g. deviated o r twisted nose, h u m p , depressed bridge,
(dental cyst), n e o p l a s m ( h a e m a n g i o m a ) , o r granula-
bifid o r p o i n t e d t i p , destruction o fn o s e (trauma, syphilis,
tions (foreign b o d y o r osteitis).
cancer).
(iv) Roof. U s u a l l y n o t seen except i n cases o f atrophic
Palpation o f nose is d o n e t o f i n d raised temperature,
rhinitis.
fixity o fskin, t h i c k e n i n g o fsoft tissues, tenderness, fluc-
(v) Lateral wall. L o o k at t h e turbinates a n d meatuses.
t u a t i o n o r crepitation.
O n l y t h e inferior a n d m i d d l e turbinates a n d their

2. Vestibule c o r r e s p o n d i n g meatuses c a n b e visualised. E x a m i n e

the colour of mucosa (congested i ni n f l a m m a t i o n a n d

It is t h e a n t e r i o r s k i n - l i n e d part o f nasal cavity h a v i n g
pale i n allergy), size of turbinates (enlarged a n d s w o l -
vibrissae a n dc a n b e easily e x a m i n e d b y tilting t h e t i p o f
len i nh y p e r t r o p h i c rhinitis, s m a l l a n dr u d i m e n t a r y i n
nose upwards. I t is e x a m i n e d f o r a furuncle, a fissure
atrophic rhinitis), discharge (discharge i n t h e m i d d l e
(chronic rhinitis), crusting, dislocated caudal e n d o ft h e
m e a t u s indicates i n f e c t i o n o f maxillary, frontal o r
s e p t u m , a n dt u m o u r s (cyst, p a p i l l o m a o r c a r c i n o m a ) .
anterior e t h m o i d a l sinuses), mass (polyp, r h i n o s p o r i -

diosis, c a r c i n o m a ) . A p r o b e test s h o u l d b e done. I t

3. Anterior Rhinoscopy
ascertains t h e site o fa t t a c h m e n t , consistency, m o b i l -

Technique Patient is seated facing t h e examiner. ity a n d sensitiveness o ft h e mass. A t t a c h m e n t o f t h e

A T h u d i c u m o r V i e n n a type o fs p e c u l u m is u s e d t o o p e n mass is f o u n d b y passing t h e p r o b e o n all its surfaces.

the vestibule. T h es p e c u l u m is h e l d i n t h e left h a n d ( b ya B l e e d i n g d u r i n g p r o b i n g indicates vascular nature o f

r i g h t - h a n d e d person) ( F i g .7 4 . 6 ) . I t s h o u l d b e fully closed the mass.

Figure 74.6

( A ) A n t e r i o r r h i n o s c o p y . ( B )T e c h n i q u e o f h o l d i n g a T h u d i c u m nasal s p e c u l u m .
 C l i n i c a l M e t h o d s in E N T

4. Posterior Rhinoscopy separately. C o m m o n substances used are the clove o i l ,

p e p p e r m i n t , coffee, a n d essence o f rose. A m m o n i a s t i m u -

Technique P a t i e n t sits f a c i n g t h e e x a m i n e r , o p e n s his m o u t h
lates t h e fibres o f C N V a n d is n o t used to test t h e sense o f
and breathes q u i e d y from the m o u t h . T h e examiner depresses
smell.
the tongue w i t h a tongue depressor and introduces posterior

rhinoscopic m i r r o r w h i c h has b e e n w a m i e d and tested o n the

back o f h a n d (Fig. 74.7). T h e m i r r o r is h e l d like a p e n and

B. Examination o f Paranasal Sinuses
carried b e h i n d the soft palate. W i t h o u t t o u c h i n g it o n the

posterior third o f tongue to avoid gag reflex, light from the

t. M a x i l l a r y sinus
h e a d m i r r o r is f o c u s s e d o n the rhinoscopic m i r r o r w h i c h fur-
2. Frontal sinus
ther illuminates the part to be examined. Patient's relaxation
3. E t h m o i d sinuses
is i m p o r t a n t so t h a t soft palate does n o t contract.
4. S p h e n o i d sinus
Structures n o r m a l l y seen o n post-rhinoscopy are s h o w n

i n Figure 74.8. L o o k for the f o l l o w i n g :

1. Maxillary Sinus
(i) C h o a n a l p o l y p o r atresia.
It is e x a m i n e d b y inspection, palpation a n d trans-
(ii) H y p e r t r o p h y o f posterior ends o f inferior turbinates.
i l l u m i n a t i o n .
(iii) Discharge i n the m i d d l e m e a t u s . I t is s e e n i n infections
M a x i l l a r y sinus has five walls a n d except for the poste-
o f maxillary, frontal o r e t h m o i d a l sinuses. Discharge
rior, all o t h e r walls can be e x a m i n e d directly.
above the m i d d l e turbinate indicates infection o f the

posterior e t h m o i d or the sphenoid sinuses.

5. Functional Examination of Nose

Test for p a t e n c y o f the nose and sense o f smell.

Patency of nose (i) Spatula test: A clean c o l d t o n g u e

d e p r e s s o r is h e l d b e l o w the nostrils to l o o k for the area o f

mist f o r m a t i o n , w h e n patient exhales (Fig. 74.9), the t w o

sides are c o m p a r e d .

(ii) Cotton-wool test: A fluff o f c o t t o n is h e l d against each

nostril a n d its m o v e m e n t s are n o t i c e d w h e n patient inhales

o r exhales.

Sense o f smell A simple t e s t is t o a s k the patient to i d e n -

F i g u r e 74.8
tify the smell o f a s o l u t i o n o r substance h e l d before the
Structures seen o n posterior rhinoscopy.
nostril w h i l e k e e p i n g the eyes closed. E a c h n o s t r i l is tested
C l i n i c a l M e t h o d s in E N T a n d N e c k M a s s e s

E x a m i n e : (b) E x a m i n a t i o n o f nose N o s e s h o u l d be e x a m i n e d

b y anterior as w e l l as posterior r h i n o s c o p y for e v i d e n c e

(i) the soft tissues o f cheek, lip, l o w e r eye l i d and the
o f discharge i n the m i d d l e m e a t u s a n d for any
m o l a r region,
n e o p l a s m .
(ii) the orbit and its c o n t e n t s , and the vision,
T r a n s i l l u m i n a t i o n is d o n e b y placing a small light source
(iii) the vestibule o f m o u t h b y everting the l i p ,
in the superomedial angle o f the o r b i t a n d observing the
(iv) u p p e r alveolus, teeth and palate,
transmission o f light f r o m the anterior w a l l o f the sinus. It
(v) the nose b y anterior a n d posterior r h i n o s c o p y ,
is c o m p a r e d o n b o t h sides. T r a n s i l l u m i n a t i o n o f frontal
( v i ) tenderness b y pressure over the canine fossa
s i n u s is o f l i m i t e d v a l u e a n d has practically b e e n a b a n d o n e d
(Fig. 74.10).
in favour o f X-rays.

Transilluniination o f maxillary sinus is d o n e b y placing a

specially m a d e light source centrally i n the m o u t h and closing 3. Ethmoid Sinuses

the lips. N o r m a l l y , a crescent o f light i n the i n f e r i o r f o r n i x and
T h e y are d i v i d e d i n t o t w o groups, the anterior a n d poste-
g l o w in the pupil, equally bright o n both sides, can be seen.
rior. T h e f o r m e r drains b e l o w the m i d d l e turbinate and
In the presence o f pus, thickened mucosa or a neoplasm, the
the latter above it. T h e y are e x a m i n e d b y inspection and
affected side d o c s n o t t r a n s m i t l i g h t . T h i s test has l i m i t e d value
palpation.
and has practically been abandoned in favour o f X-rays.

(a) E x t e r n a l e x a m i n a t i o n o f e t h m o i d sinuses includes

2. Frontal Sinus
e x a m i n a t i o n o f orbit, u p p e r and l o w e r eye lids, r o o t o f

It is also e x a m i n e d b y inspection, palpation a n d trans- nose, eye ball and vision.

i l l u m i n a t i o n . T e n d e r n e s s can be elicited o n l y i n the anterior e t h m o i d

Frontal sinus has three walls, anterior, posterior a n d sinuses. T h i s is d o n e b y gentle pressure applied o n the

floor. O n l y the anterior wall and floor l e n d themselves to m e d i a l wall o f o r b i t just b e h i n d the r o o t o f nose. T h e area

external e x a m i n a t i o n . is t e n d e r i n acute ethmoiditis.

(a) E x t e r n a l e x a m i n a t i o n F o r this, e x a m i n e the fore- (b) N a s a l e x a m i n a t i o n A n t e r i o r r h i n o s c o p y m a y reveal

head, r o o t o f nose, orbital margins, the o r b i t a n d its c o n - pus, p o l y p i , o r g r o w t h i n the m i d d l e meatus (anterior

tents. L o o k for redness, swelling, fistula, proptosis, a n d g r o u p o f e t h m o i d sinuses) o r b e t w e e n the m i d d l e turbinate

displacement o f the eye balls. a n d the s e p t u m (posterior g r o u p o f e t h m o i d sinuses).

T e n d e r n e s s o f the frontal sinus can be elicited b y pres- P r o b e test s h o u l d be d o n e to f i n d the consistency, attach-

sure o r percussion w i t h a finger o n its a n t e r i o r w a l l a b o v e m e n t and friability o f the mass.

the m e d i a l part o f e y e b r o w , or b y pressing u p w a r d s o n its Posterior r h i n o s c o p y m a y reveal pus o r g r o w t h , b e l o w

floor a b o v e the m e d i a l canthus (Fig. 74.11). or a b o v e the m i d d l e turbinate.

F i g u r e 74.10
F i g u r e 74.11
Testing for tenderness o f maxillary sinus by pressure o n the

canine fossa. Testing for tenderness o f frontal sinus.

 C l i n i c a l M e t h o d s in E N T

4. Sphenoid Sinus 2. Posterior Rhinoscopy

S p h e n o i d sinus lies deep a n d is n o t easy t o e x a m i n e T h e t e c h n i q u e is d e s c r i b e d o n page 3 8 5 . Structures to be

directly. S o m e t i m e s , its a n t e r i o r w a l l can be seen in atro- e x a m i n e d are:

p h i c rhinitis o r i n m a r k e d d e v i a t i o n o f the s e p t u m t o the

(a) Anterior wall. Posterior b o r d e r o f nasal s e p t u m , c h o a -
opposite side.
nae, posterior ends o f turbinates a n d their meatuses.
(a) A n t e r i o r rhinoscopy S p h e n o i d sinus opens i n the
(b) Lateral walls. T o r u s tubarius, o p e n i n g o f eustachian
s p h e n o e t h m o i d a l recess. A t t e n t i o n s h o u l d therefore be
tube, pharyngeal recess.
p a i d to the findings i n the olfactory fissure near the r o o f o f
(c) Floor. U p p e r surface o f soft palate.
nose. I t m a y s h o w discharge, crusts, p o l y p o r g r o w t h .
(d) Roof of posterior wall.
A p r o b e can b e used t o palpate the mass.

O n l y a small part o f n a s o p h a r y n x can be seen i n the

(b) Posterior rhinoscopy I t m a y reveal pus i nthe
m i r r o r at o n e time. T h e e x a m i n e r tilts t h e m i r r o r i n differ-
n a s o p h a r y n x o r the choana, a b o v e the m i d d l e o r superior
ent directions t o see all the walls o f the n a s o p h a r y n x , a n d
turbinate. A g r o w t h o r a p o l y p m a y also b e seen.
t h e n m e n t a l l y reconstitutes the entire picture.

Abnormal findings i n the nasopharynx include:

(a) Discharge I t m a y be seen b e l o w the m i d d l e turbinate

III. E X A M I N A T I O N O F NASOPHARYNX
(anterior g r o u p o f sinuses) o r a b o v e the m i d d l e t u r -

binate (posterior g r o u p o f sinuses).

Symptomatology (b) Crusting A t r o p h i c rhinitis o r nasopharyngitis.

(c) Mass
(i) S m o o t h pale mass—-antrochoanal p o l y p
A patient w i t h disease o f n a s o p h a r y n x presents w i t h :

(ii) P i n k l o b u l a t e d m a s s — a n g i o f i b r o m a
1. Nasal o b s t r u c t i o n .
(iii) I r r e g u l a r b l e e d i n g m a s s — c a r c i n o m a
2. Post-nasal discharge.
(iv) S m o o t h s w e l l i n g i n the r o o f - — T h o r n w a l d t ' s cyst
3. Epistaxis.
o r abscess
4. Deafness (tubal block).
(v) Irregular mass w i t h radiating folds-adenoids
5. C r a n i a l nerve palsies.
(vi) Irregular mass filling the l o w e r part o f c h o a n a —
6. E n l a r g e m e n t o f l y m p h nodes i n the neck.
m u l b e r r y h y p e r t r o p h y o f inferior turbinate.

A detailed history o f these s y m p t o m s r e g a r d i n g their

(d) B l e e d i n g D u e to posterior nasal or nasopharyngeal

p a t h o l o g y .
onset, d u r a t i o n , progression a n d severity s h o u l d be asked.

( T h e y have b e e n discussed i n the relevant sections.)

3. Other Methods

(a) Digital examination I t is a q u i c k m e t h o d to e x a m -

ine the n a s o p h a r y n x b y p a l p a t i o n b u t is u n c o m f o r t a b l e for

Examination
the patient. T h e e x a m i n e r stands b e h i n d a n d t o the right

o f the patient, invaginates patient's c h e e k w i t h his left fin-

Clinical e x a m i n a t i o n o f n a s o p h a r y n x includes:
ger a n d inserts right i n d e x finger b e h i n d the soft palate

1. A n t e r i o r r h i n o s c o p y .
into the nasopharynx. H e first e x a m i n e s the posterior b o r -

2. Posterior r h i n o s c o p y .
der o f the nasal s e p t u m , t h e n the choana, lateral w a l l a n d

3. O t h e r m e t h o d s . finally the posterior w a l l o f nasopharynx. A d e n o i d s , a n t r o -

(a) Digital e x a m i n a t i o n choanal p o l y p a n d o t h e r masses i n the n a s o p h a r y n x can be

(b) E n d o s c o p y e x a m i n e d . A v o i d this e x a m i n a t i o n i f a n g i o f i b r o m a is

(c) R e t r a c t i o n o f soft palate w i t h catheters a n d m i r - suspected.

r o r e x a m i n a t i o n
(b) E n d o s c o p y A r i g i d nasal e n d o s c o p e is p a s s e d t h r o u g h
4. C r a n i a l nerves.
the nose after local anaesthesia a n d d e c o n g e s t i o n o f nasal
5. C e r v i c a l l y m p h nodes.
m u c o s a . It gives a b r i g h t a n d m a g n i f i e d v i e w o f the

nasopharyngeal structures. U s i n g endoscopes w i t h differ-

/. Anterior Rhinoscopy
ent angles o f v i e w , i t is p o s s i b l e t o e x a m i n e structures situ-

I t is p o s s i b l e t o see o n l y a small part o f the n a s o p h a r y n x o n ated at an angle. Flexible n a s o p h a r y n g o s c o p e can also be

anterior r h i n o s c o p y . T h e v i e w can be facilitated b y d e c o n - used. I t is a l s o passed t h r o u g h the nose a n d gives a m a g n i -

gestion o f nasal a n d turbinal m u c o s a w i t h vasoconstrictors. fied v i e w .

Clinical Methods in ENT and Neck Masses

(c) Retraction o f soft palate with catheters and o f taste, d i m i n i s h e d o r perverted taste. Lesions i n these

mirror examination T h i s m e t h o d is r e s e r v e d for diffi- cases m a y be local o n the t o n g u e , e.g. heavily coated

cult cases w h e r e v i e w o f n a s o p h a r y n x is n o t o b t a i n e d b y t o n g u e , or injury t o c h o r d a t y m p a n i o r the facial nerve.

o t h e r m e t h o d s . It requires g o o d local o r general 4. Trismus. T h e r e are several causes o f trismus b u t the

anaesthesia. i m p o r t a n t ones related to the oral cavity i n c l u d e ulcerative

A soft r u b b e r catheter is p a s s e d t h r o u g h e a c h nostril a n d lesions, dental abscess, t r a u m a to m a n d i b l e o r maxilla, a n d

r e c o v e r e d f r o m the o r o p h a r y n x . B o t h ends o f catheter are m a l i g n a n t lesions o f t o n g u e , b u c c a l m u c o s a a n d r e t r o m o -

h e l d together a n d c l a m p e d . I n this w a y , soft palate is lar t r i g o n e that h a v e infiltrated deeply.

retracted forwards. N o w a m i r r o r can be i n t r o d u c e d a n d 5. Lesion or oral cavity. Patient can easily see several parts

the n a s o p h a r y n x e x a m i n e d . o f his oral cavity i n the m i r r o r a n d present w i t h an a b n o r -

m a l g r o w t h , c o a t i n g o f t o n g u e , a cleft (lip o r palate) o r a

4. Examination of Cranial Nerves fistula (oroantral). It is n o t unusual for s o m e patients o f

c a n c e r o p h o b i a to f i x their a t t e n t i o n o n the circumvallate

M a l i g n a n c y o f n a s o p h a r y n x can i n v o l v e any o f the C N I I
papillae as cancer.
to X I I ,m o r e often C N I X , X a n d X I .

5. Examination of Cervical Lymph Nodes

Examination
I t is n o t unusual for nasopharyngeal m a l i g n a n c y to present

primarily as a l y m p h n o d e mass i n the neck. L y m p h nodes E x a m i n e i n seriatim the f o l l o w i n g structures:

c o m m o n l y i n v o l v e d are u p p e r internal j u g u l a r a n d

those a l o n g the accessory n e r v e i n the posterior triangle o f 1. Lips

the n e c k .
E x a m i n e b o t h the l i p s — t h e u p p e r a n d l o w e r , b y inspec-

t i o n a n d palpation. E a c h l i p has an o u t e r (cutaneous), an

i n n e r (mucosal) surface a n d a v e r m i l i o n border. L o o k for

IV. E X A M I N A T I O N O F O R A L C A V I T Y
any swellings, vesicles, ulcers, crusts, scars, unilateral o r

bilateral clefts.

O r a l cavity extends f r o m the lips t o the level o f anterior

tonsillar pillars. Structures i n c l u d e d i n it are: 2. Buccal Mucosa

1. Lips. It can be e x a m i n e d b y asking the patient to o p e n the m o u t h

2. B u c c a l m u c o s a . a n d b y retracting the cheek w i t h a t o n g u e depressor. E x a m i n e

3. G u m s a n d teeth. the mucosa o f cheek a n d vestibule o f m o u t h . L o o k for:

4. H a r d palate.
(i) C h a n g e i n c o l o u r
5. A n t e r i o r t w o - t h i r d s o f t o n g u e .
(ii) C h a n g e i n surface appearance, e.g. ulceration, vesi-
6. F l o o r o f m o u t h .
cles o r b u l l a e ( p e m p h i g u s ) , w h i t e stria ( l i c h e n planus),
7. R e t r o m o l a r trigone.
b l a n c h e d appearance w i t h s u b m u c o s a l scars ( s u b m u -

cous fibrosis), l e u k o p l a k i a , erythroplakia, p i g m e n t a -

Symptomatology tion, atrophic change i n mucosa, s w e l l i n g o r g r o w t h .

O p e n i n g o f parotid d u c t is s e e n opposite the u p p e r

A patient w i t h disease o f the oral cavity m a y present w i t h 2nd m o l a r t o o t h . It m a y be r e d a n d s w o l l e n w i t h

o n e o r m o r e o f the f o l l o w i n g complaints: secretions flowing t h r o u g h i t o n massage o f parotid

1. Pain. It m a y be l o c a l i s e d t o a p a r t i c u l a r site i n t h e oral gland (viral or suppurative parotitis).

cavity, e.g. t o o t h , t o n g u e , b u c c a l m u c o s a , floor o f m o u t h ,

etc. S o m e t i m e s , p a i n is r e f e r r e d to the ear f r o m p a t h o l o g y 3. Gums and Teeth

in the oral cavity.
E x a m i n e the g u m s a n d teeth i n b o t h the u p p e r a n d l o w e r
2. Disturbance of salivation. X e r o s t o m i a (dryness o f
j a w s . O u t e r surface o f g u m s is e x a m i n e d b y retracting the
m o u t h ) can result f r o m m o u t h breathing, irradiation o r
cheeks a n d lips a n d the i n n e r surface b y p u s h i n g t h e t o n g u e
generalised disease o f the salivary glands. Excessive saliva-
a w a y w i t h a t o n g u e depressor.
t i o n can result f r o m ulcers o f m o u t h a n d p h a r y n x , p o o r

o r o d e n t a l h y g i e n e , ill-fitting denture, a n d i o d i d e therapy. (i) R e d a n d s w o l l e n g u m s Gingivitis

3. Disturbance of taste. Sweet, sour a n d salt tastes are (ii) U l c e r a t e d g u m s V i r a l ulcers o r

appreciated b y taste buds o n the anterior t w o - t h i r d s o f c o v e r e d w i t h a V i n c e n t ' s

t o n g u e . Patient m a y c o m p l a i n o f unilateral o r bilateral loss m e m b r a n e infections

 Clinical M e t h o d s in E N T

(iii) Hyperplasia P r e g n a n c y o r dilantin therapy (i) S h o r t f r e n u l u m : C o n g e n i t a l ankyloglossia (i.e.

(iv) G r o w t h s B e n i g n o r m a l i g n a n t neoplasms tongue-tie).

(v) L o o s e teeth M a x i l l a r y o r m a n d i b u l a r (ii) Scar: T r a u m a o r corrosive b u r n .

g r o w t h , periodontitis (iii) U l c e r : T r a u m a , erosion o fs u b m a n d i b u l a r d u c t stone,

(vi) Carious Cause o f m a x i l l a r y sinusitis i f a p h t h o u s ulcer, m a l i g n a n c y .

infected t o o t h upper, a n d L u d w i g ' s (iv) S w e l l i n g : R a n u l a , sublingual d e r m o i d , calculus o f

o r teeth angina, i f l o w e r s u b m a n d i b u l a r duct, b e n i g n o r m a l i g n a n t t u m o u r s ,

(vii) M a l o c c l u s i o n Fractures o f m a n d i b l e o r o f L u d w i g ' s angina.

teeth maxilla, abnormalities o f

t e m p o r o m a n d i b u l a r j o i n t .
7. Retromolar Trigone

L o o k f o r t h e i n f l a m m a t i o n d u e t o i m p a c t i o n o f last m o l a r
4. Hard Palate
t o o t h o r a m a l i g n a n t lesion o f this area.

L o o k for:

(i) Cleft palate C o n g e n i t a l

(ii) Oronasal fistula T r a u m a o r syphilis

| Palpation J
(iii) H i g h - a r c h e d palate M o u t h breathers
A l l lesions o f t h e oral cavity, particularly o f t h e t o n g u e ,
(iv) B u l g e T u m o u r s o f palate,
floor o f m o u t h , cheek, H p a n d palate, m u s t b e palpated.
nose o r a n t r u m
A s w e l l i n g i n t h e floor o f m o u t h s h o u l d b e e x a m i n e d b y
(v) B o n y g r o w t h i n m i d l i n e T o r u s palatinus
b i m a n u a l palpation, t o differentiate a s w e l l i n g o f s u b m a n -
(vi) Mass o r ulcer C a n c e r
dibular ( F i g .74.12) salivary gland f r o m that o f s u b m a n -

5. Tongue dibular l y m p h nodes.

O n l y oral t o n g u e (anterior t w o - t h i r d s ) is i n c l u d e d i n t h e

oral cavity. First, e x a m i n e t h e t o n g u e i n its n a t u r a l posi-

V. EXAMINATION O F OROPHARYNX

t i o n a n d t h e n ask t h e patient t o p r o t r u d e i t , m o v e i t t o t h e

right a n d left a n d t h e n u p . E x a m i n e t h e tip, d o r s u m , lateral

O r o p h a r y n x lies opposite t h e oral cavity. I t starts at t h e

borders a n d undersurface.
level o f anterior p i l l a r s a n d is b o u n d e d a b o v e b y t h e j u n c -

t i o n o f h a r d a n d soft palate a n d b e l o w b y t h e V - s h a p e d
(i) Large size: Macroglossia, h a e m a n g i o m a , l y m p -
r o w o f circumvallate papillae.
h a n g i o m a , cretinism, o e d e m a o r abscess.
Structures i n c l u d e d i n it are:
(ii) Inability t o protrude: C o n g e n i t a l ankyloglossia, can-

cer t o n g u e o r floor o f m o u t h , painful ulcer, abscess.

1. Tonsils a n d pillars

(iii) D e v i a t i o n o n p r o t r u s i o n : Paralysis C N X I Io n t h e
2. Soft palate

side o f deviation.

(iv) B a l d tongue: I r o n - d e f i c i e n c y anaemia, m e d i a n

r h o m b o i d glossitis (single patch i n m i d l i n e o n t h e

d o r s u m ) , geographical t o n g u e .

(v) Fissures: C o n g e n i t a l (Melkersson's s y n d r o m e ) ,

syphilitic. A single n o n h e a l i n g fissure m a y be

malignant.

(vi) Ulcers: A p h t h o u s traumatic (jagged t o o t h o r d e n -

ture), malignant, syphilitic o r tubercular.

(vii) W h i t e thick patch o r plaque: L e u k o p l a k i a .

( v i i i ) Proliferative g r o w t h : M a l i g n a n c y .

6. Floor of Mouth

E x a m i n e anterior part w h i c h lies u n d e r t h e t o n g u e a n d

t w o lateral gutters. Lateral gutters are better e x a m i n e d b y

t w o t o n g u e depressors; o n e retracting t h e t o n g u e , a n d t h e

other, t h e cheek. Figure 74.12

O p e n i n g o f t h e s u b m a n d i b u l a r d u c t is s e e n as a raised
P a l p a t i o n o f oral cavity.
papilla o n either side o f t h e f r e n u l u m .
C l i n i c a l M e t h o d s in E N T a n d N e c k M a s s e s

3. Base o f t o n g u e 1. Tonsils and Pillars

4. Posterior pharyngeal w a l l
(a) T o n s i l s

(i) Presence: L o o k f o r presence o r absence o f tonsils.

(ii) Size: Large a n d obstructive, small o r e m b e d d e d .

Symptomatology
(iii) Symmetry: U n i l a t e r a l o r bilateral enlargement.

(iv) Crypts: W h i t e o r y e l l o w spots at t h e openings o f

A disease o f t h e o r o p h a r y n x c a n disturb s w a l l o w i n g ,
crypts (follicular tonsillitis), w h i t e excrescences n o t
p h o n a t i o n , respiration a n dh e a r i n g . A patient w i t h disease
easily w i p e d o f f (keratosis).
o f o r o p h a r y n x presents w i t h o n eo r m o r e o f the f o l l o w i n g
(v) Membrane: D i p h t h e r i a , V i n c e n t ' s angina, m e m b r a -
complaints:
n o u s tonsillitis, etc.

\. Sore throat. A c u t e o r c h r o n i c tonsillitis, pharyngitis,

(vi) Ulcer: C a n c e r , V i n c e n t ' s angina, tuberculosis, ulcer-

ating tonsillolith.
ulcerative lesions o fp h a r y n x , e t c .

2. Odynophagia (painful s w a l l o w i n g ) . Ulcers, peritonsillar

(vii) Mass: Cystic (retention cyst), p e d u n c u l a t e d o r ses-

sile solid mass (papilloma, f i b r o m a ) , proliferative

or retropharyngeal abscess, U n g u a l tonsillitis, e t c .

g r o w t h (cancer).
3. Dysphagia (difficulty i n s w a l l o w i n g ) . Tonsillar enlarge-

ments; parapharyngeal t u m o u r ; b e n i g n o r malignant

(viii) Bulge: Peritonsillitis, parapharyngeal abscess, parapha-

ryngeal t u m o u r .
disease o f tonsils, base o f t o n g u e o r posterior pharyngeal

w a l l ; paralysis o f soft palate; globus hystericus.

Pressure o n t h e anterior pillar w i t h t h e edge o f t o n g u e
4. Change in voice. Paralysis o f palate causes hypernasality.
depressor m a y express cheesy material f r o m t h e crypts
S p a c e - o c c u p y i n g lesions o f t h e o r o p h a r y n x cause
(normal) o f frank fluid p u s (septic tonsil).
m u f f l e d o r h o t - p o t a t o voice.
Palpation o ft h e tonsil w i t h a g l o v e d f i n g e r is essential t o
5. Earache. B e n i g n ulcers o r m a l i g n a n t lesions o f the base
k n o w t h e consistency o ft h e mass (hard i n m a l i g n a n c y o r
o f t o n g u e , tonsil, p i l l a r s a n dp a l a t e cause referred pain
t o n s i l l o l i t h ) , p u l s a t i o n i nt o n s i l l a r area ( i n t e r n a l c a r o t i d artery
i n t h e ipsilateral ear.
aneurysm), palpation for a n elongated styloid process.
6. Snoring. Large tonsils a n do t h e r o r o p h a r y n g e a l lesions
(b) Pillars U n i f o r m congestion o f the pillars, tonsils a n d
m a y obstruct respiration a n d cause s n o r i n g o r sleep
pharyngeal m u c o s a is seen i n acute tonsillitis. C o n g e s t i o n
apnoea s y n d r o m e .
o f o n l y t h e pillars m a y b e a sign o f c h r o n i c tonsillitis.
7. Halitosis (bad smell from t h em o u t h ) . I nt h e o r o p h a r y n x ,
U l c e r a t i o n o r proliferative g r o w t h m a y b e a n e x t e n s i o n o f
cause m a y b e infected tonsils, post-nasal discharge o r
m a l i g n a n c y f r o m t h etonsil base o f t o n g u e o r t h e r e t r o m o -
malignancy.
lar trigone.
8. Hearing loss. A c o n d u c t i v e hearing loss d u e t o distur-

bance o f eustachian tube f u n c t i o n c a n result f r o m

enlarged tonsils ( w h i c h interfere w i t h m o v e m e n t s o f 2 . Soft Palate

soft palate), cleft palate, s u b m u c o u s palate, palatal paral-
L o o k f o r redness (peritonsillitis), b u l g e o rswelling. N o r m a l l y ,
ysis, r e c u r r e n t pharyngitis o r tonsillitis.
uvula is t h e m i d l i n e . I t b e c o m e s oedematous a n d displaced
9. Abnormal appearance. A patient m a y notice a n a b n o m i a l
to t h eopposite side i np e r i t o n s i l l a r abscess. N o t e m o v e m e n t s
f i n d i n g w h i l e l o o k i n g at his throat i n t h e m i r r o r a n d
o f soft palate w h e n t h epatient says " A a " . D e v i a t i o n o f the
t h e n consult t h edoctor. I t is n o tu n u s u a l for patient t o
uvula a n d soft palate t o t h e healthy side is a s i g n o f vagal
be c o n c e r n e d about h y p e r t r o p h i c circumvallate papil-
paralysis. T h i s m a yb e associated w i t h paralysis o f posterior
lae a n dh a v e fear o f cancer.
pharyngeal wall w h i c h shows a "curtain effect" (the paraly-

sed side m o v e s like a sliding c u r t a i n t o t h eh e a l t h y side).

A bifid u v u l a m a yb e a sign o fs u b m u c o u s cleft palate.

Examination
I n such cases, a n o t c h c a nb e p a l p a t e d i n t h e h a r d palate at

its j u n c t i o n w i t h soft palate i n t h e m i d l i n e .

First, e x a m i n e t h e o r o p h a r y n x b y asking t h e patient t o

o p e n t h e m o u t h w i d e l y . T o n g u e depressor is u s e d w h e n
3. Posterior Pharyngeal Wall
this p r e l i m i n a r y e x a m i n a t i o n is unsatisfactory, o r w h e n i t

is r e q u i r e d t o displace t h e t o n g u e t o o n e side t o e x a m i n e I t c a nb e s e e n d i r e c t l y . L o o k for l y m p h o i d nodules (granular

tonsillolingual sulcus, o r t o press o n t h e tonsils t o l o o k f o r pharyngitis), purulent discharge triclding d o w n t h e posterior

the contents o f tonsillar crypts. T h e base o f t o n g u e is pharyngeal wall (sinusitis), h y p e r t r o p h y o f lateral phaiyngeal

e x a m i n e d b y laryngeal m i r r o r . F o l l o w i n g structures o f b a n d s j u s t b e h i n d t h ep o s t e r i o r piUars ( c h r o n i c sinusitis), thin

o r o p h a r y n x are carefully e x a m i n e d . glazed m u c o s a a n d crusting (atrophic pharyngitis).

 C l i n i c a l M e t h o d s in E N T

4. Base of Tongue and Valleculae 3. Flexible or rigid fibre-optic e n d o s c o p y .

4. Assessment o f voice.
Posterior o n e - t h i r d o f tongue forms the base o f t o n g u e a n d
5. Assessment o f cervical l y m p h nodes.
lies b e t w e e n the V-shaped r o w o f circumvallate papillae and

the valleculae. V a l l e c u l a e are t w o shallow depressions w h i c h

7. External Examination of Larynx
lie b e t w e e n the base o f t o n g u e and the epiglottis.

Base o f t o n g u e a n d valleculae are best e x a m i n e d b y B o t h inspection a n d palpation are e m p l o y e d .

indirect l a r y n g o s c o p y a n d finger palpation. L o o k for:

(a) Indirect laryngoscopy L o o k forthe colour o f mucosa (i) Redness of skin, (abscess, perichondritis)

{normal or congested); p r o m i n e n t veins, varicosities at the (ii) Bulge o r swelling (extension o f g r o w t h or enlarged

base o f tongue o r lingual thyroid, ulceration {malignancy, l y m p h nodes)

tuberculosis or syphilis), solid swelling (lingual tonsil, lingual (iii) Widening of larynx ( g r o w t h o f p y r i f o r m fossa)

thyroid, l y m p h o m a , carcinoma base o f t o n g u e ) , cystic swell- (iv) Surgical emphysema (accidental o r surgical trauma)
ing (vallecular cyst, d e r m o i d o r thyroglossal cyst). (v) Change in contour o r displacement of laryngeal structures
(trauma o r neoplasm). Palpate the h y o i d bone, t h y -
(b) P a l p a t i o n o f base o f t o n g u e It should never be omit-
r o i d cartilage, t h y r o i d n o t c h , cricoid cartilage, a n d
ted. E x t e n t o f t u m o u r w h i c h infiltrates deeper i n t o the tongue
the tracheal rings.
is b e t t e r appreciated b y palpation than b y inspection. I f the
(vi) Movements of larynx. N o r m a l l y , l a r y n x m o v e s w i t h
patient fails to relax sufficientiy, palpation should be d o n e
deglutition. I t can also be m o v e d f r o m side to side
u n d e r general anaesthesia. W h e n palpating any structure i n
p r o d u c i n g a characteristic grating s o u n d (laryngeal
the o r o p h a r y n x i n a child, the examiner should invaginate the
crepitus). F i x i t y o f l a r y n x indicates i n f l a m m a t i o n o f
patient's cheek b e t w e e n his teeth w i t h finger o f the opposite
infiltration o f g r o w t h i n t o the s u r r o u n d i n g struc-
h a n d to prevent biting o n the examiner's finger.
tures. Loss o f laryngeal crepitus is d u e to postcricoid

carcinoma.

VI. EXAMINATION O F LARYNX AND 2. Indirect Laryngoscopy

LARYNGOPHARYNX
Technique Patient is seated opposite the examiner. H e

s h o u l d sit erect w i t h the head and chest leaning slightly

S y m pto m atol ogy towards the examiner. H e is a s k e d to p r o t r u d e his t o n g u e

w h i c h is w r a p p e d i n gauze a n d held b y the e x a m i n e r

A patient w i t h disease o f the larynx presents w i t h o n e o r b e t w e e n the t h u m b and m i d d l e finger. I n d e x f i n g e r is used

m o r e o f the f o l l o w i n g complaints: to k e e p the u p p e r lip o r m o u s t a c h e o u t o f the w a y

(Fig. 74.13). G a u z e piece is u s e d to get a f i r m grip o f the

1. Disorders of voice, e.g. hoarseness aphonia, p u b e r p h o -
t o n g u e a n d to protect it against injury b y the l o w e r
nia o r easy-fatiguability o f v o i c e .
incisors.
2. Respiratory obstruction.
3. Cough and expectoration.
4. Repeated clearing of throat (chronic laryngitis, b e n i g n o r

m a l i g n a n t t u m o u r s o f larynx).

5. Pain in throat (ulcerative lesions o f larynx, p e r i c h o n -

dritis o f laryngeal cartilages, arthritis o f laryngeal

joints).

6. Dysphagia (epiglottitis, aspiration o f secretions d u e to

laryngeal paralysis).

7. Mass in the neck (cervical nodes, direct extension o f

g r o w t h , laryngocele).

Examination

Clinical e x a m i n a t i o n o f l a r y n x includes:
F i g u r e 74.13
1. E x t e r n a l e x a m i n a t i o n o f larynx.
Indirect laryngoscopy.
2. Indirect laryngoscopy.
Clinical Methods in E N T and Neck Masses

Laryngeal m i r r o r (size 4 t o 6) w h i c h has b e e n w a r m e d examiner. I ff r e q u e n c y o f pulses is s a m e at w h i c h v o c a l

a n d t e s t e d o n t h eb a c k o f h a n d is i n t r o d u c e d i n t o t h e m o u t h cords are m o v i n g , t h e latter appear stationary g i v i n g m o r e

and h e l d f i r m l y against t h e u v u l a a n d soft palate. L i g h t is t i m e t o study t h e c o r d . I f frequency o fpulses is m o r e o r

focussed o n t h e laryngeal m i r r o r a n d patient is a s k e d t o less t h a n that o fv o c a l c o r d m o v e m e n t s , t h e cords are seen

breathe quietly. T o see m o v e m e n t s o ft h e cords, patient is in s l o w m o t i o n . Stroboscopes are synchronised w i t h rigid

asked t o take deep inspiration (abduction o f cords), say or fibre-optic endoscopes a n d t h e v o c a l c o r d m o v e m e n t s

" A a " ( a d d u c t i o n o f cords) a n d " E e e " ( f o ra d d u c t i o n a n d can b e r e c o r d e d o n v i d e o (video stroboscopy). S t r o b o s c o p y

tension). M o v e m e n t s o fb o t h t h e cords are c o m p a r e d . has b e e n f o u n d v e r y useful i ndiagnosis o f laryngeal paraly-

sis, c o m p l e t e n e s s o fg l o t t i c c l o s u r e d u r i n g p h o n a t i o n , v e r y
Structures seen o n indirect l a r y n g o s c o p y ( F i g . 7 4 . 1 4 )
small early laryngeal cancer, v o c a l c o r d scarring, laryngeal
Indirect laryngoscopy permits e x a m i n a t i o n o fs t r u c t u r e s o f
cyst versus p o l y p , a n dsulcus vocalis.
the o r o p h a r y n x , larynx a n d l a r y n g o p h a r y n x .

