Otorhinolaryngology

best otorhinolarngology slide

1. Otorhinolaryngology Dr Lopiso H(MD) MWUGRH Jan,2019

2. Disease of the Ear

3. Anatomy of Ear The ear is divided into: 1. External ear 2. Middle ear 3. Internal ear or the labyrinth

4. Ear anatomy .

5. THE EXTERNAL EAR The external ear consists auricle or pinna , external acoustic canal and tympanic membrane The entire pinna except its lobule and the outer part of external acoustic canal are made up of elastic cartilage covered with skin External acoustic (auditory) canal extends from the bottom of the concha to the tympanic membrane

6. Ear anatomy .

7. Parts of EAC Cartilaginous part Forms outer one-third of the canal Covered by thick skin which contains glands that secrete wax Contains hair “ fissures of Santorini ” Bony part forms inner two-thirds Covered by thin skin which is continuous over the tympanic membrane devoid of hair and ceruminous glands foramen of Huschke

8. Relations of EAC Anteriorly: Temporomandibular joint Posteriorly : Mastoid air cells and the facial nerve Superiorly: Middle cranial fossa Inferiorly: Parotid gland

9. Tympanic membrane or The Drumhead forms the partition between the EAC and the middle ear It has two parts: Pars tensa Pars flaccida ( Shrapnell’s membrane) It consists of three layers: Outer epithelial layer Inner mucosal layer Middle fibrous layer

10. Nerve supply of the external ear Pinna Greater auricular nerve (C2,3) supplies most of the medial surface and only posterior part of the lateral surface Lesser occipital (C2) supplies upper part of medial surface Auriculotemporal (V3) supplies tragus, crus of helix and the adjacent part of the helix Auricular branch of vagus nerve (Arnold’s nerve ) supplies the concha and corresponding eminence on the medial surface Facial nerve supplies the concha and retroauricular groove

11. Nerve supply…. Extrenal auditory canal Auriculotemporal (V3) supplies anterior wall and roof Arnold’s nerve supplies posterior wall and floor Sensory fibres of CN VII supply posterior wall Tympanic membrane auriculotemporal nerve supplies anterior half of lateral surface Arnold’s nerve supplies p osterior half of lateral surface Tympanic branch of CN IX supplies medial surface

12. Nerve supply .

13. The middle ear The middle ear together with the eustachian tube, aditus , antrum and mastoid air cells is called middle ear cleft Lateral wall is formed by tympanic membrane and the medial wall is formed by the labyrinth It is lined by mucous membrane and filled with air Contains three ossicles —the malleus , incus and stapes

14. The middle ear The ossicles conduct sound energy from the tympanic membrane to the oval window and then to the inner ear fluid There are two muscles—tensor tympani and the stapedius Tensor tympani attaches to the neck of malleus and tenses the tympanic membrane Stapedius attaches to neck of stapes and helps to dampen very loud sounds

15. Middle ear anatomy… .

16. THE INTERNAL EAR an important organ of hearing and balance It consists of a bony and a membranous labyrinth Bony labyrinth consists the vestibule, the semicircular canals and the cochlea Membranous labyrinth consists: the utricle and saccule the cochlear duct three semicircular ducts, and the endolymphatic duct and sac

17. Internal ear.. .

18. Mechanism of hearing A sound signal in the environment is collected by Pinna Passes through EAC and strikes the tympanic membrane Vibrations of the tympanic membrane are transmitted to stapes footplate through a chain of ossicles Movements of stapes footplate cause pressure changes in the labyrinthine fluids, which move the basilar membrane Hair cells of the organ of Corti get stimulated and transduce mechanical energy to electrical impulse Impulse travel along auditory nerve to brain

19. Auditory pathways .

20. Diseases of the external ear Pinna Perichondritis - infection or inflammation of the cartilage Can follow trauma, surgery, otitis externa or furuncule of EAC Painful, red, tender, and swollen pinna, fever Abscess, necrosis of cartilage Pseudomonas is the usual organism Rx- local ointments, systemic antibiotics, abscess drainage

21. Perichondritis and collapse of pinna .

22. Diseases of EAC Otitis externa - infection or inflammation of the EAC Classification – etiologic, disease severity Etiologic

23. OE…. Disease severity Mild OE Moderate OE Severe OE

24. Risk factors Swimmers and surfers Daily hairwashers Diabetics Psoriais sufferers People with an abnormal migration of keratin

25. Bacterial OE Localized acute OE Staphylococcal infection of the hair follicle Usually single, but may be multiple Severe pain and tenderness Pain aggravated by ear or jaw movements Periauricular lymph nodes enlargement Rx- systemic antibiotics, analgesics and local heat - incision and drainage

26. Furuncle .

27. Diffuse OE diffuse inflammation of meatal skin which may spread to involve the pinna and tympanic membrane Etiologic factors trauma to the meatal skin invasion by pathogenic organisms Risk factors Hot and humid climate Swimmers Trauma Infection of the middle ear Allergy

