Introduction What is otolaryngology? What subdivisions exist within the specialty? Is...

Introduction

What is otolaryngology?

What subdivisions exist within the specialty?

Is otolaryngology a medical or a surgical specialty?

How can you learn otolaryngology well?


The specialty deals with diseases of the head and neck region, the region from eyebrows to the collarbones

The specialty originally included the treatment of eye conditions and was commonly identified as EENT (eyes, ears, nose and throat)


As a result of the explosion of medical knowledge, ophthalmology split from otolaryngology many years ago

The American Academy of Otolaryngology recoginized the expanded breadth and changed the name to otolaryngology-head and neck suegery


Initially, otology, laryngology, rhinology, and bronchoesophagology were recognized

With increased medical knowledge, pediatric otolaryngology, otolaryngological allergy, facial plastic and constructive surgery, and head and neck surgery have been identified


Otology has been expanded to include otology, neurotology, and skull-base surgery

Otolaryngologists are interested in neurolaryngology, microvascular surgery, chemosensation (taste and smell disorders), audiology, and speech disorders.

Is otolaryngology a medical or a surgical specialty?

Actually, it is both. Many conditions are managed medically and require no surgery, whereas others require surgery

In common practice, for every 13 patients needing medical care, only one will require surgery

How can you learn otolaryngology well?

The breadth of the field and the complexity of the patients’ conditions make the specialty both challenging and stimulating

To learn it well, you should pay special attention to the disease-associated anatomic and physiological knowledge of the ear, nose and throat, as well as head and neck region

Rhinitis Rhinitis is tissue inflammation and nasal

hyperfunction that leads to nasal congestion/obstruction, rhinorrhea, nasal itching, and/or sneezing.

Pathophysiology Nasal congestion arises from engorgement

of blood vessels due to the effects of vasoactive mediators and neural stimuli.

The autonomic nervous system mediates both vascular tone and gland secretions. Sympathetic innervation constricts the vessels, decreasing congestion, whereas the parasympathetic innervation dilates the vessels, enhancing congestion.

Category

Rhinitis can be divided into allergic and nonallergic types

Allergic rhinitis Allergic rhinitis is the most common of all

atopic diseases, it affects up to 20% of the adult population in worldwide

Allergic rhinitis is clinically defined as

symptomatic disorder of nose, induced after allergen exposure, by an IgE mediated inflammation of the nasal membranes

Common allergens

PollensAnimal danderMold sporesDust mites

Immdiate Hypersensitivity

For unknown reason, some individuals encounter with antigens such as plant pollens, animal dander, mold spores, dust mites, or the certain foods, or if they are exposed to certain drugs such penicillin, the dominent T cell response is the development of TH2 cells

allergic response in allergic rhinitis

HistamineserotoninLeukotriensprostaglandins

Inflammation mediators

such as histamine, serotonin, leukotrienes, and prostaglandins

Dilating blood vessels, stimulating nerves, and which increase the glands secretion

Symptoms of allergic Rhinitis

sneezing, rhinorrhea, and nasal congestion appear promptly

Diagnosis of Allergic Rhinitis Recurrent attacks of sneezing, watery

rhinorrhea and nasal congestion, frequently with conjunctival irritation and consequently increased lacrimation, some with itching of soft palate.

The nasal passages contain clear mucoid secretion, and nasal mucous membrane is congested and varies in color from pale to dull red

Diagnosis of Allergic Rhinitis

Skin prick test Whealing response Serum specific IgE

Treatment of allergic rhinitis Avoidance of the antigen exposure an important step unfortunately it is often not practical

Pharmacotherapy includes antihistamines (topical or systemic) topical corticosteroids, cromolyn sodium (stabilizes mast cell)

Immunotherapy may beneficial in selected patients.

Immunotherapy The primary indication is symptoms not

adequately controlled by avoidance measures and pharmacotherapy

Patients with perennial symptoms may prefer immunotherapy to yearlang daily medication

It begins with low-dose injections of allergen extracts and builds to a maintenance dose.