Larynx. Epiglottis, aryepiglottic folds, arytenoids, c u n e i -

4. Assessment of Voice
f o r m a n d corniculate cartilages, ventricular bands, v e n t r i -

cles, t r u e c o r d s , a n t e r i o r c o m m i s s u r e , posterior commissure, T h e e x a m i n e r s h o u l d m a k e note o ft h e q u a l i t y o fv o i c e o f

subglottis a n drings o f trachea. the patient such as h o a r s e , r o u g h , breathy, bitonal, d y s -

Laryngopharynx. B o t h p y r i f o r m fossae, p o s t c r i c o i d p h o n i c , w h i s p e r e d o r feeble.

region, posterior w a l l o f l a r y n g o p h a r y n x .

Oropharynx. Base o f t o n g u e , lingual tonsils, valleculae,

5. Assessment of Cervical Lymph Nodes

m e d i a l a n dlateral glossoepiglottic folds.

N o e x a m i n a t i o n o f t h e l a r y n x a n d h y p o p h a r y n x is

c o m p l e t e w i t h o u t t h o r o u g h search f o r cervical l y m p h
3. Flexible or Rigid Fibre-optic Endoscopy
nodes.

(a) F l e x i b l e e n d o s c o p y I n difficult cases, w h e r e l a r y n -

geal e x a m i n a t i o n c a n n o t b e p e r f o r m e d w i t h a m i r r o r d u e

to anatomical abnormalities o r intolerance o f m i r r o r b y

VII. LYMPH NODES O F T H E
the patient, a flexible r h i n o l a r y n g o s c o p e c a nb e used. I t is
HEAD AND NECK
passed t h r o u g h t h e nose u n d e r local anaesthesia a n d gives

a g o o d v i e w o ft h e larynx, l a r y n g o p h a r y n x , subglottis a n d

e v e n u p p e r trachea. I t is a n o u t d o o r procedure. Classification (Fig. 74.15)

(b) R i g i d endoscopy F o r this purpose, a rigid fibre-

o p t i c t e l e s c o p e is u s e d . I tgives a clear, w i d e - a n g l e v i e w o f
1. U p p e r h o r i z o n t a l c h a i n o f n o d e s
(a) S u b m e n t a l
the l a r y n x a n d l a r y n g o p h a r y n x . I t is also a n o u t d o o r
( b ) S u b m a n d i b u l a r
p r o c e d u r e .
(c) P a r o t i d
Stroboscopy: A stroboscope is a device w h i c h emits
( d ) Postauricular
light i n pulses, t h e frequency o fw h i c h c a n b e set b y t h e
(e) O c c i p i t a l

(f) Facial

Base of tongue 2. L a t e r a l c e r v i c a l n o d e s T h e y i n c l u d e nodes, superfi-

cial a n d deep t o sternocleidomastoid muscle a n d i n t h e

posterior triangle.
Ventricular
fold Vallecula
(a) Superficial external j u g u l a r g r o u p

( b ) D e e p g r o u p

Epiglottis (i) Internal j u g u l a r c h a i n (upper, m i d d l e a n d l o w e r

groups)

Cuneiform (ii) Spinal accessory c h a i n

V cartilage (iii) T r a n s v e r s e cervical c h a i n

Pyriform^ ^Corniculate 3. A n t e r i o r c e r v i c a l n o d e s
fossa \ c a r t i l
°9 e

interarytenoid area (a) A n t e r i o r j u g u l a r c h a i n

( b ) Juxtavisceral c h a i n

F i g u r e 74.14 (i) Prelaryngeal

(ii) Pretracheal
S t r u c t u r e s seen o n i n d i r e c t l a r y n g o s c o p y .
(iii) Paratracheal
 Clinical Methods in E N T

1. Nodes of Upper Horizontal Chain (e) Occipital nodes T h e y lie b o t h superficial a n d deep

to splenius capitus at the apex o f the posterior triangle.

(a) S u b m e n t a l n o d e s T h e y He o n the m y l o h y o i d m u s -
Afferents c o m e f r o m scalp, s k i n o f u p p e r neck. Efferents
cle i n the s u b m e n t a l triangle, 2 to 8 i n n u m b e r .
drain i n t o u p p e r accessory c h a i n o f nodes.
Afferents c o m e f r o m the c h i n , m i d d l e part o f l o w e r lip,
(f) Facial nodes T h e y lie a l o n g facial vessels a n d are
anterior g u m s , anterior f l o o r o f m o u t h a n d tip o f
g r o u p e d according to their location. T h e y are m i d m a n -
t o n g u e .
dibular, buccinator, infraorbital a n d malar (near o u t e r can-
Efferents g o t o submandibular nodes a n d internal j u g u -
thus) nodes.
lar chain.

Afferents c o m e f r o m u p p e r a n d l o w e r lids, nose, Hps

(b) Submandibular nodes T h e y He i n submandibular tri-
a n d cheek.
angle i n relation to submandibular gland and facial artery.
Efferents drain i n t o s u b m a n d i b u l a r nodes.
Afferents c o m e from lateral part o f the l o w e r Hp, u p p e r Hp,

cheek, nasal vestibule and anterior part o f nasal cavity, gums,

teeth, medial c a n t h u s , soft palate, anterior pillar, anterior part 2. Lateral Cervical Nodes

o f tongue, submandibular and subHngual saHvary glands and

T h e y are d i v i d e d into:
floor o f m o u t h . Efferents go to internal jugular chain.

(a) S u p e r f i c i a l g r o u p I t Hes a l o n g e x t e r n a l j u g u l a r v e i n and

(c) Parotid nodes T h e y He i n relation to the parotid saH-
drains into internal jugular and transverse cervical nodes.
vary gland a n d are extraglandular and intraglandular.

Preauricular and infraauricular nodes are part o f the extrag-

(b) D e e p g r o u p I t consists o f three chains, the internal

jugular, spinal accessory a n d transverse cervical.

landular group.

Afferents c o m e f r o m the scalp, pinna, external a u d i t o r y

(i) Internal jugular chain. L y m p h nodes of internal j u g u l a r

canal, face, b u c c a l m u c o s a .
chain He anterior, lateral and posterior to internal

Efferents go to internal jugular or external jugular chain.

j u g u l a r v e i n a n d e x t e n d f r o m the digastric m u s c l e to

(d) P o s t a u r i c u l a r n o d e s ( m a s t o i d n o d e s ) T h e y H e the j u n c t i o n o f internal j u g u l a r v e i n w i t h the subcla-

b e h i n d the p i n n a over the mastoid. v i a n v e i n . T h e y are arbitrarily d i v i d e d i n t o upper,

Afferents c o m e f r o m the scalp, posterior surface o f p i n n a m i d d l e a n d l o w e r groups.

a n d skin o f mastoid. U p p e r g r o u p (jugulodigastric n o d e ) drains oral

Efferents d r a i n i n t o infra-auricular nodes a n d i n t o inter- cavity, o r o p h a r y n x , n a s o p h a r y n x , h y p o p h a r y n x , lar-

nal j u g u l a r chain. ynx a n d parotid.

; I r a , s v
l
e r s e
Lower jugular nodes
cervical chain

F i g u r e 74.15

L y m p h nodes o f head and neck.

Clinical Methods in E N T and Neck Masses

M i d d l e g r o u p drains h y p o p h a r y n x , larynx, t h y -
Examination of Neck Nodes
roid, oral cavity, o r o p h a r y n x .

L o w e r j u g u l a r g r o u p drains larynx, t h y r o i d a n d
E x a m i n a t i o n o f n e c k nodes is i m p o r t a n t , particularly i n
cervical oesophagus.
head a n d n e c k malignancies and a systematic approach
(ii) Spinal accessory chain. I t lies a l o n g the spinal accessory
s h o u l d be f o l l o w e d .
nerve. U p p e r n o d e s o f this c h a i n coalesce w i t h u p p e r
N e c k nodes are better palpated w h i l e standing at the
j u g u l a r nodes. Spinal accessory chain drains the scalp,
back o f the patient. N e c k is slightly flexed to achieve
skin o f the neck, the nasopharynx, occipital a n d pos-
relaxation o f muscles (Fig. 74.16). T h e nodes are e x a m -
tauricular nodes.
i n e d i n the f o H o w i n g m a n n e r so that n o n e is missed.
Efferents f r o m this chain drain i n t o transverse cer-

vical chain. (a) Upper horizontal chain. E x a m i n e submental, s u b m a n d i -

(iii) Transverse cervical chain (supraclavicular nodes). It lies bular, parotid, facial, postauricular a n d occipital

horizontally, a l o n g the transverse c e r v i c a l vessels, i n nodes.

the l o w e r part o f the posterior triangle. T h e m e d i a l ( b ) External jugular chain. It lies superficial to sterno-

nodes o f the g r o u p are called scalene nodes. Afferents mastoid.

to those nodes c o m e f r o m the accessory c h a i n and (c) Internal jugular chain. E x a m i n e the upper, m i d d l e and

also i n f r a c l a v i c u l a r structures, e.g. breast, l u n g , s t o m - l o w e r groups. M a n y o f t h e m lie deep to sternomas-

ach, c o l o n , o v a r y a n d testis. t o i d muscle w h i c h m a y n e e d to be displaced

posteriorly.

3. Anterior Cervical Nodes (d) Spinal accessory chain.

(e) Transverse cervical chain.
T h e y lie b e t w e e n the t w o carotids a n d b e l o w the level o f
(f) Anterior jugular chain.
h y o i d b o n e a n d consist o f t w o chains:
(g) Juxtavisceral chain. Prelaryngeal, pretracheal a n d para-
(a) A n t e r i o r j u g u l a r c h a i n It lies a l o n g a n t e r i o r j u g u l a r tracheal nodes.

v e i n a n d drains the skin o f anterior neck. W h e n a n o d e or nodes are palpable, l o o k for the

(b) Juxtavisceral chain I t consists o f prelaryngeal, p r e - f o l l o w i n g points:

tracheal, a n d paratracheal nodes. (i) L o c a t i o n o f nodes.

Prelaryngeal n o d e ( D e l p h i a n node) lies o n c r i c o t h y r o i d (ii) N u m b e r o f nodes.

m e m b r a n e a n d drains subglottic r e g i o n o f l a r y n x a n d p y r i - (iii) Size.

f o r m sinuses.

Pretracheal nodes lie i n front o f the trachea, deep to

pretracheal fascia, a n d drain t h y r o i d g l a n d a n d the trachea.

Efferents f r o m these nodes g o to paratracheal, l o w e r inter-

nal j u g u l a r a n d anterior mediastinal nodes.

Paratracheal nodes (recurrent nerve chain) lie a l o n g

recurrent laryngeal nerve and drain the t h y r o i d lobes, sub-

glottic larynx, trachea a n d cervical oesophagus.

Lymph Nodes Not Clinically Palpable

(a) R e t r o p h a r y n g e a l n o d e s T h e y He b e h i n d the p h a r y n x

and are d i v i d e d i n t o lateral a n d medial groups. Lateral g r o u p

lies at t h e l e v e l o f atlas, close to the base o f skull. M o s t supe-

rior n o d e o f the lateral g r o u p is c a U e d the node of Rouviere.

M e d i a l g r o u p lies n e a r the m i d l i n e b u t at a l o w e r level.

R e t r o p h a r y n g e a l nodes drain the nasal cavity, paranasal

sinuses, h a r d a n d soft palate, nasopharynx, posterior wall

o f the p h a r y n x and send efferents to the u p p e r internal

j u g u l a r g r o u p .

(b) S u b l i n g u a l nodes T h e y lie deep a l o n g the lingual

vessels a n d d r a i n anterior part o f the floor o f m o u t h a n d F i g u r e 74.16

ventral surface o f t o n g u e . L y m p h a t i c s from these nodes
Examination o f neck nodes.
e n d i n the s u b m a n d i b u l a r o r u p p e r j u g u l a r nodes.
 C l i n i c a l M e t h o d s in E N T

iv) Consistency. Metastatic n o d e s are hard; l y m p h o m a Level V: Posterior Cervical Group

n o d e s are f i r m and rubbery; hyperplastic nodes are
T h e y are l o c a t e d i n the posterior triangle, i.e. b e t w e e n pos-
soft. N o d e s o f metastatic m e l a n o m a are also soft.
terior b o r d e r o f sternocleidomastoid (anteriorly), anterior
v) Discrete or m a t t e d nodes.
b o r d e r o f trapezius (posteriorly), and the clavicle b e l o w .
vi) Tenderness. I n f l a m m a t o r y nodes are tender.
T h e y include l y m p h nodes o f spinal accessory chain, trans-
vii) Fixity to o v e r l y i n g skin or deeper structures.
verse cervical nodes and supraclavicular nodes. L e v e l V
M o b i l i t y s h o u l d be c h e c k e d b o t h i n the vertical
n o d e s are further subdivided i n t o upper, m i d d l e a n d l o w e r ,
a n d h o r i z o n t a l planes.
c o r r e s p o n d i n g to planes that define levels I I ,I I I a n d I V .

I
Level VI: Anterior Compartment Nodes
Classification of Neck Nodes According to
L e v e l s (see T a b l e 74.1 a n d F i g . 7 4 . 1 7 )
1 T h e y are located b e t w e e n the m e d i a l borders o f sterno-

c l e i d o m a s t o i d muscles (or carotid sheaths) o n each side,

Level I: Includes h y o i d b o n e a b o v e a n d suprasternal n o t c h b e l o w . T h e y

include prelaryngeal, pretracheal, paratracheal nodes.

I A S u b m e n t a l nodes, w h i c h lie i n the submental triangle,

i.e. b e t w e e n right and left anterior bellies o f digastric

Level VII
muscles a n d the h y o i d bone.

IB S u b m a n d i b u l a r nodes, l y i n g b e t w e e n anterior a n d T h e y are located b e l o w the suprasternal n o t c h and i n c l u d e

posterior bellies o f digastric muscle and the b o d y o f nodes o f the u p p e r m e d i a s t i n u m .

m a n d i b l e . L y m p h nodes o f supraclavicular z o n e or fossa ( H o ' s tri-

angle) (Fig. 74.18). Supraclavicular z o n e is s i t u a t e d b e t w e e n

Levels are s h o w n i n
(i) u p p e r b o r d e r o f medial e n d o f clavicle, (ii) u p p e r b o r d e r

o f lateral e n d o f clavicle and (iii) p o i n t w h e r e n e c k meets

Level If: Upper jugular Nodes
the shoulder. N o d e s i n this triangle are i m p o r t a n t i n carci-
T h e y are located a l o n g the u p p e r t h i r d o f j u g u l a r vein, i.e.
n o m a o f the nasopharynx. Metastases i n these nodes, irre-
b e t w e e n the skull base above, a n d the level o f h y o i d b o n e
spective o f their size, w o u l d place t h e m i n N , category
(or b i f u r c a t i o n o f carotid artery) b e l o w .
( A J C C , 1977). N o d e s i n this z o n e i n c l u d e l o w e r part o f

levels I V a n d V .
Level III: Middle jugular Nodes

T h e y are located along the m i d d l e t h i r d j u g u l a r v e i n , f r o m Other Groups

the level o f h y o i d b o n e above, to the level o f u p p e r b o r d e r

• R e t r o p h a r y n g e a l
o f cricoid cartilage (or w h e r e o m o h y o i d muscle crosses
• Facial
the j u g u l a r vein) b e l o w .
• Preauricular

Level IV: Lower Jugular Nodes

T h e y are located a l o n g the l o w e r t h i r d o f j u g u l a r v e i n ;

f r o m u p p e r b o r d e r o f cricoid cartilage to the clavicle.

T a b l e 74.1 I D i v i s i o n o f n e c k n o d e s a c c o r d i n g t o l e v e l s

Level I Submental (IA)

Submandibular (IB)

L e v e l II Upper jugular Hyoid bone

L e v e l III Mid jugular fa— Cricoid cart.

Level IV Lower jugular

Level V Posterior triangle g r o u p

(Spinal accessory and
transverse cervical chains)

Level VI Prelaryngeal
Pretracheal
F i g u r e 74.17
Paratracheal

Level V I I Nodes o f upper mediastinum C l a s s i f i c a t i o n o f n e c k n o d e s a c c o r d i n g t o levels.

Clinical Methods in E N T and Neck Masses

Radical Neck Dissection

I n this p r o c e d u r e , all l y m p h nodes, e x t e n d i n g f r o m the

m a n d i b l e above to the clavicle b e l o w a n d f r o m lateral b o r -

der o f sternomastoid, h y o i d b o n e a n d contralateral ante-

rior belly o f digastric, m e d i a l l y , to the anterior b o r d e r o f

trapezius p o s t e r i o r l y , are r e m o v e d . T h e dissection speci-

m e n w o u l d include:

(a) L y m p h nodes o f submental, s u b m a n d i b u l a r , upper,

m i d d l e a n d l o w e r jugular, a n d lateral (posterior) tri-

angle regions, i.e. l e v e l I t o V a l o n g w i t h its fibrofatty

tissue.

(b) S t e r n o m a s t o i d muscle.

(c) Internal j u g u l a r vein.

(d) Spinal accessory nerve.

(e) S u b m a n d i b u l a r salivary gland.

F i g u r e 74.18 (f) T a i l o f the parotid.

(g) O m o h y o i d muscle.
Supraclavicular fossa (or Ho's t r i a n g l e ) is b o u n d e d by medial

and lateral ends o f clavicle a n d the point where neck meets the It saves f o l l o w i n g structures:

shoulder. Nodes in this zone include nodes o f lower parts o f

(i) C a r o t i d artery.
levels I V a n d V.
(ii) B r a c h i a l plexus, p h r e n i c nerve, vagus nerve, cervical

sympathetic chain, m a r g i n a l m a n d i b u l a r b r a n c h o f

facial, lingual a n d hypoglossal nerves.

• Postauricular (mastoid)

• I n t r a p a r o t i d R a d i c a l n e c k dissection does n o t r e m o v e nodes o f pos-

• S u b o c c i p i t a l tauricular, suboccipital, p a r o t i d (except those i n the tail)

facial, retropharyngeal a n d paratracheal regions.

Incision used i n radical n e c k dissection (Fig. 74.19) w i l l

NECK DISSECTION d e p e n d o n the incision b e i n g used to r e m o v e the p r i m a r y

g r o w t h a n d w h e t h e r patient received any radiation.

It is a p r o c e d u r e to r e m o v e l y m p h nodes a n d the sur- C o m m o n l y , the incisions used are:

r o u n d i n g fibrofatty tissues f r o m the neck, to eradicate

(i) S c h o b i n g e r
metastases to cervical l y m p h nodes f r o m cancer o f the
(ii) M c Fee
aero digestive tract.
(iii) H o c k e y - s t i c k

(iv) Extensions f r o m G l u c k - S o r e n s o n ' s incision, used for

Classification o f Neck Dissection l a r y n g e c t o m y w i t h n e c k dissection (Fig. 74.20).

Contraindications t o radical n e c k dissection i n c l u d e :

(i) R a d i c a l n e c k dissection.
(i) U n t r e a t a b l e p r i m a r y cancer.

(ii) M o d i f i e d radical n e c k dissection.

(ii) Distant metastases.

T y p e I—Preserves C N X I
(iii) I n o p e r a b l e n e c k nodes w h e n t h e y are f i x e d to i m p o r -

T y p e II—Preserves C N X I a n d internal j u g u l a r v e i n tant structures.

T y p e I I I — P r e s e r v e s C N X I , I.J.V. a n d sternocleido- (iv) M e d i c a l illness w h i c h makes the patient unfit for major

m a s t o i d muscle. surgery.

(iii) Selective n e c k dissection

(a) S u p r a o m o h y o i d (or anterolateral) (removes level Modified Neck Dissection

I to I I I )
I t is s i m i l a r t o r a d i c a l n e c k dissection b u t w i t h preservation
(b) Lateral ( r e m o v e s n o d e s i n level I I to I V )
o f o n e or m o r e o f the f o l l o w i n g structures:
(c) Posterolateral ( r e m o v e s level I I to V suboccipital

a n d postauricular nodes) (i) Spinal accessory n e r v e

(d) A n t e r i o r c o m p a r t m e n t (removes level V I nodes) (ii) Internal j u g u l a r v e i n

(iv) E x t e n d e d n e c k dissection. (iii) S t e r n o c l e i d o m a s t o i d muscle.

 C l i n i c a l M e t h o d s in E N T

Supraomohyoid R e m o v e s levels I to I I I (anterolateral),

usually d o n e i n cancer o f oral cavity.

Lateral R e m o v e s levels I I to I V .

U s e d i n cancer o f p h a r y n x , h y p o p h a r y n x a n d larynx.

Posterolateral R e m o v e s levels I I to V w i t h postauricular

a n d occipital nodes.

U s e d i n cancer or m e l a n o m a o f skin, located i n poste-

rior scalp o r posterior u p p e r n e c k b e h i n d the line passing

t h r o u g h the tragus.

Anterior compartment R e m o v e s n o d e s at l e v e l V I , i.e.

pretracheal, paratracheal, prelaryngeal.

U s e d i n differentiated t h y r o i d cancer, subglottic, c e r v i -

cal tracheal o r h y p o p h a r y n g e a l cancers.

Figure 74.20
Extended Neck Dissection
G l u c k - S o r e n s o n ' s incision used f o r l a r y n g e c t o m y . D o t t e d lines
It consists o f r e m o v a l o f structures as i n radical n e c k dis-
s h o w i n g extensions o f incisions f o r radical neck dissection.
section a n d further e x t e n d e d to i n c l u d e additional l y m p h

n o d e groups o r n o n - l y m p h a t i c structures or b o t h .
Selective Neck Dissection
A d d i t i o n a l l y m p h n o d e groups i n c l u d e retropharyngeal,

It consists o f preservation o f one o r m o r e l y m p h n o d e groups p a r o t i d o r level V I nodes, a n d n o n - l y m p h a t i c structures

a n d all the three n o n - l y m p h a t i c structures, i.e. spinal acces- m a y i n c l u d e external carotid artery, hypoglossal nerve,

sory, sternocleidomastoid muscle a n d internal j u g u l a r vein. p a r o t i d gland, m a s t o i d tip, etc.

Neck Masses

Clinically n e c k masses can be d i v i d e d into: (A) those i n t h y r o i d gland. T h y r o g l o s s a l cyst can o c c u r a n y w h e r e i n

the m i d l i n e (Fig. 75.1), and (B) those i n the lateral aspect the course o f t h y r o i d duct (Fig. 75.4). It m a y c o n t a i n the

o f n e c k (Fig. 75.2). T h e latter can be g r o u p e d a c c o r d i n g o n l y f u n c t i o n i n g t h y r o i d tissue i n the b o d y . R a r e l y carci-

to triangles o f neck. O n l y the clinically i m p o r t a n t ones are n o m a develops i n the cyst.

described i n this chapter.

Treatment is c o m p l e t e surgical excision, i n c l u d i n g w i t h

it the b o d y o f h y o i d b o n e and core o f t o n g u e tissue a r o u n d

[ Thyroglossal D u c t C y s t ^ the tract i n the s u p r a h y o i d t o n g u e base to the f o r a m e n

c a e c u m (Sistrunk's operation). S i m p l e excision o f cyst

w i t h o u t r e m o v a l o f its t r a c t l e a d s t o recurrence.
It presents as a cystic m i d l i n e swelling, usually affecting

y o u n g c h i l d r e n b u t can o c c u r at any age (Fig. 75.3). I t is

usually r o u n d e d w i t h a diameter o f 2—4 c m . I t increases i n

size w i t h u p p e r respiratory tract infection. S o m e t i m e i t

| Sublingual D e r m o i d C y s t J
presents as a d r a i n i n g sinus i f i t has burst due to i n f e c t i o n

o r has b e e n surgically drained. Because o f the attachment It presents as a m i d l i n e submental s w e l l i n g b u t does n o t

o f thyroglossal d u c t to f o r a m e n c a e c u m at the base o f m o v e o n p r o t r u s i o n o f the t o n g u e as i t is n o t attached to

tongue, i t m o v e s w i t h t o n g u e p r o t r u s i o n . f o r a m e n c a e c u m . S o m e t i m e s it arises f r o m the floor o f

D u r i n g d e v e l o p m e n t , t h y r o i d anlage starts at f o r a m e n m o u t h a n d needs differentiation f r o m ranula. T r e a t m e n t is

c a e c u m , passes t h r o u g h base o f t o n g u e a n d t h e n descends surgical excision. A m i d l i n e d e r m o i d is a l s o s e e n j u s t a b o v e

in front, b e h i n d or t h r o u g h the h y o i d b o n e to f o r m the the suprasternal n o t c h .

1. Submental lymph node "1 Submental

2 . Dermoid f triangle
3 . Luawig s angina J
4. Thyroglossal duct cyst

5 . Aberrant thyroid

6. Delphian node enlargement

7. Thyroid isthmus tumour
8. Advanced laryngeal malignancy
9. Suprasternal dermoid or
lymph node enlargement

F i g u r e 75.1

M i d l i n e swellings o f neck.
 Occipital triangle
• Lymph nodes:
• Inflammatory
• Neoplastic
• Metastatic
Anterior triangle
ncluding its three subdivisions; digastric,
carotid and muscular triangles)
Supraclavicular triangle • Submandibular sialadenitis or tumour
• Metastatic nodes from • Submandibular lymph nodes:
infraclavicular primaries: ' Inflammatory
• Breast • Neoplastic
• Lung ' Metastatic
• Gl tract • Plunging ranula
• Kidney • Jugular lymph nodes
• Ovary, testis • Branchial cyst
• Cystic hygroma • Swelling thyroid lobe
• Subclavian aneurysm • Carotid body tumour
• Cervical rib • Parotid (tail) swelling
• Parapharyngeal tumour
• Laryngocele
• Pharyngeal pouch

Figure 75.2
L a t e r a l s w e l l i n g s o f n e c k as seen in d i f f e r e n t t r i a n g l e s o f neck.

Fora men cecum

Thyroglossa
cysts
Hyoid bone

Figure 75.3
Figure 75.4
Thyroglossal cyst.
Sites o f t h y r o g l o s s a l d u c t cysts. 1. Base o f t o n g u e , 2. Suprahyoid,

3. Subhyoid (most c o m m o n ) , 4. O n the thyroid cartilage and

5. In front o f cricoid.

Submental Nodes
Prelaryngeal and Pretracheal Nodes
T h e r e are 2 - 8 nodes situated i n the s u b m e n t a l triangle

b e t w e e n the platysma a n d m y l o h y o i d muscle. T h e y drain T h e y b e l o n g to juxtavisceral chain o f nodes a n d lie i n

chin, m i d d l e part o f l o w e r lip, incisor r e g i o n o f gingiva, front o f the l a r y n x and trachea. T h e y drain the l a r y n x and

anterior floor o f m o u t h and the tip o f tongue. trachea, t h y r o i d isthmus and anteromedial aspect o f t h y -

W h e n enlarged, the d r a i n i n g areas s h o u l d be l o o k e d for r o i d lobes. I n case o f e n l a r g e m e n t o f the a b o v e nodes,

infections o r malignancy. d r a i n i n g areas s h o u l d be e x a m i n e d .

Clinical Methods in E N T and Neck Masses

Thymic Cyst

T h y m u s develops f r o m the t h i r d pharyngeal p o u c h a n d

t h e n descends t h r o u g h the neck to the m e d i a s t i n u m .

T h y m i c r e m n a n t s m a y persist a n y w h e r e i n its p a t h f r o m

angle o f the m a n d i b l e to the m i d l i n e o f neck. S w e l l i n g is

either cystic or solid. It can o c c u r i n c h i l d r e n o r adults a n d

presents as a n e c k mass anterior and d e e p to m i d d l e t h i r d

o f sternocleidomastoid muscle. I t is a v e r y rare c o n d i t i o n .

T r e a t m e n t is s u r g i c a l e x c i s i o n . S t e r n o t o m y is r e q u i r e d i f i t

also extends i n t o the m e d i a s t i n u m .

Figure 75.5

Branchial Cyst Left sided branchial sinus discharging pus.

I t is c o m m o n i n the second decade o f life b u t can o c c u r at

T h i r d branchial cleft sinus is u n c o m m o n . Its external
any age w i t h equal frequency i n b o t h sexes. C y s t presents
o p e n i n g is at t h e same place as s e c o n d cleft sinus b u t inter-
as a s w e l l i n g i n the u p p e r part o f the n e c k anterior to
nal o p e n i n g is situated i n p y r i f o r m sinus. T r a c t passes
sternocleidomastoid muscle. Mass is s m o o t h , r o u n d , fluc-
behind both internal and external carotid vessels b u t is superfi-
tuant, n o n - t e n d e r a n d n o n - t r a n s i l l u m i n a n t . A painful
cial to vagus a n d hypoglossal nerves.
increase i n size at the t i m e o f u p p e r respiratory i n f e c t i o n

can occur. A n o m a l i e s o f the second branchial arch are the

m o s t c o m m o n . A branchial cyst m a y be associated w i t h a J ~ ~~ Plunging Ranula

sinus o r a fistula. A second arch branchial sinus has a n

external o p e n i n g at the j u n c t i o n o f l o w e r a n d m i d d l e o f
It is a pseudocyst caused b y extravasation o f m u c u s f r o m

the anterior b o r d e r o f sternomastoid a n d m a y e x u d e

obstruction to sublingual salivary gland. I t presents as a n

m u c o i d discharge. I t m a y h a v e an internal o p e n i n g i n the

isolated s w e l l i n g i n the s u b m a n d i b u l a r area a n d is trans-

tonsillar fossa. W h e n b o t h internal a n d external openings

illuminant. S o m e t i m e s p l u n g i n g ranula coexists w i t h a

are present, i t is c a l l e d a b r a n c h i a l fistula.

ranula i n the floor o f m o u t h . T r e a t m e n t is t o t a l excision

Treatment o f branchial cyst is surgical excision a l o n g a l o n g w i t h r e m o v a l o f sublingual gland.

w i t h its t r a c t , i f present.

Carotid Body Tumour

| Branchial Sinus or Fistula ( F i g . 7 5 . 5 ) £

I t arises f r o m the c h e m o r e c e p t o r cells i n t h e carotid b o d y ,

h e n c e also called c h e m o d e c t o m a . M o s d y presents after

A second arch fistula has a typical course, the k n o w l e d g e
40 years. I t is a v e r y s l o w - g r o w i n g t u m o u r a n d the history
o f w h i c h can help i n the total surgical e x t i r p a t i o n o f the
o f mass i n the n e c k m a y e x t e n d i n t o several years. I t pres-
tract. I t has:
ents as a painless s w e l l i n g w h i c h is p u l s a t i l e . B r u i t can be

(a) A n external o p e n i n g a l o n g the anterior b o r d e r o f

heard w i t h a stethoscope. I t m o v e s f r o m side to side b u t

sternocleidomastoid muscle.
n o t vertically. I t m a y e x t e n d i n t o the parapharyngeal space

( b ) A tract w h i c h ascends just deep to deep cervical fascia

a n d present i n the o r o p h a r y n x (Fig. 75.6).

a l o n g the carotid artery.

C o n t r a s t - e n h a n c e d C T a n d M R I w i t h g a d o l i n i u m are

(c) T h e tract passes deep to second arch structures, i.e.

diagnostic a n d also s h o w the extent o f the t u m o u r . M R I

external carotid artery, s t y l o h y o i d a n d posterior belly

a n g i o g r a p h y s h o w s splaying o f internal a n d external carotid

o f digastric b u t superficial to t h i r d arch structure, i.e.

arteries (Lyre's sign). S o m e t u m o u r s are f u n c t i o n a l a n d

internal carotid artery (the tract passes between internal secrete catecholamines. H e n c e s e r u m catecholamines and

a n d external carotid arteries). I t also runs superficial

urinary metanephrines a n d v a n i l l y l m a n d e l i c acid ( V M A )

to hypoglossal nerve.
s h o u l d be estimated. Fine-needle aspiration c y t o l o g y

( d ) Pierces the pharyngeal wall a n d ends i n the tonsillar

( F N A C ) o r biopsy s h o u l d n o t be d o n e because o f the

fossa.
vascularity o f t u m o u r .

C o m p l e t e excision o f the tract can be a c c o m p l i s h e d b y Treatment is s u r g i c a l w h e n the patient is y o u n g e r than

step-ladder incisions. 50 years a n d surgically fit, o r w h e n the t u m o u r extends

 Figure 75.6

( A ) A 2 3 - y e a r - o l d female p a t i e n t w i t h c a r o t i d b o d y t u m o u r w h e r e surgery w a s earlier a t t e m p t e d . ( B ) M R I neck s h o w i n g t h e t u m o u r .

( C ) M R I a n g i o g r a p h y . N o t e s p l a y i n g o f t h e e x t e r n a l c a r o t i d a r t e r y ( E C A ) a n d i n t e r n a l c a r o t i d a r t e r y ( I C A ) . T h i s is a l s o c a l l e d L y r e ' s
sign. ( D ) T u m o u r after removal.

into the o r o p h a r y n x causing difficulty i n speech, s w a l l o w i n g

Cystic Hygroma
o r breathing.

R a d i o t h e r a p y is a l s o e f f e c t i v e a n d is u s e d i n o l d e r patients
A l s o called lymphangioma or cavernous lymphangioma, it
a n d those unfit for surgery o r those w h o refuse surgery o r
occurs m o s t c o m m o n l y i n the posterior triangle o f the
h a v e a metastatic disease.
neck. I t arises f r o m o b s t r u c t i o n o r sequestration o f j u g u l a r

l y m p h sac.

It m a y be seen i n the neonate, early infancy or c h i l d h o o d .

N i n e t y p e r c e n t are seen b e f o r e 2 years o f age. W h e n present

J Parapharyngeal Tumours
at b i r t h , t h e y cause difficulty i n labour.

T h e s e t u m o u r s present i n the u p p e r n e c k near the angle o f M o s t c o m m o n l y cystic h y g r o m a is seen i n the supra-

m a n d i b l e o r r e t r o m a n d i b u l a r area. clavicular r e g i o n and m a y e x t e n d to i n v o l v e the w h o l e o f

T h e y m a y also be seen intraorally displacing the tonsil, posterior triangle or e x t e n d i n t o the axilla a n d mediastinum.

lateral pharyngeal wall and soft palate medially. T h o u g h O t h e r c o m m o n sites are axilla a n d g r o i n . It m a y o c c u r i n

m a j o r i t y o f these t u m o u r s are o f salivary g l a n d o r i g i n the t o n g u e and floor o f m o u t h .

( p l e o m o r p h i c a d e n o m a s b e i n g the m o s t c o m m o n ) others Cystic h y g r o m a is soft, cystic, m u l t i l o c u l a r , partially

like s c h w a n n o m a , n e u r o f i b r o m a , l i p o m a , h a e m a n g i o m a , compressible and brilliantly transilluminant. It m a y i n v o l v e

paraganglioma o r l y m p h n o d e metastasis i n parapharyngeal several tissue planes a n d neural a n d vascular structures. It

n o d e s are also seen. D i a g n o s i s can be established b y i m a g i n g m a y e x t e n d to i n v o l v e laryngeal o r pharyngeal structures

techniques and F N A C . to cause stridor, respiratory difficulty o r feeding problems.

Clinical Methods in E N T and Neck Masses

W h e n i n f l a m e d due to infection, it b e c o m e s painful a n d before t h e y finally subside. Surgical excision o f l y m p h

increases i n size. S p o n t a n e o u s regression is unpredictable. n o d e mass o r abscess is occasionally r e q u i r e d w h e n d r u g

treatment fails.
Treatment is s u r g i c a l e x c i s i o n w i t h preservation o f n e u -

ral a n d vascular structures. C o m p l e t e excision m a y n o t be

possible i n a single operation. B i p o l a r d i a t h e r m y is useful.

Metastatic Lymph Nodes
R u p t u r e o f cyst m a k e s dissection difficult. R e c u r r e n c e

rate after surgical excision is o n l y 5 % i f w h o l e t u m o u r is

A n y l y m p h n o d e g r o u p can be i n v o l v e d d e p e n d i n g o n the
r e m o v e d macroscopicalfy b u t i t is 5 0 % i f s o m e part is left.
site o f p r i m a r y m a l i g n a n c y . U p p e r cervical l y m p h nodes
Cystic h y g r o m a causing respiratory distress m a y b e aspi-
are c o m m o n l y i n v o l v e d i n malignancies o f u p p e r a e r o d i -
rated o r m a y require t r a c h e o s t o m y to relieve respiratory
gestive tract. N a s o p h a r y n g e a l malignancies spread to
obstruction.
accessory c h a i n o f nodes i n the posterior triangle. I n m a n y
Injection o f s c l e r o s i n g a g e n t s i s n o t f a v o u r e d as i t m a k e s
cases p r i m a r y m a l i g n a n t lesion is n o t discernible (occult
later dissection m o r e difficult.
p r i m a r y ) , a n d i n such cases the m o s t c o m m o n sites are

tonsil, base o f t o n g u e , n a s o p h a r y n x a n d p y r i f o r m sinus.

N o d e / n o d e s i n supraclavicular area s h o u l d alert the sur-

Tubercular Lymph Nodes
g e o n to the possibility o f an infraclavicular p r i m a r y i n the

l u n g , breast, stomach, c o l o n , k i d n e y , o v a r y a n d testis.

