Chapter III - ENT Pathology

Acute Coryza

Otalgia is ear pain or an earache. Primary otalgia is from pain that originates inside the ear. Referred otalgia is from pain that originates from outside the ear.

Typical sources of primary otalgia are external otitis, otitis media, mastoiditis, auricular infections, and, rarely, GERD. Dental disorders are the most common cause of referred otalgia. These include temporomandibular joint disorders, bruxism, and abscessed teeth. Tonsillitis and pharyngitis are also common causes of earaches in children. These earaches are constant or intermittent with dull, sharp, burning, or throbbing pain.

Otitis Media

Otitis media (also known as glue ear) is an inflammation of the middle ear segment of the ear. It is usually associated with a buildup of fluid and frequently causes an earache. The fluid may or may not be infected.

There are several kinds of otitis media:

• Acute otitis media is an infection that produces pus, fluid, and inflammation within the middle ear. It is frequently associated with signs of upper respiratory infection, such as a runny nose or stuffy nose.
• Otitis media with effusion is the presence of middle ear fluid for six weeks or more from the initial acute otitis media.
• Chronic otitis media may develop when the infection persists for more than two weeks.

Streptococcus pneumoniae and Haemophilus influenzae are the most common bacterial causes of otitis media. Still, antibiotics are rarely effective in shortening disease duration. Tubal dysfunction leads to the ineffective clearing of bacteria from the middle ear.

As well as being caused by Streptococcus pneumoniae and Haemophilus influenzae it can also be caused by the colds.

Another common culprit of otitis media includes Moraxella Catarrhalis, a gram negative, aerobic, and oxidase positive diplococci.

Otitis Externa

Otitis externa (also called swimmer's ear or earache) is an inflammation, irritation, or infection of the outer ear and ear canal.

Otitis externa is fairly common, especially among teenagers and young adults. Swimming in polluted water is one way to contract swimmer's ear. Trying to clean wax from the ear canal, especially with cotton swabs or small objects, can irritate or damage the skin. It is occasionally associated with middle ear infection (otitis media) or upper respiratory infections such as colds. Middle ear infections can occur after the ear drum is perforated by a fungal growth from the outer ear. Moisture in the ear predisposes the ear to infection from fungus or water-loving bacteria such as Pseudomonas.

Symptoms

Ear pain-may worsen when pulling the outer ear
Itching of the ear or ear canal
Drainage from the ear-yellow, yellow-green, pus-like, or foul smelling
Decreased hearing or hearing loss

Treatment

The goal of treatment is to cure the infection. The ear canal should be cleaned of drainage to allow topical medications to work effectively. Depending on how severe the infection is, it may be necessary for a doctor to aspirate the ear as many times as twice a week for the first two or three weeks of treatment.

Effective medications include eardrops containing antibiotics to fight infection and corticosteroids to reduce itching and inflammation and analgesics to reduce pain. Use of antibiotics to treat ear infections may result in treatment of the wrong cause of the infection because not all ear infections are bacterial; some are fungal, and it is possible to have both a bacterial and fungal ear infection.

Labyrinthitis

Labyrinthitis is a balance disorder that usually follows an upper respiratory tract infection (URI). It is, as the name suggests, an inflammatory process affecting the labyrinths that house the vestibular system (which senses changes in motion) of the inner ear.

In addition to balance control issues, a labyrinthitis patient often encounters hearing loss and tinnitus. It appears labyrinthitis is caused by a virus (the herpes virus has been implicated) but can also arise from bacterial infection, head injury, an allergy or as a reaction to a particular medicine. Both bacterial and viral labyrinthitis can cause permanent hearing loss, although this is rare. Prochlorperazine is commonly prescribed for all types of the infection, which helps with the nausea and sickness.