The causes of nonallergic rhinitis

Pharmacology (rhinitis medicamentosa)

Infection (commen cold)

Structural abnormalities

Irritation (formaldehyde)

Hormonal factors (Pregnency)

Atrophy

The causes of nonallergic rhinitis Substance abuse ( cocaine, alcohol, nicotine) Foreign bodies Trauma Temperature Exercise Recumbency Emotions

The causes of nonallergic rhinitis

Decreased nasal airflow states after laryngectomy or tracheostomy

Systemic diseases Wegener's granulomatosis Idiopathic disease vasomotor rhinitis eosinophilic or basophilic nonallergic rhinitis

Clinic picture of nonallergic rhinitis

• Main complain is nasal obstruction

• Troublesome symptom is excessive rhinorrhonea

• Post-nasal drip is sometimes a complaint

• On clinical examination the predominant finding the inferior turbinate are usually enlarged

Diagnosis and management

Diagnosis of nonallergic rhinitis is not difficult

Nasal allergy must be excluded in all cases by a careful history, skin sensitivity testing or serum specific IgE determination

Treatment depends on associated factors

Rhinitis medicamentosa Drug-induced rhinitis

It is caused by rebound nasal congestion

It is often associated with prolonged use of topical decongestants. With time, the strong vasoconstrictive effect of topical decongestants leads to the metabolic accumulation of vasodilators that are responsible for the rebound vasodilation.

Structural abnormalities that can cause rhinitis Deviated nasal septum

Turbinate hypertrophy

Nasal valve collapse

Intranasal and extranasal deformities

Polyps Neoplasms (e.g., papilloma, angiofibroma,

malignancy)

Atrophic rhinitis or ozena, is associated with atrophy of the

nasal mucosa and turbinates in association with excessive crusting and mucopurulent discharge.

This condition is marked by an extremely foul odor that can be easily detected by others.

Patients often complain of epistaxis, nasal obstruction, headaches

Atrophic rhinitis

Although the cause is unknown, hereditary, infectious, developmental, nutritional, and endocrine factors have been implicated.

Atrophic rhinitis may also be iatrogenic because it may be associated with excessive turbinate resection.

Atrophic rhinitis

Although no cure exists, treatment revolves around

Frequent saline irrigation and topical antibiotics

Surgical options have been aimed at narrowing the nasal cavity and nostril

Treatment of nonallergic rhinitis

Should be directed toward the specific cause

correction of structural problems treatment of infection

Symptomatic treatment includes the use of

steroids sympathomimetic agents anticholinergics

Surgery used in treating rhinitis

directed toward mechanical-obstructive issues

Surgeries include

septoplasty polypectomies

out-fracture of the inferior turbinates resection of hypertrophic mucosa

Sinusitis (Rhinosinusitis)

Sinusitis is extremely prevalent disorder that has a significant impact on the quality of life of affected individuals

Categories of sinusitis Clinical categories of rhinosinusitis are

largely based on the duration of symptoms and include the following:

acute up to 4 weeks chronic > 12 weeks

This classification is symptom based and should serve only as a general guideline.

Pathophysiology of sinusitis Mucosal edema of the paranasal sinuses is

the basic event leading to both acute and chronic disease.

Edema may lead to obstruction of the drainage routes of the sinuses, causing stasis of secretions.

These local changes lead to impaired mucociliary clearance, alteration in local immune defenses, and ultimately bacterial overgrowth.

Ciliary epithelium

Symptoms of acute bacterial sinusitis

Nasal drainage Nasal congestion Facial pain/pressure Postnasaldrip Hyposmia/anosmia Fever, Cough Fatigue Maxillary dental pain Ear fullness/pressure

Symptoms of acute bacterial sinusitis

The early symptoms may be difficult to distinguished from the common cold or allergic rhinitis

Headache or facial pain, nasal obstruction, mucopurulent nasal discharge (if ostia patent)

Symptoms of acute bacterial sinusitis The location of pain is related to the sinus

involved

Ethmoid—medial nose or retro-orbital pain

Sphenoid—occipital, vertex, or parietal headaches

Maxillary—suborbital tenderness, dental pain

Frontal—frontal headaches and tenderness

Diagnosis of acute bacterial sinusitis

in adults or children with a viral upper

respiratory infection does not dissipate

within 10 days (or worsens after 5-7 days)

and is accompanied by some or all of those

above symptoms.

Common organisms

Most common pathogens associated

Streptococcus pneumoniae (20-40%) Haemophilus influenzae (20-35%) and Moraxella catarrhalis (2-10%) Less common pathogens include

Staphylococcus aureus (0-9%) anaerobes (0-9%) and streptococcal species (3-9%).

Complications of sinusitis

Complications include

disease extension into the orbit or intracranial structures

facial cellulites cavernous sinus thrombosis osteomyelitis visual changes mucocele formation.


