BASIC OTOLARYNGOLOGY

SENIOR EDITORS

Prof. Mariano B. Caparas, MD Manuel O. Lim, MD

EDITOR

Angel E. Enriquez, MD (Clinical Professor)

CO-EDITOR

Joselito C. Jamir, MD

EDITORIAL BOARD

Prof. Napoleon C. Ejercito, MD (Chairman)

Prof. Armando T. Chiong, MD (Co-Chairman)

Edilberto M. Jose, MD Alfredo Q. Y. Pontejos, Jr., MD

Jaime F. Flor, MD

PROJECT EDITOR

Frederick O. Leh, MD

A joint cooperative effort of the faculty members and resident staff of the Department of Otorhinolaryngology, UP-PGH.

Published through the funds made available by the Publications Committee of the College of Medicine, University of the Philippines.

SECTIONS Otology Tumor Rhino-pharyngology Plastic-Trauma

Laryngology and Broncho-Esophagology

ILLUSTRATORS

PHOTOGRAPHY

COVER DESIGN

EDITORS Generoso T. Abes. MD loscfmo G. Hernandez, MD

Rene S. Tuazon. MD Eutrapio S. Guevara, Jr., MD

lose1ito C. Jamir, MD

Ramon E. Gonzales. MD

Ronald A Reyes, MD

Ramon E. Gonzales, MD

Copyright 1993 by Joselito C. Jamir, MD

ASST. EDITORS Rhodora A. del Rosario, MD Frederick O. Leh. MD

Gabriel O. Te, MD Albert R. Tiotuyco, MD Josel V. Mijares, MD

Joel!. Dumandan. MD

All rights resetVed. No part of this publication may be reproduced or ttansmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any

infonnation storage and retrieval system, without written pennission from the editors.

CONTRIBUTORS

GENEROSO T. ABES, MD, FPSO-HNS

Assistant Professor II, UP College of Medicine

Chairman, Dept. of ENT, Manila Doctors Hospital

Section Chief, Otology, Dept. of ENT, Philippine General HospiUlI

Chairman, Dept. of ENT, Manila Doctors Hospital

Head, Ear Research Study Group

MARIANO B. CAPARAS, MD. FPSO-HNS

Professor III, UP College of Medicine

Fonner Chairman, Dept. of ENT, Philippine General HospiUlI

ConsulUlnt, Polymedie General Hospilal

ARMANDO T. CHIONG, MD, FACS

Associate Professor III, UP College of Medicine

Fonner Chairman, Dept. arENT, Philippine General HospiUlI

and Manila Doctors HospiUlI

RHODORA A. DEL ROSARIO, MD

Senior Resident, Dept. of ENT, Philippine General HospiUlI

Member, Ear Research Study Group

NAPOLEON C. EJERCITO, MD, FACS

Professor, UP College of Medicine

Fonner Chairman, Dept. of ENT, Philippine General HospiUlI

and Medical Center Manila

ANGEL E. ENRIQUEZ, MD, FPSO-HNS

Clinical Professor, UP College of Medicine

Fonner Chairman, Dept. of ENT, Manila Central University Hospital and Ospilal ng Maynila

Consultant, Dept. of ENT, Philippine General HospiUlI

JAIME F. FLOR, MD, FPSO-HNS Assistant Professor I, UP College of Medicine Chairman, Dept. of ENT, Fatima College of Medicine Consultant, Philippine General Hospital, Cardinal Santos Hospital

and Delos Santos Hospital

EUIRAPIO S. GUEVARA, JR., MD, FPSO-HNS Assistant Professor III, UP College of Medicine Chairman, Dept. of ENT, St. Luke's Medical Center Section Chief, Plastic and Reconstructive Surgery, Dept. of ENT,

Philippine General Hospital

JOSEFINO G. HERNANDEZ, MD, FPSO-HNS Clinical Assistant Professor, UP College of Medicine Chairman, Dept. of ENT, Medical Center Manila Consultant, Philippine General Hospital, Rizal Medical Center,

and Our Lady of Fatima Hospital

JOSELITO C. JAMIR, MD, FPSO-HNS Assistant Professor IV, UP College of Medicine Section Chief, Rhinopharyngology, Dept. of ENT,

Philippine General Hospital Visiting Consultant, Manila Doctors Hospital and

De La Salle University Hospital Head, Ear Research Study Group

EDILBERTO M. JOSE, MD, FPSO-HNS Associate Professor I, UP College of Medicine Consultant, Dept. of ENT, Philippine General Hospital and

Manila Doctors Hospital

FREDERICK O. LEH, MD Former Chief Resident, Philippine General Hospital Consultant, Chinese General Hospital