Mass due to tubercular l y m p h nodes i n the n e c k is v e r y

c o m m o n i n o u r c o u n t r y . A n y l y m p h n o d e g r o u p can b e

i n v o l v e d . I t can o c c u r i n any age o r sex. I n v o l v e d l y m p h

n o d e m a y be single, m u l t i p l e or m a t t e d due to p e r i a d e n i -

tis. T u b e r c u l a r abscess m a y f o r m w h e n n o d e / n o d e s case-

ate. I t m a y b e c o m e adherent to the skin a n d u n d e r l y i n g

structures o r a d r a i n i n g tubercular sinus m a y d e v e l o p

(Figs 75.7 a n d 75.8).

Diagnosis is usually m a d e b y F N A C o r l y m p h n o d e

b i o p s y w h i c h reveals a g r a n u l o m a t o u s lesion. S o m e t i m e s

acid fast b a c i l l i ( A F B ) can be demonstrated. A F B f r o m the

aspirated o r b i o p s y material can be c u l t u r e d a n d sensitivity

established, to b e prepared for m u l t i d r u g resistant lesions.

X - r a y chest, skin test a n d w o r k - u p for o t h e r n o d a l

g r o u p i n v o l v e m e n t s h o u l d be d o n e . T u b e r c u l o s i s is also

b e c o m i n g m o r e c o m m o n due to A I D S .

Treatment consists o f initial 2 m o n t h s course o f f o u r

drugs (rifampicin, isoniazid, p y r a z i n a m i d e a n d e t h a m b u -

Figure 75.7
tol) f o l l o w e d b y 4 m o n t h s course o f rifampicin a n d isoni-
M u l t i p l e t u b e r c u l a r n o d e s in t h e neck.
azid. N o d e s m a y initially increase i n size d u r i n g t r e a t m e n t

Figure 75.8

( A ) C a s e a t i n g t u b e r c u l a r s u p r a s t e r n a l n o d e f o r m i n g abscess. ( B ) T u b e r c u l a r n o d e s in s u p r a c l a v i c u l a r a r e a ( s a m e p a t i e n t ) .
 h a n d d u e to c o m p r e s s i o n o f the l o w e r part o f brachial
Lymphomas
plexus. W h e n subclavian artery is compressed, h a n d

b e c o m e s c o l d a n d n u m b w i t h i n t e r m i t t e n t claudication o f
B o t h H o d g k i n ' s a n d n o n - H o d g k i n ' s l y m p h o m a s m a y
u p p e r l i m b . D u e to arterial c o m p r e s s i o n an a n e u r y s m m a y
present w i t h cervical l y m p h a d e n o p a t h y . O t h e r l y m p h a t i c
d e v e l o p w i t h m u r a l t h r o m b u s w h i c h m a y shoot e m b o l i to
structures o f the W a l d e y e r r i n g m a y also be i n v o l v e d a n d
the distal arterial system o f the u p p e r l i m b . C e r v i c a l rib, i f
cause s y m p t o m s o f dysphagia, serous otitis m e d i a o r respi-
a s y m p t o m a t i c , does n o t require treatment b u t s y m p -
ratory o b s t r u c t i o n . I n such cases o t h e r l y m p h nodes i n the
t o m a t i c o n e s are excised b y supraclavicular o r transaxillary
axilla, g r o i n a n d a b d o m e n s h o u l d be e x a m i n e d i n a d d i t i o n
approach.
to spleen a n d liver enlargement.

Cervical Rib
• • Sternomastoid T u m o u r

M o s d y seen i n the n e w b o r n s due t o b i r t h t r a u m a . Fibrosis

Occasionally an extra rib m a y arise f r o m the 7 t h cervical
a n d later s h o r t e n i n g o f the s t e r n o c l e i d o m a s t o i d muscle
vertebra a n d e n d anteriorly b y attaching to the first rib.
causes torticollis. Face is t u r n e d to opposite side b u t the
T h i s rib m a y p r o d u c e a b o n y h a r d l u m p i n the supra-
head is tilted o n the ipsilateral shoulder. A mass can be
clavicular r e g i o n . M o s t often it is seen o n the right b u t
palpated i n the sternocleidomastoid muscle o n physical
m a y be present o n the left or is b i l a t e r a l .
e x a m i n a t i o n . I n l o n g - s t a n d i n g cases, a s y m m e t r y o f face
Subclavian artery a n d brachial plexus w h i c h n o r m a l l y pass
a n d h e a d can d e v e l o p as a sequel.
b e t w e e n a n t e r i o r a n d m i d d l e scalene m u s c l e s o v e r t h e first rib

have n o w to pass o v e r the cervical rib (a vertebral space Treatment is p a s s i v e exercises o f the n e c k i n early stages.

higher) a n d are thus compressed. It produces n e u r o l o g i c a l S u r g e r y is d o n e w h e n the c o n d i t i o n is p e r s i s t e n t a n d likely

o r vascular s y m p t o m s . Patient m a y c o m p l a i n o f tingling to causes facial hemihypoplasia. I t consists o f division o f

sensation o r n u m b n e s s a l o n g the u p p e r side o f f o r e a r m a n d sternomastoid muscle.

Operative Surgery

76. Myringotomy 407

77. Mastoid Surgery
78. Radical Mastoidectomy
79. Modified Radical Mastoidectomy
80. Myringoplasty
81. Proof Puncture (Syn. Antral Irrigation)
82. Intranasal Inferior Meatal Antrostomy
83. Caldwell-Luc Operation
84. Submucous Resection o f Nasal Septum (SMR Operation)
85. Septoplasty 425
86. Diagnostic Nasal Endoscopy
87. Endoscopic Sinus Surgery 429
88. Direct Laryngoscopy
89. Bronchoscopy 434
90. Oesophagoscopy
9 1 . Tonsillectomy
92. Adenoidectomy
 HPT.

Myringotomy

I t is i n c i s i o n o f t h e t y m p a n i c m e m b r a n e w i t h the p u r p o s e
Steps of Operation
to drain suppurative o r n o n s u p p u r a t i v e effusion o f the

m i d d l e ear o r to p r o v i d e aeration i n case o f m a l f u n c t i o n -

Ear canal is c l e a n e d o f w a x a n d debris.
ing eustachian tube. V e n t i l a t i o n t u b e ( g r o m m e t ) m a y also
O p e r a t i o n is ideally p e r f o r m e d u n d e r operating
be r e q u i r e d i n the latter case.
m i c r o s c o p e using a sharp m y r i n g o t o m e a n d a g o o d

suction apparatus.

I n acute suppurative otitis media, a circumferential

Indications incision is m a d e i n the posteroinferior quadrant o f

t y m p a n i c m e m b r a n e , m i d w a y b e t w e e n handle o f

1. Acute suppurative otitis media malleus a n d t y m p a n i c annulus, a v o i d i n g i n j u r y to

(a) Severe earache w i t h b u l g i n g t y m p a n i c m e m b r a n e .

i n c u d o s t a p e d i a l j o i n t (Fig. 7 6 . I A ) .

(b) I n c o m p l e t e resolution w i t h o p a q u e d r u m a n d

persistent c o n d u c t i v e deafness.

(c) C o m p l i c a t i o n s o f acute otitis m e d i a , e.g. facial

paralysis, labyrinthitis o r m e n i n g i t i s w i t h b u l g i n g

t y m p a n i c m e m b r a n e .

2. Serous otitis media.

3. Aero-otitis media (to drain fluid a n d " u n l o c k " the

eustachian tube).

4. Atelectatic ear ( g r o m m e t is o f t e n inserted for l o n g - t e r m

aeration).

Contraindications F i g u r e 76.1

(A) Circumferential incision used in a c u t e s u p p u r a t i v e o t i t i s

Suspected intra t y m p a n i c g l o m u s t u m o u r . M y r i n g o t o m y m e d i a . (B) R a d i a l i n c i s i o n used in serous o t i t i s m e d i a .

in these cases can cause profuse bleeding. T y m p a n o t o m y

is preferred.

^ Anaesthesia J

I n infants a n d children, always use general anaesthesia. F o r

adults, general anaesthesia is used o n l y w h e n t y m p a n i c

Figure 76.2
m e m b r a n e is a c u t e l y i n f l a m e d . I f t h e r e is n o i n f l a m m a t i o n ,

m y r i n g o t o m y can be d o n e u n d e r local anaesthesia or n o G r o m m e t in t y m p a n i c m e m b r a n e .

anaesthesia at all.
Operative Surgery

4. I n serous otitis media, a small radial i n c i s i o n is g i v e n

Post-operative Care
i n the posteroinferior o r anteroinferior quadrant a n d

all t h e effusion sucked o u t (Fig. 7 6 . I B ) .

D a i l y m o p p i n g o f ear discharge w i l l be r e q u i r e d i n cases o f

W h e n v e n t i l a t i o n tube is t o be inserted, incision s h o u l d acute suppurative otitis media. I n serous otitis m e d i a , just

be just e n o u g h to a d m i t the t u b e (Fig. 76.2). leave a w a d o f c o t t o n w o o l for 24—48 hours.

D r u m incisions usually heal rapidly. N o w a t e r s h o u l d

be p e r m i t t e d to enter the ear canal for at least o n e w e e k ,

a n d i f a g r o m m e t has b e e n inserted, entry o f w a t e r is p r e -

Pitfalls o f M y r i n g o t o m y
v e n t e d so l o n g as g r o m m e t is i n position.

1. W h e n t y m p a n i c m e m b r a n e is thick, incision m a y

r e m a i n o n l y i n the superficial layers o f d r u m h e a d Complications

w i t h o u t c u t t i n g t h r o u g h its e n t i r e thickness.

2. I n c i s i o n i n the posterior meatal wall. T h i s m a y Injury to incudostapedial j o i n t or stapes.

h a p p e n w h e n distinction b e t w e e n d r u m - h e a d a n d 2. I n j u r y to j u g u l a r b u l b w i t h profuse bleeding, i fj u g u l a r

posterior meatal w a l l is lost, w h e n b o t h are b u l b is h i g h a n d floor o f the m i d d l e ear dehiscent.

inflamed. 3. M i d d l e ear infection.

M a s t o i d Surgery

canal b y r e m o v a l o f the posterior meatal and lateral attic

TERMINOLOGY FOR OPERATIONS
walls. T y m p a n i c m e m b r a n e remnant, f u n c t i o n i n g ossicles
PERFORMED FOR CHRONIC EAR
and the reversible mucosa and f u n c t i o n o f the eustachian
INFECTIONS
tube are preserved. T h e s e structures are necessary to r e c o n -

struct hearing m e c h a n i s m at the t i m e o f surgery or i n a

Myringoplasty 2 n d stage operation.

It is an o p e r a t i o n i n w h i c h reconstructive p r o c e d u r e is

l i m i t e d to repair o f t y m p a n i c m e m b r a n e perforation.
Radical Mastoidectomy

I t is a n operation t o eradicate disease o f the m i d d l e ear and

T y m p a n o p l a s t y W i t h o u t Mastoidectomy m a s t o i d i n w h i c h m a s t o i d , m i d d l e ear, attic a n d the a n t r u m

(tympanum = middle e a r ) are exteriorised i n t o the external ear b y r e m o v a l o f poste-

rior meatal wall. A l l r e m n a n t s o f t y m p a n i c m e m b r a n e ,

I t is a n o p e r a t i o n to eradicate disease i n t h e m i d d l e ear a n d

malleus, incus (not the stapes) c h o r d a t y m p a n i a n d the

to reconstruct the h e a r i n g m e c h a n i s m w i t h o u t m a s t o i d
mucoperiosteal l i n i n g are r e m o v e d , a n d the o p e n i n g o f

surgery, w i t h o r w i t h o u t t y m p a n i c m e m b r a n e grafting.
eustachian tube closed b y p a c k i n g a piece o f muscle or

T h i s m e a n s ossicular reconstruction o n l y o r ossicular

cartilage i n t o the eustachian tube.

r e c o n s t r u c t i o n w i t h m y r i n g o p l a s t y .

M e a t o plasty
g T y m p a n o p l a s t y W i t h Mastoidectomy

M e a t o p l a s t y is a n o p e r a t i o n i n w h i c h a crescent o f c o n c h a l
It is an operation to eradicate disease in b o t h the mastoid
cartilage is excised to w i d e n the meatus. It is invariably
and m i d d l e ear cavity, a n d to reconstruct the hearing m e c h -
c o m b i n e d w i t h all canal w a l l d o w n procedures, i.e. m o d i -
anism w i t h o r w i t h o u t t y m p a n i c m e m b r a n e grafting.
fied radical a n d radical mastoidectomies for easy access to

m a s t o i d cavity for periodic inspection and cleaning. It is

Cortical Mastoidectomy (Simple also d o n e as a n isolated p r o c e d u r e i n a sagging auricle seen

Mastoidectomy o r Schwartz O p e r a t i o n ) 1 in older people.

causes h e a r i n g
Sagging

loss a n d
auricle

r e t e n t i o n
obstructs

o f w a x .
the ear canal and

It is an exenteration o f all accessible m a s t o i d air cells p r e -

serving the posterior meatal wall.

M a s t o i d Obliteration

Modified Radical Mastoidectomy I t is a n o p e r a t i o n to eradicate m a s t o i d disease, w h e n pres-

ent, a n d to obliterate the m a s t o i d cavity. O b l i t e r a t i o n o f

I t is a n o p e r a t i o n t o eradicate disease o f t h e attic a n d mastoid, m a s t o i d c a v i t y is d o n e w i t h pedicled temporalis muscle or

b o t h o f w h i c h are exteriorised into the external auditory musculofascial tissue raised as flaps.
 Operative Surgery

L e m p e r t II—Starts f r o m t h e 1st i n c i s i o n at 1 2 o ' c l o c k

SURGICAL APPROACHES T O THE
a n d t h e n passes u p w a r d s i n a curvilinear fashion b e t w e e n
EAR AND INCISIONS tragus a n d t h e crus o fhelix. I t passes t h r o u g h t h e incisura

terminalis a n d thus does n o t c u t t h e cartilage. B o t h mas-

t o i d a n d external canal surgery c a n b e d o n e .

1. Endomeatal or transcanal approach I t is u s e d t o

raise a t y m p a n o m e a t a l flap i n o r d e r t o expose t h e m i d d l e

ear. Rosen's incision is t h e m o s t c o m m o n l y used f o r stape-

d e c t o m y . I t requires t h e meatus a n d canal t o b e w i d e

A
e n o u g h t o w o r k . I t consists o ft w o p a r t s ; (a) a s m a l l vertical

incision at 1 2 o ' c l o c k p o s i t i o n near t h e annulus a n d (b) a

curvilinear incision starting at 6 o ' c l o c k p o s i t i o n t o m e e t

the 1sti n c i s i o n i n t h e p o s t e r o s u p e r i o r r e g i o n o ft h e canals,

5 - 7 m m a w a y f r o m t h e annulus ( F i g .7 7 . 1 ) Posterior

meatal canal s k i n is raised i n c o n t i n u i t y w i t h t y m p a n i c

Lempert's endaural incision
m e m b r a n e , after dislocating t h e annulus f r o m t h e sulcus. I t

gives a g o o d v i e w o fthe m i d d l e e a r a n d ossicles. Stapes, i f

B
still c o v e r e d b y posterosuperior o v e r h a n g o fb o n y meatus,

can b e e x p o s e d b y r e m o v i n g this part o f t h e o v e r h a n g .

Lempert II

T h i s incision is also used c o m m o n l y f o re x p l o r a t o r y t y m -

p a n o t o m y t o f i n d cause f o rc o n d u c t i v e h e a r i n g loss, inlay

m y r i n g o p l a s t y o r ossicular reconstruction.

2. E n d a u r a l approach I tis u s e d f o r :

(a) E x c i s i o n o fo s t e o m a s o r exostosis o fe a r canal.

Lempert I
( b ) L a r g e t y m p a n i c m e m b r a n e perforations.

(c) A t t i c cholesteatomas w i t h l i m i t e d extension into t h e

Figure 77.2
a n t r u m .

( d ) M o d i f i e d radical m a s t o i d e c t o m y w h e r e disease is l i m - Endaural (Lempert's) incision. ( A ) Incision in the canal a n d

ited t o attic, a n t r u m , a n dpart o f mastoid. incisura terminalis. ( B )Magnified view o f A. N o t e position o f

L e m p e r t I a n d L e m p e r t II i n c i s i o n s .
E n d a u r a l a p p r o a c h is m a d e t h r o u g h L e m p e r t ' s incision

(Fig. 7 7 . 2 ) . I t consists o f2 parts:

L e m p e r t I — I t is semicircular incision, m a d e f r o m

12 o ' c l o c k t o 6 o ' c l o c k p o s i t i o n i n t h e posterior meatal

w a l l at t h e b o n y - c a r t i l a g i n o u s j u n c t i o n .

Figure 77.3
F i g u r e 77.1
Types o f postaural incisions ( A ) Sulcus incision. ( B ) Postaural
Rosen's incision. incision in adults. ( C ) Postaural incision in infants.

I
 Mastoid Surgery

3. P o s t a u r a l ( o r W i l d e ' s ) i n c i s i o n ( F i g . 7 7 . 3 ) . I t starts a t Tegmen tympani Horizontal

Short process
the highest attachment o f the pinna, follows the curve o f semicircular conal
of incus
retro auricular g r o o v e , l y i n g 1 c m b e h i n d it, a n d ends at

the m a s t o i d tip. I n infants a n d c h i l d r e n u p to 2 years o f

age, the m a s t o i d process is n o t d e v e l o p e d and the facial

nerve lies exposed near its e x i t , a n d the i n c i s i o n therefore

is s l a n t i n g p o s t e r i o r l y , a v o i d i n g l o w e r p a r t o f the mastoid.
Sinus plate
S o m e surgeons prefer to m a k e the postaural incision i n the

sulcus (retroauricular groove). Postaural i n c i s i o n is u s e d for:

Facial nerve
(i) C o r t i c a l m a s t o i d e c t o m y .

(ii) M o d i f i e d radical a n d radical m a s t o i d e c t o m y .

(iii) T y m p a n o p l a s t y : w h e n perforation extends anterior

to handle o f malleus. F i g u r e 77.4

(iv) E x p o s u r e o f C N V I I i n vertical segment.

C o r t i c a l m a s t o i d e c t o m y . P o s t e r i o r m e a t a l w a l l is l e f t i n t a c t .
(v) Surgery o f e n d o l y m p h a t i c sac.

4. A s an initial step to p e r f o r m :

(a) e n d o l y m p h a t i c sac surgery

CORTICAL MASTOIDECTOMY (b) decompression o f facial nerve

(c) translabyrinthine o r r e t r o - l a b y r i n t h i n e procedures

for acoustic n e u r o m a .
C o r t i c a l m a s t o i d e c t o m y , k n o w n as simple o r complete m a s -

t o i d e c t o m y o r Schwartz operation, is c o m p l e t e exenteration Figure 77.5 shows the various structures a n d l a n d m a r k s

o f all accessible m a s t o i d air cells a n d c o n v e r t i n g t h e m i n t o seen after cortical m a s t o i d e c t o m y .

a single cavity. Posterior m e a t a l w a l l is l e f t i n t a c t ( F i g . 7 7 . 4 . )

M i d d l e ear structures are n o t disturbed.

Anaesthesia

G e n e r a l anaesthesia.
Indications

A c u t e coalescent mastoiditis. Position

2 . I n c o m p l e t e l y resolved acute otitis m e d i a w i t h reser-

v o i r sign. Patient lies s u p i n e w i t h face t u r n e d to o n e side a n d the ear

M a s k e d mastoiditis. to be operated u p p e r - m o s t .

Anterior

Up Down

Posterior
Temporalis m

CN VII

Donaldson's line

Trautmann's Site of endolymphatic sac

triangle

Sinodura
(Citelle's) angle Digastric ridge

Sigmoid sinus plate

F i g u r e 77.5

V a r i o u s s t r u c t u r e s a n d l a n d m a r k s seen a f t e r c o r t i c a l m a s t o i d e c t o m y .
Operative Surgery

in the r o o t o f z y g o m a , retrosinus cells l y i n g b e t w e e n sinus

Steps of Operation
plate and cortex, b e h i n d the sinus, are r e m o v e d . A finished

cavity s h o u l d have bevelled edges so that soft tissue can

1. I n c i s i o n A c u r v e d postaural incision about 1 c m b e h i n d easily sit i n a n d obliterate the cavity.

b u t parallel to the retroauricular sulcus, starting at the

6. Closure of wound M a s t o i d cavity is t h o r o u g h l y
highest attachment o f pinna to the mastoid rip (Fig. 77.313).
irrigated w i t h saline to r e m o v e b o n e dust, a n d the
I n infants a n d c h i l d r e n u p to 2 years, the i n c i s i o n is
w o u n d is c l o s e d i n t w o layers. A r u b b e r drain m a y be left
short a n d m o r e h o r i z o n t a l . T h i s is t o a v o i d c u t t i n g facial
at the l o w e r e n d o f i n c i s i o n for 24—48 hours i n case o f
nerve w h i c h is superficial i n the l o w e r part o f m a s t o i d
infection o r excessive bleeding. A meatal pack s h o u l d be
(Fig. 7 7 . 3 C ) .
kept to a v o i d stenosis o f ear canal. M a s t o i d dressing is
Incision cuts t h r o u g h soft tissues u p to the p e r i o s t e u m .
applied.
T e m p o r a l i s muscle is n o t cut i n the incision.

2. Exposure of lateral surface of mastoid and

M a c E w e n ' s triangle P e r i o s t e u m is i n c i s e d i n t h e line o f Post-operative Care
first i n c i s i o n . A h o r i z o n t a l i n c i s i o n m a y be m a d e a l o n g the

l o w e r b o r d e r o f temporalis muscle for m o r e exposure. 1. Antibiotics started p r c - o p e r a t i v e l y are c o n t i n u e d post-

P e r i o s t e u m is s c r a p e d f r o m the surface o f m a s t o i d a n d operatively f o r at least o n e w e e k . C u l t u r e s w a b taken

posterosuperior m a r g i n o f osseous meatus. T e n d i n o u s f r o m the mastoid, d u r i n g operation, m a y dictate a

fibres o f sternomastoid are sharply cut and scraped d o w n . change i n the antibiotic.

A self-retaining m a s t o i d retractor is applied. 2. D r a i n , i f put, is r e m o v e d i n 24—48 hours a n d sterile

dressing done.
3. Removal of mastoid cortex and exposure of
3. Stitches are r e m o v e d o n the 6 t h day.
antrum M a s t o i d cortex is r e m o v e d w i t h burr, o r g o u g e

a n d h a m m e r . M a s t o i d a n t r u m is exposed i n the area o f

suprameatal triangle ( M a c E w e n ' s triangle). I n an adult,

a n t r u m lies 1 2 - 1 5 m m f r o m the surface. H o r i z o n t a l s e m i -

J Complications J
circular canal is i d e n t i f i e d .

I n j u r y to facial nerve.
4. R e m o v a l o f m a s t o i d air cells A l l accessible m a s t o i d air
D i s l o c a t i o n o f incus.
cells are r e m o v e d leaving b e h i n d the b o n y plate o f t e g m e n
3. I n j u r y to h o r i z o n t a l semicircular canal. Patient w i l l
t y m p a n i above, sinus plate b e h i n d a n d posterior meatal
h a v e post-operative giddiness a n d nystagmus.
wall i n front.
4. I n j u r y to s i g m o i d sinus w i t h profuse bleeding.
5. R e m o v a l o f m a s t o i d tip a n d finishing the cavity
5. I n j u r y to dura o f m i d d l e cranial fossa.
Lateral wall o f the mastoid t i p is r e m o v e d , exposing muscle
6. Post-operative w o u n d i n f e c t i o n a n d w o u n d break-
fibres o f p o s t e r i o r b e l l y o f digastric. Z y g o m a t i c cells situated
d o w n .
Radical M a s t o i d e c t o m y

R a d i c a l M a s t o i d e c t o m y is a p r o c e d u r e to eradicate disease R e m o v a l o f g l o m u s t u m o u r .

f r o m the m i d d l e ear a n d m a s t o i d w i t h o u t any attempt to C a r c i n o m a m i d d l e ear. R a d i c a l m a s t o i d e c t o m y f o l -

reconstruct hearing. Posterior meatal w a l l is r e m o v e d a n d l o w e d b y radiotherapy is an alternative to e n b l o c

the entire area o f m i d d l e ear, attic, a n t r u m a n d m a s t o i d is r e m o v a l o f t e m p o r a l b o n e i n c a r c i n o m a m i d d l e ear.

c o n v e r t e d i n t o a single cavity. A l l r e m n a n t s o f t y m p a n i c

m e m b r a n e , ossicles (except stapes footplate) a n d m u c o p e -

riosteal l i n i n g are r e m o v e d (Fig. 78.1). Eustachian tube is

obliterated b y a piece o f m u s c l e o r cartilage. A i m o f the

J Anaesthesia J
o p e r a t i o n is to p e r m a n e n t l y exteriorise the diseased area
M o s t l y , general a n a e s t h e s i a is g i v e n . L o c a l a n a e s t h e s i a can
for inspection a n d cleaning. T h e radical m a s t o i d e c t o m y is
be used i n selected cases.
i n f r e q u e n t l y r e q u i r e d these days.

Position
Indications

S a m e as f o r c o r t i c a l m a s t o i d e c t o m y .
i. W h e n all cholesteatoma c a n n o t be safely r e m o v e d ,

e.g. that i n v a d i n g eustachian tube, r o u n d w i n d o w

niche, p e r i l a b y r i n t h i n e o r h y p o t y m p a n i c cells.
Steps of Operation
2. I f previous attempts to eradicate c h r o n i c i n f l a m m a -

t o r y disease o r cholesteatoma have failed.

1. I n c i s i o n Postaural (Fig. 78.2) o r endaural (Fig. 78.3).
3. As an a p p r o a c h to petrous apex.

2. R e t r a c t i o n o f soft tissues a n d e x p o s u r e o f m a s -
Mastoid cavity Horizontal toid area M a s t o i d area f r o m posterior r o o t o f z y g o m a to

b e h i n d the suprameatal triangle a n d f r o m t e m p o r a l line

above to the l o w e r part o f m a s t o i d tip b e l o w is e x p o s e d b y

elevating the p e r i o s t e u m a n d the w o u n d retracted.

— Eust. tube 3. R e m o v a l o f b o n e a n d e x p o s u r e o f attic a n d a n t r u m

opening closed W i t h the help o f burr, b o n e is r e m o v e d f r o m the area o f
with muscle
suprameatal triangle, spine o f H e n l e , r o o t o f z y g o m a to just

Round window above the anterior meatal wall, u p p e r part o f superior meatal

wall is also r e m o v e d . T h i s w i l l expose attic a n d a n t r u m .

Identify the t e g m e n antri a n d lateral semicircular canal.

4. Removal of the "bridge" and the buttresses

D e e p e r part o f superior osseous meatal w a l l that bridges
F i g u r e 78.1
o v e r the n o t c h o f R i v i n u s is r e m o v e d .
Radical mastoidectomy. T h e entire area o f mastoid, middle
A n t e r i o r spine o f the n o t c h (anterior buttress) a n d pos-
ear, attic and a n t r u m is e x t e r i o r i s e d . Eustachian tube is o b l i t e r -
terior spine o f the n o t c h (posterior buttress) are also
ated and no attempt is m a d e to reconstruct the hearing
r e m o v e d . T h i s r e m o v e s the lateral attic wall. T h e incus
mechanism.
a n d the malleus are also r e m o v e d .
Operative Surgery

7 . I n s p e c t i o n o f the cavity a n d irrigation I t is n e c e s -

sary to ensure c o m p l e t e exteriorisation o f the attic, a n t r u m

a n d m i d d l e ear a n d m a s t o i d cavity i n t o external a u d i t o r y

meatus. A n y b o n y overhangs are r e m o v e d a n d cavity

s m o o t h e n e d w i t h p o l i s h i n g burr. Finally, it is irrigated

w i t h saline to r e m o v e any b l o o d or b o n e particles.

Posterior 8. M e a t o p l a s t y A flap, based laterally at the c o n c h a is

raised f r o m posterior a n d superior meatal w a l l a n d t u r n e d

into the m a s t o i d cavity to cover the area o f t h e facial ridge.

T h i s helps i n the epithelialisation o f the m a s t o i d cavity. A

piece o f c o n c h a l cartilage can be r e m o v e d to enlarge the

meatus a n d to facilitate inspection and access t o cavity.

9. O b l i t e r a t i o n o f the cavity I f m a s t o i d cavity is v e r y

large, it m a y be obliterated w i t h temporalis m u s c l e or

other soft tissues, t a k i n g care that n o vestige o f disease

(cholesteatoma) is b u r i e d underneath.
Figure 78.2
10. Closure of w o u n d T h e c a v i t y is p a c k e d w i t h ribbon
Types o f postaural incisions.
gauze, i m p r e g n a t e d w i t h an antibiotic/antiseptic a n d the

w o u n d is closed w i t h i n t e r r u p t e d sutures. M a s t o i d dress-

ing is applied.

Post-operative Care

1. D r e s s i n g First dressing is d o n e o n 3 r d o r 4 t h day.

R e p l a c e the o u t e r gauze a n d c o t t o n a n d l o o k for any signs

o f perichondritis o r i n f e c t i o n o f meatal pack.

S e c o n d dressing is d o n e o n 6 t h o r 7 t h day w h e n stitches

are r e m o v e d a n d meatal pack is changed. Thereafter,

c h a n g e the p a c k at w e e k l y intervals o r leave the cavity

u n p a c k e d w i t h regular suction and cleaning till epitheliali-

sation is c o m p l e t e .

2. A n t i b i o t i c A suitable antibiotic is g i v e n f o r about

a w e e k .

3. Cavity care Usually, cavity is fully epithelialised i n

2 - 3 m o n t h s . I t s h o u l d be periodically c h e c k e d (every 4 - 6
Figure 78.3
m o n t h s ) i n the first year a n d t h e n annually for r e m o v a l o f

Endaural incision. any debris o r infection. A n y granulation tissue w h i c h

delays e p i t h e l i a l i s a t i o n is r e m o v e d o r cauterised.

5. L o w e r i n g the facial ridge T h e deeper part o f poste-

rior meatal w a l l that overlies the vertical part o f facial

Complications
nerve is c a l l e d facial ridge. I t is r e m o v e d as m u c h as pos-

sible w i t h i n the safety o f V l l t h nerve so that the m a s t o i d

Facial paralysis.
cavity is f r e e l y accessible f r o m the meatus.
Perichondritis o f pinna.

6. T o i l e t of middle ear R e m n a n t s o f t y m p a n i c m e m - I n j u r y to d u r a or s i g m o i d sinus.

brane w i t h its a n n u l u s and sulcus tympanicus are r e m o v e d . Labyrinthitis, i f stapes gets dislocated.

M i d d l e ear m u c o p e r i o s t e u m a l o n g w i t h any p o l y p o r gran- Severe c o n d u c t i v e deafness o f 50 d B or m o r e . T h i s is

ulation t i s s u e is r e m o v e d . Malleus and incus are r e m o v e d i f due to r e m o v a l o f all ossicles a n d t y m p a n i c m e m b r a n e .

n o t already done. S t a p e s is l e f t i n t a c t . E u s t a c h i a n tube o p e n - C a v i t y problems. T w e n t y five percent o f the cavities d o

ing is c l o s e d b y c u r e t t i n g its m u c o s a and p l u g g i n g the o p e n - n o t heal and continue to discharge, requiring regular

ing w i t h tensor t y m p a n i muscle o r piece o f cartilage. after-care.

M o d i f i e d Radical M a s t o i d e c t o m y

It is a m o d i f i c a t i o n o f radical m a s t o i d e c t o m y w h e r e as
Position
m u c h o f the h e a r i n g m e c h a n i s m as possible is preserved.

T h e disease process w h i c h is often localised to the attic

S a m e as f o r c o r t i c a l m a s t o i d e c t o m y .
a n d a n t r u m is r e m o v e d a n d the w h o l e area fully e x t e r i -

orised i n t o the m e a t u s b y r e m o v a l o f the posterior meatal

a n d lateral attic w a l l (Fig. 79.1).

Steps of Operation

J Indications Incision, postaural o r endaural.

2. R e t r a c t i o n o f soft tissues a n d exposure o f m a s t o i d

area.
C h o l e s t e a t o m a c o n f i n e d to the attic a n d a n t r u m .
3. R e m o v a l o f cortical b o n e a n d exposure o f a n t r u m
2. Localised c h r o n i c otitis m e d i a .
a n d attic.
Irreversibly d a m a g e d tissues are r e m o v e d , preserving
Steps 2 a n d 3 are the s a m e as i n r a d i c a l mastoidectomy.
the rest t o conserve o r reconstruct h e a r i n g m e c h a n i s m .

4. R e m o v a l o f diseased tissue. Cholesteatoma, granula-

tions or u n h e a l t h y m u c o s a is r e m o v e d . Incus and h e a d

Anaesthesia
o f malleus often require r e m o v a l , i f cholesteatoma

engulfs t h e m o r extends m e d i a l to t h e m . T h e y are

M o s t l y general, local anaesthesia can be used i n selected
preserved i f possible. Lateral attic w a l l is r e m o v e d to
cases.
fully exteriorise the attic.

5. Facial ridge is l o w e r e d .

Mastoid cavity 6. M a s t o i d cavity is s m o o t h e n e d w i t h p o l i s h i n g burr,

r e m o v i n g any overhangs a n d t h e n irrigated w i t h n o r -

Horizontal semicircular canal
mal saline.

7. R e c o n s t r u c t i o n o f h e a r i n g m e c h a n i s m . Pars tensa o f

t y m p a n i c m e m b r a n e a n d m i d d l e ear, i f healthy, are

left undisturbed. I f disease extends i n t o m i d d l e ear,

o n l y the irreversible tissues are r e m o v e d .

R e c o n s t r u c t i o n o f t y m p a n i c m e m b r a n e o r ossicular

chain, i f d a m a g e d , can also b e d o n e ( m a s t o i d e c t o m y

w i t h t y m p a n o p l a s t y operation).

8. M e a t o p l a s t y a n d closure o f w o u n d is s a m e as i n r a d i -

cal m a s t o i d e c t o m y .

F i g u r e 79.1

Modified radical mastoidectomy. Posterior meatal wall is

Post-operative Care and Complications
removed to exteriorise the diseased area into the meatus and

the hearing mechanism reconstructed.

S a m e as i n r a d i c a l m a s t o i d e c t o m y .
Myringoplasty

Closure o f perforation o f pars tensa o f the t y m p a n i c m e m - (ii) P e r i c h o n d r i u m f r o m the tragus,

b r a n e is c a l l e d myringoplasty. I t has the advantage of: (iii) T r a g a l cartilage,

(iv) V e i n .
restoring the h e a r i n g loss a n d i n s o m e cases t h e tinrutus.

c h e c k i n g re-infection f r o m external auditory canal Incision for exposure o f t y m p a n i c m e m b r a n e depends

a n d eustachian tube (nasopharyngeal infection ascends o n the size o f the ear canal; i t m a y be endomeatal, endaural

easily via eustachian tube i n the presence o f perfora- or postaural.

t i o n than otherwise).

c h e c k i n g aeroallergens reaching the e x p o s e d m i d d l e

Technique
ear m u c o s a , leading to persistent ear discharge.

M y r i n g o p l a s t y can be c o m b i n e d w i t h ossicular r e c o n - Underlay Technique

struction w h e n i t is c a l l e d tympanoplasty. t. Harvesting the graft o f temporalis fascia; o r per-

Physiologic principles for m i d d l e ear r e c o n s t r u c t i o n are i c h o n d r i u m f r o m the tragus.

discussed o n page 35.

2. P r e p a r i n g t h e T . M . f o r g r a f t i n g A n i n c i s i o n is m a d e

a l o n g the edge o f perforation a n d the r i n g o f e p i t h e l i u m

Contraindications r e m o v e d . R e m o v e also a strip o f m u c o s a l layer f r o m the

i n n e r side o f perforation.

(i) A c t i v e discharge f r o m the m i d d l e ear.

3. I n s p e c t i n g the m i d d l e ear A stapes-type i n c i s i o n is
Nasal allergy. It s h o u l d be b r o u g h t u n d e r c o n t r o l
m a d e a n d the t y m p a n o m e a t a l flap raised to see the
before surgery.
integrity a n d m o b i l i t y o f the ossicular c h a i n a n d to ensure
(iii) O t i t i s externa.
that n o s q u a m o u s e p i t h e l i u m has g r o w n i n t o the m i d d l e
(iv) I n g r o w t h o f s q u a m o u s e p i t h e l i u m i n t o the m i d d l e
ear.
ear. I n such cases, excision o f s q u a m o u s e p i t h e l i u m
4. P l a c i n g the graft M i d d l e ear is p a c k e d w i t h g e l f o a m
f r o m the m i d d l e ear or a t y m p a n o m a s t o i d e c t o m y
soaked w i t h an antibiotic. A proper-sized g r a f t is p l a c e d so
m a y be required.
that its edges e x t e n d u n d e r the margins o f perforation all
(v) W h e n the other ear is d e a d o r n o t suitable for hear-
r o u n d a n d a small part also e x t e n d s o v e r the posterior canal
i n g aid rehabilitation.
wall. T y m p a n o m e a t a l flap is r e p l a c e d . A n underlay t e c h -
( v i ) C h i l d r e n b e l o w 3 years.
n i q u e has the advantage that the s q u a m o u s e p i t h e l i u m is

n o t b u r i e d i n the m i d d l e ear.
Anaesthesia

Overlay Technique
L o c a l o r general, the f o r m e r is preferred.
1. T e m p o r a l fascia o r p e r i c h o n d r i a l graft is h a r v e s t e d as

•
above.
Position
2. I n c i s i o n is m a d e i n the m e a t u s as s h o w n (Fig. 80.1)

a n d meatal s k i n raised a l o n g w i t h all e p i t h e l i u m

S u p i n e w i t h face t u r n e d to o n e side; the ear to be operated
f r o m the o u t e r surface o f t y m p a n i c m e m b r a n e
is up.
r e m n a n t .
Graft materials used are:
3. Graft placed o n the outer surface o f T . M . A slit is m a d e

T e m p o r a l i s fascia (most c o m m o n ) , i n the graft to t u c k it u n d e r the handle o f malleus.

 c

F i g u r e 80.1

Overlay t e c h n i q u e . ( A ) I n c i s i o n t o raise medial meatal skin with tympanic membrane epithelium. ( B ) Placement o f graft.
( C ) Replacement o f skin.