Orbital complications

preseptal or orbital cellulitis

owing to easy extension of infection along

the thin sinus bone surrounding the orbit

on three sides.


Meningitis is usually regarded as the most common intracranial complication of sinusitis and can arise from the sphenoid or ethmoid sinuses

Epidural and subdural abscesses are most commonly associated with frontal sinusitis

A brain abscess may also occur in the setting of sinusitis and carries a high mortality rate (20-30%). It is most often associated with frontal or ethmoid disease.

management of acute bacterial sinusitis

In addition to antibiotics, the medical management should include adjunctive treatments directed at reducing mucosal inflammation. These commonly include

nasal steroids topical decongestants (for the ostia patent) mucolytics (for mucocillary cleaning) nasal saline irrigation.

Symptoms of chronic sinusitis

Nasal drainage Nasal congestion Facial pain/pressure Postnasaldrip Hyposmia/anosmia Ear fullness/pressure Nasal polyps

Nasal polyps and sinusitis

• Apear as soft, smooth masses, varying in color, translucent, white, yellowish, pink, or fleshy

• Can arise from any part of the nasal and/or sinus mucosa, often bilateral, tend to be multiple, coexist with chronic sinusitis

Nasal polyps and sinusitis• Most commonly they

are seen in the middle meatus, but they occur also on the medial surface of the middle turbinate

Nasal polyps and sinusitis

Often involved sinus

In the majority of cases, the maxillary sinus and anterior ethmoid sinuses are involved.

This can be predicted by the anatomy of the middle meatus or infundibulum, the location for drainage of the "anterior sinuses" (maxillary, anterior ethmoid, frontal sinuses)

Opening of anterior sinuses

Treatment of chronic sinusitis The importance of bacterial infection in CRS

still remains debated Treatment options include prolonged intranasal steroids the use of systemic steroids leukotriene receptor antagonists Immunotherapy/antibiotics for select patients Surgery for select patients

Surgical intervention For chronic or recurrent sinusitis, the role

of surgery is to facilitate the natural drainage of the sinuses, when possible, through correction of identifiable anatomic aberrations.

Surgical intervention

Generally speaking, surgery is not a cure for CRS but an adjunctive treatment option for select patients.

Medical management remains the primary

option for sinusitis and is effective in the

majority of patients.

Surgical intervention

For complicated acute sinusitis, such as subperiosteal or epidural abscesses, the role of surgery is acute decompression of the affected sinuses as well as the area of abscess.

For chronic sinusitis with polyps, surgery is indicated

Functional Endoscopic Sinus Surgery (FESS)

Endoscopic sinus surgery has become the preferred technique for the surgical management of most forms of sinusitis.

FESS describes a series of techniques that use nasal endoscopes for access to the paranasal sinuses rather than external approaches.


The concept of functional surgery implies using techniques that facilitate the natural drainage patterns of the sinuses through the osteomeatal complex.


The key concept is atraumatic surgical technique, mucosal preservation, and restoration of normal sinus physiology.

FESS may be considered an option in patients with persistent symptoms of sinusitis combined with objective evidence of disease on endoscopy and/or CT despite maximal medical therapy.

Fungal sinusitis

Some form of sinusitis are caused by fungal

microorganisms within the sinonasal tract.

The fungal infection can be either invasive

or noninvasive.

The categories of fungal sinusitis

Acute fulminant invasive fungal sinusitis

Chronic invasive fungal sinusitis

Granulomatous invasive fungal sinusitis

Fungus balls, or mycetomas

Allergic fungal sinusitis

Eosinophilic fungal rhinosinusitis

Fungus balls or mycetoma

usually present as a unilateral opacification of either the maxillary or sphenoid sinus.

Patients are classically immunocompetent

without evidence of atopy

CSF Leaks

Cerebrospinal Fluid occur due to dural tears or areas of dural weakness

Otorrhea due to temporal bone fractures Rhinorrhea due to anterior or central

skull base dural defects

Important Questions

Recent trauma

History of recurrent meningitis

Recent sinus surgery, endoscopic surgery, or

neurosurgery

History of hydrocephalus, or increased

intracranial pressure

Diognosis and management

Nasal endoscopy

Beta-2-transferrin, or beta trace protein Imaging to localize defect. HRCT for bony

defects, MRI for herniations

Endoscopic surgical repair provides 90% 1st

time success

Diognosis and management

Thanks !

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