MANUEL G. LIM, MD, FACS Associate Professor I, UP CollegL of MediCine Chairman, Dept. of ENT, Philippine General Hospital Consultant, Dept. of ENT, 5t. Luke's Medical Center

and Medical Center Manila

JACOB S. MATUBIS, MD, FPSO-HNS Assistant P rofessor, UP College of Medicine Chairman, Dept. of ENT, Jose R. Reyes Memorial Hospital Consultant, Dept. of ENT, Philippine General Hospital and

St. Luke's Medical Center

JOSEL V. MUARES, MD Resident, Dept. of ENT, Philippine General Hospital Member, Ear Research Study Group

,

ALFREDO Q. Y. PONTEJOS, JR., MD, FPSO-HNS Assislant Professor I, UP College of Medicine Consulk1nt, Dept. of ENT, Philippine Geneml Hospiuu and

Manila Doclors Hospillli

GABRIEL O. TE, MD Resident, Dept. of ENT, Philippine General Hospital

ALBERT R. TIOTUYCO, MD Senior Resident, Dept. of ENT, Philippine Genoml Hospital

RENE S. TIJAZON, MD, FPSO-HNS Clinical Assiswnt Professor, UP College of Medicine Section Chief, Bronchoesophagology, Dept. of ENT,

Philippine Genoml Hospital Consultant, National Kic1ney Inslilule and SI. Luke's Medical Center

Section : Chapter I.

II. III.

Section : Chapter I.

II. III. IV.

V. VI.

VII. VIII.

IX.

Section : Chapter I.

II. III. IV.

V. VI.

Section Chapter I.

11.

111.

IV. V.

VI.

TABLE OF CONTENTS

Allied Sciences Otolaryngologic History and Physical Examination .................... I

Otolaryngologic Radiology ............................ ...................... ....... 13

Pharmacology in Otolaryngology.... ..... ..... ............ ..... ................. 24

Otology Anatomy of the Ear .................................................... ................. 33

Physiology of Hearing ......... .................... ,.................................. 46

Audiology .......................... ......................................................... 49

Dio;eases of the External Ear ........................................................ 61

Common Diseases of the Middle Ear and Mastoid ...................... 68

I nner Ear Diseases ....................................................................... 78

Facial Nerve Problems ................................................................ 87

Ear Surgery............ .... ....... ..... ... ......... ..... ....... ....... ..... ............. .... 92

Hearing Loss in Children ...................................... ...................... 98

Rhinopharyngology Anatomy and Physiology of the Nose and Pardnasal Sinuses ...... 101

Diseases of the Nose ................................................................... 108

Diseases of the Paranasal Sinuses ................................................ 130

Anatomy and Physiology of the Pharynx .. .................................. 145

Diseases of the Pharynx .............................................................. 155

Diseases of the Oral Cavity........... ...... ........... ....... ..... ..... ............ 162

Laryngology History and Physical Examination of the Larynx

and Bronchoesophagology Patient ......................................... 167

Anatomy of the Larynx ............................................................... 170

Congenital Disorders of the Larynx ............................................. 182

I nflammatory Disorders of the Larynx ........................................ 184

Neurologic Disorders of the Larynx ............................................ 187

Laryngeal Tumors .... ... .... ... ....... .............. ..... ....... ..... ... .... ..... ....... 188

Section :

Chapter 1.

II. III.

Section Chapter 1.

II.

III. IV.

Section : Chapter I.

II. III.

IV.

Bronchoesophagology Anatomy of Trachea, Bronchus and Esophagus .......................... 190

Foreign Body of the Food and Air Passages ................................ 193

Esophageal Disorder .... ....... ..... ....... ........................ ..... ....... ..... ... 202

Plastic and Reconstructive Surgery Basic Principles in the Management of Soft Tissue

Injuries of the Face ................................................................ 204

Cleft Lip and Palate ..................................................................... 213

Principles of Sldn Grafts and Flaps ............................................. 219

Maxillofacial Trauma.... ....... ..... ..... ....... ..... ..... ......... ..... .............. 225

Head and Neck (Tumors and Infections) Anatomy of Head and Neck ...................................... .................. 242

Deep Infections of the Head and Neck ................ : ....................... 251

Malignancies of the Oral Cavity .................................................. 257

Cancers of the Nose and Paranasal Sinuses ................................. 268

V . Vascular Tumors of the Nose and Nasopharynx .. ......... ... ............ 272