4. M e a t a l skin r e m o v e d earlier is n o w r e p l a c e d , c o v e r - Lateralisation ofgraft. Graft loses contact f r o m t h e m a l -

i n g t h e p e r i p h e r y o ft h e graft. E a r canal p a c k e d w i t h leus handle resulting i nc o n d u c t i v e loss. I t is prevented

g e l f o a m a n d t h e n w i t h a small antibiotic pack. b y t u c k i n g t h e graft u n d e r t h e handle.

A m o d i f i c a t i o n o f t h e overlay technique is t o place

the anterior edge o f fascia graft u n d e r t h e a n n u l u s

after r e m o v i n g t h e e p i t h e l i u m . T h i s prevents b l u n t i n g Other Procedures for Closure of Tympanic

o f

overlay
anterior canal

technique.
w h i c h is s e e n as a c o m p l i c a t i o n o f Membrane Perforation
I
5. C l o s u r e o fe n d a u r a l o r postaural incision. 1. S p l i n t a g e I t is u s e d i n fresh traumatic perforations.

6. M a s t o i d dressing. T h e t o r n edges o f t h e perforation are carefully everted

u n d e r t h e microscope a n d splinted w i t h absorbable gel-

Post-operative Care f o a m placed i n t h e m i d d l e ear t h r o u g h t h e tear. Smaller

tears c a n b e splinted o n t h e outer surface o f t h e t y m p a n i c

Stitches are r e m o v e d after 5 - 6 days. m e m b r a n e w i t h a piece o f cigarette paper, g e l f d m o r sili-

2. E a rpack is r e m o v e d after 5 - 6 days w i t h o u t d i s t u r b i n g c o n sheet.

the gelfoam.
2. C a u t e r y - p a t c h i n g T h i s is useful i n small, long-stand-

3. Patient is s e e n at 3 a n d 6 w e e k s after operation.

i n g central perforations w h e r e t h e margins, have b e c o m e

4. C o m p l e t e epithelialisation o fgraft takes 6—8 w e e k s .

epithelialised a n d chronic. I n this p r o c e d u r e , margins, o f

the perforation are cauterised w i t h 5 0 % trichloracetic acid

Complications to r e m o v e t h e epithelialised edge (or freshened w i t h a fine

p i c k used f o r myringoplasty) a n d t h e n supported w i t h a

Underlay Technique cigarette paper m o i s t e n e d w i t h 1% p h e n o l i n glycerine.

T h i s p r o c e d u r e c a n b e repeated at t w o w e e k s interval.
M i d d l e ear b e c o m e s n a r r o w .
Instead o fcigarette paper, other material such as steristrip,
Graft m a yg e t adherent t o t h e p r o m o n t o r y .
g e l f d m o r silicone sheets h a v e also b e e n used.
3. A n t e r i o r l y , graft m a ylose contact from t h e r e m n a n t o f

t y m p a n i c m e m b r a n e leading t o anterior perforation. 3. Fat-graft myringoplasty I t is also used t o close small

perforations. After local anaesthesia, edges o fperforation are

Overlay Technique
freshened w i t h 1 m m stapes h o o k . T h einside o f perforation

1. Blunting of the anterior sulcus. is a l s o s c r a p p e d . A small piece o ffat harvested f r o m t h e ear

2. Epithelial pearls. T h e y are epidermal cysts, w h e n lobule is p l u g g e d into t h e perforation like a n hour-glass.

s q u a m o u s e p i t h e l i u m is b u r i e d u n d e r t h e graft. O v e r a t i m e , t h e fat graft adheres a n d closes t h e p e r f o r a t i o n .

P r o o f Puncture (Syn. A n t r a l I r r i g a t i o n )

T h i s p r o c e d u r e involves p u n c t u r i n g the m e d i a l wall o f

maxillary sinus i n the r e g i o n o f inferior meatus a n d irrigat- Middle turbinate

ing the sinus.
Opening of
max. sinus in
middle meatus
Indications Interior meatus

Cannula
C h r o n i c a n d subacute m a x i l l a r y sinusitis w i t h dual

p u r p o s e o f : (a) c o n f i r m i n g t h e diagnosis a n d (b) w a s h -

ing o u t the pus.

T o collect the s p e c i m e n o f the antral contents for c u l -

F i g u r e 81.1

ture a n d sensitivity, o r c y t o l o g i c a l e x a m i n a t i o n to Antral puncture.

exclude early malignancy.

Contraindications
anterior e n d o f inferior turbinate a n d near the attachment

A c u t e m a x i l l a r y sinusitis f o r fear o f osteomyelitis. o f c o n c h a w i t h lateral wall. H e r e , the b o n e is v e r y t h i n

a n d can be easily p i e r c e d . T r o c a r a n d cannula are directed

t o w a r d s the h o m o l a t e r a l ear. T h e nasoantral w a l l pierces

Anaesthesia w i t h a "crack". N o w r e m o v e the trocar a n d advance the

cannula till it reaches the opposite antral wall a n d then

In adults, local anaesthesia is preferred. A p a c k o f 4 %

w i t h d r a w a little. T h e a n t r u m can n o w be irrigated w i t h

lignocaine w i t h adrenaline is k e p t i n inferior m e a t u s for

n o r m a l saline at 3 7 ° C w i t h a 20 m l o r Hagginson's syringe

10 to 15 m i n u t e s . I n children, general anaesthesia is

(Fig. 8 1 . 1 ) . S y r i n g i n g is c o n t i n u e d t i l l r e t u r n is c l e a r . After

required. A r e a o f m i d d l e meatus s h o u l d be d e c o n g e s t e d to
the p u n c t u r e is o v e r , cannula is r e m o v e d and a pack k e p t

o p e n the m a x i l l a r y o s t i u m f o r easy r e t u r n o f fluid.

in the inferior meatus to c o n t r o l bleeding.

Position
Diagnosis of Antral Pathology

Sitting p o s i t i o n is p r e f e r r e d i n all adults, w h e n using local

T h i n a m b e r - c o l o u r e d fluid, f l o w i n g f r o m cannula
anaesthesia. W h e n using general anaesthesia, patient is
i m m e d i a t e l y o n p u n c t u r e a n d c o n t a i n i n g cholesterol
placed i n t o n s i l l e c t o m y position.
crystals, indicates presence o f antral cyst.

B l o b s o f m u c o p u s i n washings indicate hyperplastic

Technique sinusitis.

3, Presence o f f o u l - s m e l l i n g pus w h i c h easily m i x e s w i t h

T h e lateral w a l l o f inferior meatus is p u n c t u r e d w i t h irrigating fluid indicates suppuration. I n such cases,

L i c h t w i t z trocar a n d cannula at a p o i n t 1.5-2.0 c m f r o m antral w a s h m a y be repeated o n c e o r t w i c e a w e e k .

 Proof Puncture (Syn. Antral Irrigation)

anterolateral w a l l o f the maxilla a n d has failed t o

Post-operative Care
pierce the nasoantral wall.

2. Orbital injury and cellulites. I f trocar a n d cannula pierces

1. Pack is r e m o v e d after a b o u t an h o u r .
the r o o f o f a n t r u m .
2. A n t i b i o t i c s s h o u l d be g i v e n f o r 5 - 6 days i n cases o f
3. Puncture of the posterior antral wall. This w o u l d cause
suppuration.
s w e l l i n g i n posterior part o f cheek.
3. Nasal decongestant drops s h o u l d be used to i m p r o v e
Bleeding d u e to injury to nasal mucosa.
patency o f the o s t i u m .
5. Air embolism. I t is r a r e b u t m a y p r o v e fatal. T h i s c o m -
4. Analgesics m a y be r e q u i r e d for headache o r post-
plication can be p r e v e n t e d b y a v o i d i n g insufflation o f
operative pain.
air i n t o the a n t r u m after lavage.

Note: T h i s o p e r a t i o n is n o w b e i n g p e r f o r m e d less often.

Complications M o s t surgeons prefer to get a C T t o find the m i d d l e meatal

p a t h o l o g y causing o b s t r u c t i o n to sinus o s t i u m a n d deal

1. Swelling of check. This is d u e to faulty technique. w i t h sinus disease a n d meatal p a t h o l o g y b y functional

I n this case, cannula lies i n the soft tissues o v e r the endoscopic sinus surgery (FESS) at t h e same t i m e .
 Intranasal I n f e r i o r M e a t a l A n t r o s t o m y

Intranasal Inferior M e a t a l A n t r o s t o m y is a p r o c e s s o f m a k -
Natural opening
ing an o p e n i n g i n the nasoantral w a l l o f the inferior meatus
maxillary sinus
b y intranasal route. Maxillary
Nasal cavity

J Indications ~J Inferior turbinate

C h r o n i c p u r u l e n t maxillary sinusitis.

C o ntraind ications J F i g u r e 82.1

I n t r a n a s a l a n t r o s t o m y in t h e i n f e r i o r m e a t u s .
1. Irreversible change i n sinus mucosa, e.g. p o l y p o i d a l

h y p e r t r o p h y .

Presence o f osteitis.

Suspicion o f m a l i g n a n c y .
o f nose as possible (Fig. 82.1). Intrasinus pus/debris is

r e m o v e d b y suction. P a c k i n g into the sinus a n d nose m a y

Anaesthesia b e r e q u i r e d i f there is s e v e r e bleeding.

L o c a l o r general anaesthesia.
Post-operative Care

Position
Intrasinus a n d nasal p a c k is r e m o v e d i n 24—48 hours.

S a m e as i n s u b m u c o u s resection ( S M R ) o p e r a t i o n

(see C h a p t e r 84). Complications J

F e w c o m p l i c a t i o n s .
Technique
Post-operative bleeding.

2. I n j u r y t o nasolacrimal duct.
Inferior t u r b i n a t e is f r a c t u r e d m e d i a l l y a n d u p w a r d s w i t h a

large periosteal elevator. Nasoantral w a l l o f inferior meatus Note: T h e s e days, intranasal a n t r o s t o m y is p e r f o r m e d i n

is p e r f o r a t e d w i t h a c u r v e d haemostat a n d t h e n this o p e n - t h e m i d d l e meatus. M i d d l e meatal a n t r o s t o m y is m o r e

ing is e n l a r g e d , forwards w i t h Kerrison's bone-forceps a n d physiological a n d is p e r f o r m e d w i t h nasal endoscopes a n d

b a c k w a r d s w i t h L u c ' s o r s i d e - b i t i n g r i n g forceps. O p e n i n g o t h e r surgical instruments used i n functional endoscopic

s h o u l d be 1.5 to 2 c m i n d i a m e t e r a n d as c l o s e to the floor sinus surgery.

Caldwell-Luc O p e r a t i o n

C a l d w e U - L u c o p e r a t i o n is a p r o c e s s o f o p e n i n g t h e m a x i l -
Contraindications
lary a n t r u m t h r o u g h canine fossa b y sublabial approach

a n d dealing w i t h t h e p a t h o l o g y inside t h e a n t r u m .
Patient b e l o w 1 7 years o f age.

Indications
Anaesthesia
i i
C h r o n i c m a x i l l a r y sinusitis w i t h irreversible changes
General anaesthesia w i t h cuffed endotracheal t u b e a n d a
i n t h e sinus m u c o s a .
pharyngeal pack. C a n b e d o n e u n d e r local anaesthesia.
R e m o v a l o f foreign bodies o r r o o t o f a t o o t h .

D e n t a l cyst.

O r o a n t r a l fistula. J Position
Suspected n e o p l a s m i n t h e a n t r u m a n d its biopsy.

6. R e c u r r e n t antrochoanal p o l y p . R e c l i n i n g w i t h h e a d - e n d o f t h e table raised. Patient lies

7. Fracture o f m a x i l l a o r b l o w - o u t fractures o f t h e supine w i t h face t u r n e d slightly t o t h e opposite side.

orbit.

8. A s a n approach t o e t h m o i d s ( H o r g a n ' s transantral

e t h m o i d e c t o m y ) .
| Technique J

9. A p p r o a c h t o pterygopalatine fossa f o r l i g a t i o n o f

m a x i l l a r y artery. 1. I n c i s i o n A h o r i z o n t a l incision w i t h its ends u p w a r d is

10. V i d i a n n e u r e c t o m y . m a d e b e l o w t h e gingivolabial sulcus, f r o m lateral incisor

B Antrostomy opening with inferior

turbinate showing through

Incision' J

* A fc fc »
Cut edge
bone of canine fossa

F i g u r e 83.1

C a l d w e l l - L u c o p e r a t i o n . ( A ) Incision. ( B ) Inside v i e w a n d position o f a n t r o s t o m y .

CL
Operative Surgery

to the 2 n d m o l a r (Fig. 83.1). I t cuts t h r o u g h m u c o u s

Post-operative Care
m e m b r a n e a n d p e r i o s t e u m .

2. Elevation of flap T h e m u c o p e r i o s t e a l flap is raised Ice packs o v e r the c h e e k i n the first 2 4 h o u r s p r e -

f r o m the canine fossa to the infraorbital n e r v e a v o i d i n g v e n t o e d e m a , h a e m a t o m a a n d d i s c o m f o r t t o t h e

injury to the nerve. patient.

3. O p e n i n g the a n t r u m U s i n g c u t t i n g b u r r or g o u g e P a c k i n g i n the sinus a n d nose can be r e m o v e d i n

a n d h a m m e r , a h o l e is m a d e i n the a n t r u m . O p e n i n g is 2 4 - 4 8 hours.

enlarged using Kerrison's p u n c h . A n t i b i o t i c s are g i v e n f o r 5—7 days.

Patient s h o u l d a v o i d b l o w i n g his nose for 2 w e e k s to

4. D e a l i n g w i t h p a t h o l o g y O n c e maxillary a n t r u m has
a v o i d surgical e m p h y s e m a .
b e e n o p e n e d , p a t h o l o g y is r e m o v e d . Diseased antral

m u c o s a can b e r e m o v e d w i t h elevators, curettes a n d for-

ceps. Cyst, b e n i g n t u m o u r , foreign b o d y o r a p o l y p is

Complications
r e m o v e d .

5. M a k i n g nasoantral w i n d o w A c u r v e d haemostat is 1. Post-operative bleeding. T h i s can be c o n t r o l l e d b y

p u s h e d i n t o the a n t r u m f r o m the inferior meatus a n d t h e n nasal pack.

this o p e n i n g is enlarged w i t h Kerrison's a n d side-biting 2. Anaesthesia o f the c h e e k due t o stretching o f infraor-

forceps t o m a k e a w i n d o w , 1.5 c m i n diameter. bital nerve. It m a y last f o r a f e w w e e k s or m o n t h s .

Anaesthesia o f teeth.
6. Packing the antrum R i b b o n gauze, impregnated
4. I n j u r y to nasolacrimal duct.
w i t h l i q u i d paraffin or F u r a c i n ™ ( F u r a c i n ™ is 0 . 2 % w / w
Sublabial fistula.
nitrofurazone) o i n t m e n t can b e p a c k e d i n the a n t r u m a n d
O s t e o m y e l i t i s o f maxilla (rare).
its e n d b r o u g h t o u t f r o m the nasoantral w i n d o w i n t o the

nose. I n t r a s i n u s p a c k i n g is d o n e i fthere is s e v e r e bleeding.

Note: E v e r since the advent o f endoscopic sinus surgery,
P a c k is also k e p t i n the nose.
indications for C a l d w e l l - L u c o p e r a t i o n have decreased.

7. C l o s u r e o f w o u n d Sublabial incision is closed w i t h F E S S can achieve all that can be d o n e t h r o u g h C a l d w e l l -

o n e o r t w o catgut sutures. L u c surgery.

S u b m u c o u s Resection o f Nasal
Septum (SMR Operation)

2. Incision A c u r v i l i n e a r incision w i t h f o r w a r d c o n v e x -
Indications
ity is m a d e at t h e m u c o c u t a n e o u s j u n c t i o n o n the left side

o f the s e p t u m . It cuts o n l y t h r o u g h the m u c o s a a n d

1. D e v i a t e d nasal s e p t u m ( D N S ) causing s y m p t o m s o f
p e r i c h o n d r i u m .
nasal o b s t r u c t i o n a n d recurrent headaches.

2. D N S causing o b s t r u c t i o n to ventilation o f paranasal 3. Elevation of mucoperichondrial a n d periosteal

sinuses a n d m i d d l e ear, resulting i n recurrent sinusitis flap Plane o f dissection is i m p o r t a n t . I t s h o u l d b e beneath

a n d otitis m e d i a . the p e r i c h o n d r i u m a n d p e r i o s t e u m (Fig. 8 4 . I A ) .

3. R e c u r r e n t epistaxis f r o m septal spur. 4. Incision o f the cartilage C a r t i l a g e is i n c i s e d j u s t poste-

4. A s a part o f septorhinoplasty for cosmetic c o r r e c t i o n rior to the first i n c i s i o n . A v o i d c u t t i n g the opposite m u c o -

o f external nasal deformities. p e r i c h o n d r i u m , otherwise, it w i l l result i n perforation.

5. A s a p r e l i m i n a r y step i n h y p o p h y s e c t o m y (trans-septal
5. E l e v a t i o n o f o p p o s i t e m u c o p e r i c h o n d r i u m and
trans-sphenoidal approach) or vidian n e u r e c t o m y
periosteum W i t h the elevator passed t h r o u g h the carti-
(trans-septal approach).
lage incision, m u c o p e r i c h o n d r i a l a n d periosteal flap is

raised f r o m the opposite side o f the s e p t u m (Fig. 8 4 . I B ) .

Contraindications 6. Removal o f cartilage a n d bone N o w w o r k i n g

b e t w e e n the t w o flaps, cartilage a n d b o n e are r e m o v e d .

1. Patients b e l o w 17 years o f age. I n such cases, a c o n - Cartilage can be r e m o v e d w i t h Ballenger s w i v e l knife a n d

servative surgery (septoplasty) s h o u l d be d o n e . b o n e w i t h Luc's forceps. B o n y spur or ridge can b e

2. A c u t e episode o f respiratory infection. r e m o v e d w i t h g o u g e a n d h a m m e r . Preserve a strip o f car-

B l e e d i n g diathesis. tilage a b o u t 1 c m w i d e a l o n g the dorsal a n d caudal b o r d e r

U n t r e a t e d diabetes o r hypertension. o f the s e p t u m to p r e v e n t collapse o f the b r i d g e o f nose o r

retraction c o l u m e l l a (Fig. 84.2).

7. S t i t c h i n g O n e o r t w o c a t g u t o r silk stitches are applied

Anaesthesia
i n the initial m u c o p e r i c h o n d r i a l incision.

L o c a l anaesthesia is p r e f e r r e d . G e n e r a l anaesthesia is used

8. P a c k i n g R i b b o n gauze, smeared w i t h an antibiotic

o i n t m e n t or l i q u i d paraffin, is p a c k e d i n each nasal cavity

in c h i l d r e n a n d apprehensive adults.
to p r e v e n t collection o f b l o o d b e t w e e n the flaps. Nasal

dressing is applied.

Position

R e c l i n i n g p o s i t i o n w i t h h e a d - e n d o f the table raised. Post-operative Care

1. Patient is placed i n semi-sitting p o s i t i o n to prevent

Steps of Operation o o z i n g o f b l o o d . O u t e r nasal dressing is c h a n g e d i f

soaked i n b l o o d .

1. I n f i l t r a t i o n o f n a s a l s e p t u m I t is d o n e i n its subper- A soft diet s h o u l d be taken i n the first t w o post-

i c h o n d r i a l planes w i t h 2% x y l o c a i n e a n d 1:50,000 operative days t o m i n i m i s e active mastication w h i c h

adrenaline. causes bleeding.

 2. Septal haematoma. Evacuate the h a e m a t o m a a n d g i v e n

intranasal p a c k i n g o n b o t h sides o f s e p t u m for equal

pressure.

3. Septal abscess. T h i s can f o l l o w i n f e c t i o n o f septal

h a e m a t o m a .

4. Perforation. W h e n tears occur o n o p p o s i n g side o f

m u c o u s m e m b r a n e .
Figure S4.1
5. Depression of bridge. Usually occurs i n supratip area d u e to

S u b m u c o u s resection o f nasal s e p t u m : ( A ) Incision a n d eleva- too m u c h r e m o v a l o f cartilage along the dorsal border.

t i o n o f f l a p o n t h e left. ( B ) Elevation o f f l a p o n t h e right after 6. Retraction of columella. O f t e n seen w h e n caudal strip o f

incising the septal cartilage. (C) Closing the incision.
cartilage is n o t preserved.

7. Persistence of deviation. It usually occurs due to inade-

quate surgery a n d m a y require revision operation.

3. Pain, i f any, s h o u l d be c o n t r o l l e d w i t h analgesics.
8. Flapping of nasal septum. R a r e l y seen, w h e n t o o m u c h
A n t i b i o t i c c o v e r is g i v e n for 5 - 6 days.
o f septal f r a m e w o r k has b e e n r e m o v e d . S e p t u m ,
Nasal packs are gently r e m o v e d after 2 4 h o u r s a n d
w h i c h n o w consists o f t w o m u c o p e r i c h o n d r i a l flaps,
thereafter, decongestant nasal d r o p s a n d steam inhala-
m o v e s to the right o r left w i t h respiration.
tions are g i v e n daily for 5—6 days.
Toxic shock syndrome. I t is r a r e after septal surgery. I t
Silk stkch, i f any, is r e m o v e d o n 5 t h o r 6 t h day.
can f o l l o w staphylococcal (sometimes streptococcal)
Patient should avoid trauma to the nose for several days.
i n f e c t i o n a n d is characterised b y nausea, v o m i t i n g ,

p u r u l e n t secretions, h y p o t e n s i o n a n d rash. It s h o u l d

Complications be diagnosed early. I t is treated b y r e m o v a l o f p a c k -

ing, h y d r a t i n g the patient, m a i n t a i n i n g b l o o d pres-

1. Bleeding. I t m a y require repacking, i f severe. sure a n d a d m i n i s t e r i n g p r o p e r antibiotics.

Septoplasty

Septoplasty is a c o n s e r v a t i v e a p p r o a c h to septal surgery; as As a n a p p r o a c h t o h y p o p h y s e c t o m y .

m u c h o f t h e septal f r a m e w o r k as possible is retained. I. R e c u r r e n t epistaxis d u e t o septal spur.

M u c o - p e r i c h o n d r i a l / p e r i o s t e a l f l a p is g e n e r a l l y r a i s e d o n l y

o n o n e side. T h i s o p e r a t i o n has almost replaced t h e S M R

operation.
Contraindications

[ Indications 1. A c u t e nasal o r sinus infection.

2. U n t r e a t e d diabetes.

S y m p t o m a t i c deviated s e p t u m . H y p e r t e n s i o n .

As a part o f septorhinoplasty f o r cosmetic reasons. 4. B l e e d i n g diathesis.

F i g u r e 85.1

S e p t a l c a r t i l a g e is s t r a i g h t e n e d b y s c o r i n g t h e c a r t i l a g e o n c h e c o n c a v e s i d e t o r e m o v e i n t e r l o c k e d c a r t i l a g e s t r e s s e s ( A ) , o r b y s h a v i n g

t h e c o n v e x side o f c a r t i l a g e ( B ) , D i s l o c a t e d s e p t a l c a r t i l a g e c a n be r e p l a c e d in t h e m a x i l l a r y g r o o v e o r o n t h e a n t e r i o r nasal spine by

excision o f t h e c a r t i l a g e a l o n g t h e f l o o r o f nose a n d fixing it w i t h a s u t u r e (C).

Operative Surgery

5. R e m o v e maxillary crest to realign the septal cartilage.

Anaesthesia
6. C o r r e c t the b o n y s e p t u m b y r e m o v i n g the d e f o r m e d

parts. D e f o r m e d septal cartilage is corrected b y vari-

L o c a l o r general.
ous m e t h o d s , such as:

(i) S c o r i n g o n the concave side (Fig. 85.1).

(ii) C r o s s - h a t c h i n g or m o r s e l i z i n g .
Position
(iii) Shaving.

(iv) W e d g e excision.
S a m e as f o r S M R operation.
F u r t h e r m a n i p u l a t i o n s like r e a l i g n m e n t o f nasal spine,

separation o f septal cartilage f r o m u p p e r lateral carti-

Technique lages, i m p l a n t a t i o n o f cartilage strip i n the c o l u m e l l a

o r the d o r s u m o f nose m a y be required.

Trans-septal sutures are p u t to coapt m u c o p e r i c h o n -

1. Infiltrate the s e p t u m w i t h 1 % lignocaine w i t h adrena-
drial flaps.
line, 1:100,000.
Nasal pack.
I n cases o f d e v i a t e d s e p t u m , m a k e a slightly c u r v i l i n -

ear incision, 2 - 3 m m a b o v e the caudal e n d o f septal

cartilage o n the concave side (Killian's incision). I n

case o f c a u d a l dislocation, a transfixion o r h e m i t r a n s -

Post-operative Complications J
f i x i o n (Freer's) incision is m a d e .
S a m e as f o r S M R operation.
R a i s e m u c o p e r i c h o n d r i a l / m u c o p e r i o s t e a l flap o n o n e

side only. 1. Bleeding.

4. Separate septal cartilage f r o m the v o m e r a n d e t h m o i d 2. Septal haematoma and abscess.

plate a n d raise m u c o p e r i o s t e a l flap o n the opposite Septal perforation.

side o f septum. Persistence of septal deviation, or e x t e r n a l nasal deformity.

D i a g n o s t i c Nasal Endoscopy

L i k e anterior a n d posterior r h i n o s c o p y , e n d o s c o p y o f nose

Technique
a n d n a s o p h a r y n x helps i n the diagnosis o f diseases o f nose,

paranasal sinuses ( P N S ) a n d the nasopharynx. Because o f

After nasal packs are r e m o v e d , e n d o s c o p y is p e r f o r m e d b y
the b r i g h t e r i l l u m i n a t i o n , m a g n i f i c a t i o n a n d angled v i e w
three passes:
p r o v i d e d b y the endoscopes, i t is p o s s i b l e to e x a m i n e all

clefts a n d crevices o f the nose a n d nasopharynx. I t is an

First Pass (Examination of nasopharynx and
i m p o r t a n t part o f e x a m i n a t i o n o f nose a n d nasopharynx.
inferior meatus)

1. First o b t a i n a general v i e w o f the nasal cavity. L o o k

^ Indications
for a n y septal d e v i a t i o n o r spurs a n d t h e i r size, m u c o u s

or p u r u l e n t discharge i n the nasal cavity a n d c o l o u r o f

T o diagnose any disease o f the nose a n d P N S .
the nasal m u c o u s m e m b r a n e .
2. T o diagnose source o f b l e e d i n g i n epistaxis.
2. Pass the endoscope a l o n g the floor o f nose i n t o the
3. T o assess r e s p o n s e t o m e d i c a l o r surgical t r e a t m e n t o f
n a s o p h a r y n x a n d e x a m i n e : (i) o p e n i n g o f eustachian
the nose a n d P N S disease.
tube, (ii) walls o f nasopharynx, (iii) u p p e r surface o f
4. T o take a precise b i o p s y f r o m nose a n d nasopharynx.
soft palate a n d u v u l a , a n d (iv) o p e n i n g o f eustachian

t u b e o f opposite side. T o see these structures e n d o -

s c o p e is rotated.
Anaesthesia
3. W i t h d r a w the e n d o s c o p e slightly a n d e x a m i n e

t h e m a r g i n s o f c h o a n a a n d p o s t e r i o r ends o f
T o p i c a l anaesthesia w i t h 4% x y l o c a i n e a n d a vasoconstrictor
turbinates.
(oxymetazoline), f i r s t as a n a s a l spray a n d t h e n nasal packs.
4. W i t h d r a w endoscope s l o w l y a n d at the same t i m e

e x a m i n e inferior meatus f o r o p e n i n g o f nasolacrimal

Position d u c t a n d Hasner's valve. Slight pressure o v e r the lac-

r i m a l sac m a y express a d r o p o r t w o o f lacrimal fluid

Sitting o r supine. t h r o u g h the nasolacrimal o p e n i n g .

Instruments Second Pass (Examination of the sphenoethmoidal recess,

superior meatus and openings of sphenoid sinus and
posterior ethmoidal cells)
!. 4 m m 3 0 ° endoscope

2.7 m m 3 0 ° e n d o s c o p e 1 R e q u i r e d w h e n nasal E n d o s c o p e is passed m e d i a l to m i d d l e turbinate to

2.7 n u n 7 0 ° endoscope j passages are n a r r o w e x a m i n e posterior part o f m i d d l e turbinate, s p h e n o e t h -

2. Freer's elevator o r elevator w i t h a s u c t i o n c h a n n e l m o i d a l recess, superior turbinate a n d meatus, o p e n i n g s o f

S u c t i o n tips p o s t e r i o r e t h m o i d cells ( i n t h e superior meatus) a n d o p e n -

B i o p s y forceps i n g o f s p h e n o i d sinus i n the posterior wall o f s p h e n o e t h -

5. A n t i f o g solution o r S a v l o n ™ t o p r e v e n t f o g g i n g o f m o i d a l recess b e t w e e n the nasal s e p t u m a n d superior

the endoscopic lens. turbinate.

Operative Surgery

Third Pass (Examination of the middle meatus in detail) are seen f r o m b e h i n d f o r w a r d , e.g. basal l a m i n a , b u l l a e t h -

moidalis, hiatus semilunaris, sinus o f the turbinate a n d

E n d o s c o p e is p a s s e d f r o m the front i n t o the m i d d l e meatus.
u n c i n a t e process a n d the frontal recess.
S o m e t i m e s m i d d l e turbinate needs to be displaced m e d i -

ally o r 2.7 m m 3 0 ° e n d o s c o p e h a v e to be used. E x a m i n e

uncinate process, bulla ethmoidalis, hiatus semilunaris,

J| Complications
sinus o f the turbinate (cavity o n lateral side o f m i d d l e t u r -

binate) a n d the frontal recess. S o m e t i m e s b l e e d i n g can o c c u r d u e to suction o r m a n i p u -

S o m e t i m e s m i d d l e m e a t u s is b e t t e r entered f r o m b e h i n d lation o f instruments. It is usually m i l d a n d easily c o n -

w h e r e the s p a c e is w i d e r t h a n f r o m the front a n d structures trolled b y vasoconstrictor nasal drops.

Endoscopic Sinus Surgery

E n d o s c o p i c surgeiy has m a d e a great c o n t r i b u t i o n towards C o n t r o l o f epistaxis b y endoscopic cautery.

m a n a g e m e n t o f sinus disease. Indications for c o n v e n t i o n a l R e m o v a l o f foreign b o d y f r o m the nose o r sinus.

operations like those o f C a l d w e l l - L u c , frontal sinus opera- 9. E n d o s c o p i c septoplasty.

tions, external e t h m o i d e c t o m y have greatly reduced.

E n d o s c o p i c surgery is m i n i m a l l y invasive surgery a n d does

Advanced Nasal Endoscopic Techniques
n o t require skin incisions or r e m o v a l o f i n t e r v e n i n g b o n e to

access t h e disease. I n t h e sinuses, ventilation a n d drainage o f

1. R e m o v a l o f b e n i g n t u m o u r s , e.g. i n v e r t e d papillomas
the sinuses is established preserving the nasal a n d sinus
or a n g i o f i b r o m a s .
m u c o s a a n d its f u n c t i o n o f m u c o c i l i a r y clearance. A d v a n c e s
O r b i t a l abscess o r cellulitis m a n a g e m e n t .
in endoscopic surgery have b e e n possible d u e to:
3. D a c r y o c y s t o r h i n o s t o m y .

D e v e l o p m e n t o f better optics. R e p a i r o f C S F leak.

2. I m p r o v e d b r i g h t e r i l l u m i n a t i o n . 5. Pituitary surgery.

3. D e v e l o p m e n t o f m i c r o s u r g i c a l instruments to w o r k O p t i c n e r v e d e c o m p r e s s i o n .

w i t h the endoscopes a n d precise r e m o v a l o f tissue 7. O r b i t a l d e c o m p r e s s i o n for Graves disease.

w i t h sharp cuts w i t h o u t stripping the m u c o s a . 8. C o n t r o l o f posterior epistaxis (endoscopic c l i p p i n g o f

4. C o n c o m i t a n t d e v e l o p m e n t s i n i m a g i n g techniques sphenopalatine artery).

like C T a n d M R I to precisely define the area o f C h o a n a l atresia.

p a t h o l o g y .

5. I n t r o d u c t i o n o f p o w e r e d i n s t r u m e n t a t i o n i n the f o r m
Contraindications
o f soft-tissue shavers also called m i c r o - d e b r i d e r s (to

r e m o v e nasal polyps, soft-tissue masses o r m u c o s a )

I n e x p e r i e n c e a n d lack o f p r o p e r i n s t r u m e n t a t i o n .
h e l p r e d u c e b l e e d i n g to a great extent w h i l e b o n e -
Disease inaccessible b y endoscopic procedures, e.g.
c u t t i n g drills help endoscopic surgery o f frontal sinus,
lateral frontal sinus disease a n d stenosis o f internal
lacrimal sac, etc. to r e m o v e b o n y o b s t r u c t i o n .
o p e n i n g o f frontal sinus.
6. T h e latest a d v a n c e m e n t has b e e n the c o m p u t e r - a s -
Osteomyelitis.
sisted i m a g e - g u i d e d navigational surgery i n difficult

cases or revisional surgery w h e n l a n d m a r k s are n o t

easy t o identify. T h r e a t e n e d intracranial or intraorbital c o m p l i c a t i o n .

Indications Anaesthesia
G e n e r a l anaesthesia is p r e f e r r e d b y m o s t o f the surgeons.

Local anaesthesia w i t h i.v. sedation can be used i n adults

1. C h r o n i c bacterial sinusitis unresponsive to adequate
w h e n l i m i t e d w o r k is t o b e d o n e .
m e d i c a l treatment.

R e c u r r e n t acute bacterial sinusitis.

P o l y p o i d rhinosinusitis (diffuse nasal polyposis). Position

F u n g a l sinusitis w i t h fungal ball o r nasal p o l y p i .

A n t r o c h o a n a l p o l y p . Patient lies flat i n supine position w i t h h e a d resting o n a

M u c o c e l e o f f r o n t o e t h m o i d o r s p h e n o i d sinus. r i n g or h e a d rest. S o m e also prefer to raise it b y 1 5 ° .

Operative Surgery

T e c h n i q u e s (Fig. 87.1

T w o surgical techniques are f o l l o w e d :

(a) A n t e r i o r to posterior ( S t a m m b e r g e r ' s technique): I n

this t e c h n i q u e surgery proceeds f r o m uncinate p r o -

cess b a c k w a r d to s p h e n o i d sinus. A d v a n t a g e o f this

t e c h n i q u e is to tailor the extent o f surgery to the

extent o f disease.

Posterior to anterior (Wigand's technique): Surgery

starts at the sphenoid sinus and proceeds anteriorly

along the base o f skull a n d medial orbital wall. T h i s is

mostly d o n e i n extensive polyposis or i n revisional

sinus surgery.
F i g u r e 87.1

E n d o s c o p i c s u r g e r y in p r o g r e s s . E n d o s c o p e a n d o t h e r s u r g i c a l
Steps of Operation instruments are passed through the nose and surgery per-
f o r m e d by looking at t h e m o n i t o r .
1. R e m o v e the pledgets o f c o t t o n k e p t for nasal d e c o n -

gestion a n d topical anaesthesia.

2. Inspect the nose w i t h 4 m m 0 ° e n d o s c o p e or d o c o m -

plete nasal e n d o s c o p y i f n o t already d o n e .

3. Inject submucosally 1 % lignocaine w i t h 1:100,000

adrenaline u n d e r e n d o s c o p i c c o n t r o l (Fig. 87.2):

(a) O n the lateral w a l l , near the u p p e r e n d o f m i d d l e

turbinate.

(b) O n the lateral wall, just b e l o w the first injection.

(c) O n the lateral wall, just a b o v e the inferior

turbinate. Middle
Inferior turbinate
(d) I n the m i d d l e turbinate, posterior aspect.
turbinate
(e) Posterior aspect o f nasal septum.

4. R e p l a c e c o t t o n pledgets and repeat injections o n the

opposite side i f bilateral F E S S is t o b e d o n e . F i g u r e 87.2

Medialise the m i d d l e turbinate and identify the uncinate p r o - Sites o f i n j e c t i o n ( i n d i c a t e d by stars) j u s t a n t e r i o r t o u n c i n a t e

cess a n d bulla ethmoidalis. I f m i d d l e turbinate is l a r g e , partial process o n t h e lateral w a l l o f r i g h t side o f nose.

o r total t u r b i n e c t o m y is p e i f o n n e d . I n case o f c o n c h a bullosa,

l a t e r a l l a m e l l a is r e m o v e d . D e f i n i t i v e surgical steps include:

1. Uncinectomy U n c i n a t e p r o c e s s is i n c i s e d w i t h sickle cells. I t is p e n e t r a t e d i n the l o w e r and medial part w i t h

knife a n d r e m o v e d w i t h Blakesley forceps. a small curette and then r e m o v e d w i t h Blakesley for-

2. Identification and enlargement of maxillary ceps. Posterior e t h m o i d cells are exentcrated. O p t i c

ostium M a x i l l a r y o s t i u m lies a b o v e the inferior tur- nerve is at risk i f O n o d i c e l l is p r e s e n t . O n o d i c e l l is a

binate a n d posterior to l o w e r t h i r d o f uncinate p r o - posterior e t h m o i d cell w h i c h extends into the sphenoid

cess. O n c e localised, it is enlarged anteriorly w i t h a b o n e lateral a n d superior to the sphenoid sinus.

b a c k - b i t i n g forceps o r posteriorly w i t h a t h r o u g h c u t - C l e a r a n c e o f frontal recess a n d frontal sinuso-

straight forceps. tomy I f f r o n t a l s i n u s is c l e a r o n C T scan a n d patient

3. Bullectomy B u l l a ethmoidalis is p e n e t r a t e d w i t h also does n o t suffer f r o m frontal headaches, n o t h i n g

curette o r Blakesley forceps a n d r e m o v e d . A v o i d n e e d to be d o n e . I n the event o f frontal sinus disease,

injury to m e d i a l orbital wall, skull base o r anterior frontal recess is cleared a n d frontal sinus drainage

e t h m o i d a l arteiy. established.

