T. Metin Önerci

External Ear Canal

Diseases of the external ear canal are common and very disturbing. They may cause severe pain as well as hearing loss. Cerumen, which is the most common disease of the external ear canal, may cause conductive-type hearing loss. Cerumen is the product of both the sebaceous and apocrine glands, which are located in the cartilaginous portion of the external ear canal. There are two basic types, “wet” and “dry.” Caucasians have a greater than 80% probability of having wet, sticky, honey-colored ear wax. In the Mongoloid races the dry, scaly, rice-brand type is more common. The skin of the external ear canal is migratory and does not desquamate. There is no need to clean the ear canal. In some people there is excessive cerumen production. The cerumen is generally occluded in the narrowest part of the external ear canal at its midportion. These patients need periodic cleaning. Use of cotton swabs can push the cerumen deeper in the ear canal, which occludes the ear canal completely and makes removal more difficult. Otomycosis, polyps, foreign bodies, osteomas, and acute infections of the external ear canal are other important diseases.

Diagnosis in otorhinolaryngology

Ear.- Ear Anatomy.- ENT Examination.- The Pinna.- External Ear Canal.- Otitis Media with Effusion.- Acute Otitis Media.- Chronic Otitis Media.- Facial Nerve Paralysis.- Complications of Otitis Media.- Hearing Loss.- Otalgia.- Temporal Bone Fractures.- Tinnitus.- Vertigo.- Nose.- The Common Cold and the Flu.- Rhinitis.- Allergic Rhinitis.- Nasal Vestibulitis and Nasal Furunculosis and Mucormycosis.- Sinusitis.- Complications of Sinusitis.- Nasal Polyposis.- Nasal Obstruction.- Septum.- Epistaxis.- Traumas.- Nasolacrimal obstructions.- Tumors.- Throat & Neck.- Acute Tonsillopharyngitis.- Adenoids.- Snoring.- Temporomandibular Joint.- Airway Obstructions.- Hoarseness.- Cysts.- Salivary Gland Tumors.- Oral Cavity.- Neck Masses.- Neck Malignancies.

Nasal Vestibulitis and Nasal Furunculosis and Mucormycosis

Infection of the skin of the nasal vestibule is termed nasal vestibulitis. It may be secondary to constant rhinorrhea, nose-picking, or viral infections such as herpes simplex and herpes zoster. Foreign bodies frequently cause vestibulitis in children due to purulent discharge. Nasal furunculosis is Staphylococcus aureus infection of the hair follicles. Nose-picking is the frequent cause of furunculosis. Topical and if necessary systemic antibiotics are prescribed. The patient should be instructed not to squeeze out pus from this area. Since the veins draining this area are valveless and directly join the cavernous sinus, there is a potential risk of spreading infection to the cavernous sinus via these facial veins. Eczema may also mimic vestibulitis. In these patients steroid base ointment may help the condition. In persistent vestibulitis neoplastic disease such as basal cell or squamous cell carcinoma should be kept in mind.

Physiology and Pathophysiology of Sneezing and Itching: Mechanisms of the Symptoms

Sneeze is a coordinated protective respiratory reflex which arises due to stimulation of the upper respiratory tract, particularly the nasal cavity. Actually, activation of the central and peripheral nervous system plays a major role in the pathophysiology of this process. In fact, little is known about the sneeze reflex action, which sometimes becomes a sign associated to a series of different medical conditions. In this chapter, we aimed to review the physiology, pathophysiology, etiology, diagnosis, treatment, and complications of sneezing and itching.

The Common Cold and the Flu

Both the flu and the common cold are respiratory illnesses that are caused by different viruses. The flu is an infection of the respiratory system caused by the influenza virus, whereas the common cold is caused by rhinoviruses. Common cold/ acute viral rhinosinusitis is defined as duration of symptoms for less than 10 days. Acute nonviral rhinosinusitis is defined as an increase of symptoms after 5 days or persistent symptoms after 10 days with less than 12 weeks’ duration. Although the symptoms are similar and it is difficult to tell the difference between the common cold and the flu based on symptoms alone, the flu is worse than the common cold. There is usually fever (temperature above 39°C), and symptoms such as headache, body aches, extreme tiredness, sore throat, and dry cough are more common and intense. Symptoms appear suddenly. People with colds are more likely to have a runny or stuffy nose. Colds generally do not result in serious health problems, such as pneumonia, bacterial infections, or hospitalizations.

