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Current Issues in Otolaryngology

Steven D. Pletcher MDAssistant Professor

Department of Otolaryngology –Head and Neck Surgery

University of California, San Francisco

Otorhinolaryngology – Head and Neck Surgery

Formerly known as ENTEarly Nights and TennisEasy, Not Tough

Ear, Nose, and Throat

Ear

Hearing Loss

Case #172 y/o woman with hearing loss and tinnitusOtologic History

No vertigo, otalgia, or otorrheaNo history of prior surgery or frequent infections

+ history of hearing loss in family (father and grandfather)Went to “Rock concerts” in the sixties

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Case #1

PMH: noneMeds: noneExam

Vth and VIIth nerves normalNormal appearance of tympanic membrane

Case #1

Tuning fork tests (512 Hz)Weber: MidlineRinne: Air conduction > Bone Conduction Bilaterally

Weber & Rinne Tests Audiogram

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Diagnosis

PresbycusisTreatment

Consideration of Hearing AidsListening strategies and assistive devicesAvoidance of noise exposure

New Frontiers?Implantable hearing aidsCochlear Implants “partial insertion”

Case #2

Hearing Loss

Case #236 y/o woman with hearing loss and tinnitus

Symptoms worse on right sideOtologic History

No vertigo, otalgia, or otorrheaNo prior ear surgery No history of ear infections+ family history of hearing loss (mother in late 20’s)No history of noise exposure

Case #2

PMH: recently delivered first childMeds: noneExam

Vth and VIIth nerves normalNormal appearance of tympanic membrane

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Case #2Tuning fork tests (512 Hz)

Weber: To the RightRinne

Bone conduction > Air conduction bilaterally

Audiogram

Most Likely Diagnosis?

Meniere’s diseaseOtosclerosisOtitis Media with EffusionCholesteatomaAcoustic Neuroma

DiagnosisOtosclerosis

Disease of abnormal bone remodeling within the middle/inner earMost patients present with unilateral conductive hearing loss and normal TM examination

More severe cases may be bilateral with associated sensorineural hearing loss

Conductive loss due to fixation of the Stapes footplate within the Oval Window

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Ear Picture Otosclerosis

Patients often have a family history of hearing lossIn women, symptoms may worsen during pregnancy

Otosclerosis

TreatmentHearing AidSurgery (Stapedectomy/Stapedotomy)

Stapes Surgery

Popularized by Dr. John Shea in the 1956Revolutionized treatment of otosclerosis

Stapes bone partially removedProsthesis inserted and linked to incus

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Stapes Surgery

Results90% with complete or near complete correction of conductive component of hearing loss9% with no change in hearing1% with complete sensorineural loss

Post-op Audiogram

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Post-op Audiogram

Case #3

Hearing Loss

Case #360 y/o woman with right-sided hearing loss and tinnitusOtologic History

No vertigo, otalgia, or otorrheaNo history of prior surgery or frequent infectionsNo history of hearing loss in family Went to “Rock concerts” in the sixties

Case #3

PMH: noneMeds: noneExam

Vth and VIIth nerves normalNormal appearance of tympanic membrane

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Case #3

Tuning fork tests (512 Hz)Weber MidlineRinne Air conduction > Bone Conduction Bilaterally

Audiogram

Next Step In Evaluation/Treatment?

Hearing Aid evaluation/referralCT scan of the brain/temporal boneCochlear implantationMRI of the brain/temporal bone

Diagnosis

Assymetric Sensorineural Hearing LossPlan: MRI

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MRI Acoustic Neuroma

Vestibular SchwannomaBenign nerve sheath tumor from the vestibular component of the VIIIth nerve

Most commonly presents as assymetricsensorineural hearing lossMay have associated imbalance and Vthnerve palsy

