Ent conditions for physiotherapists

ENT CONDITIONS FOR PHYSIOTHERAPISTS

A. Thangamani ramalingam PT, MSc(PSY), MIAP

Ears Hearing loss including BAHA(bone

anchored hearing aid) Ear discharge Earache Balance disorders Tinnitus

Nose Nasal blockage Nasal deformity Cosmetic surgery / Rhinoplasty Facial pain Sinusitis Allergic Rhinitis e.g. hay fever and

house dust mite allergy Tumours of the nose and sinuses.

Throat Sore throat including tonsillitis Snoring Hoarse voice Swallowing disorders Tumours of the throat and larynx.

Head and neck Facial weakness Neck swellings Thyroid disorders Salivary gland diseases

Cosmetic Procedures Rhinoplasty Otoplasty Children Glue ear Adenoidectomy Tonsillectomy Obstructive sleep apnoea

Common problems managed by an ENT specialist include hearing

balance problems, tumours of the nose, sinuses, throat and larynx, allergies, snoring, voice and swallowing disorders, inflammation of the throat and laryngitis. 

Sinusitis paranasal sinuses

› Frontal› Maxillary› Ethmoid› Sphenoid Acute/chronic sinusitis

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Sinusitis

Nasal congestion

Purulent rhinorrhea

Postnasal drip

Headache

Facial pain

Anosmia

Cough, fever

Rhinitis

Nasal congestion

Rhinorrhea clear

Runny nose

Itching, red eyes

Nasal crease

Seasonal symptoms

causes- Viral upper respiratory infections Allergic and non allergic stimuliImmunodeficiency disordersAnatomic changes-Deviated septum,

Pollens

House dust mite

Allergic foods and beverages

Tobacco smoke

Perfumes

Cleaning solutions

Burning candles

Cosmetics

Car exhaust

diesel fumes

Hair spray

Acute symptoms Chronic

Mucopurulent nasal discharge

Swelling of nasal mucosa

Mild erythema

Facial pain (unusual in children)

Periorbital swelling

Nasal discharge

Nasal congestion

Headache

Facial pain or pressure

Olfactory disturbance

Fever and halitosis

Cough (worse when lying down)

Acute treatment Chronic Antihistamines

recommended if allergy present› Oral or topical

Decongestants› Oral or topical

Antibiotic when indicated (bacteria)

Nasal irrigation Guaifenesin 200-400 mg

q4-6 hrs Hydration

Nasal steroid spray

Guafenesin

Decongestants

Steam inhalation

Nasal irrigation

Antibiotics with exacerbations

Otitis Media Can be acute or chronic

Can be with or without serous effusion (acute or chronic)

Can be acute or chronic suppurative

Can co-exist with otitis externa

Otitis media with serous effusion= glue ear

Acute Otitis Media

Common in children Unwell/pyrexia, otalgia/discharge Tenderness over the mastoid Discharge in meatus Loss of outline of drum and landmarks TM: red, bulging, oedematous or perforation. Mostly viral but can be Streptococcus/Haemophilus

Analgesia

Antibiotics

Amoxicillin is the usual first-line for 5 days. If severe symptoms present, or there has been a previous episode of AOM within the last month, use high doses (double the standard dose). Erythromycin (use high doses) or Clarithromycin (use standard doses) are alternative antibiotics if documented allergy to penicillin.

Complications

Progression to glue ear hearing impairment Perforation Mastoiditis Labyrinthitis Meningitis Intracranial sepsis or facial nerve palsy.

Recurrent episodes may lead to atrophy and scarring of the eardrum, chronic perforation and otorrhoea, cholesteatoma, permanent hearing loss, chronic mastoiditis and intracranial sepsis.

Serous Otitis Media

Serous otitis media with retraction

Otitis media+effusion-Glue ear

Dull retracted TM May show air-fluid level Conductive hearing loss

Management It usually follows a cold and spontaneously

resolves; this may take up to 6 weeks Surgery: adenoidectomy or myringotomy and

grommet insertion. Hearing aids: persistent OME, not for surgery

Treatments not recommended are antihistamines,decongestants, steroids , homeopathy, cranial osteopathy, acupuncture, dietary modification, including probiotics, immunostimulants, massage

Chronic Otitis Media

Recurrent ear discharge Hearing loss, painless Perforation of the TM – central Presence of cholesteatoma Marginal, Attic perforation Offensive discharge, bleeding,

granulations

Complications: Vestibular symptoms Facial palsy

Intracranial complications

Ear drum Perforations

Safe perforations may allow infection to enter the middle earconductive deafness

Unsafe perforations retraction of the tympanic membrane- part of the drum becomes sucked inwards and may gradually enlarge. when the retraction becomes extensive, keratinous debris builds up in the retraction and may become infected and an acquired cholesteatoma develops