Physiology of Lacrimal Drainage

There are many factors contributing to lacrimal elimination, but the most important mechanism is canalicular and sac pump mechanism. Canalicular pump is probably more important than the sac pump because following DCR, tears are still drained through the canaliculi to the nose. The pressure gradient between the canaliculi and the sac cannot be produced if the canaliculus is slit open. Therefore, the lacrimal canaliculi should be preserved and should not be damaged. Tear elimination is equivalent through the upper and lower canalicular systems. Therefore, attention should be given not to damage both the upper and lower canaliculus.

The Nose and the Eustachian Tube

Normal functioning of the ear is closely related to the health status of the nose and paranasal sinuses. Pathologies of the nose, sinuses, and nasopharynx play an important role in the cause, treatment, and sequelae of ear disease. Sniffing creates negative pressure in the nose, in the nasopharynx, and in the middle ear, causing middle ear pathologies in patients with hyperpatent eustachian tube. Nose blowing increases intranasal propelling viscous fluid into the paranasal sinuses and middle ear. Sneezing elevates intranasal pressure tenfold times less compared to nose blowing. However, sneezing while the nasal passages are blocked may lead to an increase in nasopharyngeal pressure, causing a failure of the valve which protects the entrance to the eustachian tube. The positive middle ear pressures with bilateral nasal obstruction are caused by tubal openings synchronized into the positive phase of nasopharyngeal pressure generation. Increase in the environmental pressure in the presence of nasal obstruction interferes with eustachian tube functioning; thus, the tube may remain closed and may be “locked.” Continued increase causes barotrauma.

Chronic Otitis Media

Patients with chronic otitis media often complain of hearing loss and aural discharge. Hearing loss may be simply due to tympanic membrane perforation or due to fixation or disruption of the ossicles. The tympanic membrane perforation may involve a small part or the whole tympanic membrane. If there is no annulus, these perforations are called marginal perforations. The presence of cholesteatoma necessitates surgical treatment. The aim of surgery is to eradicate infection and to create a functioning middle ear space with restoration of hearing.

Complications of Otitis Media

The complications of acute or chronic middle ear diseases still carry a very high mortality rate if not treated properly, although the incidence of complications has been decreasing significantly after the introduction of antibiotics. The infection may spread to neighboring structures either by bone erosion or preformed pathways. Facial nerve paralysis due to chronic otitis media with cholesteatoma requires urgent surgical treatment. Acute mastoiditis may be the first sign of other complications. It may first cause sagging of the posterosuperior canal wall and postauricular edema. Acute mastoiditis should be treated as soon as possible after diagnosis with myringotomy, antibiotics, and simple mastoidectomy if necessary.

Temporal Bone Fractures

Temporal bone fractures are classified into two main groups: longitudinal and transverse fractures. Longitudinal fractures are much more frequent. The incidence of longitudinal fractures is four times greater than of transverse fractures. Generally, temporal and parietal blows are associated with longitudinal fractures. Conductive-type hearing loss is generally accompanied by longitudinal temporal bone fractures. Facial nerve injury may occur at the geniculate ganglion area and is only seen in 15% of longitudinal fractures. Tympanic membrane perforation or bleeding into the middle ear may also be seen. Transverse fractures generally occur due to frontal or occipital trauma. They frequently affect the facial nerve and inner ear. Hemotympanum may be associated with transverse fractures, but tympanic membrane perforation is not seen. Temporal bone fractures do not always follow these general guidelines, and some fractures are mixed. These fractures are evaluated according to the type of lesions.