Otolaryngology is the branch of medicine that specializes in the diagnosis and treatment of ear, nose, throat, and head & neck disorders. The full name of the specialty is otolaryngology-head and neck surgery. Practitioners are called otolaryngologists-head and neck surgeons, or sometimes otorhinolaryngologists (ORL). A somewhat outdated, but nevertheless commonly used term for this specialty is ENT (ear nose and throat).

Ears and nose are both sense organs specially adapted for receiving stimuli of sound and smell, respectively.

Anatomy and Physiology

An ear is an organ used by an animal to detect sound waves. The term may refer to the entire system responsible for collection and early processing of sound (the beginning of the auditory system), or merely the externally visible part. Not all animals have ears in the same part of the body.

Mammals, including humans, have two ears, one on each side of the head.

1. The outer ear is the external portion of the ear and includes the eardrum.

2. The middle ear includes the ossicles (three tiny bones), two muscle tendons (of the stapedius and tensor tympani muscles), and two nerve bundles (the horizontal portion of the facial nerve and a branch of the facial nerve called the chorda tympani).

3. The inner ear comprises both the organ of hearing (the cochlea) and the labyrinth or vestibular apparatus, the organ of balance located in the inner ear that consists of three semicircular canals and the vestibule.

Outer Ear

The outer ear is the external portion of the ear and includes the eardrum. The visible part is called the pinna, or auricle, and functions to collect and focus sound waves. Many mammals can move the pinna (with the auriculares muscles) in order to focus their hearing in a certain direction in much the same way that they can turn their eyes. Humans, as opposed to other mammals, do not have this ability. From the pinna the sound pressure waves move into the ear canal, a simple tube running to the middle ear. This tube amplifies frequencies in the range 3 kHz to 12 kHz.

The human ear has earlobes at the bottom that are vestigial but are used by many people to provide an attachment point for earrings. The earlobe is usually formed cleft from the side of the face and hangs from the rest of the ear but occasionally will be found looking fused and "lobeless" due to a recessive gene. The helix is the outer edge of the outer ear

Middle Ear

The middle ear is the hollow portion of the ear behind the eardrum. The middle ear contains one or more ossicles, which amplify vibration of the eardrum into pressure waves in the fluid in the inner ear. The middle ear has also been called the tympanic cavity, or cavum tympani. The middle ear makes contact with the outside via the eardrum, the brain via the oval window, and the nasal cavity via the eustachian tube.

Ossicles

The middle ear contains three tiny bones known as the ossicles: malleus, incus, and stapes. The ossicles were given their Latin names for their distinctive shapes; they are also referred to as the hammer, anvil, and stirrup, respectively. The ossicles amplify vibration of the eardrum, into pressure waves of the fluid in the cochlea (or inner ear). The eardrum is fused to the malleus, which connects to the incus, which in turn connects to the stapes. The footplate of the stapes fits snugly into the oval window. Vibrations of the stapes footplate introduce pressure waves in the inner ear. The ratio in area between the tympanic membrane and the oval window results in an effective amplification of approximately 14 db, peaking at a frequency of around 1 kHz. The combined transfer function of the outer ear and middle ear gives humans a peak sensitivity to frequencies between 1 kHz and 3 kHz.

The movement of the ossicles may be stiffened by two muscles, the stapedius and tensor tympani, which are under the control of the facial nerve and trigeminal nerve, respectively. These muscles contract in response to loud sounds, thereby reducing the transmission of sound to the inner ear. This is called the acoustic reflex.

Of surgical importance are two branches of the facial nerve, which also pass through the middle ear space. These are the horizontal and chorda tympani branches of the facial nerve. Damage to the horizontal branch during surgery can lead to partial, unilateral facial paralysis.

Inner Ear

The inner ear comprises both:

· The organ of hearing (the cochlea)

· The labyrinth or vestibular apparatus, the organ of balance located in the inner ear that consists of three semicircular canals and the vestibule.

Cochlea

The cochlea (Latin for "snail") is a spiraled, hollow, conical chamber of bone filled with perilymph and endolymph (in the scala media), a fluid medium that receives the sound vibrations transmitted from the air to the oval window through the ear drum and ossicles of the middle ear (see above). Running through its centre is the cochlea duct, which contains the spiral Organ of Corti, the receptor organ responsible for hearing. The bony cavity of the cochlea is divided into three separate chambers: the scala vestibuli, which lies superior to the cochlea duct and abuts the oval window; the scala media, which is the membranous cochlea duct containing endolymph and the organ of Corti; and the scala tympani, which lies inferior to the scala media and terminates at the round window. The two bony chambers (scala vestibuli and scala tympani) both contain perilymph and join together at the cochlear apex, a region called the helicotrema. Separating the scala vestibuli from the scala media is the Reissner's membrane. The basilar membrane separates the scala media from the scala tympani. Sitting on top of the basilar membrane is a cellular layer known as the Organ of Corti, which is lined with hair cells — sensory cells topped with hair-like structures called stereocilia.