UNSAFE SAFE

Source Cholesteatoma Mucosa

Odour Foul Inoffensive

Amount Usually scant, never profuse

Can be profuse

Nature Purulent Mucopurulent

Unsafea)In the attic orb)In the posterior region. These are often linear rather than ovalc)Or involve the eardrum margin

Safe

d) In the anterior region ore) In the inferior regionf) And not involving the eardrum margin

Safe anterior perforation

Safe inferior perforation

Unsafe perforation

Unsafe posterior perforation

Cholesteotoma

Cholesteatoma is "a three dimensional epidermoid structure exhibiting independent growth, replacing middle ear mucosa, resorbing underlying bone, and tending to recur after removal." There is usually a persistent or recurrent scanty cream coloured offensive discharge and progressive hearing loss due to ossicular destruction or toxin induced sensory hearing loss.

Normal ear drum

Serous Otitis media

Chronic suppurative otitis media

Chronic suppurative otitis media involves a perforation (hole) in the tympanic membrane and active bacterial infection within the middle ear space for several weeks or more.

There may be enough pus that it drains to the outside of the ear (otorrhea), or the purulence may be minimal enough to only be seen on examination using a binocular microscope.

This disease is much more common in persons with poor Eustachian tube function. Hearing impairment often accompanies this disease

FACIAL PALSY

Facial nerve is a mixed nerve, having a motor root and a sensory root

Sensory root “nerve of Wrisberg” - the anterior 2/3 of the tongue and general sensation from the concha and retroauricular skin

Motor root - mimetic muscles of the face secretomotor - lacrimal, submandibular and

sublingual glands as well as those in the nose and palate.

ANATOMY

Intracranial part Intratemporalpart

MeatalLabyrinthine

Tympanic, horizontalMastoid, vertical

Extracranial part

Nucleus-Pons. Branches

Greater superficial petrosal nerve:

Nerve to stapedius:Chorda tympani:Comunicating branch:Posterior auricular nerve:Muscular branches:Peripheral branches: “Pes

anserinus”

Causes Central:

› Brain abscess› Pontine glioma› Poliomyelitis› Multiple sclerosis

Intacranial part:› Acoustic neuroma› Meningioma› Metastatic CA› Meningitis

Extracranial part:› Parotid gland CA› Parotid gland surgery› Parotid gland injury› Neonatal facial nerve injury

CongenitalMöbius Syndrome

Intratemporal part:› Idiopathic:

Bell’s palsy› Melkersson’s syndrome› Infections:

ASOM CSOM Herpes Zoster Oticus -Ramsay Hunt syndrome

› Trauma: Surgical: Mastoidectomy, Stapedectomy

› Accidental:# temporal bone

› Neoplasms: Glomus jugulare tumour Facialnerveneuroma Metastatic CA

Systemic:› DM› Hypothyroidism› Uremia› PAN› Wegener’s granulomatosis› Sarcoidosis› Leprosy› Leukemia

Classification of Severity of injury

Saunderland classification:› 1°: Partial block: Neuropraxia› 2°: Loss of axons: axonotemesis› 3°: Injury to the endoneurium: neurotemesis› 4°: Injury to the perineurium: partial transection› 5°: Injury to the epineurium: complete transection

Tests

Nerve Excitability Test: NET

Maximum stimulation Test: MST

Electroneurography: ENoG

Electromyography: EMGPure-tune audiometry

Topodiagnostics:Schirmer’s test:Stapedial reflex:Taste test:Submandibular salivery

flow test: Warton’s ducts

Bell's phenomenon

House-Brackmann Facial Nerve Grading Scale

I NormalII Normal tone and symmetry at rest

Slight weakness on close inspectionGood to moderate movement of foreheadComplete eye closure with minimum effortSlight asymmetry of mouth with movement

III Normal tone and symmetry at restObvious but not disfiguring facial asymmetrySynkinesis may be noticeable but not severe+/- hemifacial spasm or contractureSlight to moderate movement of foreheadComplete eye closure with effortSlight weakness of mouth with maximum effort

IV Normal tone and symmetry at restAsymmetry is disfiguring or results in obvious facial weaknessNo perceptible forehead movementIncomplete eye closureAsymmetrical motion of mouth with maximum effort

V Asymmetrical facial appearance at restSlight, barely noticeable movementNo forehead movementIncomplete eye closureAsymmetrical motion of mouth with maximum effort

Complications Residual paralysis keratitis Synkinesis Tics and spasms Crocodile tears Frey’s syndrome “gustatory

sweating” Psychological and social

stigma

Labyrinthitis 

Labyrinthitis is an ailment of the inner ear and a form of unilateral vestibular dysfunction. It derives its name from the labyrinths that house thevestibular system, which senses changes in head position.