Acoustic Neuroma

Differential DiagnosisMeningiomaEpidermoid tumorMetastasis

Bilateral acoustic neuromas are diagnostic of neurofibromatosis type 2

Acoustic Neuroma

TreatmentObservation

Old patient, small tumor

Radiosurgery (Gamma Knife)Pretty old patient, pretty small tumor

Microsurgery Young patient or large tumorNeurotologist and Neurosurgeon

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Hearing Loss

Conductive SensorineuralCerumenImpactionTM Perforation Effusion/OMOtosclerosis

PresbycusisNoise InducedCongenitalAcoustic Neuroma

Nose

Nasal Congestion and Drainage

Case #444y/o man with nasal congestion and clear nasal drainageHPI

Frequent sneezingHeadachesItchy eyes

Case #4

PMH: asthmaMeds: sudafedExam

Bilateral inferior turbinate enlargementClear nasal mucus

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Next Step In Evaluation/Treatment

Empiric trial of antihistamine/nasal steroidAllergy testingCT scan of the sinusesAntibiotic treatmentAnti-leukotriene medication

Case #4

DiagnosisAllergic Rhinitis

TreatmentTrial of antihistamine/nasal steroid sprayAllergy testingSinus CT scan if refractory symptoms

Allergic Rhinitis

Affects 35-50 million AmericansOften associated with other “atopic”symptoms

Allergic Rhinitis

Treatment OptionsAntihistamines (oral, intranasal)Steroid Nasal SpraysAllergen AvoidanceCromolyn Nasal SprayImmunotherapyAnti-leukotriene agentsDecongestants

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Case #5

Nasal Congestion and Drainage

Case #544y/o man with nasal congestion and clear nasal drainage for 6 monthsHPI

“I Always have a cold”Facial congestion/pressureIntermittent HeadacheOccasional exacerbations with green/yellow drainageLoss of smell

Case #5

PMH: asthmaMeds: has tried nasonex, claritin, sudafed, and multiple antibiotics without improvementExam

Bilateral inferior turbinate enlargementClear nasal mucus

Sinusitis

Major FactorsFacial Pressure/PainFacial CongestionNasal ObstructionNasal DischargeHyposmia/AnosmiaPurulence on ExamFever (acute sinusitis)

Minor FactorsHeadacheFever (chronic sinusitis)HalitosisFatigueDental PainCoughEar pressure/fullness

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Case #5

DiagnosisPossible Sinusitis

EvaluationNasal EndoscopyCT scan

Chronic SinusitisCT Findings

Nasal Endoscopy Video Chronic Sinusitis

Chronic inflammatory disease of the sinuses

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What Causes Chronic Sinusitis?

Bacterial InfectionFungal InfectionSystemic Immune DysfunctionImpaired Mucociliary Clearance

Chronic Sinusitis

TreatmentAntibiotics & Steroids (Oral vs. Topical)Surgery for patients refractory to medical management

Debridement Video

Case #6

Nasal Drainage

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Case #644y/o woman with clear nasal drainage for 6 monthsHPI

Always right-sided“Gush of water” when I get up in the morningProfessional “9-ball” player, drips on pool table when she leans over to shootNo nasal congestion or facial pain/pressureRare headache

Case #6

PMH: ObesityMeds: has tried nasonex, claritin, sudafed, and multiple antibiotics without improvementExam

Normal nasal examPatient leans over …

Case #6

DiagnosisRhinorrhea … ? etiology

EvaluationNasal EndoscopyCollect fluid for Beta-2 Transferrin evaluation CT scan

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CSF Leak

Post-surgicalEndoscopic Sinus SurgeryNeurosurgery (Pituitary and other skull base tumors)

Post-traumaticSpontaneous

CSF Leak

SpontaneousCommonly in obese, middle aged womenOften delay in diagnosisRisk of meningitis approximately 5%/year

May present with meningitis

Spontaneous CSF Leak

Endoscopic RepairIntrathecal flouresceinSkull base defect identified and cleaned Two-layer repair

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SKULL BASE

MUCOSAL OVERLAY GRAFT

INTRACRANIALCAVITY

NASAL CAVITY

Two Layer RepairCARTILAGE UNDERLAY GRAFT

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Throat

Hoarseness

Case #744y/o man with worsening hoarseness over the past 6 monthsHPI

Mild intermittent throat painDescribes voice as “gravely”Symptoms worse in morning and eveningGlobus sensation when swallowing, but no dysphagiaNon-smoker, drinks 2-3 glasses of wine/night

