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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