Labyrinthitis is usually caused by a virus, but it can also arise from bacterial infection, head injury, extreme stress, an allergy or as a reaction tomedication. Both bacterial and viral labyrinthitis can cause permanent hearing loss.

Labyrinthitis often follows an upper respiratory tract infection (URTI).

Predisposing factors

smoke drink large quantities of alcohol allergies habitually fatigued extreme stress aspirin

Infection usually occurs by one of three routes

Meninges-the middle ear space-hematogenous spread Labyrinthitis Meningogenic: through the IAC, cochlear aqueduct, both

(bilateral) Tympanogenic: extension of infection from the middle ear,

mastoid cells or petrous apex-most common through the round or oval window (unilateral)

Hematogenous: least common

Symptoms dizziness vertigo loss of balance nausea and vomiting tinnitus (ringing or buzzing in your ear) loss of hearing in the high-frequency rangein one ear difficulty focusing eyes In very rare cases, complications can include permanent

hearing loss.

Rehabilitation

Gaze stability exercises - moving the head from side to side while fixated on a stationary object (aimed to restore the Vestibulo-ocular reflex) An advanced progression of this exercise would be walking in a straight line while looking side to side by turning the head.

Habituation exercises - movements designed to provoke symptoms and subsequently reduce the negative vestibular response upon repetition. Examples of these include Brandt-Daroff exercises.

Functional retraining - including postural control, relaxation, and balance training.

Treatment

Antihistamines like clarinex (prescription) or allegra, benadryl, and claritin (over-the-counter)

Medications that can reduce dizziness and nausea, such as antivert

Sedatives like diazepam Corticosteroids like prednisolone

Otosclerosis Primary metabolic bone disease of the otic capsule

and ossiclesResults in fixation of the ossicles and conductive

hearing lossMay have sensorineural component if the cochlea is

involvedOsseous dyscrasiaResorption and formation of new boneLimited to the temporal bone and ossiclesHereditary, endocrine, metabolic, infectious, vascular,

autoimmune, hormonal

Pathology

Phase1-Active (otospongiosis phase) Osteocytes, histiocytes, osteoblasts Active resorption of bone Dilation of vessels Schwartze’s sign-grey/pink discoloration

Phase2-Mature (sclerotic phase)› Deposition of new bone (sclerotic and less dense than

normal bone)

labyrinthine otosclerosis /Cochlear Otosclerosis

May cause SNHL via Toxic metabolites Decreased blood supply Direct extension Disruption of membranes

Associated symptoms› Dizziness› Otalgia› Otorrhea› Tinnitus

Vestibular symptoms› Most commonly dysequilibrium› Occasionally attacks of vertigo with rotatory nystagmus

Complications in Stapes Surgery

Facial nerve displacement (Perkins, 2001)› Facial nerve is compressed superiorly with No.

24 suction (5 second period)› Perkins describes laser stapedotomy while

nerve is compressed Vertigo Recurrent Conductive Hearing Loss

Auditory tests

The hearing level is quantified relative to 'normal' hearing in decibels (dB), with higher numbers of dB indicating worse hearing. Hearing loss can be graded as follows: 

Normal hearing: less than 25 dB in adults and 15 dB in children.Mild hearing loss: 25-39 dB.Moderate hearing loss: 40-69 dB.Severe hearing loss: 70-94 dB.Profound hearing loss: 95+ dB.

Hearing loss of 100 dB is nearly equivalent to complete deafness for that particular frequency. A score of 0 is normal. It is possible to have scores less than 0, which indicates better-than-average hearing.

Description Relative Positive/negative

In a normal ear, air conduction (AC) is better than bone conduction (BC)

AC > BC this is called a positive Rinne

In conductive hearing loss, bone conduction is better than air

AC < BC negative Rinne

In sensorineural hearing loss, bone conduction and air conduction are both equally depreciated, maintaining the relative difference of bone and air conductions

AC > BC positive Rinne

In sensorineural hearing loss patients there may be a false negative Rinne

AC < BC negative Rinne

Weber without

lateralization

Weber lateralizes left

Weber lateralizes

right

Rinne both ears AC>BC

Normal/bilateral sensorineural loss

Sensorineural loss in right

Sensorineural loss in left

Rinne left BC>AC

Conductive loss in left

Combined loss : conductive and sensorineural loss in left

Rinne right BC>AC

Combined loss : conductive and sensorineural loss in right

Conductive loss in right

Rinne both ears BC>AC

Conductive loss in both ears

Combined loss in right and conductive loss on left

Combined loss in left and conductive loss on right

The Hearing in Noise Test (HINT)  Tympanogram Acoustic reflex  Audiometer hearing test speech tests Whisper test Watch test

ENT Surgery

ENT surgeons diagnose and treat conditions of theears, nose, throat, head and neck, and undertakesome cosmetic procedures.