VI. Salivary Gland Tumors ............................................................... 278

VII. Cancer of the Larynx........... ...... ........... ....... ..... ... ......... ....... ..... ... 283

VIII. Thyroid Carcinoma ...................................................... :.... .......... 288

IX. Other Tumors of the Head and Neck ........................................... 293

X. Neck Masses .............................................................. ....... , ......... 303

References

Index

.................................................................................................... 311

................................................................................... ................. 314

LIST OF FIGl RES

1.1 The use of the headmirror as the source of light .... ....... ... ................ 7 1.2 Proper positioning of patient ................................. ,......................... 8 1.3 Structures seen on posterior rhinoscopy.......................................... 11 1.4 Structures seen on indirect laryngoscopy........................................ 12 1.5 Positions for mastoid series ............................................................. 15 1.6 Towne's view.................................................................................. 16 1.7 Schuller's view................................................................................ 16 1.8 Mayer's view ...................................................... :........................... 17 1.9 Cholesteatoma as seen on Towne's view......................................... 17 1.10 Positions for x-rays of the temporal bone ........................................ 18 1.11 Positions for sinus x-ray ................................................................. 20 1.12 Water's view................................................................................... 20 1.13 Structure of penicillin ..................................................................... 24

1.14 Structure of erythromycin ............................................................... 27 1.15 Structure of chloramphenicol ....................................................... ,.. 28

2.1 The auricle and external auditory meatus ................ ............ ............ 34 2.2 The external auditory canal ................... >......................................... 34 2.3 The tympanic membrane ................................................................ 36 2.4 The middle ear ........................................................................... ;.... 37 2.5 Boundaries of the mastoid cavity.................................................... 38 2.6 The ossicles ....... ............ ............ .......................... .............. ..... ........ 39 2.7 The bony labyrinth ..................................................................... .... 41 2.8 The membranous labyrinth ............................................................. 42 2.9 Cross·section of the cochlea............................................................ 43 2.10 The central auditory pathway.......................................................... 44

2.11 The facial nerve .............................................................................. 45 2.12 Displacement of sensory hairs in the crista ampullaris .................... 48 2.13 The Weber test ............................................................................... 51 2.14 Audiogram sample and symbols ..................................................... 53 2.15 Conductive hearing loss .................................................................. 54 216 Sensorineural hearing loss .............................................................. 54 2.17 Mixed hearing loss ......................................................................... 54

2.18 Sample audiogram of patient .......................................................... 56

2.19 Results of the Bekesy test ....... ........................................................ 58

2.20 ABR wave pattern . .. . ....... ..... ....... ..... ............ ............ ............ ..... ..... 60

2.21 Removal of cerumen ....................................................................... 62

2.22 Perichondritis ........... ........ ......... ... ............ ......... ..... ....... ... ......... ..... 66

2.23 Facial paralysis ........................... .................................................... 88

2.24 Surgery for perichondritis ............................................................... 93

2.25 Myringotomy ................................................................................. 93

2.26 Simple mastoidcctomy .................................................. ................. 94

2.27 Radical mastoidectomy ............... ........... ............................. ............ 95

2.28 T ypcs of tympanoplasty.... ....... ..... ..... .......................... ............ ....... 96

3.1 The external nose ........... ................. ................................................ 101

3.2 The nasal septum ........... .................................................... . ............ 103

3.3 The latcral nasal wall ............................................. : ........................ 103

3.4 Blood supply of the septum ............................................. ............... 104

3.5 Blood supply of the lateral nasal wall ............................................. 105

3.6 Nerve supply of the nose ................................................................ 106

3.7 Antcrior packing.... ..... ....... ....... ... ......... ................. ..... .................... 114

3.8 Anterior packing completed ................... , ........................................ 114

3.9 Postcrior packing ............................................................................ liS 3.10 Posterior packing with an anterior pack .......................................... 115

3.11 Inflated foley catheter as posterior pack .......................... ................ 116

3.12 Thc paranasal sinuses ..................................................................... 130

3.13 Coronal section of the nose and paranasal sinus .............................. 131

3.14 Water's view with air-fluid Icvel ..................................................... 135

3.15 The Caldwell-Luc antrostomy ..................................... ................... 137

3.16 Maxillary carcinoma prescnting as a maxillary bulge ..................... 144

3.17 Divisions of the pharynx ................................................................. 146

3.18 The palatine tonsil .......................................................................... 147

3.19 Thc constrictor muscles of the pharynx ........................................... 148

3.20 Muscles of the soft palate ........ ........ .... ..................... .............. ........ 149

3.21 Blood supply of the pharynx ........................................................... lSI 3.22 Facial laycrs and spaces, sagittal section ......................................... 152