28. Diffuse OE Acute phase hot burning sensation followed by pain Ear discharge Hearing loss Inflamed and swollen meatus Regional LAP Chronic phase irritation and strong desire to itch Scanty discharge, crust Meatal skin thickening, swelling, scaling and fissuring Meatal stenosis

29. Diffuse OE- chronic form .

30. Treatment Acute phase Ear toilet Medicated wicks Antibiotics Analgesics Chronic phase Reduce meatal edema Alleviate itching Surgery

31. Malignant (necrotizing) OE a rare and serious form of otitis externa caused by pseudomonas infection usually in the elderly diabetics, or in immunosuppressed patients excruciating pain and appearance of granulations in the ear canal cranial nerve palsies spreads to temporomandibular fossa , mastoid, middle ear and petrous bone Ix- Gallium-67 scan

32. Malignant OE .

33. Treatment Ear toilet Systemic antibiotics(6-8 weeks) Control diabetes

34. Otomycosis fungal infection of the ear canal occurs due to Aspergillus niger , A. fumigatus or Candida albicans It is seen in hot and humid climate areas Secondary fungal growth in patients using topical antibiotics for of OE or middle ear suppuration.

35. Otomycosis … intense itching, discomfort or pain in the ear watery discharge with a musty odour and ear blockage sodden, red and oedematous meatal skin white, brown or black mass

36. Treatment Ear toilet Keep the ear dry Topical antifungals Antibiotic/steroid ointment

37. Foreign bodies of ear Non-living FB a piece of paper or sponge, grain seeds (rice, wheat, maize), slate pencil, piece of chalk or metallic ball bearings, cotton swab, broken end of matchstick Living FB mosquitoes, beetles, cockroach, an ant, maggots

38. Methods of foreign body Forceps removal Syringing Suction Microscopic removal with special instruments Postaural approach For living FB, the insect should be killed first !!!

39. Syringing .

40. Acute suppurative otitis media an acute inflammation of middle ear by pyogenic organ-isms Commonlly occurs in infants and children of lower socioeconomic group Typically, follows viral infection of upper respiratory tract Routes of infection Via eustachian tube Via external ear Hematogenous

41. Predisposing factors Recurrent attacks of URTIs Measles, diphtheria or pertussis Infections of tonsils and adenoids Chronic rhinitis and sinusitis Allergic rhinitis Tumours of nasopharynx Packing of nose or nasopharynx for epistaxis Cleft palate

42. Microbiology Most common organisms in infants and young children Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis

43. Stages of ASOM Stage of tubal occlusion earache ,deafness tympanic membrane is retracted loss of light reflex conductive deafness Stage of presuppuration marked earache fever , restlessness deafness and tinnitus Hyperemic, congested tympanic membrane Conductive hearing loss

44. Stages…….. 3. Stage of suppuration Excruciating earache Fever spike, vomiting, convulsion Deafness Tympanic membrane bulging with loss of landmarks 4. Stage of resolution tympanic membrane ruptures Local and systemic signs of inflammation begins to decrease Discharge in external ear canal TM perforation

45. Stages… 5. Stage of complication Complications occur due to highly virulent organism or decreased host immune status acute mastoiditis , subperiosteal abscess facial paralysis, labyrinthitis , petrositis extradural abscess, meningitis, brain abscess or lateral sinus thrombophlebitis

46. Acute otitis media .

47. Treatment Antibacterial therapy Analgesics and antipyretics Nasal decongestants Ear toilet Myringotomy

48. . .

49. Otitis media with effusion accumulation of non-purulent effusion in the middle ear cleft effusion is thick, viscid and mostly sterile Commonly seen in school-going children Aetiology Malfunctioning of eustachian tube Allergy Unresolved otitis media Viral infections

50. Clinical features Hearing loss Delayed and defective speech Mild earaches Otoscopic findings Dull and opaque TM with loss of light reflex Retraction of TM Restricted mobility of TM Hearing tests- Tuning fork, Audiometry

51. OME .

52. Treatment Medical Decongestants Antiallergic measures Antibiotics Middle ear aeration Surgical Myringotomy and aspiration of fluid Grommet insertion Tympanotomy or cortical mastoidectomy Surgical treatment of causative factor

53. Treatment… . Grommet Myringotomy

54. Sequelae of OME Atrophic TM and atelectasis of the middle ear Ossicular necrosis Tympanosclerosis Retraction pockets and cholesteatoma Cholestrol granuloma

55. Chronic suppurative otitis media long-standing infection of a part or whole of the middle ear cleft characterized by ear discharge and a permanent perforation higher incidence in developing countries affects both sexes and all age groups

56. Classification of chronic otitis media Clinically Tubotympanic- safe or benign type Atticoantral- unsafe or dangerous type Pathologic

57. CSOM Tubotympanic type- safe or benign type Common during childhood involves anteroinferior part of middle ear cleft Usually polymicrobial infection Etiology Acute otitis media Ascending infections via the eustachian tube Food allergy