Cochelar ImplantTymanoplasty - Ear Drum RepairStapedectomyLarygectomySinus surgeryOssiculoplastyBronchoscopyGrommet insertionGrommet RemovalMyringotomyParotid Gland Removal - ParotidectomyNasal Polyp RemovalSeptoplastySubmucous Resection - SMRTonsillectomyTurbinates of Nose - Resection

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Larynx

Laryngeal symtoms

Voice changes-hoarseness,puberphonia,vocal asthenia&functionalaphonia

Stridor-noisy respiration Dysnoea Weak cry Dry cough Painful swallowing

Laryngectomy

Complete Laryngectomy Partial Laryngectomies Supraglottic laryngectomy Vertical hemilaryngectomy Carcinoma supraglottic / subglottic / glottic

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Incisions

Sorenson’s incision

Gluck’s incision

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Laryngectomy

Naso gastric tube for few days(ryle’s)Drains may be removed on the 3rd or 4th

day after surgery (corrugator rubber tube)Tracheotomy care/vitals monitoringMobility/pulmonary careStitches removed on 7-10 daysSpeech Rehabilitation Esophageal speech Electro larynx. Tracheo esophageal puncture

(neoglottis formation)

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Complications

Cardiac arrest Hemorrhage Pulmonary embolism Pulmonary pneumonia Atelectasis Fistula

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Pharyngeal laryngectomy

Partial/total with laryngectomy Repair and reconstructive surgeries

Thyroidectomy

Lobectomy and isthmusectomy Bilateral subtotal thyroidectomy Near total thyroidectomy Total thyroidectomy

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Thyroid

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Thyroidectomy

Causes

Carcinoma Large nodular thyroid compressing the

airway

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Complications Recurrent laryngeal nerve paralysis Bleeding Hypo parathyroidism Infection

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Mastoidectomy A mastoidectomy is a surgical procedure that removes an infected

portion of the mastoid bone when medical treatment is not effective. A mastoidectomy is performed to remove infected mastoid air cells

resulting from ear infections, such as mastoiditis or chronic otitis, or by

inflammatory disease of the middle ear (cholesteatoma). The mastoid air cells are open spaces containing air that are located

throughout the mastoid bone, the prominent bone located behind the ear that projects from the temporal bone of the skull. The air cells are connected to a cavity in the upper part of the bone, which is in turn connected to the middle ear. Aggressive infections in the middle ear can thus sometimes spread through the mastoid bone.

Mastoidectomies are also performed sometimes to repair paralyzed facial nerves.

Causes

A mastoidectomy is often an initial step in removal of lateral skull base neoplasms, including vestibular schwannomas, meningiomas, temporal bone paragangliomas (glomus tumors), and epidermoids.

Complications of otitis media, including intratemporal or intracranial suppuration and lateral venous sinus thrombosis, often necessitate a mastoidectomy

A simple mastoidectomy consists of opening the mastoid cortex and identifying the antrum.

A complete or canal wall up mastoidectomy necessitates removal of all of the mastoid air cells along the tegmen, sigmoid sinus, presigmoid dural plate, and posterior wall of the external auditory canal. The posterior wall of the external auditory canal is preserved.

A canal wall down mastoidectomy includes a complete mastoidectomy in addition to removal of the posterior and superior osseous external auditory canal. The tympanic membrane is reconstructed to separate the mucosal lined middle ear space from the mastoid cavity and ear canal.

A modified radical mastoidectomy is identical to a canal wall down mastoidectomy except the middle ear space and native tympanic membrane are not manipulated. This procedure is useful when there is no extension of cholesteatoma in the middle ear space or medial to the malleus head or incus body. This procedure is often indicated in patients with a cholesteatoma in their only or better hearing ear.

A radical mastoidectomy is a canal wall down mastoidectomy in which the tympanic membrane and ossicles are not reconstructed, thus exteriorizing the middle ear and the mastoid. The eustachian tube is often obliterated with soft tissue to reduce the risk of a chronic otorrhea. A skin graft can be placed in the middle ear to reduce the risk of mucosalization and otorrhea

Complications

persistent ear discharge infections, including meningitis or brain abscesses hearing loss facial nerve injury temporary dizziness temporary loss of taste on the side of the tongue