A prominent and debilitating symptom of labyrinthitis is chronic dizziness. The vestibular system is a set of sensory inputs, which aid balance control systems by measuring changes in rotational and linear motion. The brain combines visual cues with sensory input from the vestibular system to determine adjustments required to retain balance. When working properly, the vestibular system also relays information on head movement to the eye muscle, forming the vestibulo-ocular reflex, in order to retain continuous visual focus during motion. When the vestibular system is affected by labyrinthitis, rapid, undesired eye motion (nystagmus), often results from the improper indications of rotational motion. Nausea, anxiety, and a general ill feeling are common due to the distorted balance signals that the brain receives from the inner ear. Recovery from acute labyrinthine inflammation generally takes from one to six weeks.

Labyrinthitis and AnxietyChronic anxiety is a common side effect of labyrinthitis, which can produce tremors, heart palpitations, panic attacks and depression. Often a panic attack is one of the first symptoms to occur as labyrinthitis begins. While dizziness can occur from extreme anxiety, labyrinthitis itself can precipitate a panic disorder.

Labyrinthitis and Vertigo

Barotitis

Barotitis is caused by the changes in the barometric pressures, usually caused by the takeoff or landing of an airplane. Problems include ear pain, ringing, diminished hearing and, sometimes, dizziness. Alternate terms include aerotitis, aerotitis media, barotitis media, and otic barotrauma. Bacterial infections are treated with antibiotics in the form of eardrops or oral medications. The patients are encouraged to complete the entire course of therapy least the disease should recur. Blocked eustachian tubes are generally opened with medicated nasal drops. Severe or chronic otitis media requires an insertion of a plastic drainage tube to drain the pus or fluid. Ruptured eardrum is repaired with the procedure called tympanoplasty. Otitis externa or swimmer's ear is treated with antibiotic, antifungal, or corticosteroid ear drops.

Hearing Loss

A hearing impairment is a decrease in one's ability to hear (i.e. perceive auditory information). While some cases of hearing loss are reversible with medical treatment, many lead to a permanent disability (often called deafness). If the hearing loss occurs at a young age, it may interfere with the acquisition of spoken language and social development. Hearing aids and cochlear implants may alleviate some of the problems caused by hearing impairment, but are often insufficient. People who have hearing impairments, especially those who develop a hearing problem later in life, often require support and technical adaptations as part of the rehabilitation process.

Causes

There are five causes of hearing loss: long term exposure to environmental noise, genetic factors, disease processes affecting the ear, medication and physical trauma.

Types

There are three major types of hearing loss: neural/sensorineural, conductive, or a combination of both. Treatment depends upon the type of hearing loss that is present.

Sensorineural
Sensorineural hearing loss is caused by damage/malfunction of the inner ear (cochlea, eighth cranial nerve) or auditory brainstem. This can be divided further into a sensory hearing loss (inner ear) or a neural hearing loss (brainstem).

Conductive
Conductive hearing loss is caused by damage/malfunction of the middle or outer ear system (external ear canal, eardrum, or structures in the middle ear space including the malleus, incus and stapes bones).

Combination
Mixed hearing loss is caused by both conductive and sensorineural causes.

Quantification of hearing loss

The severity of hearing loss is measured by the degree of loudness, as measured in decibels a sound must attain before being detected by an individual. Hearing loss may be ranked as mild, moderate, severe or profound. It is quite common for someone to have more than one degree of hearing loss (i.e. mild sloping to severe). The following list shows the rankings and their corresponding decibel ranges:

Mild: for adults: between 25 and 40 db
for children: between 15 and 40 db
Moderate: between 41 and 55 db
Moderately severe: between 56 and 70 db
Severe: between 71 and 90 db
Profound: 90 db or greater

Unilateral hearing loss
People with unilateral hearing loss (single sided deafness/SSD) can hear normally in one ear, but have trouble hearing out of the other ear. Problems with this type of deficit is inability to localize sounds (ie. unable to tell where traffic is coming from) and inability to process out background noise in a noisy environment, such as in a restaurant.

Treatment

In order to treat the hearing loss, the physician prescribes a hearing aid if the loss is not severe. The type of hearing aid depends on the cause of the hearing loss. The patients are also trained in lip-reading. In some cases of otosclerosis, the surgery (stapedectomy) is performed to take out the malfunctioning stapes, and a prosthesis is inserted, which conducts sound vibrations to the inner ear.