4. Penetration o f basal lamella a n d r e m o v a l o f p o s - O p e n i n g o f frontal sinus is situated lateral to

t e r i o r e t h m o i d cells Basal l a m e l l a is t h e d i v i d i n g thin a t t a c h m e n t o f m i d d l e turbinate, m e d i a l to m e d i a l

b o n y s e p t u m b e t w e e n anterior and posterior e t h m o i d orbital wall, anterior to anterior e t h m o i d a l artery and

 E n d o s c o p i c Sinus Surgery

posterior to agger nasi cell(s). Surgery i n the area o f

T a b l e 87.1 Major and minor complications o f endoscopic
frontal recess is challenging as any disrespect to the
sinus surgery
m u c o s a i n this area w o u l d lead to stenosis o f frontal

sinus o p e n i n g w i t h m u c o c e l e f o r m a t i o n o r recurrent
Major Minor

frontal sinusitis. 1. O r b i t a l haemorrhage 1. Periorbital ecchymosis

6. Sphenoidotomy T h i s step is d o n e after clearance o f 2. Loss o f vision/blindness 2. Periorbital emphysema

posterior e t h m o i d cells or after frontal s i n u s o t o m y . It 3. Diplopia 3. Post-operative epistaxis

is o m i t t e d i f s i n u s is h e a l t h y . I n this p r o c e d u r e anterior 4. CSF leak 4. Post-operative infection:

5. Meningitis rhinitis or sinusitis

wall o f s p h e n o i d s i n u s is r e m o v e d , and pus a n d inspis-
6. Brain abscess 5. Adhesions
sated material f r o m w i t h i n the sinus r e m o v e d . T h e r e
7. Massive haemorrhage 6. S t e n o s i s o f m a x i l l a r y o r
are t w o w a y s to r e m o v e the anterior sinus wall:
requiring frontal sinus opening
(a) B y e n t e r i n g the s p h e n o i d sinus anterior a n d infe-
bloodtransfusion 7. E x a c e r b a t i o n o f asthma
rior to the e t h m o i d cavity created b y the a b o v e
8.Intracranial 8. H y p o s m i a
steps.
haemorrhage and 9. Dental pain
(b) B y enlarging the o p e n i n g o f s p h e n o i d sinus w i t h
direct brain t r a u m a

Blakesley forceps o r J-curette. Sinus o p e n i n g is 9. A n o s m i a

identified after r e m o v a l o f the posterior-inferior 10. Injury to internal carotid

p o r t i o n o f superior turbinate near the nasal sep- artery in sphenoid sinus

t u m a n d about 1.0 c m a b o v e the u p p e r b o r d e r o f 11. Injury to nasolacrimal

posterior choana. duct and epiphora

Nasal packs Finally the nasal packs are applied, i f

12. Death

septal surgery has also b e e n d o n e w i t h F E S S o r to stop

any b l e e d i n g f r o m the nasal cavity.

Endoscopic toilet B l o o d clots, crusts a n d debris are

r e m o v e d b y s u c t i o n a n d forceps from the e t h m o i d

Post-operative Care
area lateral to m i d d l e turbinate. A n y adhesion f o r m a ¬

t i o n i n the nose is d i v i d e d w i t h suction. H e a l t h y

It is individualised a c c o r d i n g to the extent o f surgery
m u c o s a s h o u l d n o t be disturbed. S u c t i o n can be d o n e
done.
from w i t h i n the m a x i l l a r y sinus w i t h a c u r v e d c a n -

I. Removal of nasal packs Nasal packs, i fkept, are nula. Since the endoscopic c l e a r a n c e is a p a i n f u l p r o -

r e m o v e d at the t i m e o f discharge 24 hours after the cess, topical nasal anaesthetic w i t h a decongestant is

operation. sprayed before the procedure.

2. Antibiotics A n intraoperative intravenous antibiotic

Patient pays w e e k l y visits for i n s p e c t i o n o f the cavity for
( a m o x y c l a v , cephalosporin or q u i n o l o n e ) is a d m i n i s -
4 w e e k s and thereafter as r e q u i r e d till mucosalisation o f
tered a n d t h e n c o n t i n u e d f o r 7—10 days b y oral
the c a v i t y is c o m p l e t e .
route.

Antihistaminics F o r allergic patients.

A. Analgesics F o r relief o f post-operative pain. Complications

7). Nasal irrigations Saline i r r i g a t i o n s are started after

1 w e e k post-operatively to r e m o v e b l o o d clots, crusts T h e y are similar to c o n v e n t i o n a l surgery o f e t h m o i d c o m -

a n d secretions a n d c o n t i n u e d o n c e or t w i c e a day for plex and can be d i v i d e d i n t o m a j o r and m i n o r . M o s t l y

1 w e e k . they i n v o l v e orbit o r skull base, o r are o f general nature

h. Steroid nasal sprays R e q u i r e d i n cases o f nasal allergy (see T a b l e 87.1). M a n y o f the c o m p l i c a t i o n s are prevent-

or those operated f o r nasal polyps. able b y careful surgical technique.

D i r e c t Laryngoscopy

I t is d i r e c t v i s u a l i s a t i o n o f l a r y n x a n d h y p o p h a r y n x . children, n o anaesthesia m a y be r e q u i r e d i f p r o c e d u r e is

for diagnostic purpose.

^ Position j
Indications ^^^J
A. Diagnostic
Patient lies s u p i n e . H e a d is e l e v a t e d b y 10—15 c m b y plac-
1 - W h e n i n d i r e c t l a r y n g o s c o p y is n o t possible as i n
i n g a p i l l o w u n d e r the o c c i p u t o r b y raising h e a d flap o f
infants a n d y o u n g children, and the s y m p t o m a t o l o g y
the o p e r a t i o n table. N e c k is f l e x e d o n t h o r a x a n d the h e a d
points to l a r y n x a n d / o r h y p o p h a r y n x , e.g. hoarseness,
e x t e n d e d o n atlanto-occipital j o i n t (Barking-dog position).
dyspnoea, stridor a n d dysphagia.

2. W h e n indirect laryngoscopy has n o t b e e n successful,

e.g. due to excessive gag reflex o r o v e r h a n g i n g epiglot- Procedure |

tis o b s c u r i n g a p a r t o f t h e complete v i e w o f the larynx.

3. T o e x a m i n e h i d d e n areas of: 1. A piece o f gauze is p l a c e d o n the u p p e r teeth to p r o -

Hypopharynx: Base o f tongue, valleculae a n d l o w e r tect t h e m against trauma.

part o f p y r i f o r m fossa. 2. L a r y n g o s c o p e is lubricated w i t h a little autoclaved

Larynx: I n f r a h y o i d epiglottis, anterior c o m m i s s u r e , l i q u i d paraffin o r gelly.

ventricles a n d subglottic region. 3. L a r y n g o s c o p e is h e l d b y the handle i n the left hand.

4. T o f i n d the extent o f g r o w t h and take a biopsy. R i g h t h a n d is used, to retract the lips and guide the

laryngoscope and to handle s u c t i o n a n d instruments.

B. Therapeutic
4. L a r y n g o s c o p e is i n t r o d u c e d b y o n e side o f the t o n g u e

1. R e m o v a l o f b e n i g n lesions o f larynx, e.g. p a p i l l o m a , w h i c h is p u s h e d to the opposite side till posterior

f i b r o m a , v o c a l n o d u l e , p o l y p or cyst. t h i r d o f t o n g u e is reached. I t is t h e n m o v e d to the

2. R e m o v a l o f f o r e i g n bodies f r o m l a r y n x a n d m i d l i n e a n d lifted f o r w a r d to b r i n g the epiglottis i n

h y p o p h a r y n x . v i e w .

3. D i l a t a t i o n o f laryngeal strictures. 5. L a r y n g o s c o p e is n o w a d v a n c e d b e h i n d the epiglottis

a n d lifted f o r w a r d without levering it on the upper teeth or

jaw (Fig. 88.1). T h i s gives g o o d v i e w o f the interior o f
Contraindications
the larynx.

6. I f anterior c o m m i s s u r e laryngoscope is b e i n g used, its

Diseases o r injuries o f cervical spine.
tip can b e advanced further b e t w e e n the ventricular
2. M o d e r a t e o r m a r k e d respiratory o b s t r u c t i o n unless
bands to e x a m i n e the ventricles a n d anterior c o m m i s -
the a i r w a y has b e e n p r o v i d e d b y tracheostomy.
sure. It can be passed b e t w e e n the v o c a l cords to
3. R e c e n t coronary o c c l u s i o n o r cardiac decompensation.
e x a m i n e the subglottic r e g i o n .

F o l l o w i n g structures are e x a m i n e d serially: Base o f

Anaesthesia t o n g u e , right a n d left valleculae, epiglottis, (its tip,

lingual a n d l a r y n g e a l surfaces), right a n d left p y r i f o r m

G e n e r a l a n a e s t h e s i a is p r e f e r r e d t h o u g h this p r o c e d u r e can sinuses, aryepiglottic folds, arytenoids, p o s t - c r i c o i d

be p e r f o r m e d u n d e r local anaesthesia. I n infants a n d y o u n g region, b o t h false cords, anterior a n d posterior

 Direct Laryngoscopy

the p r o c e d u r e is c o m p l e t e d , laryngoscope is w i t h d r a w n

a n d lips a n d teeth e x a m i n e d for any injury.

Post-operative Care

1. Patient is k e p t i n c o m a p o s i t i o n t o p r e v e n t aspiration

o f b l o o d or secretions.

2. Patient's respiration s h o u l d be w a t c h e d for a n y l a r y n -

geal spasm a n d cyanosis.

3. T r a u m a to larynx, especially i f repeated attempts at

l a r y n g o s c o p y have b e e n m a d e . It m a y lead t o l a r y n -

geal o e d e m a a n d respiratory distress.

4. B l e e d i n g m a y occur from the o p e r a t i v e site. P a t i e n t m a y

spit b l o o d . Care should be taken to prevent aspiration.

Complications
Direct laryngoscopy.

I n j u r y to lips a n d t o n g u e i f t h e y are n i p p e d b e t w e e n
c o m m i s s u r e , right a n d left ventricles, right a n d left
the teeth a n d the laryngoscope.
v o c a l cords a n d subglottic area. M o b i l i t y o f v o c a l
I n j u r y t o teeth. T h e y m a y get dislodged a n d fall into
cords s h o u l d also be observed.
p h a r y n x .

A r i g h t - a n g l e d telescope can be used to see the u n d e r - B l e e d i n g .

surface o f vocal cords a n d the walls o f the subglottis. After Laryngeal oedema.
Bronchoscopy

B r o n c h o s c o p y is o f t w o types:
Technique

R i g i d .

Flexible fibre optic. T h e r e are t w o m e t h o d s to i n t r o d u c e b r o n c h o s c o p e :

1. Direct method. H e r e bronchoscope is introduced

directly t h r o u g h the glottis.

RIGID BRONCHOSCOPY 2. Through laryngoscope. H e r e g l o t t i s is f i r s t exposed w i t h

the h e l p o f a spatular type laryngoscope a n d t h e n the

b r o n c h o s c o p e is i n t r o d u c e d t h r o u g h t h e laryngoscope
Indications
into the trachea. L a r y n g o s c o p e is t h e n w i t h d r a w n .

T h i s m e t h o d is u s e f u l i n infants a n d y o u n g children,
A. Diagnostic
a n d i n adults w h o have short n e c k a n d t h i c k t o n g u e .

I. T o f i n d o u t the cause for w h e e z i n g , haemoptysis, o r

u n e x p l a i n e d c o u g h persisting for m o r e than 4 weeks.

W h e n X - r a y chest shows:
Details of Technique

(a) Atelectasis o f a segment, lobe or entire l u n g

1. A piece o f gauze is p l a c e d o n the u p p e r teeth f o r their

(b) O p a c i t y localised to a segment o r l o b e o f l u n g

p r o t e c t i o n against injury.
fc) Obstructive e m p h y s e m a — t o exclude foreign b o d y

2. Proper-sized b r o n c h o s c o p e is l u b r i c a t e d w i t h a swab
(d) H i l a r o r mediastinal shadows

o f autoclaved l i q u i d paraffin or gelly. I t is h e l d b y t h e shaft

3. V o c a l c o r d palsy.
in surgeon's right h a n d in a p e n - l i k e fashion. Fingers o f
4. C o l l e c t i o n o f b r o n c h i a l secretions for culture a n d sen-
the left h a n d are used to retract the u p p e r lip a n d g u i d e the
s i t i v i t y tests, a c i d fast b a c i l l i , fungus, m a l i g n a n t cells.
b r o n c h o s c o p e .

B. Therapeutic 3. N o w l o o k i n g t h r o u g h the scope, tip o f epiglottis is

identified first a n d the scope passed b e h i n d it a n d the epi-

1. R e m o v a l o f foreign bodies.
glottis lifted f o r w a r d to expose the glottis. N o w b r o n c h o -
2. R e m o v a l o f retained secretions or m u c u s p l u g i n cases
s c o p e is r o t a t e d 9 0 ° c l o c k w i s e so t h a t its b e v e l l e d t i p is i n the
o f h e a d injuries, chest trauma, thoracic or a b d o m i n a l
axis o f glottis t o ease its e n t r y i n t o t h e trachea. O n c e trachea
surgery, o r c o m a t o s e d patients.
is e n t e r e d , s c o p e is r o t a t e d b a c k to the original position.

4. B r o n c h o s c o p e is g r a d u a l l y a d v a n c e d a n d the entire

t r a c h e o b r o n c h i a l tree e x a m i n e d . A x i s o f b r o n c h o s c o p e
Anaesthesia
s h o u l d be m a d e to c o r r e s p o n d w i t h axes o f the trachea

a n d b r o n c h i . T o achieve this, head a n d n e c k are flexed to

G e n e r a l anaesthesia w i t h n o endotracheal tube o r w i t h
the left w h e n e x a m i n i n g the right b r o n c h i a l tree a n d vice
o n l y a small b o r e catheter is o f t e n p r e f e r r e d . I t can also be
versa.
d o n e u n d e r topical surface anaesthesia.
O p e n i n g s o f all t h e segmental b r o n c h i i n b o t h the lungs

are e x a m i n e d seriatim.

Position 5. D i r e c t v i s i o n , r i g h t a n g l e d a n d r e t r o g r a d e tele-

scopes c a n b e used f o r m a g n i f i c a t i o n a n d d e t a i l e d

S a m e as for direct laryngoscopy. e x a m i n a t i o n .

 6. B i o p s y o f the lesion o f suspicious area can be taken. D o n o t force b r o n c h o s c o p e t h r o u g h closed glottis.

7. Secretions can be collected for exfoliative c y t o l o g y , 3. R e p e a t e d r e m o v a l a n d i n t r o d u c t i o n o f b r o n c h o s c o p e

o r bacteriologic e x a m i n a t i o n . s h o u l d be avoided.

4. P r o c e d u r e s h o u l d n o t be p r o l o n g e d b e y o n d 20 m i n -

utes i n infants a n d children, o t h e r w i s e it m a y cause

Post-operative Care
subglottic o e d e m a i n post-operative p e r i o d .

K e e p the patient i n h u m i d atmosphere.

W a t c h for respiratory distress. T h i s c o u l d be due to FLEXIBLE FIBRE OPTIC

laryngeal spasm o r subglottic o e d e m a i f the p r o c e d u r e BRONCHOSCOPY
h a d been u n d u l y p r o l o n g e d o r the b r o n c h o s c o p e

i n t r o d u c e d repeatedly. Inspiratory stridor a n d supra-

T h e s e days, flexible fibre optic b r o n c h o s c o p y has replaced
sternal retraction w i l l indicate n e e d for tracheostomy.
rigid b r o n c h o s c o p y for diagnostic procedures particularly

in adults. I t provides m a g n i f i c a t i o n a n d better i l l u m i n a -

Complications tion, a n d because o f the smaller size o f scope, p e r m i t s

e x a m i n a t i o n o f subsegmental b r o n c h i . I t is also easy t o use

I n j u r y to teeth a n d lips. in patients w i t h n e c k o r j a w abnormalities w h e r e rigid

2. H a e m o r r h a g e f r o m the b i o p s y site. b r o n c h o s c o p y m a y almost be impossible technically. T h i s

3. H y p o x i a a n d cardiac arrest. p r o c e d u r e can be p e r f o r m e d u n d e r topical anaesthesia a n d

Laryngeal o e d e m a . is v e r y useful for bedside e x a m i n a t i o n o f the critically i l l

patients. T h e s u c t i o n / b i o p s y channel p r o v i d e d i n the

fibrescope helps to r e m o v e secretions, inspissated plugs o f

Precautions During Bronchoscopy m u c u s o r e v e n small foreign bodies. Flexible b r o n c h o -

scope can also be easily passed t h r o u g h endotracheal tube

Select p r o p e r size o f b r o n c h o s c o p e a c c o r d i n g to o r the t r a c h e o s t o m y o p e n i n g . H o w e v e r , it has l i m i t e d

patient's age (see T a b l e A l i n A p p e n d i x I I ) . utility i n c h i l d r e n because o f the p r o b l e m s o f ventilation.

Oesophagoscopy

O e s o p h a g o s c o p y is o f t w o types: R e c e d i n g m a n d i b l e .

4. A n e u r y s m o f aorta f o r fear o f r u p t u r e a n d fatal

1. R i g i d oesophagoscopy.
h a e m o r r h a g e .
Flexible fibre-optic oesophagoscopy.
A d v a n c e d heart, liver o r k i d n e y disease m a y be a

relative c o n t r a i n d i c a t i o n .

RIGID OESOPHAGOSCOPY

Indications Anaesthesia J

G e n e r a l anaesthesia w i t h oro-tracheal i n t u b a t i o n , w i t h
A. Diagnostic
tube i n the left c o r n e r o f the m o u t h . I t can b e p e r f o r m e d

1. T o investigate cause f o r dysphagia, e.g. cancer u n d e r local anaesthesia i n selected individuals.

oesophagus, cardiac achalasia, strictures, oesophagitis,

diverticula, etc. Position

T o f i n d cause for retrosternal b u r n i n g , e.g. reflux

oesophagitis or hiatus hernia. S a m e as for direct laryngoscopy. Patient lies s u p i n e , h e a d

3. T o f i n d cause for haematemesis, e.g. oesophageal is elevated b y 1 0 - 1 5 c m , n e c k flexed o n chest, a n d h e a d

varices. e x t e n d e d at atlanto-occipital j o i n t . T h e purpose o f this

4. Secondaries n e c k w i t h u n k n o w n p r i m a r y (as a p a r t o f position is t o attain the axes o f m o u t h , p h a r y n x a n d

p a n e n d o s c o p y ) . oesophagus i n a straight line to pass the rigid tube easily.

T h i s p o s i t i o n can be a c h i e v e d w i t h the help o f a n assistant

B. Therapeutic o r a special h e a d rest.

1. R e m o v a l o f a foreign b o d y .

2. D i l a t a t i o n i n case o f oesophageal strictures o r cardiac

Technique
achalasia.

3. E n d o s c o p i c r e m o v a l o f b e n i g n lesions, e.g. f i b r o m a ,
1. A piece o f gauze is placed o v e r the u p p e r teeth t o
p a p i l l o m a , cysts, etc.
p r o t e c t teeth a n d lips.
4. I n s e r t i o n o f Soutar's or M o u s s e a u — B a r b i n tube i n pal-
2. O e s o p h a g o s c o p e is lubricated w i t h a s w a b o f a u t o -
liative treatment o f oesophageal c a r c i n o m a .
claved l i q u i d paraffin o r jelly.
5. I n j e c t i o n o f oesophageal varices.
3. T h e o e s o p h a g o s c o p e is h e l d b y its p r o x i m a l e n d i n a

p e n - l i k e fashion a n d i n t r o d u c e d i n t o the m o u t h b y

Contraindications the right side o f the t o n g u e a n d t h e n t o w a r d s the

m i d d l e o f its d o r s u m .

1. T r i s m u s — m a k e s the p r o c e d u r e technically difficult.

N o w there are 4 basic steps:
5 Disease o f cervical spine, e.g. cervical trauma, s p o n d y l o -

sis, t u b e r c u l o u s s p i n e , o s t e o p h y t e s , kyphosis. T h e y m a k e Identification of arytenoids. O n c e o e s o p h a g o s c o p e has

rigid oesophagoscopy technically difficult. Flexible fibre- b e e n i n t r o d u c e d to the b a c k o f t o n g u e , i t is a d v a n c e d

optic oesophagoscopy is p e r f o r m e d i n t h e s e cases. gently b y the left t h u m b a n d i n d e x finger. Epiglottis

 Oesophagoscopy

is first seen, t h e n the endotracheal tube a n d a little

further d o w n arytenoids can be identified.

2. Passing the cricopharyngeal sphincter. K e e p i n g the tip o f

oesophagoscope strictly i n the midline, b e h i n d the lar-

y n x , i t is l i f t e d w i t h m o v e m e n t s o f left t h u m b to o p e n

the h y p o p h a r y n x . W i t h s l o w b u t sustained pressure,

the sphincter will o p e n a n d t h e n the tip o f o e s o p h a g o -

scope can be g u i d e d easily i n t o t h e oesophagus. N e v e r

apply force to o p e n the sphincter. Sometimes, a fine

b o u g i e can be used to find the l u m e n . A n additional

dose o f muscle relaxant m a y be required i f sphincter

does n o t open. O n c e oesophagus has been entered, it

is easier to advance the scope, p r o v i d e d , oesophageal

l u m e n is k e p t constantly i n v i e w .

3. Crossing the aortic arch and left bronchus. I n an adult, this

natural n a r r o w i n g lies a b o u t 25 c m f r o m the incisors.

A o r t i c pulsation can b e seen. W h e n crossing this area,

h e a d o f the patient is s l i g h t l y l o w e r e d so that o e s o p h -

ageal l u m e n is i n l i n e w i t h that o f the scope.

4. Passing the cardia. H e a d and shoulders r e m a i n b e l o w

F i g u r e 90.1

the level o f the table, head b e i n g slightly h i g h e r than

Flexible f i b r e o p t i c o e s o p h a g o s c o p y .
the shoulders a n d m o v e d slightly to the right. A t this

stage, the oesophagoscope points to the left anterior-

superior iliac spine. C a r d i a is i d e n t i f i e d b y its redder

obstruction to respiration a n d cyanosis. T r e a t m e n t is
a n d m o r e velvety o r rugose mucosa.
i m m e d i a t e w i t h d r a w a l o f oesophagoscope.
Never forget to inspect the oesophageal w a l l again w h e n

the o e s o p h a g o s c o p e is w i t h d r a w n .

FLEXIBLE FIBRE OPTIC

OESOPHAGOSCOPY
Post-operative Care

L. Sips o f p l a i n w a t e r f o l l o w e d b y usual diet m a y be Its m a i n advantage o v e r the rigid o e s o p h a g o s c o p y is t h a t i t

g i v e n i n an u n e v e n t f u l oesophagoscopy. is a n o u t d o o r procedure, does n o t require general anaes-

2. Patient is w a t c h e d for pain i n the interscapular r e g i o n , thesia a n d can be used i n patients w i t h abnormalities o f

surgical e m p h y s e m a o f neck, and abrupt rise o f t e m - spine o r j a w w h e r e rigid e n d o s c o p y is t e c h n i c a l l y difficult.

perature. T h e y indicate oesophageal perforation. T h e oesophagus, s t o m a c h a n d d u o d e n u m can all b e e x a m -

i n e d i n o n e sitting. G o o d i l l u m i n a t i o n and m a g n i f i c a t i o n

p r o v i d e d b y the fibrescope helps i n the accurate diagnosis

Complications
o f the m u c o s a l disease a f f e c t i n g t h e s e sites a n d permits tak-

i n g o f precision biopsies, r e m o v a l o f small foreign bodies

X. Injury to lips and teeth. o r b e n i g n t u m o u r s , dilatation o f w e b s o r strictures and

2. Injury to arytenoids. e v e n i n j e c t i o n o f b l e e d i n g varices w i t h sclerosing agents

3. Injury to pharyngeal mucosa. T h e y are all the result o f ( F i g . 9 0 . 1 ) . I n cases o f m a l i g n a n t disease, o e s o p h a g e a l stent

careless t e c h n i q u e a n d can be a v o i d e d . can be placed as a p a l l i a t i v e measure.

4. Peforation of oesophagus. M o s t often it occurs at the site T h e p r o c e d u r e is p e r f o r m e d u n d e r local anaesthesia

o f Killian's dehiscence (near cricopharyngeal sphincter) w i t h o r w i t h o u t i n t r a v e n o u s sedation. T h e patient lies i n

w h e n u n d u e f o r c e has b e e n u s e d t o pass t h e oesophago- left lateral p o s i t i o n a n d fibrescope is passed t h r o u g h a

scope. Surgical e m p h y s e m a develops w i t h i n an h o u r o r plastic m o u t h p r o p i n t o the p h a r y n x , p o s t - c r i c o i d area

so a n d the patient complains o f pain i n the interscapular a n d oesophagus, insufflating air as the e n d o s c o p e is

region. T h i s m a y be complicated b y abscess i n retro- advanced, to o p e n the l u m e n o f oesophagus. T h e s e days

pharyngeal space o r m e d i a s t i n u m . flexible fibre o p t i c o e s o p h a g o s c o p y has practically

Compression of trachea. O e s o p h a g o s c o p e m a y press o n replaced rigid o e s o p h a g o s c o p y except i n s o m e cases o f

posterior tracheal wall, especially i n c h i l d r e n , causing f o r e i g n bodies.

Tonsillectomy

2. Glossopharyngeal n e u r e c t o m y . T o n s i l is r e m o v e d first
Indications
and t h e n I X nerve is s e v e r e d i n the b e d o f tonsil.

3. R e m o v a l o f styloid process.
T h e y are d i v i d e d into:

Contraindications
A. Absolute

Recurrent infections of throat. T h i s is t h e m o s t c o m m o n H a e m o g l o b i n l e v e l less t h a n 10 g % .

indication. R e c u r r e n t i n f e c t i o n s are further defined as: 2. Presence o f acute i n f e c t i o n i n u p p e r respiratory tract,

(a) Seven o r m o r e episodes i n o n e year, o r e v e n acute tonsillitis. B l e e d i n g is m o r e i n the pres-

(b) F i v e episodes per year for 2 years, b r ence o f acute infection.

(c) T h r e e episodes per year f o r 3 years, o r C h i l d r e n u n d e r 3 years o f age. T h e y are p o o r surgical

(d) T w o weeks or m o r e o f lost school o r w o r k i n one risks.

year. 4. O v e r t o r s u b m u c o u s cleft palate.

Peritonsillar abscess. I n children, t o n s i l l e c t o m y is d o n e B l e e d i n g disorders, e.g. l e u k a e m i a , p u r p u r a , aplastic

4 - 6 w e e k s after abscess has b e e n treated. I n adults, sec- anaemia, h a e m o p h i l i a .

o n d attack o f p e r i t o n s i l l a r abscess f o r m s the absolute 6. A t the t i m e o f e p i d e m i c o f p o l i o .

indication. U n c o n t r o l l e d systemic disease, e.g. diabetes, cardiac

3. Tonsillitis causing febrile seizures. disease, h y p e r t e n s i o n or asthma.

H y p e r t r o p h y o f tonsils causing 8. T o n s i l l e c t o m y is a v o i d e d d u r i n g the p e r i o d o f menses.

• a i r w a y o b s t r u c t i o n (sleep apnoea)

• difficulty i n deglutition
Anaesthesia
• interference w i t h speech.

Suspicion of malignancy. A unilaterally enlarged tonsil

Usually done u n d e r general anaesthesia w i t h endotracheal
m a y be a l y m p h o m a i n children a n d a n e p i d e r m o i d
intubation. I n adults, it m a y be d o n e u n d e r local anaesthesia.
c a r c i n o m a i n a d u l t s . A n e x c i s i o n a l b i o p s y is done.

Position
B. Relative

D i p h t h e r i a carriers, w h o d o n o t respond to antibiotics.

R o s e ' s p o s i t i o n , i.e. p a t i e n t lies s u p i n e w i t h head e x t e n d e d
Streptococcal carriers, w h o m a y be the source o f
by p l a c i n g a p i l l o w u n d e r the shoulders. A r u b b e r ring is
infection t o others.
placed u n d e r the h e a d t o stabilise it (Fig. 91.1). H y p e r -
C h r o n i c tonsillitis w i t h b a d taste o r halitosis w h i c h is
extension s h o u l d always be a v o i d e d .
unresponsive to m e d i c a l treatment.

R e c u r r e n t streptococcal tonsillitis i n a patient w i t h

Steps of Operation (Dissection and
valvular heart disease.
Snare Method)
I
C . As a Part of Another Operation
B o y l e - D a v i s m o u t h gag is i n t r o d u c e d a n d o p e n e d . I t

1. Palatopharyngopiasty w h i c h is d o n e f o r sleep apnoea is h e l d i n place b y Draffin's b i p o d s o r a string o v e r a

s y n d r o m e . pulley (Figs 91.2 a n d 91.3).

 Tonsillectomy

T o n s i l is grasped w i t h t o n s i l - h o l d i n g forceps a n d N o w the t o n s i l is h e l d at its u p p e r pole a n d traction

p u l l e d medially. applied d o w n w a r d s and medially. Dissection is c o n -

3. Incision is m a d e i n the m u c o u s m e m b r a n e w h e r e it t i n u e d w i t h tonsillar dissector or scissors until l o w e r

reflects from the tonsil to anterior pillar. It m a y be pole is r e a c h e d (Fig. 91.4).

e x t e n d e d a l o n g the u p p e r p o l e to m u c o u s m e m b r a n e N o w w i r e l o o p o f tonsillar snare is t h r e a d e d o v e r the

b e t w e e n the tonsil a n d posterior pillar. tonsil o n to its p e d i c l e , tightened, a n d the pedicle cut

4. A b l u n t c u r v e d scissor m a y be used to dissect the tonsil a n d the tonsil r e m o v e d .

f r o m the peritonsillar tissue a n d s e p a r a t e its u p p e r pole.

F i g u r e 91.1 Figure 91.3

R o s e ' s p o s i t i o n f o r t o n s i l l e c t o m y . N e c k is e x t e n d e d b y a s a n d T o n s i l l e c t o m y . B o y l e - D a v i s m o u t h g a g is s u p p o r t e d o n D r a f f i n ' s

b a g u n d e r t h e s h o u l d e r s a n d t h e h e a d is s u p p o r t e d o n a r i n g . bipods.

Figure 91.2

Set o f i n s t r u m e n t s f o r t o n s i l l e c t o m y .
(I) K n i f e in k i d n e y t r a y , ( 2 ) & ( 3 ) T o o t h e d a n d non-toothed Waugh's forceps, (4) Tonsil holding forceps, (5) Tonsil dissector
a n d a n t e r i o r pillar r e t r a c t o r , ( 6 ) Luc's f o r c e p s , ( 7 ) Scissor, ( 8 ) C u r v e d a r t e r y f o r c e p s , ( 9 ) Negus a r t e r y f o r c e p s , ( 1 0 ) T o n s i l l a r snare,
(II) B o y l e D a v i s m o u t h g a g w i t h t h r e e sizes o f t o n g u e b l a d e s , ( 1 2 ) Doyen's m o u t h gag, (13) A d e n o i d curette, (14) Tonsil swabs,
( 1 5 ) N a s o p h a r y n g e a l pack, ( 1 6 ) T o w e l clips.
7. A gauze s p o n g e is p l a c e d i n t h e fossa a n d pressure
T a b l e 91.1 Techniques o f tonsillectomy/tonsillotomy
applied f o ra f e w m i n u t e s .

8. B l e e d i n g points are tied w i t h silk. P r o c e d u r e is Cold Methods

repeated o n t h e o t h e r side. I Dissection a n d snare ( m o s t common)

II Guillotine method
III Intracapsular (capsule preserving) tonsillectomy with
Post-operative Care debrider

IV H a r m o n i c scalpel ( u l t r a s o u n d )

V Plasma-mediated ablation technique

1. I m m e d i a t e g e n e r a l c a r e
VI Cryosurgical technique
(a) K e e p t h e patient i n c o m a p o s i t i o n until fully r e c o v -
Hot methods
ered f r o m anaesthesia.
I Electrocautery
( b ) K e e p a w a t c h o n b l e e d i n g f r o m t h e nose a n d m o u t h .
II Laser t o n s i l l e c t o m y o r t o n s i l l o t o m y
(c) K e e p c h e c k o n vital signs, e.g. pulse, respiration a n d
(C0 2 o r KTP)
b l o o d pressure.
III Coblation tonsillectomy

2. D i e t W h e n patient is fully recovered h e is p e r m i t t e d t o IV Radio frequency

take liquids, e.g. c o l d m i l k o r i c e cream. S u c k i n g o f i c e

cubes gives relief f r o m pain. D i e t is g r a d u a l l y built f r o m

soft t o solid food. T h e y m a yt a k e custard, jelly, soft b o i l e d

eggs o r slice o f b r e a d soaked i nm i l k o n t h e2 n d day. Plenty

o f fluids s h o u l d b e encouraged. 3. Laser tonsillectomy. I t is i n d i c a t e d i n c o a g u l a t i o n disor-

3. O r a l h y g i e n e Patient is g i v e n C o n d y ' s o r salt w a t e r

ders. B o t h K T P - 5 1 2 a n d C O lasers h a v e b e e n used b u t

the f o r m e r is p r e f e r r e d . T e c h n i q u e is s i m i l a r t o o n e used
gargles 3 - 4 times a d a y .A m o u t h w a s h w i t h plain w a t e r

i n dissection m e t h o d .
after every feed helps t o k e e p t h e m o u t h clean.

4. Laser tonsillotomy. A n o t h e r m e t h o d is laser tonsillo-

4. Analgesics Pain, locally i n t h e throat a n d referred t o
t o m y w h i c h aims t o r e d u c e t h esize o f tonsils. I t is i n d i c a t e d
ear, c a n b e relieved b y analgesics like paracetamol. A n
in patients w h oa r e u n a b l e t o tolerate general anaesthesia.
analgesic c a nb e g i v e n half a n h o u r before meals.
Tonsils are r e d u c e d b y laser a b l a t i o n u p t o anterior pillars
5. A n t i b i o t i c s A suitable antibiotic can b e g i v e n orally o r
b y stage repeated applications.
b y i n j e c t i o n f o ra w e e k .
5. Intracapsular tonsillectomy. W i t h t h e use o f p o w e r e d

Patient is u s u a l l y sent h o m e 2 4 hours after operation instruments (debrider) t o n s i l is r e m o v e d b u t its capsule is

unless there is s o m e c o m p l i c a t i o n . Patient c a n r e s u m e h i s preserved i n t h e h o p e t o reduce post-operative pain.

n o r m a l duties w i t h i n 2 weeks. 6 . Harmonic scalpel. I t u s e s u l t r a s o u n d t o c u t a n d c o a g u l a t e

O t h e r m e t h o d s f o rt o n s i l l e c t o m y (Table 91.1) tissues. I t is a c o l d m e t h o d w i t h less tissue d a m a g e a n d post-

1. Guillotine method. Largely a b a n d o n e d . I t can b e d o n e operative pain c o m p a r e d t o electrocautery technique.

o n l y w h e n tonsils are m o b i l e a n d tonsil b e dhas n o t b e e n 7. Plasma-mediated ablation technique. I n this ablation

scarred b y repeated infections. m e t h o d , p r o t o n s are energized t o break m o l e c u l a r b o n d s

2. Electrocautery. B o t h u n i p o l a r a n d bipolar electrocau- b e t w e e n tissues. I t is a c o l d m e t h o d a n d does n o t cause

tery hasb e e n used. I t r e d u c e s b l o o d loss b u tcauses t h e r m a l t h e r m a l injury.

injury t o tissues. 8 . Coblation tonsillectomy.

 Tonsillectomy

9. Cryosurgical technique. Tonsil is frozen b y application o f B. Delayed

cryoprobe a n d then a l l o w e d to thaw. T w o applications, each

1. Secondary haemorrhage. U s u a l l y seen b e t w e e n the 5 t h
o f 3—4 minutes, are applied. Tonsillar tissue w i l l u n d e r g o
to 1 0 t h post-operative day. It is the result o f sepsis
necrosis a n d later fall o f f l e a v i n g a g r a n u l a t i n g surface. B l e e d i n g
a n d p r e m a t u r e separation o f the m e m b r a n e . U s u a l l y ,
is less d u e t o t h r o m b o s i s o f vessels c a u s e d b y freezing.
it is h e r a l d e d b y b l o o d s t a i n e d s p u t u m b u t m a y b e

profuse.

S i m p l e measures like r e m o v a l o f clot, topical application

Complications
o f dilute adrenaline or h y d r o g e n p e r o x i d e w i t h pressure

usually suffice. F o r profuse b l e e d i n g , general anaesthesia is

A. Immediate
g i v e n a n d b l e e d i n g vessel is electrocoagulated o r ligated.

1. Primary haemorrhage. O c c u r s at t h e t i m e o f operation. I t S o m e t i m e s , a p p r o x i m a t i o n o f pillars w i t h mattress sutures

can b e c o n t r o l l e d b y pressure, ligation o r electrocoagula- m a y b e r e q u i r e d . S o m e t i m e s , external carotid ligation m a y

t i o n o f the b l e e d i n g vessels. also be required.