58. Clinical features-- TTCSOM Ear discharge- non-offensive, mucoid or mucopurulent , constant or intermittent Hearing loss Polyp TM Perforation

59. Polyp .

60. TT…. Investigations Microscopic examination of ear Audiogram Culture and sensitivity of ear discharge Mastoid X-rays/CT scan temporal bon

61. Treatment Ear toilet Ear drop Systemic antibiotics Precautions Treat concomitant conditions Surgery

62. Atticoantral type also called unsafe or dangerous type involves postero -superior part of middle ear cleft ( attic,antrum , posterior tympanum and mastoid) Polymicrobial infection Ear discharge- Usually scanty, but always foulsmelling Hearing loss Bleeding from ear

63. Atticoantral type…. Perforation- attic or marginal( postero superior ) TM retraction pocket Cholesteatoma

64. Investigations Examination under microscope Hearing tests X-ray mastoids/CT scan temporal bone Culture and sensitivity of ear discharge

65. TREATMENT Surgery Remove the disease Reconstructive

66. D/ ce b/n TT and AA type of CSOM . Tubotympanic or safe type Atticoantral or unsafe type Discharge Profuse, mucoid , odourless Scanty, purulent, foul smelling Perforation Central Attic or marginal Polyp Pale Red and fleshy Granulations Uncommon Common Cholesteatoma Absent Present Complications Rare Common Audiogram Mild to moderate conductive deafness Conductive or mixed deafness

67. Sequelae of otitis media Perforation of tympanic membrane Ossicular erosion Atelectasis and adhesive otitis media Tympanosclerosis Cholesteatoma formation Conductive hearing loss due to ossicular erosion or fixation Sensorineural hearing loss Speech impairment Learning disabilities

68. Complications of Suppurative Otitis Media Risk factors Age extremes Low socioeconomic status Immunocompromise Virulence of organism Preformed pathways Cholesteatoma

69. Complications….. Pathways of spread of infection Direct bone erosion Venous thrombophlebitis Preformed pathways

70. Indicators of complications in CSOM Pain Vertigo Persistent headache Facial weakness Loss of appetite and sleepiness Fever, nausea and vomiting Irritability and neck rigidity Diplopia Ataxia Abscess round the ear

71. Classification Intratemporal Mastoiditis Petrositis Facial paralysis Labyrinthitis Intracranial Extradural abscess Subdural abscess Meningitis Brain abscess Lateral sinus thrombophlebitis Otitic hydrocephalus

72. Hearing Loss

73. Classification .

74. Organic HL .

75. Conductive hearing loss Results from interferences with the conduction of sound to reach cochlea The lesion may lie in the external ear and tympanic membrane, middle ear or ossicles up to stapediovestibular joint The cause may be congenital or acquired

76. Congenital causes Meatal atresia Fixation of stapes footplate Fixation of malleus head Ossicular discontinuity Congenital cholesteatoma

77. Acquired causes External ear Any obstruction in the ear canal- wax, foreign body, furuncle, acute inflammatory swelling, tumour or atresia of canal Middle ear Perforation of tympanic membrane Fluid in the middle ear Mass in middle ear Disruption of ossicles Fixation of ossicles Eustachian tube blockage

78. Characteristics of CHL Negative Rinne test, i.e. BC > AC Weber lateralized to poorer ear Normal absolute bone conduction Low frequencies affected more Audiometry shows bone conduction better than air conduction with air-bone gap Loss is not more than 60 dB Speech discrimination is good

79. Tuning fork test . Rinne test Rinne test Weber test

80. Management Removal of canal obstructions Removal of fluid Removal of mass from middle ear Stapedectomy Tympanoplasty Hearing aid

81. Sensorineural hearing loss (SNHL) Results from lesions of the cochlea, cranial nerve VIII or central auditory pathways Congenital or acquired Congenital Prenatal factors- congenital anomalies, infections during pregnancy, ototoxic drugs during pregnancy, radiation Perinatal causes- perinatal asphyxia, prematurity and low birth weight, birth injuries, neonatal jaundice, neonatal meningitis or sepsis

82. SNHL…. Acquired SNHL Genetic - Familial progressive SNHL Nongenetic Infections of labyrinth Trauma to labyrinth or VIIIth nerve Noise-induced hearing loss Ototoxic drugs Ménière’s disease Systemic disorders

83. Characteristics of SNHL Positive Rinne test, i.e. AC >BC Weber lateralized to better ear Bone conduction reduced High frequencies affected more No air- bone gap on audiometry Loss may exceed 60 dB Speech discrimination is poor Difficulty in hearing in the presence of noise

84. Management Early detection of SNHL is important to stop its progress, reverse it or to start an early rehabilitation programme Treat infections Discontinue ototxic drugs Stay away from noisy environments Hormone replacement therapy Surgery

85. Ototxic drugs .

86. References .

87. . Thank You