Presbycusis

The tiny hair cells that line the cochlea degenerate with age. These cells are responsible for, sending the messages to the brain through the auditory nerves. Deterioration of these cells makes hearing difficult. This sensory-neural hearing loss is known as presbycusis. Hearing loss usually begins gradually after the age of sixty, and is usually more noticeable in men than women. Over time, the detection of high-pitched sounds becomes more difficult. Both ears tend to be affected.

Otosclerosis

Otosclerosis is a hearing condition in which the stapes in the ear becomes attached to the surrounding bone by an abnormal bone growth. Sound transmission is progressively impaired so that hearing in the affected ear deteriorates.

Laryngitis
Laryngitis is an inflammation of the larynx. It causes hoarse voice or the complete loss of the voice because of irritation to the vocal folds (vocal cords). It is categorized as acute if it lasts less than a few days. Otherwise it is categorized as chronic.

Laryngitis is often caused by a virus or by bacteria.

Other causes include smoking, various allergies, reflux and straining the voice through singing or shouting.

Home treatments

• Ibuprofen and aspirin may help alleviate fever and some of the discomfort associated with laryngitis.
• Avoid speaking when possible. Speak softly, but do not whisper.
• Drink warm liquids such as tea or a honey-lemon drink.
• Take cough drops/throat lozenges. If unavailable, suck on hard candy.
• Stay hydrated, drink plenty of liquids; water, orange juice, etc.
• Humidifiers and warm showers can also help alleviate some symptoms.
• Avoid airborne irritants such as smoke and allergens.
• Gargle with a salt-water rinse; avoid mouth rinses containing alcohol which can dry the throat (however, these can be helpful when the cause of the infection is bacterial.)

Ménière’s Disease

Ménière's disease (or syndrome, since its cause is unknown) was first described by French physician Prosper Ménière in 1861. It is a balance disorder of the inner ear.

The symptoms of Ménière’s are variable; not all sufferers experience the same symptoms. However, four symptoms are considered to comprise so-called "classic Ménière’s":

• periodic episodes of rotary vertigo (the abnormal sensation of movement) or dizziness.
• fluctuating, progressive, unilateral (in one ear) or bilateral (in both ears) hearing loss, often in the lower frequency ranges.
• unilateral or bilateral tinnitus (the perception of noises, often ringing, roaring, or whooshing), sometimes variable.
• a sensation of fullness or pressure in one or both ears

Ménière’s often begins with one symptom, and gradually progresses. A diagnosis may be made in the absence of all four classic symptoms.

Cause

The exact cause of Ménière's disease is not known, but it is believed to be related to endolymphatic hydrops or excess fluid in the inner ear. It is thought that endolymphatic fluid bursts from its normal channels in the ear and flows into other areas causing damage. This may be related to swelling of the endolymphatic sac or other issues in the vestibular system of the inner ear, which is responsible for the body's sense of balance. The symptoms may occur in the presence of a middle ear infection, head trauma or an upper respiratory tract infection, or by using aspirin, smoking cigarettes or drinking alcohol.

Treatment

The patient is asked to restrict fluid intake and take a diuretic to lower the level of the body fluid. In some cases, electrocochleography may also be per-formed in which a probe is inserted under local anesthesia through the eardrum to mea-sure the eardrum to measure the electrical activity. Medical treatment includes usage of antihistamines (Benadryl, Antivert, Valium), antinausea drugs (dimenhydrinate, Transderm), or steroids (prednisone) to alleviate the episodes of Meniere Disease. Sometimes surgery may also be recommended. Another treatment is chemical labyrinthectomy, in which a drug (such as gentamicin) that "kills" the vestibular apparatus is injected into the inner ear. Lipoflavonoid is also recommended for treatment by some doctors.

Pharyngitis is a painful inflammation of the pharynx, and is colloquially referred to as a sore throat. Infection of the tonsils, tonsillitis (American English: tonsillitis) may occur simultaneously.