2. Reactionary haemorrhage. O c c u r s w i t h i n a p e r i o d o f Transfusion o f b l o o d or plasma, d e p e n d i n g o n b l o o d

2 4 h o u r s a n d can be c o n t r o l l e d b y s i m p l e measures such as loss, is g i v e n . Systemic a n t i b i o t i c s are g i v e n f o r c o n t r o l o f

r e m o v a l o f the clot, application o f pressure o r v a s o c o n - infection.

strictor. Presence o f a clot prevents the c l i p p i n g a c t i o n o f 2. Infection. I n f e c t i o n o f tonsillar fossa m a y lead to

the superior constrictor m u s c l e o n the vessels w h i c h parapharyngeal abscess o r otitis m e d i a .

pass t h r o u g h i t ( c o m p a r e p o s t - p a r t u m uterine bleeding). I f 3. Lung complications. A s p i r a t i o n o f b l o o d , m u c u s or tis-

a b o v e measures fail, ligation o r electrocoagulation o f the sue fragments m a y cause atelectasis or l u n g abscess.

b l e e d i n g vessels can b e d o n e u n d e r general anaesthesia. 4 . Scarring in soft palate and pillars.

3. Injury to tonsillar pillars, uvula, soft palate, t o n g u e or 5. Tonsillar remnants. Tonsil tags o r tissue, left d u e t o

superior constrictor m u s c l e d u e to b a d surgical t e c h n i q u e . inadequate surgery, m a y get repeatedly infected.

4 . Injury to teeth. 6. Hypertrophy of lingual tonsil. T h i s is a l a t e c o m p l i c a t i o n

5 . Aspiration of blood. a n d is c o m p e n s a t o r y t o loss o f palatine tonsils.

6. Facial oedema. S o m e patients get o e d e m a o f the face S o m e t i m e s , l y m p h o i d tissue is l e f t i n the plica t r i a n g u -

particularly o f the eyelids. laris n e a r the l o w e r p o l e o f tonsil, w h i c h later gets h y p e r -

7. Surgical emphysema. R a r e l y occurs d u e t o injury to t r o p h i e d . Plica triangularis s h o u l d , therefore be r e m o v e d

superior constrictor muscle. d u r i n g t o n s i l l e c t o m y .

Adenoidectomy

A d e n o i d e c t o m y m a y be indicated alone o r i n c o m b i n a -
Steps of Operation
t i o n w i t h t o n s i l l e c t o m y . I n the latter event, adenoids are

r e m o v e d first and the n a s o p h a r y n x p a c k e d before starting

B o y l e - D a v i s m o u t h - g a g is inserted. B e f o r e actual
tonsillectomy.
r e m o v a l o f adenoids, n a s o p h a r y n x s h o u l d always b e

e x a m i n e d b y retracting the soft palate w i t h c u r v e d e n d

o f the tongue depressor a n d b y digital palpation, to c o n -

Indications
f i n n t h e d i a g n o s i s , t o assess t h e s i z e o f a d e n o i d s mass and

to push the lateral a d e n o i d masses t o w a r d s the m i d U n e .

A d e n o i d h y p e r t r o p h y causing snoring, m o u t h breath-
P r o p e r size o f " a d e n o i d c u r e t t e w i t h g u a r d " is i n t r o d u c e d
ing, sleep apnoea s y n d r o m e o r speech abnormalities,
into the nasopharynx till its free e d g e t o u c h e s t h e poste-
i.e. (rhinolalia clausa).
r i o r b o r d e r o f nasal s e p t u m a n d is t h e n p r e s s e d backwards
R e c u r r e n t rhinosinusitis.
to engage the adenoids. A t this level, head should be
C h r o n i c secretory otitis m e d i a associated w i t h ade-
slighdy flexed to a v o i d injury to the o d o n t o i d process.
n o i d hyperplasia.
W i t h gentle s w e e p i n g m o v e m e n t , adenoids are shaved
R e c u r r e n t ear discharge i n b e n i g n C S O M associated
off (Fig. 92.1). Lateral masses are similarly r e m o v e d
w i t h a d e n o i d i t i s / a d e n o i d hyperplasia.
w i t h smaller curettes; small tags o f l y m p h o i d tissue left
D e n t a l m a l o c c l u s i o n . A d e n o i d e c t o m y does n o t c o r -
b e h i n d are r e m o v e d w i t h p u n c h forceps.
rect dental abnormalities b u t w i l l p r e v e n t its recur-
Haemostasis is a c h i e v e d b y p a c k i n g the area f o r s o m e -
rence after o r t h o d o n t i c treatment.
time. Persistent bleeders are electrocoagulated u n d e r

vision. I f b l e e d i n g is still n o t controlled, a postnasal

p a c k is l e f t f o r 24 hours.
Contraindications

I . Cleft palate or s u b m u c o u s palate. R e m o v a l o f ade-

noids causes v e l o p h a r y n g e a l insufficiency i n such

cases.

H a e m o r r h a g i c diathesis.

3. A c u t e infection o f u p p e r respiratory tract.

Anaesthesia

A l w a y s general, w i t h oral endotracheal i n t u b a t i o n .

Position

F i g u r e 92.1
S a m e as f o r t o n s i l l e c t o m y . H y p e r e x t e n s i o n o f n e c k s h o u l d
Adenoidectomy.
always be a v o i d e d .
 indicator. T r e a t m e n t is same as for per-operative
Endoscopic Adenoidectomy
haemorrhage. Postnasal pack u n d e r general anaesthe-

sia is o f t e n required.
T h e s e days adenoids can be r e m o v e d m o r e precisely b y
Injury to eustachian tube opening.
using a debrider u n d e r endoscopic c o n t r o l .
3. Injury to pharyngeal musculature and vertebrae. T h i s i s d u e
to hyperextension o f n e c k and u n d u e pressure o f

Post-operative Care curette. C a r e s h o u l d be taken w h e n operating patients

o f D o w n ' s s y n d r o m e as 1 0 - 2 0 % o f t h e m have atlanto-

axial instability.
S a m e as i n t o n s i l l e c t o m y . T h e r e is n o dysphagia a n d patient

is u p a n d about early.
4. Griesel syndrome. Patient c o m p l a i n s o f n e c k p a i n and

develops t o r t i c o l l i s . M o s d y i t is d u e to spasm o f paraspi-

nal muscles, b u t can be d u e to atlanto-axial dislocation

Complications r e q u i r i n g cervical collar a n d even traction.

5. Velopharyngeal insufficiency. I t is n e c e s s a r y t o c h e c k for

1. Haemorrhage, usually seen i n i m m e d i a t e post-operative s u b m u c o u s cleft palate b y inspection a n d palpation

period. N o s e a n d m o u t h m a y b e full o f b l o o d o r the before r e m o v a l o f adenoids.

o n l y i n d i c a t i o n m a y be v o m i t u s o f d a r k - c o l o u r e d 6. Nasopharyngeal stenosis d u e to scarring.

b l o o d w h i c h the patient had b e e n s w a l l o w i n g gradually 7. Recurrence. T h i s is due to r e g r o w t h o f a d e n o i d tissue

in post-operative period. R i s i n g pulse rate is another left b e h i n d .

R a d i o l o g y in E N T

(iv) L a b y r i n t h w i t h its vestibule

TEMPORAL BONE (v) C o c h l e a

(vi) M a s t o i d a n t r u m .

1. L a w ' s v i e w I t is l a t e r a l o b l i q u e v i e w o f mastoid.
4. T o w n e ' s v i e w I t is a n t e r o p o s t e r i o r v i e w w i t h 3 0 ° tilt

Patient lies i n s u c h a w a ythat sagittal plane o ft h e skull is f r o m above a n d i n front. I t s h o w s b o t h petrous p y r a m i d s

parallel t o t h e f i l m a n d X - r a y b e a m is p r o j e c t e d 1 5 ° w h i c h c a nb e c o m p a r e d .

cephalocaudal. Structures seen are:

Structures seen are:

A r c u a t e e m i n e n c e a n dsuperior semicircular canal.

(i) E x t e r n a l a u d i t o r y canal s u p e r i m p o s e d o n internal (ii) M a s t o i d a n t r u m .

a u d i t o r y canal. (iii) Internal a u d i t o r y canal.

(ii) M a s t o i d a i r cells. (iv) T y m p a n i c cavity.

(iii) T e g m e n . (v) C o c h l e a .

(iv) Lateral sinus plate. (vi) E x t e r n a l a u d i t o r y canal.

(v) T e m p o r o m a n d i b u l a r j o i n t .
T h i s v i e w is u s u a l l y t a k e n f o r acoustic n e u r o m a , a n d

" K e y area" o ft h e mastoid, i . e .attic, aditus a n d a n t r u m apical petrositis.

are n o tw e l l seen. 5. T r a n s o r b i t a l v i e w T h i s v i e w is t a k e n w i t h o c c i p u t o n

2. Schuller's v i e w Similar t o L a w ' s v i e w b u t c e p h a l o - the film w i t h o r b i t o m e a t a l line at right angles t o t h e film.

caudal b e a m makes a n angle o f3 0 ° t o t h e sagittal. X - r a y b e a m passes t h r o u g h t h e orbit.

Structures seen are: Structures seen are:

(i) E x t e r n a l canal s u p e r i m p o s e d o n internal canal (i) Internal a u d i t o r y canal.

(ii) M a s t o i d a i r cells (ii) C o c h l e a .

(iii) T e g m e n (iii) L a b y r i n t h .

(iv) Lateral sinus plate (iv) E n t i r e petrous p y r a m i d p r o j e c t e d t h r o u g h t h e orbit.

(v) C o n d y l e o f m a n d i b l e
Since b o t h petrous p y r a m i d s are seen, structures o n o n e
(vi) S i n o - d u r a l angle
side c a n b e c o m p a r e d w i t h t h e those o ft h e o p p o s i t e side.
(vii) A n t r u m a n d u p p e r part o fattic (i.e. k e y area).
T h i s v i e w is u s u a l l y d o n e f o r acoustic n e u r o m a a n d

petrous p y r a m i d .
T h i s v i e w is t a k e n t o see t h e extent o f p n e u m a t i s a t i o n ,

destruction o f intercellular septa (as i n m a s t o i d i t i s ) , l o c a - 6. S u b m e n t o v e r t i c a l view T h i s v i e w is t a k e n w i t h ver-

t i o n o f sinus plate a n dt e g m e n , cholesteatoma a n d l o n g i t u - tex near t h e film a n dX - r a y b e a m p r o j e c t e d at right angles

dinal fracture o fp e t r o u s p y r a m i d . to t h e f i l m f r o m t h e s u b m e n t a l area.

3. Stenver's view T h i s v i e w is t a k e n i n such a w a y that Structures seen are:

l o n g axis o ft h e petrous b o n e lies p a r a l l e l t o t h e f i l m .

(i) E x t e r n a l a u d i t o r y canal.
Structures seen are:
(ii) M i d d l e ear cleft, i.e. m a s t o i d cells, m i d d l e ear a n d

(i) E n t i r e petrous p y r a m i d eustachian tube.

(ii) A r c u a t e e m i n e n c e (iii) Internal a u d i t o r y canal.

(iii) Internal a u d i t o r y meatus (iv) S p h e n o i d sinus.

(v) F o r a m e n ovale a n d s p i n o s u m . (ii) Z y g o m a .

(vi) C a r o t i d canal. (iii) Z y g o m a t i c arch.

(iv) M a n d i b l e a l o n g w i t h c o r o n o i d a n d c o n d y l o i d

processes.

PARANASAL SINUSES
R i g h t a n d left o b l i q u e v i e w s T h e y a r e t a k e n t o see
the posterior e t h m o i d sinuses a n d the optic f o r a m e n o f the
1. W a t e r s ' v i e w ( O c c i p i t o m e n t a l v i e w o r n o s e - c h i n p o s i -
c o r r e s p o n d i n g side.
tion). I t is t a k e n i n such a w a y that nose a n d c h i n o f the

patient t o u c h the f i l m w h i l e X - r a y b e a m is p r o j e c t e d f r o m

b e h i n d . W a t e r s ' v i e w w i t h o p e n m o u t h is p r e f e r r e d as i t
X-RAYS FOR NASAL FRACTURES

also s h o w s s p h e n o i d sinus. I n this v i e w , petrous b o n e s are

p r o j e c t e d b e l o w the m a x i l l a r y antra. 1. L a t e r a l v i e w of nasal bones B o t h r i g h t a n d left lat-

Structures seen are: eral v i e w s s h o u l d be taken. Fracture line a n d depression o r

elevation o f the fractured s e g m e n t is seen. L o w e r part o f

(i) M a x i l l a r y sinuses (seen best).
nasal bones is t h i n , a n d fractured m o r e frequently. Groove
(ii) F r o n t a l sinuses.
for ethmoidal nerve and vessels can be seen running downwards
(iii) S p h e n o i d sinus ( i ft h e film is t a k e n w i t h o p e n m o u t h ) .
and forwards and may look like fracture line.
(iv) Z y g o m a .

(v) Z y g o m a t i c arch. 2. Occlusal view o f nasal bone I n this t h e X - r a y film

(vi) Nasal b o n e . is h e l d b e t w e e n the teeth, a n d central b e a m is p r o j e c t e d

(vii) F r o n t a l process o f maxilla. p e r p e n d i c u l a r to the film. B o t h sides o f the nasal p y r a m i d

(viii) S u p e r i o r orbital fissure. are seen. Fracture line a n d lateral displacement o f the nasal

(ix) I n t r a t e m p o r a l fossa. p y r a m i d is s e e n clearly.

3. Waters' view I t gives e n d - o n v i e w o f nasal arch.

2. C a l d w e l l view (Occipitofrontal v i e w o r nose-forehead
Fractures o f right a n d left nasal b o n e s a n d their lateral dis-
position). T h e v i e w is t a k e n w i t h nose and forehead t o u c h -
p l a c e m e n t can b e seen.
ing the f i l m a n d X - r a y b e a m is p r o j e c t e d 15—20° caudally.

Structures seen are:

NECK, LARYNX AND PHARYNX

(i) F r o n t a l sinuses (seen best).

(ii) E t h m o i d sinuses.

(iii) M a x i l l a r y sinuses. Lateral view of neck I t is a n e x t r e m e l y useful v i e w i n

(iv) F r o n t a l process o f z y g o m a a n d z y g o m a t i c process o f E N T . I n a n o r m a l person, it shows:

frontal b o n e .
(i) O u t l i n e o f base o f tongue.
(v) S u p e r i o r m a r g i n o f orbit a n d l a m i n a papyracea.
(ii) Vallecula.
(vi) S u p e r i o r orbital fissure.
(iii) H y o i d b o n e .
(vii) F o r a m e n r o t u n d u m (inferolateral to superior orbital
(iv) Epiglottis a n d aryepiglottic folds.
fissure).
(v) A r y t e n o i d s .

3. L a t e r a l v i e w Lateral side o f the skull lies against the (vi) False a n d true cords w i t h ventricle i n b e t w e e n t h e m .

f i l m a n d X - r a y b e a m is p r o j e c t e d perpendicular f r o m the (vii) T h y r o i d a n d cricoid cartilages.

o t h e r side. (viii) S u b g l o t t i c s p a c e a n d trachea.

Structures seen are: (ix) Prevertebral soft tissues.

(x) C e r v i c a l spine.
(i) A n t e r i o r a n d posterior extent o f sphenoid, frontal

(xi) Pretracheal soft tissues a n d t h y r o i d .

a n d m a x i l l a r y sinuses.

(ii) Sella turcica.

T h i s v i e w helps i n the diagnosis of:
(iii) E t h m o i d sinuses.
(i) F o r e i g n bodies o f larynx, p h a r y n x a n d u p p e r o e s o p h -
(iv) A l v e o l a r process.
agus a n d to differentiate a f o r e i g n b o d y o f the a i r w a y
(v) C o n d y l e a n d n e c k o f m a n d i b l e .
f r o m that o f the f o o d passage.
4. Submentovertical (Basal) view This v i e w is taken
(ii) A c u t e epiglottitis ( T h u m b sign).
as d e s c r i b e d earlier.
(iii) R e t r o p h a r y n g e a l abscess.
Structures seen are:
(iv) P o s i t i o n o f t r a c h e o s t o m y tube, T - t u b e o r laryngeal

S p h e n o i d , posterior e t h m o i d a n d maxillary sinuses stent.

(seen best i n that order). (v) Laryngeal stenosis.

(vi) Fractures o f larynx a n d h y o i d b o n e a n d their T h e structures seen are:

displacement.
(i) Nasal cavity. A foreign b o d y i n the nose can b e seen.

(vii) C o m p r e s s i o n o f trachea b y t h y r o i d o r r e t r o p h a r y n -
I n t e r r u p t i o n o f air c o l u m n f r o m nose to n a s o p h a r y n x

geal masses.
m a y indicate a t u m o u r or choanal atresia.

(viii) Caries o f cervical spine, associated w i t h r e t r o p h a r y n -

(ii) Soft palate.

geal abscess o r osteophytes i n cervical vertebrae o r

(iii) R o o f a n d posterior wall o f nasopharynx. A d e n o i d
injuries o f spine.
mass m a y be seen arising f r o m posterosuperior

Anteroposterior view of neck This v i e w is useful t o w a l l o f n a s o p h a r y n x a n d c o m p r o m i s i n g the

differentiate a foreign b o d y o f larynx f r o m that o f o e s o p h - airway.

agus. I t is a l s o d o n e t o see any c o m p r e s s i o n o r displace-

A n t r o c h o a n a l p o l y p m a y also s h o w a soft tissue density,

m e n t o f trachea b y lateral n e c k masses, e.g. t h y r o i d t u m o u r s

but usually a c o l u m n o f a i r is s e e n b e t w e e n the mass a n d

or enlargement.
posterior w a l l o f nasopharynx. T h i s c o l u m n o f air differ-

Soft tissue lateral v i e w o f n a s o p h a r y n x T h i s is u s u a l l y entiates a n t r o c h o a n a l p o l y p f r o m o t h e r nasopharyngeal

taken t o assess soft tissue masses i n the n a s o p h a r y n x e.g., masses arising f r o m posterosuperior wall o f n a s o p h a r y n x

adenoids, antrochoanal p o l y p or a n g i o f i b r o m a . e.g. a n g i o f i b r o m a .

A B

Law's view o f mastoid. ( A ) Note n o r m a l structures and pneumatisation o n the right. (B) O n the left side mastoid is s c l e r o t i c with

destruction (arrows) o f the "key area" due to cholesteatoma.

T r a n s o r b i t a l view. N o t e b o t h p e t r o u s p y r a m i d s are p r o j e c t e d t h r o u g h the o r b i t s . I n t e r n a l a u d i t o r y m e a t u s a n d l a b y r i n t h s are seen o n
b o t h sides. I n t e r n a l a u d i t o r y c a n a l s o f b o t h sides are n o r m a l in s h a p e a n d d i m e n s i o n s (arrows).

W a t e r s ' view w i t h o p e n m o u t h . N o t e haziness o f left maxillary

sinus due to mucosal hypertrophy (arrow). Other sinuses W a t e r s ' v i e w . N o t e o p a c i t y in r i g h t m a x i l l a r y sinus d u e t o sinusitis
appear normal. (arrow).
Radiology in E N T

W a t e r s ' v i e w s h o w i n g c a r c i n o m a r i g h t m a x i l l a r y sinus. N o t e : ( i ) S o f t tissue e x p a n s i o n , (ii) B o n y d e s t r u c t i o n o f w a l l s o f m a x i l l a r y sinus.

 Radiology in E N T

Lateral view—nasal bones. N o t e f r a c t u r e o f nasal b o n e ( a r r o w ) . O c c l u s a l v i e w s h o w i n g a s t o n e in r i g h t s u b m a n d i b u l a r d u c t .

Radiology in E N T

(A) P.A. v i e w — n e c k a n d chest with denture at the level o f t h o r a c i c inlet. Denture is r a d i o l u c e n t but t w o metallic hooks are visible

(arrow). ( B ) Lateral view—neck o f the same patient s h o w i n g metallic hooks at thoracic inlet ( a r r o w ) .
X - r a y lateral v i e w neck s h o w i n g a c h i c k e n b o n e in t h e o e s o p h a - S o f t tissue lateral v i e w neck s h o w i n g a f r u i t seed ( C h i k u ) in t h e
gus opposite C 7 and C g farrows). s u b g l o t t i c region o f larynx f a r r o w ) . N o t e : T h e patient needed
t r a c h e o s t o m y ( b l a c k a r r o w ) t o relieve o b s t r u c t i o n .

P.A. c h e s t in a c h i l d w i t h a r a d i o l u c e n t f o r e i g n b o d y ( a p e a n u t )
in right b r o n c h u s . N o t e : (i) Collapse o f right l u n g a n d shift o f
P.A. v i e w c h e s t . A r a d i o - o p a q u e f o r e i g n b o d y ( n a i l ) i n t h e r i g h t m e d i a s t i n u m t o t h e s a m e side, (ii) Raised d o m e o f d i a p h r a g m
bronchus. o n t h e r i g h t , (iii) E m p h y s e m a l e f t l u n g .
Radiology in E N T

P.A. v i e w chest s h o w i n g a h a i r p i n in t h e right bronchus.

H y p o d e r m i c injection needle in the trachea in an adult. Sudden

gasp due t o a pat on the back from an unnoticed friend when

he w a s b u s y p r i c k i n g his teeth.

Radiograph (lateral view neck) s h o w i n g retropharyngeal

abscess. N o t e increase in width o f prevertebral soft tissues

Soft tissue lateral view neck showing retro-pharyngeai and opposite C 6 a n d also gas s h a d o w due to gas-producing organ-

retro-oesophageal abscess due t o a fish bone in a 25-years-old isms. T o diagnose retropharyngeal abscess, the prevertebral

female. Note: (i) increased prevertebral soft tissue shadow soft tissue s h a d o w should exceed width o f b o d y o f C 2 (or

( m a x i m u m against C ) . (ii)C o m p r e s s i o n o f trachea

7 c o m p r o m i s - should be m o r e than 7 m m ) in b o t h children a n d adults oppo-

i n g t h e a i r w a y , ( i i i )S t r a i g h t e n i n g o f c e r v i c a l s p i n e , ( i v ) V e r t e b r a l site C Opposite C , s the soft tissue shadow should exceed

bodies a n d intervertebral spaces are normal. 14 m m i n c h i l d r e n less t h a n 15 years a n d 22 m m in adults.

 Radiology in ENT

Epiglottis
Hyoid bone

Laryngeal
stenosis

Trachea
Prevertebral
shadow

Lateral view neck s h o w i n g calcification in the t h y r o i d g l a n d .

Xeroradiograph (lateral view neck). Note laryngeal stenosis

involving supraglottic, glottic and subglottic regions.

S o f t tissue lateral view—nasopharynx. Note a large adenoid

S o f t tissue radiograph (lateral neck) showing tracheal com- mass almost completely obstructing the nasopharyngeal air-

pression due t o thyroid mass. way (arrowheads).

 Cardiac achalasia (Megaoesophagus). There is a failure of
B a r i u m s w a l l o w in a p a t i e n t w i t h d y s p h a g i a . N o t e i r r e g u l a r n a r - | o w e r o e s o p h a g e a l s p h i n c t e r t o relax w i t h d i l a t a t i o n o f o e s o p h a -
rowing o f lower oesophagus due to carcinoma. g u s d u e t o s t a s i s G f food. A c h a l a s i a is d u e t o d e g e n e r a t i o n of

g a n g l i o n cells o f A u e r b a c h ' s plexus.

Appendices

Appendix I: Some Memorable Nuggets for Rapid Review 457

Appendix II: Instruments 463
Appendix III 476
A p p e n d i x I: Some M e m o r a b l e
Nuggets f o r Rapid Review*
1. A c u t e epiglottitis i n c h i l d r e n is c a u s e d b y Haemophilus influenzae type B . I t p r o d u c e s a typical "Thumb sign"
o n lateral X - r a y film. A m p i c i l l i n was considered the d r u g o f choice b u t n o w m a n y organisms h a v e b e c o m e resis-

tant to i t a n d ceftriaxone is preferred.

2. A c u t e f u l m i n a n t fungal sinusitis is an invasive sinusitis a n d is c o m m o n l y seen i n diabetics, H I V infected

patients a n d transplant patients r e c e i v i n g c h e m o t h e r a p y for i m m u n o s u p p r e s s i o n . T h e r a p y i n such cases s h o u l d be

urgent, aggressive surgical d e b r i d e m e n t a n d a m p h o t e r i c i n - B .

3. Acute laryngotracheobronchitis o r c r o u p is a v i r a l i n f e c t i o n c a u s e d b y p a r a i n f l u e n z a e type 1, 2, a n d s o m e t i m e s

3. Critical area i n v o l v e d is s u b g l o t t i c l a r y n x p r o d u c i n g o e d e m a w i t h stridor a n d respiratory distress. X - r a y (P.A.

v i e w ) l a r y n x s h o w s typical "steeple sign" b u t X - r a y s are a v o i d e d as any m a n i p u l a t i o n m a y precipitate acute

obstruction.

4. Adenocarcinoma of ethmoid is m o s t l y seen i n those e x p o s e d to w o o d - d u s t .

5. A d e n o i d facies, seen i n a d e n o i d hyperplasia, consists o f c r o w d e d teeth, h i g h - a r c h e d palate a n d u n d e r d e v e l o p e d

p i n c h e d nostrils.

6. Ammonia is n o t used to test sense o f smell as it stimulates fibres o f trigeminal nerve s u p p l y i n g the nose a n d n o t

the olfactory ones.

7. Angio-oedema. D e f i c i e n c y o f C } esterase i n h i b i t o r causes a n g i o - o e d e m a . D e f i c i e n c y o f this i n h i b i t o r causes

increased p r o d u c t i o n o f C } esterase. T h i s leads t o anaphylatoxins w h i c h cause capillary p e r m e a b i l i t y a n d o e d e m a .

D e f i c i e n c y o f C ( e s t e r a s e i n h i b i t o r is a n i n h e r i t e d c o n d i t i o n .

2 2
8. A r e a o f adult t y m p a n i c m e m b r a n e is 9 0 m m , o f w h i c h o n l y 55 m m is functional. A r e a o f stapes footplate is

3.2 m m 2
. A r e a ratio (or h y d r a u l i c r a t i o ) is 17:1. A c c o r d i n g to other w o r k e r s , functional area is 4 5 m m 2
a n d

area ratio 1 4 : 1 .

9. Arnold-Chiari malformation. Cerebellar tonsils project t h r o u g h the f o r a m e n m a g n u m .

10. Axis o f ossicular rotation passes b e t w e e n anterior process o f malleus to short process o f incus.

11. Battle's sign is e c c h y m o s i s o v e r the m a s t o i d seen i n fractures o f t e m p o r a l bone.

12. Bell's p h e n o m e n o n is seen i n l o w e r m o t o r n e u r o n paralysis o f C N V I I . T h e eyeball turns u p a n d o u t w h e n

t r y i n g to close the eye.

13. Bill's island. I t is a t h i n plate o f b o n e left o n s i g m o i d sinus w h e n i t is t o b e retracted d u r i n g surgery. I t s h o u l d be

differentiated f r o m Bill's bar.

14. Blue d r u m is s e e n i n h a e m o t y m p a n u m (due to t e m p o r a l b o n e fracture), glue ear, g l o m u s t u m o u r o r h a e m a n -

g i o m a o f m i d d l e ear.

15. Broyle's ligament. Small l i g a m e n t w h i c h connects b o t h v o c a l cords at the anterior c o m m i s s u r e to the t h y r o i d

cartilage.

16. Bryce's sign. Seen m laryngocele. W h e n the s w e l l i n g is p r e s s e d , a g u r g l i n g s o u n d is p r o d u c e d .

Note: For details a n d better understanding, the r e a d e r is a d v i s e d to refer the relevant section o f the book.
17. C a r c i n o m a of nasopharynx is c a u s e d , a m o n g other factors, b y Epstein-Barr virus. M o s t c o m m o n site o f origin

is fossa o f R o s e n m u l l e r (pharyngeal recess). M o s t c o m m o n histological variety is s q u a m o u s cell c a r c i n o m a , a n d

radiotherapy is t h e t r e a t m e n t o f choice.

18. Carhart's notch is s e e n i n otosclerosis. B o n e c o n d u c t i o n c u r v e s h o w s m a x i m u m loss at 2 0 0 0 H z .

19. Caroticotympanic artery is a b r a n c h o f internal carotid artery. I t anastomoses w i t h branches o f external carotid

system i n the m i d d l e ear.

20. C H A R G E syndrome consists o f C o l o b o m a , H e a r t defects, choanal Atresia, R e t a r d e d g r o w t h , G e n i t a l h y p o -

plasia a n d E a r anomalies.

21. C h o a n a l atresia is m o r e often unilateral, m o r e c o m m o n i n females (2:1), m o r e often o n the right side a n d m o r e

often b o n y than m e m b r a n o u s (9:1).

22. Chordoma arises f r o m the r e m n a n t s o f n o t o c h o r d . Characteristic a p p e a r a n c e o n h i s t o l o g y is p h y s a l i f e r o u s c e l l s —

f o a m y cells w i t h c o m p r e s s e d nuclei.

23. Cochlea is a c o i l e d t u b e m a k i n g 2.5 t o 2 . 7 5 turns. W h e n straightened i t measures 3 2 m m .

24. Costen's s y n d r o m e is a b n o r m a l i t y o f t e m p o r o m a n d i b u l a r j o i n t d u e to defective b i t e . I t is c h a r a c t e r i s e d b y otalgia,

feeling o f b l o c k e d ear, t i n n i t u s a n d s o m e t i m e s vertigo. Pain also radiates t o frontal, parietal a n d occipital region.

25. D a l r y m p l e ' s sign. Seen i n Grave's disease. I t is a c l i n i c a l s i g n s h o w i n g retraction o f u p p e r l i d w i t h u p p e r scleral

s h o w .

26. D o n a l d s o n ' s line passes t h r o u g h h o r i z o n t a l canal a n d bisects the posterior canal. I t is l a n d m a r k f o r e n d o l y m -

phatic sac w h i c h lies a n t e r i o r a n d inferior t o i t ( F i g . 7 6 . 4 )

27. Dysphagia lusoria is d u e t o compression o f oesophagus b y subclavian artery. I t occurs w h e n right subclavian

artery arises f r o m thoracic aorta a n d passes i n f r o n t o f o r b e h i n d t h e oesophagus.

28. Elastic fibrocartilage is s e e n i n p i n n a , epiglottis, corniculate, c u n e i f o r m cartilages a n d apices o f the a r y t e n o i d

cartilages. I t does n o t u n d e r g o calcification. H y a l i n e cartilage is seen i n t h y r o i d , cricoid, a n d greater part o f

a r y t e n o i d cartilages. I t u n d e r g o e s calcification.

29. Endolymph is p r o d u c e d b y cells o f stria vascularis o f the cochlea a n d dark cells o f t h e vestibular l a b y r i n t h . I t is

absorbed b y e n d o l y m p h a t i c sac.

30. Endolymphatic sac. I t is l o c a t e d posterior t o m a s t o i d s e g m e n t o f C N V I I , inferior t o posterior semicircular

canal a n d superior t o j u g u l a r b u l b .

31. Eustachian tube is 3 6 m m l o n g , o n e - t h i r d is b o n y a n d t w o thirds cartilaginous. N o r m a l l y , i t remains closed.

O p e n i n g o f t h e tube is a n a c t i v e process d u e t o c o n t r a c t i o n o f T e n s o r veli palatini muscle w h i l e closure is passive

d u e t o recoil o f t h e cartilage.

32. Exostosis o f external auditory canal are m u l t i p l e a n d usually associated w i t h c o l d w a t e r s w i m m i n g w h i l e

o s t e o m a o f external canal is u s u a l l y s i n g l e a n d occurs at suture lines, e.g. t y m p a n o m a s t o i d .

33. External auditory canal o f an adult is 2 4 n u n i n l e n g t h . O u t e r o n e - t h i r d ( 8 m m ) is c a r t i l a g i n o u s a n d i n n e r t w o

thirds (16 m m ) are b o n y .

34. Fluctuating hearing loss is s e e n i n o t i t i s m e d i a w i t h effusion (serous otitis media), M e n i e r e ' s disease, p e r i l y m p h

fistula a n d m a l i n g e r i n g .

35. Fluctuating h e a r i n g loss. I t is s e e n i n M e n i e r e ' s disease, p e r i l y m p h fistula, a u t o i m m u n e disorder o f i n n e r ear

a n d syphilitic labyrinthitis.

36. Frenzel manoeuvre. I t is u s e d t o o p e n the eustachian tube a n d ventilate the m i d d l e car b y c o n t r a c t i n g muscles

o f t h e floor o f m o u t h a n d p h a r y n x w h i l e nose, m o u t h a n d glottis are closed. I t is a l i t t l e m o r e difficult t o learn

than Valsalva m a n o e u v r e .

37. Frey's syndrome. T h e r e is f l u s h i n g a n d s w e a t i n g o f skin o f p a r o t i d r e g i o n d u r i n g eating. I t is s e e n after p a r o t i -

d e c t o m y . Parasympathetic fibres s u p p l y i n g t h e p a r o t i d g l a n d are misdirected after p a r o t i d e c t o m y a n d innervate

sweat glands o f t h e p a r o t i d area. T y m p a n i c n e u r e c t o m y (section o f t y m p a n i c b r a n c h o f C N I X ) w i l l interrupt

these fibres.
 Some Memorable Nuggets for Rapid Review

38. Fungal sinusitis is m o s t l y c a u s e d b y Aspergillus.

39. Galen's anastomosis. I t is a n a s t o m o s i s b e t w e e n superior a n d recurrent laryngeal nerves.

40. G e l l e ' s test compares intensity o f b o n e - c o n d u c t e d t u n i n g fork s o u n d w i t h o u t a n d w i t h raising pressure o n the

t y m p a n i c m e m b r a n e w i t h Siegel's s p e c u l u m . N o r m a l l y , G e l l e ' s t e s t is p o s i t i v e b e c a u s e i n t e n s i t y o f h e a r i n g decreases

w h e n air pressure is r a i s e d i n external a u d i t o r y canal. I n ossicular fixation o r ossicular discontinuity, increased air

pressure makes n o changes i n the s o u n d intensity. (Gelle's negative).

4 1 . Gradenigo's syndrome consists of: (i) ear discharge (suppurative otitis m e d i a ) , (ii) diplopia ( C N V I paralysis),

a n d (iii) retro-orbital pain ( C N V ) i n v o l v e m e n t . I t is d u e to petrositis—a c o m p l i c a t i o n o f otitis media.

42. Griesinger's sign is o e d e m a o v e r the m a s t o i d a n d is s e e n i n lateral sinus thrombosis. It is due to t h r o m b o s i s o f

m a s t o i d emissary v e i n i m p e d i n g v e n o u s drainage a n d thus causing o e d e m a o v e r the mastoid.

43. G u t m a n n ' s p r e s s u r e test. I t is d o n e i n p u b e r p h o n i a . Pressing o n the t h y r o i d p r o m i n e n c e i n a b a c k w a r d a n d

d o w n w a r d d i r e c t i o n relaxes the o v e r stretched v o c a l cords a n d thus l o w - p i t c h e d v o i c e can be p r o d u c e d .

44. Habenula perforata. I t is t h e area w h e r e branches o f cochlear nerves enter the cochlea. O p e n i n g s m a y be w i d e

leading to a p e r i l y m p h gusher i n stapes surgery. T h i s c o n d i t i o n is a s s o c i a t e d w i t h enlarged internal acoustic meatus

a n d stapes f i x a t i o n o f congenital origin. I t is a n X - l i n k e d disease a n d can be diagnosed o n C T .

45. Hennebert's phenomenon. D y s e q u i l i b r i u m f o l l o w i n g nose b l o w i n g o r lifting a heavy object. Seen i n peri-

l y m p h fistula (do n o t confuse w i t h H e n n e b e r t ' s sign).

46. Hennebert's sign is a p o s i t i v e f i s t u l a sign i n the absence o f fistula. Seen i n congenital syphilis due to excessively

utricular adhesions to stapes. A l s o seen i n s o m e cases o f M e n i e r e ' s disease.

47. H i d d e n areas o f the l a r y n x i n c l u d e i n f r a h y o i d epiglottis, anterior c o m m i s s u r e , subglottis, ventricle a n d apex o f

p y r i f o r m fossa.

48. Horner's syndrome consists o f ptosis, miosis (constriction o f pupil), anhidrosis a n d e n o p h t h a l m o s due to paraly-

sis o f c e r v i c a l sympathetics.

49. H y r t l e ' s fissure, also called t y m p a n o m e n i n g e a l hiatus, i t is a n e m b r y o n i c r e m n a n t that connects C S F space to

m i d d l e ear just anterior a n d inferior to the r o u n d w i n d o w . It runs parallel to cochlear aqueduct. It can be the

source o f congenital C S F o t o r r h o e a or m e n i n g i t i s f r o m m i d d l e ear infections. N o r m a l l y i t gets obliterated.

50. I n any case o f unilateral otitis m e d i a w i t h effusion i n an adult, rule o u t nasopharyngeal p a t h o l o g y especially

the c a r c i n o m a .

5 1 . I n F i t z g e r a l d - H a l l p i k e ( b i t h e r m a l c a l o r i c ) test, t h e r m a l s t i m u l a t i o n occurs i n the h o r i z o n t a l semicircular

canal. C o l d w a t e r ( 3 0 ° C ) causes nystagmus t o the opposite side w h i l e w a r m w a t e r ( 4 4 ° C ) to the same side.

R e m e m b e r C O W S ( C o l d - O p p o s i t e - W a n n - S a m e ) .

52. Inverted papilloma or R i n g e r t z t u m o u r arises f r o m the lateral w a l l o f nose. I t is c h a r a c t e r i s e d b y s q u a m o u s

o r transitional cell e p i t h e l i u m w i t h ribrovascular stroma. I n w a r d g r o w t h o f e p i t h e l i u m towards stroma lends the

n a m e o f i n v e r t e d p a p i l l o m a to i t . I t is a s s o c i a t e d w i t h s q u a m o u s cell c a r c i n o m a in 10—15% o f patients.

53. Jugular foramen syndrome is p a r a l y s i s o f C N I X , X a n d X I . I t is s e e n i n c a r c i n o m a nasopharynx, g l o m u s j u g u -

lare, large acoustic n e u r o m a o r t h r o m b o p h l e b i t i s o f j u g u l a r bulb.

