1. Babak Saedi. MD Assistant professor of Tehran university

2. Ear anatomy & physical examination  External ear  Middle ear  Internal ear

3. http://www.earaces.com/anatomy.htm#Cross%20Section%20Of%20Ear

4. Normal TM  Malleus (short process and handle  Cone of light  Incus  Pars tensa  The unbelievable UMBO

5. Right TM

6. Middle Ear  The inner ear communicates with the acoustic environment outside of the body by means of a funnel (pinna), a short tube (the EAC), a thin membrane TM and three small bones.  The purpose of the middle ear and ossicular chain is to overcome the impedance mismatch of going from an air filled outer ear to a fluid filled inner ear.

7. Middle Ear http://www.iurc.montp.inserm.fr/cric/audition/english/ear/fear.htm

8. Ossicles

9. Impedance Mismatch  The purpose of the middle ear and ossicular chain is to overcome the impedance mismatch of going from an air filled outer ear to a fluid filled inner ear.  Like yelling to someone underwater. About a 30 dB loss.

10. Inner Ear  There are three sections of the inner ear: semicircular canals (superior, lateral, posterior), vestibule (mid- section) and the cochlea (snail shaped).  The vestibule and semicircular canals serve to function in balance not hearing.  The cochlea functions in hearing, by changing fluid energy into neural energy. Basic Structures http://oto.wustl.edu/cochlea/intro1.htm

11. http://www.neurophys.wisc.edu/h%26b/auditory/anatomy/a09.html

12. Cerumen in canal  May advise parents to soften first  May remove yourself in office  At the VA: May remove a lot of ear wax in the ER

13. Differential Diagnosis  external otitis or furunculosis of external auditory meatus: post auricular tenderness.  bullous myringitis: the earache may be intense but deafness only slight, the membrane may be obscured by a large hemorrhagic bleb or blebs.

14. Otitis Media  Red, Bulging  Hyperemia  Dullness of light reflex  Opaque

15. ASOM  Acute suppurative otitis media is one of the most common infections of childhood. It may accompany any upper respiratory tract infection such as the common cold, measles, scarlet fever, or influenza. When virulent bacteria invade the middle ear, an acute suppuration occurs.

16. Bacteriology  The hemolytic streptococcus, staphylococcus, the pneumococcus and hemophilos are most commonly responsible for the infection.

17. Serous OM  Bulging, amber drum  Decreased mobility

18. Tympanic Membrane Perforation

19. CSOM OR COM  Neglected or recurrent infection of the middle ear may eventually produce a chronic change in the mucosa of the ear or destruction of the periosteum covering the ossicles, The infection then tends to become chronic. Chronic infection of the middle ear is much more common in persons who had ear disease in early children. Disease of the ear in infancy and early children may arrest the normal pneumatization of the mastoid. It is possible that the same process alters the mucosa of the middle ear, so that it is more susceptible to recurrent infection than is the normal ear.

20. Cholestatoma  Epithelium work as a tumor  Complications :meningitis, labyrantitis, facial paralysis and brain abscess  tympanomastoidectomy

21. Tumor  Benign : osteoma, chondroma,glumous  Malignant : SCC, BCC,ACC and metastasis

22. Ear: Squamous cell carcinoma

23. Hearing loss  Conductive  Sensory neural  Mixed  Diagnosis :PTA, TYMPANOMETRY, SDS, & SRT  TRETMENT

24. Conductive  COM  Otosclerosis  Trauma  Congenital

25. Sensory neural  Congenital  Trauma  Infection  Presbucosis  Drugs  Tumor  Menier  occupational

26. Congenital  Rubella  Syphilis  Toxoplasmosis  Kernicterus  Drugs  Anoxia

28. Ethmoid Maxilla Palatine Lacrimal Pterygoid plate of Sphenoid Nasal Inferior Turbinate Bony Structure

29. Arterial Supply External Carotid Maxillary A. Sphenopalatine Internal Carotid Ophthalmic A. Ant. Ethmoid Post. Ethmoid Supraorbital Supratrochlear

30. Facial Analysis Analysis of nose is very important

31. Sinus  Maxillary  Frontal  Ethmoid  Sphenoid

33. Ethmoid Bulla Uncinate Process Hiatus Semilunaris

34. Function of Nose & Paranasal Sinuses  Humidifying and warming inspired air  Regulation of intranasal pressure  Increasing surface area for olfaction  Lightening the skull  Resonance  Absorbing shock  Contribute to facial growth

35. Nasal & sinus disease  Infection  Rhinitis  Epitasis  Tumor  Trauma

36. Viral Rhinosinusitis  Most upper respiratory infections are viral  Short lived, last less than 10 days  Sinus mucosa as well as nasal mucosa is involved  Most will clear without antibiotics  Treatment: decongestants, nasal lavage, rest, fluids

37. Classification of Bacterial Sinusitis  Acute bacterial sinusitis- infection lasting 4 weeks, symptoms resolve completely (children 30 days)  Subacute bacterial sinusitis- infection lasting between 4 to 12 weeks, yet resolves completely (children 30-90 days)  Chronic sinusitis- symptoms lasting more than 12 weeks (children >90 )

38. Bacteria Involved in Acute Bacterial Sinusitis  Streptococcus pneumoniae 30%  Haemophilus influenza20%  Moraxella catarrhalis10%

39. Antibiotics for Acute Bacterial Sinusitis  Amoxicillin 500 mg tid for 10-14 days  First line choice in most areas  Local differences in antibiotic resistance occur  Where beta-lactamase resistance is an issue  Amoxicillin/clavulanate  Cefuroxime  Cefexim  Cefprozil

40. CT Scan Maxillary and Ethmoid Sinuses

41. Sinusitis

42. Sinus endoscopy

43. Allergic Rhinitis

44. Nasal Polyp

45. Septal deviation

46. Foreign body

47. Malignant tumor