The major cause is infection, of which 90% are viral, the remainder caused by bacterial infection and rarely oral thrush (fungal candidiasis e.g. in babies). Some cases of pharyngitis are caused by irritation from agents such as pollutants, chemicals, or smoke.

Pharyngitis is generally treated with broad-spectrum antibiotics, which may range penicillin, azithromycin, erythromycin, doxycycline, and ceftriaxone.

Types

Viral sore throats-These comprise about 90% of all infectious cases and can be a feature of many different types of viral infections.

• Adenovirus
• Orthomyxoviridae which cause Influenza
• Infectious mononucleosis ("glandular fever") caused by the Epstein-Barr virus. Herpes simplex virus can cause multiple mouth ulcers.
• Measles

Pharyngitis
Bacterial sore throat-The most common bacterial agent is streptococcus.

Diphtheria is a potential life threatening upper respiratory infection caused by Corynebacterium diphtheriae which has been largely eradicated in developed nations since the introduction of childhood vaccination programs, but is still reported in the Third World and increasingly in some areas in Eastern Europe. Antibiotics are effective in the early stages, but recovery is generally slow.

Treatment
The treatment of pharyngitis will vary according to the cause.

• Iodine compounds sold as Betadine or TCP can be gargled to shorten the duration of the infection. These compounds are effective anti-viral agents.
• Antibiotics are only helpful when a bacterial infection is the cause of the sore throat. For bacterial sore throats, antibiotics have been shown to only affect the degree of pain by day 4 and shorten the average natural duration by 16 hours overall (14 people need be treated for a week to reduce the duration by one day.)

Symptomatic Treatment

• Lozenges (cough medicine) are often used for short-term pain relief.
• Gargling with warm salty water is a popular household remedy, although there is only anecdotal evidence this gives other than temporary relief and likewise for the use of aspirin gargles.
• Warm tea can help temporarily alleviate the pain of a sore throat.
• Analgesics such as NSAIDs can help reduce the pain associated with a sore throat.

Sinusitis

Sinusitis is inflammation, either bacterial, fungal, viral, allergic or autoimmune, of the paranasal sinuses.

By location
Sinusitis is classified by the sinus cavity, which it affects:

• Maxillary sinusitis-causes pain in the maxillary area (e.g., toothache, headache)
• Frontal sinusitis-causes pain in the frontal sinus cavity (located behind/above eyes), headache
• Ethmoid sinusitis-causes pain between and/or behind eyes, headache
• Sphenoid sinusitis-causes less generalized pain, headache

Acute vs. chronic

Sinusitis can be acute (going on less than four weeks), subacute (4-8 weeks) or chronic (going on for 8 weeks or more).

Both types of sinusitis have similar symptoms, and are thus often difficult to distinguish.

Acute sinusitis

Acute sinusitis is often brought on by bacteria, such as Haemophilus influenzae, streptococci, or staphylococci. It is usually precipitated by an earlier upper respiratory tract infection, generally of the viral type.

Chronic sinusitis:Chronic sinusitis is one of the most common complications of the common cold.

Symptoms include nasal congestion; facial pain; headache; fever; general malaise; thick green or yellow discharge; feeling of facial 'fullness' worsening on bending over.

In a small number of cases, chronic maxillary sinusitis can also be brought on by the spreading of bacteria from a dental infection. Chronic hyperplastic eosinophilic sinusitis is a noninfective form of chronic sinusitis.

Treatment

Therapeutic measures include simple painkillers (aspirin, paracetamol (acetaminophen) or similar), inhaling steam, nasal irrigation or jala neti using a warm saline solution, hot drinks including tea and chicken soup, over-the-counter decongestants, and getting plenty of rest. If sinusitis doesn't improve within 48 hours, or is causing significant pain, one should see a doctor, who may prescribe antibiotics or nasal steroids. If the recommended doses and duration of antibiotic treatment(s) are ineffective, one should consult a doctor; who may suggest further treatment by a qualified specialist.