3.23 Peripharyngeal spaces in an oblique section .................................... 152

3.24 Quincy's abscess .. ........................................................................... 159

4.1 Divisions of the larynx .................................................................... 170

4.2 Cartilages of the larynx ................................................................... 172

4.3 Cartilages of the larynx ................................................................... 173

4.4 The extrinsic muscles of the larynx ................................................ . 175

4.5 The intrinsic muscles of the larynx ..... .............. ..... ... ..... ... .............. 175

4.6 The intrinsic muscles of the larynx .. .. ....... ..... ..... ....... ... .... ..... ......... 176

4.7 Innervation of the larynx .... ... ............. ...................... ... .... ........ .. ... .. . 178

4.8 Lymphatic drainage of the larynx .... ......................................... .... .. 180

4.9 Findings on direct laryngoscopy ............ .......... ........... .................... 181

5.1 Foreign body, coin ........ .................................................................. 196

5.2 Orientation of flat objects in the esophagus .. .. ... .............. ..... .. .. .. ... .. 198

5.3 Proper application of forceps .. ... ....... ... .. .. ............................ .. ... ...... 198

5.4 Exploration of esophagus .......... ...................................................... 199

5.5 Orientation of foreign body in relation to lumen of the esophagus .. 199

5.6 Endogastric version ... ......... ......... .. .. .. ... ...... ..... ............................... 200

5.7 Endogastric straightening ........ . .................................. .. ................... 200

5.8 Point-shealed method . .. .. ....... ........ ... .. .. .. ... . .. ................................ .. 201

5.9 Removal of Balut white .................................. : ............................... 201

6.1 Types of cleft lip ................... ................................... .. ... .. .. ... ........... 217

6.2 Incomplete and complete cleft palate ... .. ....... ... ... ..... ... .. ... ......... ...... 218

6.3 Millard rotation-advancement flap ............................ .. .................... 218

6.4 Forehead flap ........ : ......................................................................... 222

6.5 Trapezius flap ................................................................................. 223

6.6 Pectoralis major myocutaneous flap . ..... .. ..... .. ... . . .. .......................... 223

6.7 Delto-pectoral flap .............................................. ... .. , ...................... 224

6.8 Sternocleidomastoid flap ..... , .......................................................... 224

6.9 Nasal bone fracture ............................. ............ .............. .... ... .. .. ..... .. 227

6.10 Frequency of mandibular fracture . .................................................. 228

6.11 The favorable and unfavorable mandibular fracture ........................ 229

6.12 Anterior view - Lefort I fracture ....... .. .... .. ..... ... .. ................ ..... ........ 232

6.13 Lateral view - Lefort I fracture....... ......... ............ ................ ............ 232

6.14 Anterior view - Lefort II fracture ........................ ......... ................... 233

6.15 Lateral view - Lefort II fracture ................................... ................... 233

6.16 Anterior view - Lefort III fracture.... ............ ................ ................... 234

6.17 Lateral view - Lefort III fracture.... ............ .......... .............. ............. 234

6.18 Tripod fracture ............. .. .... .. .... ......................... ................ ... ........... 235

6.19 Incision sites for zygomatic fracture ......... : ..................................... 236

6.20 Open reduction using Gillies incision and periosteal elevator .......... 237

6.21 Open reduction using a lid incision ................................................. 237

7.1 Triangles of the neck .... .. .. .. ... ...... .. .. ................................. .............. 243

7.2 Lymph node groups of the head and neck . ........ .. .. .... ... . ....... ........... 244

7 .3 Lymphatic drainage of the head and neck ........... ........ ......... ........... 244

7.4 Veins of the head and neck ............................................................. 247

7.5 Arteries of the head and neck ....... ......... ..... ..... ....... .......... ............... 249

7.6 Submandibular space infection ....................................................... 252

7.7 Retropharyngeal space infection ..................................................... 255

7.8 The oral cavity ............................................................................. : .. 258

7.9 Buccal carcinoma ........................................................................... 265

7.10 Types of.fissural cyst .... ....... ..... ...... ............. ..... ....... ..... ....... ..... ... ... 294

7.11 Types of odontogenic cyst .... ....... ... ....... ........................ .............. ... 294

7.12 Radicular cyst .... ............ ....... ..... ..... ..... ....... ................... ............ ..... 296

7.13 Dentigerous cyst ............ .... ............................................................. 297

7.14 Hemangioma .. ......... ..... ....... ..... ....... ..... ....... ............ ..... ....... ..... ...... 299

7.15 Lymphangioma .............................................................................. 300

7.16 Fibrosarcoma .................................................................................. 302