54. Kallmann syndrome is a n o s m i a a n d congenital h y p o g o n a d i s m .

55. Kartagener's syndrome consists o f recurrent sinusitis, bronchiectasis a n d situs inversus. Ciliary m o t i l i t y is dis-

turbed. E l e c t r o n m i c r o s c o p e s h o w s absence o f dye inside arms i n A - t u b u l e s .

56. Korner's septum, s o m e t i m e s seen d u r i n g m a s t o i d surgery, is a b o n y plate separating superficial s q u a m o u s cells

f r o m the deeper petrosal air cells. A n t r u m lies d e e p to it.

57. Krause's nodes are l y m p h nodes situated i n the j u g u l a r f o r a m e n . E n l a r g e m e n t o f these nodes compresses o n C N

I X , X a n d X I , causing j u g u l a r f o r a m e n s y n d r o m e .

58. L a r y n x has three i m p o r t a n t spaces: pre-epiglottic, paraglottic a n d R e i n k e ' s . T h e first t w o are i m p o r t a n t because

they are i n v a d e d b y c a r c i n o m a arising i n the laryngeal mucosa. Reinke's space is o f t e n affected b y o e d e m a a n d

causes p o l y p o i d degeneration o f vocal cords.

59. Lermoyez syndrome is a variant o f M e n i e r e ' s disease. Patient first gets hearing loss a n d tinnitus. A n attack o f

vertigo follows a n d relieves tinnitus a n d i m p r o v e s hearing.

60. L e v e r ratio b e t w e e n the h a n d l e o f malleus a n d the l o n g process o f i n c u s is 1.3:1.

61. Lhermitte's sign. A rare sign seen after radiation o f cervical spine. Electrical current-like sensation is f e l t i n b o t h

arms, dorsal spine a n d b o t h legs o n f l e x i n g the neck.

62. Lyre sign. It is splaying apart o f internal a n d external carotid arteries o n a n g i o g r a m i n cases o f carotid b o d y

t u m o u r o f the n e c k .

63. M a l l e u s a n d i n c u s a r e d e r i v e d f r o m t h e first a r c h . S t a p e s d e v e l o p s f r o m s e c o n d a r c h e x c e p t its footplate

a n d annular l i g a m e n t w h i c h are derived f r o m the otic capsule.

64. Marcus G u n n pupil. T h i s is d u e to i n t e r r u p t i o n o f afferent papillary p a t h w a y d u e to retrobulbar neuritis o r any

o t h e r optic n e r v e disease. W h e n light is p u t o n the diseased side, the pupils o f b o t h sides r e m a i n dilated b u t w h e n

the light is p u t o n the healthy side it constricts b o t h the pupils. I n the latter case p u p i l o n diseased side constricts

d u e to consensual reflex because the efferent p a t h w a y o n diseased side is n o r m a l . I t is an i m p o r t a n t sign d u r i n g

e n d o s c o p i c sinus surgery for any i n j u r y to the optic nerve.

65. Mastoid antrum lies 12—15 m m deep f r o m the surface o f suprameatal triangle i n an adult. T h e thickness o f the

b o n e o v e r l y i n g the a n t r u m is o n l y 2 m m at b i r t h a n d t h e n increases at the rate o f 1 m m per year.

66. M a s t o i d tip d o e s n o t d e v e l o p till 2 years; h e n c e postaural incision to o p e n the m a s t o i d before this age needs

to be m o d i f i e d to a v o i d i n j u r y to the facial nerve.

67. Michel aplasia. T h e r e is total lack o f d e v e l o p m e n t o f i n n e r ear. It can be confused radiologically w i t h

labyrinthine ossification a n d can be distinguished b y M R I w h i c h m a y s h o w m e m b r a n o u s l a b y r i n t h i n the

latter.

68. Modiolus is t h e central b o n y axis o f cochlea and measures 5 m m i n length.

69. M o s t c o m m o n o r g a n i s m responsible for acute bacterial sinusitis is Strep, pneumoniae f o l l o w e d b y H. influ-

enzae. A n a e r o b i c a n d m i x e d infections are seen i n sinusitis o f dental o r i g i n .

70. M o s t c o m m o n o r g a n i s m s i n a c u t e otitis m e d i a are Streptococcus pneumoniae, H. influenzae a n d Moraxella catarrh-

alis i n decreasing order.

71. M o s t c o m m o n site f o r e p i s t a x i s (90%) is L i t t l e ' s a r e a s i t u a t e d o n anteroinferior part o f nasal s e p t u m .

72. M o s t c o m m o n site o f i n v o l v e m e n t i n s t a p e d i a l o t o s c l e r o s i s is l o c a t e d at the anterior edge o f oval w i n d o w

in the area o f fissula ante fenestram.

73. M o u s e - n i b b l e d appearance o f v o c a l cords is c a u s e d b y t u b e r c u l o s i s .

74. Mucormycosis is acute invasive fungal infection i n v o l v i n g nose a n d paranasal sinuses, w h e r e fungal h y p h a e

invade b l o o d vessels c a u s i n g i s c h a e m i c necrosis. C o m m o n l y involves lateral nasal walls a n d turbinates a n d q u i c k l y

spreads to orbit, palate, face a n d c r a n i u m . T r e a t m e n t is s u r g i c a l d e b r i d e m e n t a n d a m p h o t e r i c i n - B .

75. Muller's manoeuvre. U s e d to f i n d the level a n d degree o f o b s t r u c t i o n i n sleep-disordered breathing. I t is p e r -

f o r m e d w h i l e using flexible nasopharyngoscope. First the e x a m i n e r sees t h e u p p e r airways at rest a n d t h e n d u r i n g

the t i m e w h e n patient m a k e s m a x i m a l inspiratory effort w i t h nose a n d m o u t h closed. Base o f t o n g u e , lateral p h a -

ryngeal wall a n d palate are e x a m i n e d for collapsibility a n d then rated f r o m 0 ( m i n i m a l collapse) to 4 + ( c o m p l e t e

collapse).

76. M u l t i p l e juvenile laryngeal papillomatosis is a b e n i g n c o n d i t i o n caused b y h u m a n papilloma virus subtype 6 & 11.

T r e a t m e n t o f choice is repeated excision w i t h C O . , laser. M a l i g n a n t c h a n g e is u n c o m m o n unless radiation has

b e e n used as a m o d e o f treatment.

77. N e a r l y 8 0 % o f c a r c i n o m a s i n v o l v i n g paranasal sinuses are s q u a m o u s cell. Maxillary sinus is t h e m o s t fre-

quently involved sinus. O t h e r sites i n decreasing o r d e r ai e_
nasal cavity, e t h m o i d sinuses, frontal a n d s p h e n o i d

sinus.

78. N e c r o t i s i n g otitis e x t e r n a , also called m a l i g n a n t otitis externa, is c a u s e d b y p s e u d o m o n a s infection i n an elderly

patient w i t h diabetes.

79. Node of Rouviere is t h e m o s t superior n o d e o f the lateral g r o u p o f retropharyngeal nodes.

 Some Memorable Nuggets for Rapid Review

80. N o i s e - i n d u c e d h e a r i n g loss s h o w s a d i p at 4 0 0 0 H z i n air c o n d u c t i o n curve o f audiogram.

8 1 . Non-invasive forms o f fungal sinusitis are (i) fungal ball a n d (ii) fungal allergic sinusitis presenting w i t h

polyps. T h e y d o n o trequire antifungal treatment.

82. N u m b n e s s i n t h e posterosuperior meatal wall (supplied b y C N V I I ) is s e e n i n acoustic n e u r o m a a n d is c a l l e d

Hitzelberger sign.

83. Ortner's syndrome is p a r a l y s i s o f recurrent laryngeal nerve a n d cardiomegaly.

84. Otic capsule—-the so-called b o n y labyrinth ossifies f r o m 14 centres. O s s i f i c a t i o n starts a t 1 6 t h w e e k a n d ends

b y 20—21st w e e k o f gestation.

85. Paralysis o f stapedial m u s c l e (supplied b y C N V I I ) causes hyperacusis o r p h o n o p h o b i a .

86. Patients w i t h cleft palate have eustachian tube dysfunction a n d develop persistent otitis m e d i a w i t h effusion a n d

recurrent acute otitis media.

87. Posterior cricoarytenoid is t h e o n l y abductor muscle o f t h e larynx. I t is s u p p l i e d b y recurrent laryngeal

nerve.

88. Pouch of Luschka. D u r i n g d e v e l o p m e n t , n o t o c h o r d is a t t a c h e d t o t h e e n d o d e r m i n t h e area o f nasopharynx

p r o d u c i n g a n i n v a g i n a t i o n p o u c h . Persistence o fthis p o u c h causes T h o r n w a l d t ' s cyst w h i c h m a yg e t i n f e c t e d t o

f o n n a n abscess.

89. Preoperative open biopsy. I t is n o t d o n e i n a n a n g i o f i b r o m a o fn a s o p h a r y n x , g l o m u s t u m o u r o fthe m i d d l e ear,

carotid b o d y t u m o u r o ft h e n e c k a n dparapharyngeal t u m o u r s w h i c h appear t o b e b e n i g n .

90. Prussak's space lies m e d i a l t o pars f l a c c i d a , lateral t o t h e n e c k o f malleus a n d above the lateral process o f malleus.

A n t e r i o r l y , posteriorly a n d superiorly, i t is b o u n d e d b y lateral malleal ligament. Posteriorly, i t also has a g a p

t h r o u g h w h i c h t h e space c o m m u n i c a t e s w i t h e p i t y m p a n u r h .

9 1 . Psammoma bodies. F o u n d i n papillary c a r c i n o m a o f t h y r o i d gland.

92. Rathke's pouch. I t forms anterior pituitary a n d m a y persist as c r a n i o p h a r y n g e a l canal.

93. Recruitment is a n a b n o r m a l g r o w t h i nloudness a n d is s e e n i n c o c h l e a r lesions.

94. Rhinophyma is d u e t o h y p e r t r o p h y o f sebaceous glands o f nasal t i p . I t is associated w i t h acne rosacea.

95. Rhinoscleroma is c a u s e d b y a g r a m - n e g a t i v e c o c c o b a c i l l u s - K / e t a i W / i i rliinosderomatis. T h e disease passes t h r o u g h

three stages—catarrhal, g r a n u l o m a t o u s a n d cicatricial. I t causes w o o d y infiltration o ft h e u p p e r lip. O t h e r areas

i n v o l v e d are larynx (subglottic region) a n dtrachea leading t o airway obstruction. M i k u l i c z ' cells a n dR u s s e l l b o d -

ies a r e characteristically seen o n histology.

96. R i s k factors associated w i t h laryngeal cancer are s m o k i n g , use o f alcohol, gastro-oesophageal reflux, e x p o -

sure t o w o o d - d u s t , asbestos a n d volatile chemicals, n i t r o g e n m u s t a r d a n d previous ionising radiation. Genetic

susceptibility also plays a great role.

97. R i s k factors associated w i t h nasal a n d paranasal sinus m a l i g n a n c y are: w o o d dust, nickel a n d c h r o m i u m

plating industries, i s o p r o p y l oil, volatile hydrocarbons a n d s m o k i n g .

98. Russell bodies. Seen i n rhinoscleroma. Plasma cells are seen t o c o n t a i n r o u n d e d eosinophilic structures o n

histopathology.

99. Samter's triad consists o f nasal polypi, b r o n c h i a l asthma a n d aspirin sensitivity.

100. Schaumann's bodies. Seen i n sarcoid g r a n u l o m a .

101. Schneiderian membrane (mucosa). I t is a n o t h e r n a m e for respiratory m u c o s a o f nose and consists o f pseudo-

stratified ciliated c o l u m n a r cells.

102. S c h w a r t z sign is a p i n k reflex, seen t h r o u g h intact t y m p a n i c m e m b r a n e , i n t h e area o f oval w i n d o w . I t indicates

active otosclerosis usually d u r i n g pregnancy.

103. S i n u d u r a l angle, also called Citelli's angle, is situated b e t w e e n t h e s i g m o i d sinus and m i d d l e fossa dura plate.

104. Sluder's neuralgia. I t is c h a r a c t e r i s e d b y neuralgic p a i n i n l o w e r half o f face w i t h nasal congestion, r h i n o r r h o e a

a n d increased l a c r i m a t i o n . I t is d u e t o n e u r a l g i a o fs p h e n o p a l a t i n e ganglion.
105. Solid angle is t h e area w h e r e three b o n y s e m i c i r c u l a r canals meet.

106. Structures o f ear fully f o r m e d b y b i r t h are: m i d d l e ear, malleus, incus, stapes, l a b y r i n t h a n d the cochlea.

107. T o n e decay, also c a l l e d a u d i t o r y f a t i g u e , is c h a n g e i n a u d i t o r y threshold w h e n a c o n t i n u o u s tone is p r e s e n t e d to

the ear. I t is s e e n i n acoustic n e u r o m a a n d o t h e r retrocochlear lesions.

108. T r a u t m a n n ' s triangle is b o u n d e d b y the b o n y labyrinth anteriorly, s i g m o i d sinus posteriorly a n d the dura o r

superior petrosal sinus superiorly (Fig. 76.4).

109. Treatment o f choice for antrochoanal p o l y p i n a c h i l d is f u n c t i o n a l endoscopic sinus surgeiy (FESS) or intra-

nasal p o l y p e c t o m y . C a l d w e l l - L u c o p e r a t i o n is avoided.

110. Trotter's (or Sinus o f M o r g a g n i ) s y n d r o m e or triad is seen i n nasopharyngeal c a r c i n o m a w h i c h spreads

laterally to i n v o l v e the sinus o f M o r g a g n i i n v o l v i n g i n m a n d i b u l a r nerve. I t is c h a r a c t e r i s e d by:

(i) C o n d u c t i v e h e a r i n g loss (due t o eustachian tube obstruction).

(ii) Ipsilateral i m m o b i l i t y o f soft palate.

(iii) N e u r a l g i c p a i n i n the distribution o f V .

T r i s m u s a n d preauricular fullness m a y be associated w i t h the above.

H i . Tullio phenomenon. L o u d s o u n d produces v e r t i g o . I t is s e e n i n congenital syphilis o r w h e n three f u n c t i o n i n g

w i n d o w s are present i n the ear e.g. fistula o f semicircular canal, fenestration o p e r a t i o n i n the presence o f m o b i l e

footplate o f stapes.

112. Turban epiglottis is due to o e d e m a a n d infiltration o f the epiglottis a n d is caused b y laryngeal tuberculosis.

Lupus—a f o r m o f tuberculosis, o n the o t h e r h a n d , eats a w a y a n d destroys the epiglottis.

113. Tympanic membrane develops f r o m all the three g e r m i n a l layers: e c t o d e r m (outer epithelial layer) m e s o d e r m

( m i d d l e fibrous layer) a n d e n d o d e r m (inner m u c o s a l layer).

114. Vertical a n d anteroposterior dimensions o f m i d d l e ear are 15 m m each w h i l e transverse d i m e n s i o n is 2 m m

at m e s o t y m p a n u m , 6 m m above at t h e e p i t y m p a n u m a n d 4 m m b e l o w i n the h y p o t y m p a n u m . T h u s , m i d d l e ear

is t h e n a r r o w e s t b e t w e e n the u m b o a n d p r o m o n t o r y .

115. Vocal nodules o c c u r at t h e j u n c t i o n o f anterior w i t h m i d d l e t h i r d o f vocal cords as t h i s i s t h e m a x i m u m v i b r a t o r y

area d u r i n g speech.

116. Vomeronasal organ. I t is a v e s t i g e a l structure earlier related to smell. I t can s o m e t i m e s be v i s u a l i z e d as a p i t o n

the anteroinferior part o f nasal s e p t u m .

117. Wallenberg s y n d r o m e (posterior inferior cerebellar artery s y n d r o m e ) is d u e to t h r o m b o s i s o f posterior

inferior cerebellar artery causing ischaemia o f lateral part ot m e d u l l a . I t is c h a r a c t e r i s e d by:

(i) V e r t i g o , nausea a n d v o m i t i n g

(ii) H o r n e r ' s s y n d r o m e

(iii) D y s p h a g i a

(iv) D y s p h o n i a

(v) A t a x i a w i t h t e n d e n c y to fall t o the i n v o l v e d side

(vi) Loss o f p a i n a n d t e m p e r a t u r e sensation o n same side o f face a n d contralateral side o f limbs.

118. Wrisberg's cartilage. A n o t h e r n a m e for c u n e i f o r m cartilage situated i n aryepiglottic fold. I t is f i b r o e l a s t i c carti-

lage a n d does n o t u n d e r g o calcification.

119. Woodruff's plexus. I t is a plexus o f veins situated inferior to posterior e n d o f inferior turbinate. I t is a site o f

posterior epistaxis i n adults.

A p p e n d i x II: I n s t r u m e n t s

T h i s section intends t o i n t r o d u c e o n l y t h e c o m m o n l y used instruments i n operative surgery a n d is b y n o m e a n s a n exhaus-

tive list. O t h e r instruments used f o r r o u t i n e diagnostic E N T e x a m i n a t i o n are dealt w i t h o n page 3 7 9 .

EAR INSTRUMENTS

Myringotome. U s e d for m y r i n g o t o m y .

Mollison's m a s t o i d retractor. U s e d i n m a s t o i d e c t o m y t o retract soft tissues after i n c i s i o n a n d elevation o f flaps. I t is self-

retaining a n d haemostatic.

Jansen's self-retaining mastoid retractor. U s e d i n m a s t o i d e c t o m y similar t o M o l l i s o n ' s retractor.

Appendices

L e m p e r t ' s endaural retractor. U s e d for endaural a p p r o a c h to ear surgery. I t has t w o lateral blades w h i c h retract the flaps

a n d a t h i r d central blade w i t h holes. T h e central blade retracts the temporalis muscle. T h e central blade can be fixed to the

b o d y o f the retractor b y its hole.

Lempert's endaural speculum. I t is l i k e V i e n n a m o d e l nasal s p e c u l u m b u t c u r v e d . I t is u s e d to spread o p e n the meatus

w h e n g i v i n g local injection or m a k i n g an endaural incision.

Mastoid gouge. U s e d to r e m o v e b o n e i n m a s t o i d surgery. V a r i o u s sizes are available.

Lempert's curette (scoop). U s e d for r e m o v a l o f b o n y septa and granulations i n m a s t o i d surgery.

M a c E w e n ' s curette a n d cell seeker. U s e d i n m a s t o i d surgery to e x p l o r e the air cells w i t h o n e e n d a n d to curette the

i n t e r v e n i n g septa a n d granulations w i t h the other.

0
Farabeuf's periosteal elevator. U s e d for elevation o f p e r i o s t e u m f r o m the m a s t o i d cortex i n m a s t o i d e c t o m y .
 NOSE INSTRUMENTS

Lichtwitz trocar and cannula. U s e d for p r o o f p u n c t u r e (antral lavage). P u n c t u r e is d o n e i n the inferior m e a t u s as this

site is e a s i l y accessible a n d safe.

Tilley's h a r p o o n . U s e d for intranasal a n t r o s t o m y i n the inferior meatus. Its advantage lies i n the r e m o v a l o f the b o n y

chips w h e n the i n s t r u m e n t is w i t h d r a w n so that they d o n o t fall i n t h e sinus c a v i t y . I t is r a r e l y u s e d these days.

Tilley's antral burr. U s e d to enlarge a n d s m o o t h e n the h o l e m a d e b y h a r p o o n i n intranasal inferior meatal a n t r o s t o m y .

N o l o n g e r used n o w .

Rose's sinus d o u c h i n g c a n n u l a . U s e d i n irrigation o f m a x i l l a r y sinus w h i c h already has a nasoantral w i n d o w due to

intranasal a n t r o s t o m y o r C a l d w e l l - L u c operation. D i r e c t i o n o f the t i p is i n d i c a t e d b y the h o o k outside.

Luc's forceps. U s e d i n C a l d w e l l - L u c o p e r a t i o n (to r e m o v e m u c o s a ) , S M R . o p e r a t i o n (to r e m o v e b o n e o r cartilage),

p o l y p e c t o m y (to grasp a n d avulse p o l y p ) and to take b i o p s y f r o m the nose o r throat.

Nasal snare (Krause's). U s e d for r e m o v a l o f nasal p o l y p i . P o l y p is e n g a g e d i n the w i r e l o o p a n d avulsed. Its use has

greatly declined.
St. C l a i r T h o m s o n ' s nasal s p e c u l u m . I t has l o n g blades w h i c h are concave f r o m inside. U s e d i n nasal surgery, e.g. S M R

o p e r a t i o n o r septoplasty.

Killian's long-bladed nasal s p e c u l u m . U s e d i n S M R o r septoplasty o p e r a t i o n to k e e p m u c o p e r i o s t e a l flaps away.

Tilley's dressing forceps. U s e d f o r nasal p a c k i n g , ear dressing, r e m o v a l o f foreign bodies f r o m the nose. I t has a b o x joint.

H a r t m a n n ' s dressing forceps. Similar to above forceps. I t has a s c r e w joint. T h e j a w is s e r r a t e d a n d g r o o v e d .

Wilde's dressing forceps. U s e d for p a c k i n g the nasal cavity o r ear canal. I t acts o n spring action.
Ballenger's swivel knife. U s e d i n r e m o v a l o f septal cartilage i n S M R operation. T h e blade o f k n i f e revolves automatically

a n d changes d i r e c t i o n w h e n c u t t i n g the cartilage anteroposteriorly d o w n w a r d s , a n d posteroanteriorly. Different sizes o f

blades are also s h o w n .

Killian's nasal gouge (bayonet-shaped). U s e d f o r r e m o v a l o f septal spurs o r b o n y crests a n d ridges i n S M R operation.

Freer's d o u b l e - e n d e d elevator. U s e d for elevation o f m u c o p e r i c h o n d r i u m or periosteum i n S M R o r septoplasty operation.

Asch's s e p t u m forceps. U s e d for r e d u c i n g fractures o f nasal septum.

 THROAT INSTRUMENTS

Boyle-Davis m o u t h gag. U s e d f o r o p e n i n g t h e m o u t h a n d retracting t h e t o n g u e anteriorly. T o n g u e blades o f various sizes

can be interchanged according t o t h e age o f t h e patient. I t is u s e d f o r various operations o n the oral cavity (palate surgery),

o r o p h a r y n x ( t o n s i l l e c t o m y , surgery o f soft palate, pharyngoplasty), nasopharynx ( a d e n o i d e c t o m y , excision o fa n g i o f i b r o m a ) .

Doyen's mouth gag. U s e d to keep t h e m o u t h o p e n f o r intraoral surgery w h e n retraction o f t h e t o n g u e is n o t r e q u i r e d

o r desirable. M o s t l y used f o r t o n g u e surgery. I t is a p p l i e d o n o n e s i d e o f t h e m o u t h o n m o l a r teeth.

Jenning's m o u t h gag. U s e is s i m i l a r t o t h e o n e a b o v e . I t is a p p l i e d i n t h e c e n t r e o f the m o u t h .

Draffin's bipod. E a c h p o d has f o u r rings. T h e y c a n b e assembled t o v a r y t h e h e i g h t at w h i c h t h e t o n g u e blade o f t h e

B o y l e - D a v i s m o u t h gag c a n b e suspended. T h e l o w e r e n d o f each p o d c a n b e placed i n o n e o f t h e several depressions i n

M a g a u r a n ' s plate (Vide infra).

Magauran's plate

Tonsil holding forceps (Denis Browne's). U s e d f o r h o l d i n g the tonsil d u r i n g t o n s i l l e c t o m y b y dissection m e t h o d .

Tonsil dissection forceps w i t h teeth (Waugh's). F o r incision i n m u c o u s m e m b r a n e a n d dissection o f tonsil.

— — = ^IIIIfflTTTTTTT TF' r T f — a f c *
Yankauer's suction tube. U s e d for suction i n t o n s i l l e c t o m y a n d o t h e r oral o r o r o p h a r y n g e a l operations.

T o n s i l dissector a n d anterior pillar retractor. O n e e n d is u s e d to dissect t h e tonsil a n d the o t h e r t o retract the anterior

pillar to inspect the fossa f o r any b l e e d i n g p o i n t .

Tonsil artery forceps (straight a n d curved). Straight forceps is u s e d to catch the b l e e d i n g p o i n t a n d c u r v e d o n e is used

as r e p l a c e m e n t forceps before t y i n g w i t h a ligature.

Negus artery forceps. Its tip is sharply c u r v e d . T h e forceps is used as r e p l a c e m e n t forceps to ligate the b l e e d i n g

p o i n t .

N e g u s K n o t tyer. H e l p s to carry the ligature k n o t u p to the tip o f artery forceps h o l d i n g the vessel a n d tie it.

E v e s ' tonsil snare. U s e d f o r t o n s i l l e c t o m y . After the t o n s i l has b e e n dissected t i l l i t s l o w e r p o l e , s n a r e is p a s s e d r o u n d the

tonsil to engage the pedicle a n d t h e n firmly closed. It crushes a n d cuts the pedicle t h e r e b y m i n i m i s i n g bleeding.

Peritonsillar abscess forceps. U s e d for drainage o f peritonsillar abscess.

St. C l a i r T h o m p s o n ' s curette w i t h guard. U s e d i n a d e n o i d e c t o m y . C u r e t t e shaves o f f the a d e n o i d mass w h i l e the

g u a r d holds the tissue a n d prevents its slipping.

 LARYNX AND TRACHEA INSTRUMENTS

T r a c h e a l h o o k ( b l u n t a n d s h a r p ) . Blunt tracheal hook ( A ) is used to retract t h y r o i d isthmus u p w a r d s or d o w n w a r d s to

expose the trachea.

Sharp tracheal hook ( B ) is a p p l i e d t o l o w e r b o r d e r o f c r i c o i d cartilage t o stabilise t h e trachea and prevents its m o v e m e n t s d u r i n g

respiration w h e n m a k i n g incision i n the tracheal wall.

^ —^ZE=^0
T r a c h e a l dilator. U s e d t o k e e p o p e n the tracheal edges after incision i n the trachea so that t r a c h e o s t o m y t u b e can be

easily inserted. A c u r v e d artery forceps can be easily used i n place o f a tracheal dilator.

Laryngoscope. U s e d for direct l a r y n g o s c o p y (diagnostic o r therapeutic). I t has a single or a t w i n light carrier w h i c h can

be c o n n e c t e d t o a cold-light source t h r o u g h a flexible cable. O l d e r m o d e l s have a small electric b u l b w h i c h w o r k s o n bat-

teries o r a transformer. T h e r e are several m o d e l s o f laryngoscope. T h e size o f laryngoscope used w i l l v a r y w i t h the age o f

the patient.

Instruments used for microlaryngeal surgery

1. L a r y n g o s c o p e

2. C h e s t support

3. S u c t i o n tip a n d o t h e r instruments

4. F i b r e o p t i c c o r d

5. V a r i o u s types o f m i c r o l a r y n g e a l instruments

6. S p e c i m e n bottle
 2 3

Oesophagoscope. U s e d f o r diagnostic o r therapeutic oesophagoscopy. L e n g t h o f o e s o p h a g o s c o p e a n d its l u m e n vary

w i t h the age o f the patient. M e c h a n i s m o f i l l u m i n a t i o n is s i m i l a r t o that o f laryngoscope. H a n d l e , at the p r o x i m a l e n d o f

oesophagoscope, indicates the d i r e c t i o n o f the b e v e l at the distal end.

Bronchoscope. S i m i l a r to o e s o p h a g o s c o p e b u t has openings at the distal part o f the tube w h i c h help i n v e n t i l a t i o n o f

contralateral l u n g o r side b r o n c h i . I t s d i s t a l t i p is also b e v e l l e d t o f a c i l i t a t e its passage b e t w e e n the cords. Size o f b r o n c h o -

scope w i l l v a r y w i t h the age o f the patient. F o r indications a n d t e c h n i q u e o f b r o n c h o s c o p y , (see page 434). Size o f b r o n -

c h o s c o p e f o r different age groups is g i v e n i n T a b l e A l .

Table A1 Size o f t r a c h e o s t o m y t u b e a n d b r o n c h o s c o p e a c c o r d i n g t o a g e

Age Inner diameter of tracheostomy tube (mm) Size of bronchoscope tube (mm)
Preterm-1 month 2.5-3.0 2.5

1-6 m o n t h s 3.5 3.0

6-18 months 4 3.5

18 m o n t h s t o 3 years 4.5 4.0

3 - 6 years 5 4.5

6 - 9 years 5.5 5.0

9 - 1 2 years 6.0 6.0

12-14 years 7.0 6.0

Source: Wyatt ME, Bailey C M , Whiteside JC. Update on paediatric tracheostomy tubes. Laryngoi. Otol. 1999; 113: 3 5 - 4 0 and Tracheostomy:
A Multi-professional Handbook. Claudia, Russell and Basil Matta (editors). G M M : London, 2004.
T r a c h e o s t o m y tubes for adults. V a r i o u s types available are:

i- U n c u f f e d a n d cuffed tubes
2. D o u b l e cuff tube. Each c u f f can b e inflated alternately t o p r e v e n t pressure necrosis at o n e site.

3. Fenestrated tube. Single o r m u l t i p l e holes are situated at t h e u p p e r curvature. T h e hole{s) help i n speech p r o d u c t i o n

o r i n w e a n i n g f r o m t r a c h e o s t o m y

4. Adjustable flange l o n g - t u b e . E x t r a l e n g t h t r a c h e o s t o m y tubes are used w h e n pretracheal tissues a r e t h i c k o r s w o l -

len o r t o by-pass a g r o w t h o r stenosis i n trachea. Flange i n these cases c a n b e adjusted

5. Single l u m e n tube. T h e r e is n o i n n e r cannula

6. D o u b l e l u m e n tube. T h e y have a n i n n e r cannula inside a n o u t e r cannula. I t is e a s i e r t o r e m o v e , clean a n d replace

the i n n e r cannula, k e e p i n g o u t e r cannula i n place f o r breathing.

7. Suction-aid tracheostomy tubes. T h e y have a small tube e n d i n g above t h e c u f f to suck o u t pharyngeal secretion

a n d p r e v e n t their aspiration.

Classification o f tubes a c c o r d i n g to the material. A tracheostomy tube m a ybe made of:

• Silver—an alloy o fs i l v e r , c o p p e r a n dphosphorus, e.g.Fuller, N e g u s , Jackson's tube.

71
P V C ( p o l y v i n y l chloride): T h e y are disposable, single use tubes a n d t h e r m o l a b i l e , a n dthus adjust t o tracheal l u m e n .

• Silicone: Bacteria a n d secretions d o n o t adhere t o t h e tube a n d there is m i n i m u m o f crusting

3
Siliconised P V C : I t has t h e properties o f b o t h P V C a n d silicon, i.e. i t is t h e r m o l a b i l e a n d adjusts t o tracheal wall w h i l e

silicon prevents crusting.

1
Silastic: I t is soft a n d non-irritating, a n d m i n i m i z e s crusting

• A r m o u r e d tubes: T h e y are plastic tubes r e i n f o r c e d b y a spiral o r rings o f stainless steel. T h e y are n o t easily k i n k e d

Fuller's tracheostomy tube. I t consists o f an o u t e r tube a n d a n i n n e r tube, t h e latter b e i n g slightly longer. O u t e r tube is

m a d e o ft w o blades, w h i c h w h e n pressed together, c a n b e easily i n t r o d u c e d i n t o t h e t r a c h e o s t o m y o p e n i n g . I n n e r tube

has a h o l e i n t h e centre so that patient c a n still h a v e a chance t o breathe f r o m t h e l a r y n x e v e n w h e n tube is b l o c k e d at its

o u t e r e n d .

Jackson's tracheostomy tube. I t has three parts: o u t e r tube, i n n e r t u b e a n d a n obturator. O u t e r tube is n o t split,

i n n e r tube c a nb e fixed t o t h e shield o ft h e o u t e r tube b y a lock. T h eo b t u r a t o r helps i n t h e i n t r o d u c t i o n o ft u b e into t h e

trachea.

Outer fube

nner fube

Obturator or
Pilot
Cuffed tracheostomy tube. W h e n c u f f is i n f l a t e d , it prevents aspiration o f p h a r y n g e a l secretions into the trachea. I t c a n

also p r e v e n t a i r - l e a k . I t is u s e d w h e n there is d a n g e r o f aspiration o f p h a r y n g e a l secretions as i n u n c o n s c i o u s patient o r

w h e n p a t i e n t is p u t o n a respirator. C u f f s h o u l d be deflated e v e r y 2 h o u r s for 5 m i n u t e s t o p r e v e n t d a m a g e to trachea a n d

cartilage necrosis. N o w a d a y s , tubes w i t h t w o cuffs are available a n d inflation o f the c u f f can be alternated to a v o i d c u f f

pressure at o n e site i n trachea.

Cuffed suction-aid tracheostomy tube. I t is l i k e an o r d i n a r y cuffed t u b e b u t also has a s u c t i o n t u b e w h i c h reaches

a b o v e the cuff. It helps t o suck o u t p h a r y n g e a l secretion collected a b o v e the cuff. S u c t i o n s h o u l d always be d o n e before

deflating the c u f f so that a c c u m u l a t e d p h a r y n g e a l secretions d o n o t get aspirated into the trachea.

L e n g t h o f the tube — Size o f t u b e x 3 ( i n c m )

For e x a m p l e , i n a 4 - y e a r - o l d c h i l d size o f the t u b e = ~ + 4 = 5 m m

L e n g t h o f the tube — 5 x 3 — 15 c m

R o u g h l y size o f the t u b e is s i z e o f t h e child's little finger.

How to select size of tracheostomy tube in adults

T r a c h e o s t o m y t u b e f o r a d u l t s is s e l e c t e d b y s i z e o r n u m b e r o f t h e t u b e . L a r g e r the n u m b e r ( s i z e ) g r e a t e r is t h e i n n e r d i a m -

eter (see T a b l e A l ) .I n adults, tubes o f i n n e r d i a m e t e r v a r y i n g b e t w e e n 6 a n d 9 o r 10 m m are used. S o m e t i m e s size o f tube

is e x p r e s s e d i n F r e n c h gauge ( F G ) .

F G = o u t e r d i a m e t e r X n (II — 3.14 o r a p p r o x 3)
F o r e x a m p l e , a t u b e o f 36 F G w i l l have an o u t e r d i a m e t e r o f nearly 12.0 m m . Size o f Jackson's o r N e g u s tube is usually

indicated b y F G .

L a r y n g e a l m a s k airway. L a r y n g e a l m a s k a i r w a y ( L M A ) is a d e v i c e w i t h a tube a n d a laryngeal m a s k w h i c h fits o v e r the

supraglottic r e g i o n . Size o f m a s k is s e l e c t e d a c c o r d i n g to the w e i g h t o f the patient. T h e c u f f o f m a s k is f i r s t deflated a n d

p o s i t i o n e d o v e r the l a r y n x a n d later inflated. I t is u s e d w h e r e face m a s k is i n e f f e c t i v e a n d i n t u b a t i o n difficult. O t h e r a d v a n -

tages o f L M A i n c l u d e :

• T o intubate the patient w i t h endotracheal tube (less 6 m m 1 D ) d i r e c d y o r t o first pass a stylet a n d t h e n rail-road e n d o -

tracheal tube.

s
T o pass f l e x i b l e b r o n c h o s c o p e for fibreoptic assessment o f a i r w a y a n d t h e n pass t h e stylet.

L M A is n o t as e f f e c t i v e as e n d o t r a c h e a l tube to p r e v e n t aspiration o f gastric secretions. Its use is c o n t r a i n d i c a t e d i n obstruc-

t i o n i n the area o f glottis a n d subglottis, a n d c a n n o t be used i n those w i t h trismus.