If left untreated, sinusitis can lead to bronchitis and pneumonia.

A recent advance in the treatment of sinusitis is a type of surgery called FESS - functional endoscopic sinus surgery, whereby normal clearance from the sinuses is restored by removing the anatomical and pathological obstructive variations that predispose to sinusitis. This replaces the less effective Caldwell-Luc surgery.

Tinnitus

Tinnitus is a phenomenon of the nervous system connected to the ear, characterized by perception of a ringing or beating sound (often perceived as sinusoidal) with no external source. This sound may be a quiet background noise, or loud enough to drown out all outside sounds. It is sometimes referred to as "the club disease" as many people get temporary tinnitus at loud clubs or concerts.

Tinnitus can be objective (the sound, e.g., a bruit, can be perceived by a clinician) or subjective (perceived only by the patient).

Causes of tinnitus include:

• A sudden loud noise, prolonged exposure to loud music through PA systems or personal stereos, exposure to an excessively noisy work environment without ear protection, (Eg. industrial)
• Hearing loss (20 per cent of cases: chronic noise damage and presbycusis)
• Head injury (especially basal skull fracture)
• Drugs: aspirin overdose, loop diuretics, aminoglycoside, quinine
• Temporomandibular and cervical spine disorders
• Suppurative otitis media (also chronic infection and serous OM)
• Otosclerosis
• Ear wax
• Ménière’s disease
• Impacted wisdom teeth
• Hypertension and atherosclerosis
• Acoustic neuroma
• Palatal myoclonus (objectively detectable)
• Arteriovenous fistulae and arterial bruits (objectively detectable)
• Severe anemia and renal failure
• Glomus jugulare tumors (objectively detectable)
• Lyme Disease
• Stress and depression
• Thyroid disorders, such as hyperthyroidism or hypothyroidism

The treatment involves curing the patient of the underlying disease, changing the drug regimen, and using a hearing aid or tinnitus masker.

Vertigo

Vertigo, sometimes called a headrush, is a major symptom of a balance disorder. It is the sensation of spinning while the body is stationary. With the eyes shut, there will be a sensation that the body is in movement, called subjective vertigo; if the eyes are open, the surroundings will appear to move past the field of vision, called objective vertigo.

The effects may be slight. It may cause nausea or, if severe, may give rise to difficulty with standing and walking. Vertigo is usually associated with a problem in the inner ear balance mechanisms (vestibular system), in the brain, or with the nerve connections between these two organs. The most common cause is benign positional vertigo.

We are able to maintain our equilibrium and balance in space with the help of vision, touch, hearing, and the vestibular system in the inner ear. Many areas of the brain also contribute to our sense of equilibrium. Disturbance or malfunctioning in any of these areas can result in the diseases of dizziness, such as vertigo, disequilibrium, or lightheadedness. True vertigo (an illusion of motion) often comes with a feeling of nausea and vomiting, and the person feels that the room is moving around him or as if he himself is moving around the room. The vertigo may originate in the vestibular region of the Inner ear or in the brain itself. There can be many reasons for vertigo, e.g. tumors, head injuries, Meniere disease, allergic rhinitis inner ear infection, or extremely high doses of certain medicines.

Disequilibrium is a slightly less severe from of imbalance and can result from the degeneration of the nerve. It is an unsteady feeling of falling and can result of alcoholism as well.

Important:

• Vertigo should not be confused with dizziness. Dizziness is an unpleasant feeling of light-headedness, giddiness or fuzziness often accompanied by nausea.
• Vertigo is often used, incorrectly, to describe a fear of heights.
• Vertigo is often experienced when breathing helium, as a result of helium flow instead of oxygen to the brain.

Based upon the cause of dizziness, a physician may prescribe dimenhydrinate (Hydrate) or meclizine (Antivert). Inner ear infections are treated by the antibiotics. In case the vertigo is the result of some other underlying disease, treatment of that disease contributes to the final treatment of vertigo.