As the stapes oscillates against the oval window in response to sound, the perilymph within the scala vestibuli also oscillates. For very low frequencies (below 20Hz), the pressure waves propagate along the complete route of the cochlea - up scala vestibuli, around helicotrema and down scala tympani to the round window. Frequencies this low do not activate the organ of Corti and are below the threshold for hearing. Higher frequencies do not propagate to the helicotrema but are transmitted through the endolymph in the cochlea duct to the perilymph in the scala tympani. The hair cells in the organ of Corti are tuned to certain sound frequencies, being responsive to high frequencies near the oval window and to low frequencies near the apex of the cochlea.

All excited hair cells send nerve impulses to the brain, which are perceived as a sound of whatever pitch the hair cell is associated with. A very strong movement of the endolymph due to very loud noise may cause hair cells to die. This is a common cause of partial hearing loss and is the reason why anyone using firearms or heavy machinery should wear earmuffs or earplugs.

Vestibular Apparatus

The vestibular apparatus is filled with the same endolymph as the cochlea, but instead of detecting sound, it detects rotation of the head. If a line is drawn through the middle of each of the three semicircular canals, perpendicular to the plane in which the canal lies, the three lines would be perpendicular. They would represent three axes of rotation. Any rotation could be represented as three simultaneous rotations about the three axes.

Function and Mechanism of Hearing

Ear is the organ for hearing and balance (equilibrium) in the body. The structure of the car converts vibrations of air into f1uid vibrations and then into sensory impulses. These sensory impulses are carried through the auditory nerve or the vestibulocochlear nerve to the centers in the brain for interpretation for hearing and equilibrium.

External auditory meatus conveys vibrations of sound to the tympanic membrane and is about 1 inch long. A waxy secretion called cerumen is produced in this part. Its main function is to prevent dust particles, foreign bodies, etc., to reach the delicate part of middle ear or inner ear. Tympanic membrane or eardrum marks the beginning of the middle ear (tympanic cavity). Tympanic cavity is the site for the eustachian tube. From here, the tube runs forward into nasopharynx, where it opens. This tube helps in equalizing air pressure on each side of the tympanic membrane. This tube is also called a pharyngotympanic tube. The sound waves collected from the pinna and auditory meatus strike against the tympanic membrane. From the tympanic membrane the sound waves pass through bones called auditory ossicles. This chain of bones (ossicles) transmits the vibrations from tympanic membrane to inner ear. The inner ear is the most delicate part, consisting of several cavities, which channel in the temporal bone. Its two main parts (cavities) are a bony labyrinth and a membranous labyrinth inside it. Both are fluid-filled cavities. The fluid inside the bony labyrinth and outside membranous labyrinth is called perilymph. The fluid inside the membranous labyrinth is called endolymph. Bony labyrinth is divided into three regions, namely, semicircular canals, vestibule and cochlea. Vestibule is the central part with which all other parts communicate. It contains two sacs, saccule and utricle. The utricle is connected to semicircular canals, and from the saccule arises the cochlea. Fluid within saccule and utricle passes freely among the sacs and excess fluid is stored in the endolymph sac for return to circulation. Receptors (hair cells) on both these structures, along with semicircular canals, help in maintaining equilibrium. Movement of the endolymph within the membranous labyrinth caused by head movement and head position stimulates the hair cells, which generate impulses through the vestibulocochlear nerve and in response to this we make appropriate movements to co-ordinate the head’s activity and maintain balance.

The third area of inner ear is cochlea, which is a spiral tube twisted on itself. The cochlea has a membranous labyrinth inside it, which is called cochlear duct and contains endolymph. The surrounding cochlear duct on the inside is the basilar membrane, which has many sensory structures called organ of Corti, which contain hair cel1s that are re-ceptors for auditory stimuli. When three ossicles vibrate, they transfer the vibrations to the fluid within the cochlea, which is then set into motion. This moving fluid (endolymph) within the cochlea moves the basilar membrane and, as a result, the hair cells attached to the organ of Corti are stimulated. These impulses (stimuli) are transmitted to the brain for interpretation as sound.

