Introduction What is otolaryngology? What subdivisions exist within the specialty? Is otolaryngology a medical or a surgical specialty? How can you learn otolaryngology well?

What is otolaryngology? 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)

What is otolaryngology? 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

What subdivisions exist within the specialty? 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

What subdivisions exist within the specialty? 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 Pollens Animal dander Mold spores Dust 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 Histamine serotonin Leukotriens prostaglandins

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.

Complications of sinusitis Orbital complications preseptal or orbital cellulitis owing to easy extension of infection along the thin sinus bone surrounding the orbit on three sides.

Complications of sinusitis 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

Nasal polyps and sinusitis

Nasal polyps and sinusitis

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

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.

Functional Endoscopic Sinus Surgery (FESS) The concept of functional surgery implies using techniques that facilitate the natural drainage patterns of the sinuses through the osteomeatal complex.

Functional Endoscopic Sinus Surgery (FESS) 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

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