A p p e n d i x III

1 C u p = 2 4 0 m L

2 C u p s = 1 P i n t = 4 7 0 m L

4 C u p s = 1 Q u a r t = 9 5 0 m L

= 1 G a l l o n = 3.79 litres

1 O u n c e = 28.35 g

1 P o u n d = 4 5 0 . 0 g

1 K i l o g r a m s = 2.2 P o u n d s

K i l o ( = 1 0 0 0 ) eq 1 Kilolitre = 1000 litres

H e c t o ( = 1 0 0 ) e q 1 H e c t o l i t r e = 100 litres

D e c a ( = 1 0 ) e q 1 Decalitre = 10 litre

D e c i ( 1 / 1 0 ) eq 1 D e c i l i t r e = 0.1 litre

C e n t i ( = 1 / 1 0 0 ) e q 1 Millilitre = 0.01 litre

M M ( = 1 / 1 0 0 0 ) e q 1 Millilitre = 0.001 litre

R e a d similarly for metres a n d grams

1 T e a s p o o n f u l = 5 m L

1 T a b l e s p o o n f u l = 15 m L

1 O u n c e = 0.065 g ( r o u n d e d o f f to 60 m i l l i g r a m s )

15 Grains = l g

1 m L = 2 0 D r o p s ( m i n i m s )

Prefix Notation Terminology Examples

Giga 10 9
Billion Gegabyte

Mega TO 6
Million Megahertz

Kilo 10 3
Thousand Kilogram

Milli 10" 3
One thousandth Milligram

Micro tor* One millionth Microvolts

Nano 10" 9
One billionth Nanometre

-12 One trillionth Picotesla

Pico 1 0
Index

Adenoids 258 play 117, 131

A b d u c t o r paralysis, bilateral 318 anatomy o f 258 pure tone 27

Abscess blood supply o f 258 speech 28, 117, 131
b e h i n d t h e ear 88 clinical features o f 258 visual reinforcement 131
Bezold 87 diagnosis o f 259 A u d i o m e t r i c zero 24

brain, otogenic 92 lateral v i e w n a s o p h a r y n x for 446, 453 Auditory

cerebellar 93 treatment o f 259 neuropathy 33

Citelli's 88 A d e n o i d facies 259, 457 Auditory brainstem

extradural 91 Aditus 7 implant 123

intratonsillar 276 ad a n t r u m 7 response 28, 31
Luc's 88 Aero-otitis media 74 Aural rehabilitation 134
meatal 87 prevention o f 74 A u r i c l e (see also P i n n a ) 3, 1 1 7
orbital 213 A I D S basal cell c a r c i n o m a o f 117, 118
parapharyngeal 281 E N T manifestations o f 374 cutaneous h o r n o f 118
drainage o f 283 epidemiology o f 373 dermoid o f 117
parotid 277 Kaposi's sarcoma in 375 frostbite o f 55
peritonsillar 278 lymphoma in 374 graft f r o m cartilage o f 3
postauricular 87 A i r cell system, o f mastoid 8 haemangiomas o f 117, 118

retropharyngeal 280 Airways haematoma o f 54

acute 280 foreign body o f 445 keloid o f 56, 117
chronic 281 Angiofibroma, nasopharynx 262 keratoacanthoma o f 118
septal 166 Ankyloglossia 232 lacerations o f 55
subdural 91 Anosmia 157, 165 melanoma o f 118

temporal lobe 93 Anotia 54, 55 neurofibroma o f 118

zygomatic 87 A n t e r i o r recess, o f m e a t u s 4 papilloma o f 118
Absolute bone c o n d u c t i o n ( A B C ) test 26 Antral irrigation 418 squamous cell carcinoma o f 119
Acoustic meatus, external 5 complications o f 419 trauma o f 54
relations o f 5 diagnosis o f antral p a t h o l o g y 418 tumours o f 117
Acoustic neuroma 124 i n c h r o n i c m a x i l l a r y sinusitis 418 Axonotmesis 104

a u d i o l o g i c a l tests i n 125 technique o f 418

c a l o r i c test i n 125 A n t r o s t o m y , intranasal 420 B

cochleovesfibular symptoms 124 complications o f 420 Basilar m e m b r a n e 12

c r a n i a l n e r v e palsies i n 124 in middle meatus 420 Bat ear 54, 381

C T scan i n 124 technique o f 420 Battle's sign 457

CSF examination 126 Antrum, o f mastoid 7 Behcet's syndrome 229, 230

e v o k e d response a u d i o m e t r y 126 A p h t h o u s ulcers 230, 274 Bell's palsy 105

M R I in 126 Arnold's nerve 5 aetiology o f 105

n e u r o l o g i c a l test 125 Artificial larynx 331 clinical features o f 106

r a d i o l o g i c a l test 126 Aspirin burn 230 diagnosis o f 106

stapedial reflex decay test 125 Audiogram, pure tone 27 prognosis o f 106
v e s t i b u l a r test 125 speech 28 steroids i n 106
Acoustic trauma 40 Audiometry 27 Bell's p h e n o m e n o n 106, 457
Adenoidectomy behaviour observation 131 Benign tumours

c o m p l i c a t i o n s after 443 Bekesy 28 fibroma 284

indications o f 442 e v o k e d response 31 haemangioma 284

o p e r a t i v e steps o f 442 impedance 28, 132 lipoma 284
Benign tumours (contd) palliative 370 Cyst
mucous cyst 284 toxicity of drugs of 372 branchial 88, 399, 400
neuroma 284 types of 370 dermoid 117, 159, 398
papilloma 284 work-up of patient before 372 thymic 400
pleomorphic adenoma 284 Choanal atresia 178, 458 thyroglossal 398, 399
Bing test 27 eustachian tube in 61—63 Cystic hygroma 401
Blow out fractures 198,421 Cholesteatoma 75
Blue drum, causes of 427 acquired, primary 59, 75-76 D
Bodies secondary 75-76 Deaf child
Psammoma 461 classification 75 aetiology of 127
Russell 172,461 congenital 75-76 causes of 127, 128
Schaumann 461 genesis of 75 education of 133
Boerhaave's syndrome 349 Cholesterol granuloma 81 evaluation of 128
Brachytherapy 266, 367 Chondrodermatitis nodularis chronica hearing aid in 132
Bronchia] foreign body 342 beliefs 56 parental guidance in 132
emphysema in 344 Chorda tympani 10, 102 risk factors of 128
pneumothorax in 343 Chronic suppurative otitis media (CSOM) speech and language development in 132
removal of 316 76 vocational guidance 133
types of obstruction 344 atticoantral 77 Deaf, definition of 42
Bronchoscope 473 complications of 82 Decannulation, principles in 339, 340
size of, in different ages 473 features of 79 Decibel 23, 24, 43, 113
Bronchoscopy 434 safe type 77 Deglutition (see also Swallowing) 255-257,
flexible fibreoptic 435 Citelli's angle (see sinodural angle) 354
rigid 434 Cochlea 11, 18-20, 46 Delta sign 95
anaesthesia of 434 central neural pathways 46 Diffuse oesophageal spasms 351
complications of 435 electrical potentials of 19 Diphtheria, faucial 274, 308, 309
indications of 434 frequency localisation in 19 Discrimination score 28, 113, 126
positions of 434 microphonic 18, 19 Dizziness 22, 381
post-operative care 435 summating potential 19 DNS 163-165
precautions during 435 Cochlear dysplasia aetiology of 163
technique of 434 Alexander 127 clinical features of 164
Buccal mucosa, carcinoma of 239 Bing-Siebenman 127 treatment of 165
Bulla ethmoidalis, of middle meatus 151, Michel 127 types of 164
152 Mondini 127 Drumhead (see also Tympanic
Sheibe 127 membrane) 3
C Cochlear implant(s) 138 Dynamic range 24
Caldwell-Luc operation 421 components and functioning of 138 Dysphagia 354-355
cheek anaesthesia after 421 complications of 141 investigations in 355
contraindications of 421 evaluation 140 lusona 354
indications of 421 MED-EL 138 oesophageal causes 354
technique of 421 nucleus 138 preoesophageal causes 354
Caloric test 48 outcomes of 139 Dysphonia 334
bithermal 48 surgery for 140 plica ventricularis 334
Cancerophobia 388 Cochlear nerve 16, 19 ventricular 334
Candidiasis, chronic hypertrophic 230 Cody's operation 116
of oral cavity 229 Conus elasticus 300, 302 E
Cardiac achalasia 454 Cottle test 164, 165 Eagle's syndrome 287
Carhart's notch 99, 458 Cricothyrotomy 299, 340, 344 Ear
Carotid body tumour 399, 400 Cristae of semicircular ducts 19 anatomy of 3
Cavernous sinus thrombosis 214 structure of 20 development of 14
Central, auditory tests 33 Crocodile tears 106, 110 examination of 381, 382
Cerumen 59 Crowe-Beck test 95 external 3
Cervical lymph nodes Cryosurgery nerve supply of 5
classification of 392 advantages of 365 foreign bodies of 60
in malignancy of nasopharynx 388 disadvantages of 365 internal 10
methods of examination of 394 technique of 365 maggots in 61, 176
Chemodectoma uses of 365 middle 5
middle ear 287, 400 CSF rhinorrhoea 178 Earache (see Otalgia)
neck 402 aetiology of 178 Electrocochleography 31, 113, 114
Chemotherapy diagnosis of 178 in Meniere's disease 111-114
adjuvant 370 localisation of 179 Electrolarynx 331
drugs used in 372 sites of leakage 178 Electromyography 104, 105, 293
for head and neck 370, 371 Curtain effect 390 Electroneuronography 104
Electro nystagmography 49, 5(1 extracranial part 102 Galvanic test 49
Endolymph intracranial part 102 Gastro-oesophageal reflux 352
secretion and absorption of 111 intratemporal part 102 complications of 352
Endolymphatic hydrops (see also maximal stimulation test 104 Gelle's test 27. 459
Meniere composition disease) nucleus of 101 Gingivostomatitis 229
Endolymphatic sac 11. 12 severity of injury 103 Globus hystericus 352, 390
Endoscopic sinus surgery 186, 429 surgeiy of 11(1 Glomus tumour, middle ear 120
Epiglottis surgical landmarks of 103 Glottis 302, 326
lupus of 462 Facial paralysis 105 Glue ear 71. 457
thumb sign of 308 causes of 105 Gradenigo's syndrome 82, 89, 459
turban 462 central 109 Granular cell myoblastoma 237
Epiglottitis, acute 3(17, 308 complications after 109 Granular cell tumour 237,
Epistaxis exposure keratitis in 109 322, 325
anterior nasal packing in 191 hypoglossal-facial anastomosis HO Granuloma
causes of 190 in acute otitis media 89 pregnancy 237
classification of 191 in chronic otitis media 90 pyogenic 237
from Little's area 190 in ear surgery 106 Griesinger's sign 95, 459
general measures in 193 in fractures of temporal bone 107 Grommet, in otitis media with
management of 191 in intratemporal neoplasms 108 effusion 73
posterior packing in 192 localisation of lesion in 109
sites of 191 nerve graft in III) H
SMR operation and 193 peripheral branches in 102 Haematoma, septal 165
Epirympanum 5, 6, 10 recurrent 106 Hair cells 16
Epulis, congenital 237 stapedial reflex in 109 inner and outer, differences of 17
Equilibrium, of body, maintenance of 22 taste-testing in 109 Hair cells of cochlea 16
Erythroplakia 238 tubercular otitis media and 83 nerve supply of 17
Ethmoidectomy, extranasal 186 Facial recess, of middle car 7 Halitosis 390
intranasal 209 Facialridge413-415 Hallpike manoeuvre 46, 47, 51
Ethmoid sinus(es), anatomy of 202 Fenestration operation 36, 90, 100 Hearing aid(s) 132
examination of 386 FESS 186. 419 bone-anchored (BAHA) 136, 137
malignancy of 223 Fick's operation 116 CROS 135
Eustachian tube 63-68 Fissula ante fenestram 97 fitting of 135
anatomy of 63 Fissures of Santorini 4 implantable 137
disorders of 66 Fistula indications for 134
examination of 68 oflabyrinth 90 types of 134
functions of 64 oroantral 200 Hearing, assessment of 25
function tests of 65 sublabial 422 clinical tests ot 25
patulous 67 Fistula test 47 finger friction test 25
retraction pockets of 67 Fitzgerald-Hallpike test 48 tuning fork test 26
structure of 63 Foramen of Huschke 4 voice tests in 25
Exostosis, ear canal 117, 118 Foreign bodies of air passages 342-344 watch test 25
External auditory canal 118 aetiology of 342 Hearing impaired, assistive devices
ceruminoma of 1 19 clinical features of 342 for 141
squamous carcinoma of 119 diagnosis of 343 aural rehabilitation in 141
tumours ot 119 management of 344 lip-reading for 141
External auditory meatus (see also Acoustic nature of 342 speech conservation in 141
meatus, external) Fracture (s) Hearing impairment and percentage
bony 4 naso-orbital 196 loss 27
cartilaginous 4 of face 195 Hearing level (HL) 24
External ear canal 5, 56 of mandible 199 Hearing loss 25, 43
atresia of 57 of maxilla 198 and difficulty in hearing speech 43
trauma of 57 of nasal bones 195 assessment of, in infants and
External ear, tumours of 117-119 of orbital floor 198 children 131
ot zygoma 197 classification of 34
F of zygomatic arch 198 conductive 34
Face, fractures of 195 Frenzel's manoeuvre 458 aetiology of 34
injuries of 195 Frey's syndrome 9, 458 in different lesions of conductive
Facial nerve 1 0 1 - 1 1 0 Functional aphonia 334 apparatus 34
anatomy of 101 Furuncle, ol nasal vestibule 161 management of 35
blood supply of 102 degrees of 43
branches of 102 G degree of handicap in 43
course of 101 Galen's anastomosis 459 familial progressive 39
electrodiagnostic tests 104 Gait, in vestibular lesions 47 fluctuating 112, 458
Hearing loss {could) Infected sebaceous cyst 87 Larynx
genetic, associated with syndromes Infectious mononucleosis 269, 274 abscess of 306
129, 131 Inflammatory disorders 56 adult papilloma of 325
labyrinthitis and 38 Infundibulum, ethmoidal, of nose 152 amyloid tumour 323
mixed 25 Inner earfluids12 anatomy of 299
noise-induced 40 instrumental devices 134 benign neoplasms of 322
non-organic 29 Intensity 23 cancer of 326
audiometric tests for 33 Internal nose 150, 153 diagnosis of 327
ototoxic drugs and 39 Intratemporal neoplasms 108 glottic 327
sensorineural 37 Intratympanic muscles 9 subglottic 327
aetiology of 37 supraglottic 327
congenital 37 K TNM classification 326
diagnosis of 38 Keratosis obturans 61 treatment of 329
management of 38 Keratosis pharyngitis 270 cartilages of 299
social and legal aspects of 42 Kiesselbach's plexus 162,190 congenital 314
specific forms of 38 Killian's dehiscence 253, 289, 437 contact ulcer of 436
sudden 38, 41 Kobrak test, modified 48 cyst of 314
aetiology of 41 Korner's septum 8, 9, 459 development, embryologies! 302
management of 41 diagnosis of 327
steroid therapy in 41 L diphtheria of 308
unilateral 45 Labyrinth evaluation in 306
Hearing, mechanism of 17 blood supply of 13 examination of 391
normal frequency range of 24 bony 11, 97 foreign body of 60, 445, 446
physiology of 17 membranous 14 fungal infections of 313
travelling wave theory of 19 of ear 12 glottic 327
Heimlich manoeuvre 344 otic 97, 98 granular cell tumour 322, 325
Herpangina 229, 269 pars inferior of 14 hidden areas of 329
Herpes zoster oticus 58, 62, 107 pars superior of 14 indirect laryngoscopy in 391
Hiatus hernia 350 periotic 97, 116 infants and children 303
Hiatus semilunaris 151-153, 428 Labyrinthitis 70 juvenile papillomas of 324
Hitzelberger's sign 124 Laryngeal cancer leukoplakia of 322, 323
HIV infection 373-375 conservation surgery in 329 lupus 312
AIDS patients 373 risk factors in 326 membranes of 300
antiretroviral drugs in 376 treatment of 329 movements of cords in 391
course of 373 Laryngeal paralysis 317 mucus membrane of 302
diagnosis of 375 causes of 317 nerve supply of 317
epidemiology of 373 classification of 317 oedema of 305
ENT manifestations in 373, 374 congenital 317 paediatric 303
in health workers 375 total laryngectomy in 330 paralysis of 317
modes of transmission 373 Laryngeal foreign body 342, 344 physiology of 303
needle stick injury and 375 Laryngectomy scleroma of 313
management of 375 partial 330 signs of 310
universal precautions in 375 total, in cancer larynx 330 spaces of 302
Hoarseness 333 Laryngitis stenosis of 314
aetiology of 333 acute 307 stndor 315
causes of 333 atrophic 312 subglottic 327
investigations in 333 chronic 310,311 subglottic haemangioma 314, 316
Horgan's operation 421 hyperaemic 310,311 supraglottic 327
Horner's syndrome 52, 264, 459 hyperplastic 310 symptoms in, disease of 382
Hyperbaric oxygen therapy 363 Laryngocele 322, 323 syphilis of 310, 312
Hypernasality 335, 390 Laryngoscopy TNM classification 326
Hyponasality 334 anaesthesia of 432 trauma of 305
Hypopharynx 257 complications of 433 treatment of 329
anatomy of 257 direct 432 tuberculosis of 310, 312
functions of 257 indications of 432 ventricle of 301
lymphatics of 257 indirect, for base of tongue 432 virus responsible for 308
tumours of 288 post-operative care 433 widening of 391
Hyposmia 157, 431 procedure of 432 Laser(s)
Hypotympanum 5, 6 technique of indirect 391 CO, in ENT 361
Laryngotomy 336, 340 photodynamic therapy 362
I Laryngotracheobronchitis 309, 457 properties of 361
Implantable hearing aids 137 tracheostomy in 309, 338 safety precautions in use of 362
Incus 89 Laryngomalacia 314 surgery with 361
 types of 361 in mastoiditis 86 cleft 10, 14
Lateral sinus thrombophlebitis 94 modified radical 409 divisions of 6
aetiology of 94 radical 409 examination of 383
clinical features of 95 cavity care in 414 floor of 5
complications of 95 complications of 414 glomus tumour of 120, 461
delta sign in 95 indications of 413 audible bruit in 121
internal jugular vein ligation in 96 operation of 413 cranial nerve palsies in 121
pathology of 94 Schwartz operation 409,411 treatment of 121
Lederman's classification 221 Mastoiditis 85 lateral wall 6
Lermoyez syndrome 114,460 acute 85 lining of 10
Leukoplakia, oral cavity 238 and furunculosis of meatus 87 lymphatic drainage of 10
Lip, carcinoma of 239 complications of 87 medial wall 6
Little's area 162, 190, 191 masked 88 ossicles of 8
Lop ear 17, 54 petrositis 85 posterior wall 6
Loudness discomfort level 24 Maxillary sinus rhabdomyosarcoma of 123
Ludwig's angina 277 carcinoma of 220 roof of 6
Lymphatic drainage of ear 10 classification of 221 sarcomas of 123
Lymphatics of clinical features of 220 tumours, metastatic 108
alveolar ridges 228 diagnosis of 221 tumours of 120
buccal mucosa 228 prognosis of 223 Migraine, basilar 52
floor of mouth 228 radiograph in 454 Minor salivary gland tumours 243
hard palate 228 staging of 222 Mixed salivary tumour 243, 264
Killian's dehiscence 253, 290 treatment of 222 benign 247
hps 227 examination of 381 malignant 243
retromolar trigone 227 mucocele of 211 Motion sickness 22
tongue 227 surgery for chronic infections 209 Mouth, floor of 227, 389
Lyre's sign 400, 401 transillumination of 386 carcinoma of 238
Meatoplasty 409, 414, 415 examination of 389
M Meatus palpation of 389
MacEwen's triangle, in mastoid inferior, of nose 150 Mucocele
surgery 412 middle 150, 151 frontal 211
Macroglossia 389 superior 153 maxillary 212
Macula, of utricle and saccule 19 Meatus, ear 56 of paranasal sinuses 211
structure of 20 atresia, acquired 61 of ethmoid 212
Maggots, nose 177 stenosis of 61 sphenoid 212
ear 61 MED-EL 137 Mucocele, of lip 237
Malleus 9, 14 Median rhomboid glossitis 232, 389 Mucociliary mechanism, of nose 1
Masking 24 Melkersson's syndrome 105, 106,389 Mucoepidermoid, carcinoma 248
Mast cell 180, 181 Meniere's disease 51, 111 tumour 248
mediators in allergic rhinitis 181 acute attack 115 Mucous blanket 156
non-specific stimuli acting on 181 clinical features of 1 12 Muller's manoeuvre 293
Mastoid diagnosis of 114 Mumps 244
air cell system 5, 8 examination of 113 Myiasis, of nose 166, 176
antrum 7 hypothyroidism and 112 Myringitis, bullosa 62
development of 8 intennittent pressure pulse granulose 62
examination of 381 therapy 116 Myringoplasty 416,417
key area of 444 investigations in 113 advantages of 416
obliteration 409 labyrinthectomy 116 anaesthesia of 416
types of 8 pathology of 111 complications of 417
Mastoid, cells of 5 sac decompression in 116 contraindications of 416
marginal 8 sense of fullness in ear I 12 graft materials in 416
perilabyrinthine 8 staging of 115 overlay technique of 35, 416
perisinus 8 treatment of 115 complications of 417
peritubal 8 variants of 114 position of 416
retrofacial 8 vertigo in 112 post-operative care 417
squamosal 8, 9 Meningitis 92 underlay technique of 35. 416
tegmen 7, 8 Mesotyiupanum 5 complications of 417
tip 8 Microtia 54 Myringotomy
zygomatic 8 Middle ear 5 complications of 408
Mastoidectomy anterior wall 6 anaesthesia of 407
complications of 414 atelectasis of 73 contraindications of 407
cortical 413 blood supply of 10 in acute otitis media 89
indications of 413 carcinoma of 122 incisions, used in 407
Myringotomy (contd)
indications of 407
in otitis media with effusion 71
pitfalls of 408
post-operative care 408
steps of operation 407
N modified 396
Nares, stenosis of 161
atresia of 161
Nasal bones 445
fractures 445
radiology of 444
Nasal bridge depression after
SMR 4, 158
Nasal cavity 216
angiofibroma of 216
blood supply of 188
carcinoma of 216
glioma of 216, 217
inverted papilloma of 216
lymphoma of 216, 218
malignant melanoma of 217, 236
neoplasms of 216
nerve supply of 154
walls of 170
Nasal cycle 155
Nasal endoscopy 427
Nasal fractures 195, 445
types of 195
Nasal reflexes 157
Nasal synechia 178
Nasoalveolar cyst 161, 188
Nasopharyngeal fibroma 261
aetiology of 261
clinical features of 261
extensions of 261
pathology of 261
radiotherapy, in 263
site of origin and growth 261
surgical approaches to 262
Nasopharyngeal bursa 255
Nasopharyngeal cancer 263-264, 318
aetiology of 263, 264
clinical features of 264
diagnosis of 265
geographical distribution of 263
pathology of 264
treatment of 266
Nasopharyngitis 259, 260, 387
acute 259
chronic 260
Nasopharynx
cancer of 264
chordoma of 263, 264. 458
examination of 26(1
cranial nerves in 266
digital 365. 387. 442
endoscopic 263. 288
functions of 255
lining of 255
lymphatics of 255
malignant tumours of 72, 267
stenosis after adenoidectomy 259, 294, rodent ulcer of 160
473 saddle 39, 158, 173
symptoms in disease of 269 sarcoidosis of 172, 175
tumours of 265, 267 syphilis of 173
Neck tuberculosis of 173
dissection 396 vestibule of 154, 173
extended 439 Nystagmus 46
degrees of 46
tadiology of 396 in cerebellar disorders 48
selective 397 in Meniere's disease 1 1 1
structures seen in lateral view 396 optokinetic 48, 49
Neck masses 398 spontaneous 53
Neuralgia. Sluder's 461
Neurapraxia 103, 104 O
Neurodermatitis, ear 57, 59 Odynophagia 279, 390
Neurotmesis 104 Oesophageal speech 331, 332
Nicotine stomatitis 233 Oesophagoscopy 436
Node(s) anaesthesia of 436
delphian 394. 398 complications of 436
facial 393 contraindications of 436
internal jugular 396,397 flexible fibreoptic 437
metastatic 395 indications of 436
occipital 392-394 perforation of oesophagus in 349, 437
of Rouviere 394, 460 position of 436
of Krause 459, 465 post-operative care 437
parotid 10, 393 rigid 436, 437
preauricular 382, 393 technique of 436
prelaryngeal 393, 394 tracheal compression in 357
pretracheal 394 399 Oesophagotomy 353, 357
recurrent nerve chain of 394 cervical 357
scalene 394, 403 transthoracic 357
spinal accessory 393 Oesophagus
submandibular 393, 394 applied anatomy of 347
submental 393-395 barium swallow 352, 454
supraclavicular 353, 395 benign neoplasms of 219, 352
tubercular 402 corrosive burns of 349
Noise-induced hearing loss 40 denture in 389, 450
audiogram in 38-44 disorders of 351
permissible noise exposure levels 40 foreign body of 352, 436, 449
Noise trauma 40 motility disorders of 355
Noise, types of 23 nut-cracker 35 1
Nose scleroderma of 351
anatomy of 14, 149 skip lesions of 353
cartilages of 162 sphincters of, lower 348
cellulitis 158, 161 upper 347
crooked 158, 159 spontaneous rupture of 349
dermoid cyst of 159 Ohngren's line 221
examination of 116, 316 Olfaction 155, 157
external 149 Olfactory neuroblastoma 216, 217
external tumours of 158 Oncocytoma 248, 335
functions of 157 Oral cavity
fungal infections of 172 anatomy of 225, 227
glioma of 159 carcinoma of 242
granuloma, non-healing midline, 175 aetiological factors 238
granulomatous lesions of 172 erythroplakia of 238
hump 158, 384 examination of 234, 355, 379
leprosy of 313 Kaposi's sarcoma of 243, 374, 375
lupus of 312 leukoplakia of 240. 362
malignant tumours of 188 lymphatic drainage of 228
mucormycosis 175, 363 lymphoma of 243
olfactory part 221 melanoma of 243
patency test of 385 melanosis of 238
respiratory part 221 moniliasis of 23(1
 non-squamous malignancies of 236, Otosclerosis 97 fungal 269
243 aetiology of 97 granular 269, 277
premalignant lesions of 236 anatomy of 97 keratosis 270
thrush 230 cochlear 97 Pharyngotympanic tube (sec also
Orbital apex syndrome 211-213 differential diagnosis of 99 Eustachian tube) 3, 63
Orbital cellulitis 206, 213, 214 hearing aid in 100 Pharynx 253
Organ of corti 16 histologic 97 abscesses in relation to 254, 280
Oropharynx pathology of 98 anatomy of 253
anatomy of 253 signs of 98 divisions of 254
examination of 380 stapedial 97 Phonasthenia 334
functions of 256 symptoms of 98 Phonation 303
lymphatic drainage of 256 treatment of 99 Photodynamic therapy 362
tumours of 284 types of 97 Pinna 3, 54-57
Ossicles 8, 18, 25 Ototoxicity 39, 52, 371 congenital disorders of 54
Ossiculoplasty 35 Oval window 6, 7, 9 examination of 381
Otalgia 143 Overtones 23 perichondritis 55, 56
psychogenic 144 polychondritis, relapsing 56
referred 143 P Pleomorphic adenoma 216, 247,
Otic capsule 97, 461 Pachydermia laryngis 311,352 284
Otitic hydrocephalus 85, 95, 96 Palatine arch, carcinoma of 287 Polypectomy, nasal 186
Otospongiosis (see also Otosclerosis) Papilloma, inverted 216 Polyp(s) 185
Otitis externa 57 Palate, carcinoma of 239 aetiology of 185
acute, localised 57 Paracusis Willisii 98 antrochoanal 185-188
chronic stenotic 58 Paraglottic space 300, 302 ear 74, 75
diffuse 58 Paranasal sinus ethmoidal 186
eczematous 57, 59 Caldwell view 445 glomus tumour, as 120
fungal 57, 58 lateral view 445 nasal 182, 185
haemorrhagica 57, 58 radiology of 446 Ponticulus 6, 7
malignant 57 submentovertical 444, 445 PORP 36, 37, 362
necrotising 58 Waters' view 445, 447 Positional test (see Hallpike manoeuvre)
seborrhoeic 57, 59 Parapharyngeal space 254, 282 47, 51, 383
Otitis media 69-74 tumours of 287, 288 Postcricoid carcinoma 289,391
acute, suppurative 69 Parosmia 157 Posturography 50
aetiology of 69 Parotitis, viral 244 Preauricular sinus 117
stages of 69 Parotid 244 Presbycusis 31, 38, 41, 42
treatment of 70 abscess of 245, 277 types of 41
atticoantral 77 actinomycosis of 245 Pre-epiglottic space 302
bacteriology in 78 stones in duct of 245 Processus cochleariformis 6
cholesteatoma in 75 tuberculosis of 245 Promontory 6, 103
chronic suppurative 77 Passavant's ridge 255, 348 Proof puncture (see Antral irrigation) 418,
atticoantral 77 Percutaneous dilatational tracheostomy 419, 485
tubotympanic 77 341 Prorympanum 5
types of 77 Perforation(s), ear 67 Prussak's space 461
complications of 84 in CSOM 76, 77 Pure tones 23, 27, 33
hearing loss in 81 multiple 78 Pyocele 211, 212
necrotising 71 Perichondritis, of pinna 55, 56, 414 Pyriform fossa (sinus) 257, 288
ossicular necrosis in 81 Perilymph 12 carcinoma of 288
perforations in 75 circulation of 12
recurrent, acute 73 composition of 12 Q
retraction pockets in 75 Perilymph fistula 52
secretory 71 Petrositis 89 Quinsy 278, 279
syphilitic 83 Pharyngeal pouch 289
treatment of 80 aetiology of 289 R
tubercular 83 clinical features of 290 Radiation 366-369
tubotympanic 77, 81 diagnosis of 290 care of patients 369
unresolved 72 pathology of 289 complications of 369
with effusion 71 treatment of 290 dose of 367
in nasopharyngeal pathology 387, Pharyngeal wall, posterior, carcinoma of modes of 367
459 289 planning of 368
unilateral 459 Pharyngitis sources of 367
Otoacoustic emissions 32, 132 acute 259, 260 types of 366, 368
Otolith organs 19 atrophic 27(1, 390 unit ot 367
Otomycosis 58 chronic 269, 277 Radiation mucositis 232
Radiofrequency surgery in ENT 363
Radiotherapy 366 vasomotor 183 perforation of 166
and surgery 367 viral 168 silastic button in 167
care of patient, during 369 Rhinolalia 334 Short increment sensitivity index (SISI) 1
complications of 369 aperta 335 Sialadenitis, chronic recurrent 245
conformal 367 clausa 334 Sialectasis 245
curative 329, 369 Rhinolith 176 Sinodural angle 461
intensity modulated 367 Rhinophyma 159, 160, 461 Sinus(es), paranasal 201
megavoltage 367, 369 Rhinoscleroma 172 anatomy of 201
modes of 367 Rhinoscopy 384 benign tumours of 219
orthovoltage 367, 369 anterior 384 development of 203
palliative 368 technique of 384 endoscopic surgery of 210
planning in 368 posterior 385 ethmoidal 202
post-operative 368 structures seen in 385 fibrous dysplasia of 219
pre-operative 368 technique of 385 frontal 202
Ramsay-Hunt syndrome 107 Rhinosporiodiosis 174 malignancies of 219
Ranula 237, 238, 400 Ringertz's tumour 216 malignancy of
plunging 237 Rinne test 26 ethmoidal 202
Rathke's pouch 255,461 false negative 26 frontal 202
Recruitment 31 Romberg test 47 maxillary 201
Recurrent laryngeal nerve 318 Rosenthal's canal 17 mucocele of 211
paralysis of 317, 318 Rotation test 49 mucus drainage of 203
bilateral 318 Round window 6 sphenoid 202
combined 320 ventilation of 203
unilateral 318 S Sinusitis 204
Reinke's oedema 311,323 Saccule of labyrinth 11 acute 204
space 311, 323 Sacculotomy 116 aetiology of 204
Reissner's membrane 12,16 Salivary gland(s) 101, 108, 110, 247 ethmoid 202
Retraction pockets 62, 67, 68 malignancy of 247 frontal 206
Retromolar trigone 227, 389 minor, tumours of 236 trephination in 206
applied anatomy of 227 sarcoma of 249 maxillary 205
carcinoma of 242 Samter's triad 461 pathology of 205
Retropharyngeal abscess 280, 445 submandibular stone in duct 449 chronic 208
X-rays of 452 tumours of 247, 248 bacteriology of 208
Rhinitis 180 Scala, media 11 clinical features of 208
allergic 180 tympani 11 diagnosis of 209
aetiology of 180 vestibuli 11 pathology of 208
clinical features of 181 Scarpa's ganglion 20 pathophysiology of 208
complications of 182 Schirmer's test 109, 125 surgery for 209
diagnosis of 182 Schwabach's test 26 treatment of 209
immunotherapy in 182 Schwartz sign 461 complications of 211
investigations of 182 Scutum 7 intracranial 213
pathogenesis of 180 Semicircular canals 6 local 211
steroids m 182 Sensation level (SL) 24 orbital 213
treatment of 182 Septal haematoma 165,424 osteomyelitis as 212
atrophic 170 after septoplasty 425 fungal 461
primary 170 after SMR 423 Sinus of Morgagni 253,255,462
secondary 171 Septal perforation 166, 426 Sinus tympani 6, 7, 82
surgery of 171 after septoplasty 425 Sjogren's syndrome 245, 246
unilateral 171 Septoplasty 425, 426 Smell, disorders of 157
bacterial 168 anaesthesia of 425 testing of 157
caseosa 171 contraindications of 425 SMR, see submucous resection
chronic 168 indications of 425 complications of 424
drug-induced 184 position of 426 contraindications of 423
emotional 184 post-operative complications of 426 indications of 423
from hypothyroidism 184 techniques of 426 operation of 423
gustatory 184 Septum, of nose 162, 166 Solid angle 462
honeymoon 184 anatomy of 162 Sound 23
hypertrophic 169 anterior dislocation of 162 complex 23
irritative 168 blood vessels of 162 frequency of 23
medicamentosa 184 crooked 158 intensity of 23
non-airflow 184 deviated 158 loudness of 23
sicca 171 fractures of 162 overtones 23
 pitch of 23 Frey's 10, 110, 249, 458 complications of 339
pure tone 23 Goldenhar's 130 elective 336
velocity of 23 Heerfordt's 105 emergency 336
Sound level metre 24 Jervell and Lange-Nielson's 129 functions of 336
Space(s), head and neck infection of 277 Kallman's 459 indications of 336
masticator 282, 283 Klippel-Feil 128-130 permanent 337
parapharyngeal 281 Ortner's 461 technique of 337
Speech, after laryngectomy 275, 279, 401 Pendred 127, 129 tube, care of 339
disorders of 333 Pierre-Robin sequence 130 types of 336
oesophageal 331 Ransay-Hunt 107 Tracheostomy tube 445
tracheo-oesophageal 332 Stickler's 130 cuffed 336, 340
Speech discrimination 28 Treacher-Collin's 129 Fuller's 344
Speech frequencies 24, 28 Usher's 129 Jackson's 473
Speech reception threshold 24, 27, 28 van der Hoeve 130 size of 473
Sphenoid sinus Waardenburg's 129 Tracheal 342
examination of 387 Wildervanch 130 foreign body 342
malignancy of 224 Syringing of ear, technique 60 audible slap in 342
masticator 266, 282, 283 methods of removal 344
parapharyngeal 281 palpatory thud in 342
Sphcnoidotomy T-cell lymphoma 175 Trautmann's triangle 89,411,462
in chronic sphenoiditis 209 Tectorial membrane 16 Tripod fracture 197
Stapedectomy 84, 90, 99 Temporal bone fractures 107 Trismus 388
Stapedial reflex 109 Tensor tympani muscle 6, 10, 414 Trotter's method 191
Stapedius muscle 6 Thomwaldt's disease 255, 260 Trotter's triad 264
Stapes 6, 8 Threshold shift, temporary 40 Tuning fork test(s) 26
Stapes mobilization 100 permanent 40 Tunnel of corti 16
Stenger test 42 Thumb sign 308, 369, 445, 457 Tympanic membrane 17, 18
in non-organic hearing loss 42 Tinnitus 145-146 annulus tympanicus of 4
Stria vascularis 12 causes 145 atrophic 62
Stridor masking of 146 colour of 382
aetiology of 315 objective 145 curved membrane effect 18
endoscopy in 315 psychogenic 145 development of 429
management of 316 subjective 145 examination of 382
radiography of 316 treatment of 145 hydraulic action of 18
treatment of 316 types of 145 layers of 4
types of 315 Tongue 229, 230 maUeal folds of 4
Stuttering 335 fissures of 232 mobility of 383
Styalgia 287 geographical 232 nerve supply of 5
Styloid process, elongated 287 hairy 231 normal 59
Subiculum 6, 7 lesions of 232 pars flaccida of 4
Submucous cleft palate 67, 390, 438, 443 oral, carcinoma of 236 pars tensa of 4
Submucous fibrosis 233 tie 232 perforations of 62, 69
aetiology of 233 Tonsil retracted 61
clinical features of 233 anatomy of 278 rupture of 62
findings of 234 lingual, diseases of 276 tympanosclerosis of 62
pathogenesis of 233 membrane over 274 Tympanic plexus 10
pathology of 233 Tonsillectomy 438 Tympanogram 30
surgery, in 235 coblation 440 types of 30
treatment of 234 Guillotine 440 Tympanometry 29
Submucous resection (SMR) 165,420 laser 440 Tympanoplasty 35, 416
Superior laryngeal nerve 317 techniques of 440 principles of 35
paralysis of 317 Tonsillitis types of 35
Superior orbital fissure syndrome 213 acute 272 Tympanosclerosis 62, 73
Supratip area 166, 424 chronic 275 Tympanotomy 73
Swallowing, physiology of 347 follicular 273
Syndromes 128, 129 parenchymatous U
Alport's 128 diphtheritic 275 Ulcer(s)
Apert's 129 Torus 237 aphthous 230
Branchio-oto-renal 130 Torus tubarius 63, 67 in blood disorders 231
Costen's 458 Toxic shock syndrome 192, 424 in drug allergy 232
Crouzon's 129 Tracheostomy 336 traumatic, of oral cavity 230
Down's 67, 130,443 care after 339 with skin disorders 230
Umbo 4, 61, 96, 462 nuclei of 20 W
Utricle 21 Vestibular neuronitis 51,52 Waldeyer's ring 254-256, 272
Vestibulitis 161 Wallenberg's syndrome 52, 462
V Vestibular system 19 Warthin's tumour 248
Van del Hoeve syndrome 97 central 20 Wax ear
Velopharyngeal insufficiency 157, 335, disorders of 51 complications of 59
443 peripheral 51 Wax granuloma 60
Vertigo 51 physiology of 21 Weber test 26, 383
cerebellar disease 53 Vestibule 11 Wegener's granuloma 166, 175
cervical 53 of labyrinth 1 1 Woodruffs area 190
due to drugs 52 oflarynx 301 Word recognition score 28
epilepsy and 53 of nose 150
bead trauma and 51 Vestibulotoxic drugs 52 X
Meniere's disease and 51, 111 Vidian nerve 154.202 Xeroradiograph 316, 453
multiple sclerosis and 53 Vidian neurectomy 183,421,423 X-ray temporal bone 38
ocular 53 Vincent's infection 229 Law's view 444, 446
perilymph leak and 128 angina 229 Schuller's view 444
psychogenic 53 Vocal cord(s) 299 Stenver's view 444
tumours of brainstem and 53 adductors of 300 submentovertical view 444
vertebrobasilar insufficiency and 52 false 300 Towne's view 444
Vestibular folds 301 polypoid degeneration of 311 transorbital view 444, 447
Vestibular functions 46 Vocal nodule(s) 322
assessment of 46 polyp 78 Z
Vestibular nerve 20 Vocal rehabilitation, after total Zenker's diverticulum 289, 290
central connections of 20 laryngectomy 331 Zygoma, fractures of 197