· The eighth cranial nerve or the auditory nerve supplies the special sense of hearing and the olfactory or first cranial nerve supplies the sense of smell.

· Stirrup, found in ear, is the smallest bone in the human body.

Nose and Throat

Nose and throat have already been discussed in the anatomical section in detail. Below mentioned are few important points in regards to otorhinolaryngology.

Breathing starts with the air entering the nasal cavity. The nasal cavi-ties, also known as nostrils, are divided into the right and the left sides by a vertical partition called septum. These nasal cavities have mucous membranes and small hairs, called vibrissae, which warm, moisten, and filter the incoming air. The receptors for the sense of smell are also located in the nasal cavities among the epithelial cells. These receptors are known as olfactory neurons, and they are located up in the nasal cavities. The nose is the primary organ for smelling. As we sniff, the air flows through the nose and over structures called turbinates in the nasal cavity. The turbulence caused by this disruption slows the air and directs it toward the olfactory epithelium. At the surface of the olfactory epithelium, odor molecules carried by the air contact olfactory receptor neurons, which transduce the features of the molecule into electrical impulses in the brain.

Air passes from the nasal cavities to the pharynx.

The pharynx is the combined part of the digestive system and respiratory system of many animals. It is situated immediately posterior to the mouth and nasal cavity, and is cranial to the oesophagus, larynx, and trachea. Because both food and air pass through the pharynx, special adaptations are necessary to prevent choking or aspiration when food or liquid is swallowed. In humans the pharynx is important in vocalization.

The human pharynx is conventionally divided into three sections:

· Nasopharynx, lying behind the nasal cavity. Posterosuperiorly this extends from the level of the junction of the hard and soft palates to the base of skull, laterally to include the fossa of Rosenmüller. The inferior wall consists of the superior surface of the soft palate.

· Oropharynx, which lies behind the oral cavity. The anterior wall consists of the base of tongue and vallecula; the lateral wall is made up of the tonsil, tonsillar fossa, and tonsillar (faucial) pillars; the superior wall consists of the inferior surface of the soft palate and the uvula.

· Hypopharynx which includes the pharyngoesophageal junction (postcricoid area), the piriform sinus, and the posterior pharyngeal wall.

Adenoids, also known as pharyngeal tonsils, are located in the nasopharynx. The palatine tonsils, at times referred to as just tonsils’, are located in the oropharynx. The larynx is found in the laryngopharynx and is responsible for sound production or phonation. There is a leaf-shaped structure situated at the top of the larynx, which closes the passage to the lungs while swallowing, thus preventing the food particles and other irritants from entering the lungs. This leaf-shaped structure is called epiglottis The larynx is a short passage that connects the pharynx with the trachea

Physical Assessment

In transcription, physical assessment with regards to ears, nose, and throat is usually bundled up with examination of the eyes and the head and is generally transcribed under the heading HEENT (H-head, E-eyes, E-ears, N-nose, T-throat.) The assessment begins with external exam of the ears and nose and the oral mucosa. After a cursory and brief external exam, the physician then proceeds to each individual part. Usually starts with proper examination of the inner ear with otoscopy. External auditory canal and tympanic membranes are inspected for color, translucency and position of the eardrum and wax and tear of the eardrums are specially looked for. The tympanic membranes generally appear translucent and pinkish gray in color and any significant variation in the texture usually denotes some disease process. The tympanic membranes are then checked for mobility with air inflation and the malleus for its oblique position behind the upper part of the drum. After this hearing assay is done with specific tests already discussed above.

After examination of the ears, the physician the proceeds with inspection of the nose. The nasal bone, cartilage, passages, inferior and middle turbinates are all inspected through a speculum or by tilting the tip of the nose with a penlight. More focus is given to the contour of the septum and the color of the mucus membrane. After this comes the inspection of the throat or the oral cavity. The patient is asked to open the mouth and checked for bad breath, lesions, tonsillitis, caries, uvular anomalies, palatal anomalies, tongue texture, and for any oral mucosal ulcers or lesions. The examination then usually concludes with a direct and indirect laryngoscopy to look for any vocal chord paralysis, lesions, nodes, adenoids, etc.

Pathological Conditions

Acute coryza

One of the most widespread illnesses-acute coryza or upper respiratory infection-is generally referred to as the common cold. This pathology is characterized by sore throat, sneezing, nasal congestion, and runny nose. This disease condition is highly contagious and easily spreads from one person to another. A physician diagnoses the condition by the presence of the above-mentioned symptoms. Sometimes, he also asks for a throat culture in order to rule out strep or other bacterial infections. There is no cure for this disease, and the body’s own immune system heals itself in five to six days. However, this disease can lead to other complications. The doctor may prescribe medications like Sudafed, oxymetazoline (Afrin), guaifenesin (Entex), to name a few.