Case #7

PMH: HTNMeds: atenolol, ASA, occasional pepcidExam

Oral cavity WNLNo nasal abnormalitiesNo cervical adenopathy

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Case #7

Laryngoscopy

Laryngopharyngeal Reflux

Laryngeal manifestations of GERDMay occur without symptoms of heartburn

Typical presentations include hoarseness, globus sensation, chronic sore throatVariable findings on laryngoscopy

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Laryngopharyngeal Reflux

Gold-standard for diagnosis is 24 hour double pH probeOften treated empirically with PPIArea of controversy

Case #8

Hoarseness

Case #867y/o man with hoarseness for the past monthHPI

No painIncreased effort of speaking“Breathy” voiceVoice worsens throughout dayOccasional coughing with thin liquidsNon-smoker, drinks 2-3 glasses of wine/week

Case #8

PMH: HTNMeds: atenololExam

Oral cavity WNLNo nasal abnormalitiesNo cervical adenopathy

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Case #8

Laryngoscopy

Unilateral Vocal Fold Paralysis

Compromise of the vagus or recurrent laryngeal nerve

Vagal injuries with associated sensory deficit and increased incidence of aspiration

Unilateral Vocal Fold Paralysis

PresentationHoarseness “Breathy voice”Vocal Fatigue? AspirationSymptoms worse with acute onset of injuryNOT associated with stridor/airway compromise

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Unilateral Vocal Fold Paralysis

IatrogenicNeoplasticIdiopathic

Unilateral Vocal Fold Paralysis

Iatrogenics/p thyroidectomyAnterior approach C-spine surgeryCardiac SurgeryPosterior Fossa Neurosurgery

May be “stretch injury” with return of function up to 6 months following surgery

Unilateral Vocal Fold Paralysis

NeoplasticLaryngeal cancerThyroid malignanciesPulmonary malignancies Mediastinal metastasis or primary tumorsSkull base neoplasms

Unilateral Vocal Fold Paralysis

Idiopathic? ViralMay recover function 6-12 months following initial insult

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Unilateral Vocal Fold Paralysis

Work-upImage the course of the recurrent laryngeal nerveLaryngeal EMG?

Unilateral Vocal Fold Paralysis

TreatmentTemporary

Vocal cord injection/medializationVarious materials, most last approx 4 months

PermanentLaryngeal framework surgery (Thyroplasty)Arytenoid adductionReinnervation surgeryTeflon (?Hydroxyapetite) injection

Case #9

Hoarseness

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Case #954y/o man with worsening hoarseness over the past 6 monthsHPI

Mild intermittent throat painGlobus sensation when swallowing, but no dysphagia25 pack/year smoking history, drinks 6-pack of beer/night

Case #9

PMH: HTNMeds: atenolol, ASA, occasional pepcidExam

Oral cavity WNLNo nasal abnormalitiesNo cervical adenopathyHalitosis

Case #9

Laryngoscopy

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Case #9

Laryngeal Mass, R/O CancerDirect Laryngoscopy, Biopsy

Path -> Squamous Cell Carcinoma

Laryngeal Cancer

Tobacco and EtOH are primary risk factors4:1 male to female ratioClinical Presentation often depends on site of origin

Anatomy SlideLaryngeal Cancer

GlottisEarlier presentation (voice change)Decreased risk of cervical metastasis

SupraglottisLater presentationIncreased risk of cervical metastasis

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Laryngeal Cancer

TreatmentSurgery, Radiation, and Chemotherapy are three treatment modalitiesStage of cancer and local expertise determines treatment approachOverall trend towards increased use of radiation/chemotherapy and “laryngeal conservation” surgery

Acknowledgements

Mark Courey and Jaime Chang UCSF Laryngology

Lawrence Lustig Otology/Neurotology