Earaches

Otalgia is ear pain or an earache. Primary otalgia is from pain that originates inside the ear. Referred otalgia is from pain that originates from outside the ear.

Typical sources of primary otalgia are external otitis, otitis media, mastoiditis, auricular infections, and, rarely, GERD. Dental disorders are the most common cause of referred otalgia. These include temporomandibular joint disorders, bruxism, and abscessed teeth. Tonsillitis and pharyngitis are also common causes of earaches in children. These earaches are constant or intermittent with dull, sharp, burning, or throbbing pain.

Otitis media

Otitis media (also known as glue ear) is an inflammation of the middle ear segment of the ear. It is usually associated with a buildup of fluid and frequently causes an earache. The fluid may or may not be infected.

There are several kinds of otitis media:

1. Acute otitis media is an infection that produces pus, fluid, and inflammation within the middle ear. It is frequently associated with signs of upper respiratory infection, such as a runny nose or stuffy nose.

2. Otitis media with effusion is the presence of middle ear fluid for six weeks or more from the initial acute otitis media.

3. Chronic otitis media may develop when the infection persists for more than two weeks.

Streptococcus pneumoniae and Haemophilus influenzae are the most common bacterial causes of otitis media. Still, antibiotics are rarely effective in shortening disease duration. Tubal dysfunction leads to the ineffective clearing of bacteria from the middle ear.

As well as being caused by Streptococcus pneumoniae and Haemophilus influenzae it can also be caused by the colds.

Another common culprit of otitis media includes Moraxella Catarrhalis, a gram negative, aerobic, and oxidase positive diplococci.

Otitis Externa

Otitis externa (also called swimmer's ear or earache) is an inflammation, irritation, or infection of the outer ear and ear canal.

Otitis externa is fairly common, especially among teenagers and young adults. Swimming in polluted water is one way to contract swimmer's ear. Trying to clean wax from the ear canal, especially with cotton swabs or small objects, can irritate or damage the skin. It is occasionally associated with middle ear infection (otitis media) or upper respiratory infections such as colds. Middle ear infections can occur after the ear drum is perforated by a fungal growth from the outer ear. Moisture in the ear predisposes the ear to infection from fungus or water-loving bacteria such as Pseudomonas.

Symptoms

· Ear pain-may worsen when pulling the outer ear

· Itching of the ear or ear canal

· Drainage from the ear-yellow, yellow-green, pus-like, or foul smelling

· Decreased hearing or hearing loss

Treatment

The goal of treatment is to cure the infection. The ear canal should be cleaned of drainage to allow topical medications to work effectively. Depending on how severe the infection is, it may be necessary for a doctor to aspirate the ear as many times as twice a week for the first two or three weeks of treatment.

Effective medications include eardrops containing antibiotics to fight infection and corticosteroids to reduce itching and inflammation and analgesics to reduce pain. Use of antibiotics to treat ear infections may result in treatment of the wrong cause of the infection because not all ear infections are bacterial; some are fungal, and it is possible to have both a bacterial and fungal ear infection.

Labyrinthitis

Labyrinthitis is a balance disorder that usually follows an upper respiratory tract infection (URI). It is, as the name suggests, an inflammatory process affecting the labyrinths that house the vestibular system (which senses changes in motion) of the inner ear.

In addition to balance control issues, a labyrinthitis patient often encounters hearing loss and tinnitus. It appears labyrinthitis is caused by a virus (the herpes virus has been implicated) but can also arise from bacterial infection, head injury, an allergy or as a reaction to a particular medicine. Both bacterial and viral labyrinthitis can cause permanent hearing loss, although this is rare. Prochlorperazine is commonly prescribed for all types of the infection, which helps with the nausea and sickness.

Labyrinthitis and Vertigo

A prominent and debilitating symptom of labyrinthitis is chronic dizziness. The vestibular system is a set of sensory inputs, which aid balance control systems by measuring changes in rotational and linear motion. The brain combines visual cues with sensory input from the vestibular system to determine adjustments required to retain balance. When working properly, the vestibular system also relays information on head movement to the eye muscle, forming the vestibulo-ocular reflex, in order to retain continuous visual focus during motion. When the vestibular system is affected by labyrinthitis, rapid, undesired eye motion (nystagmus), often results from the improper indications of rotational motion. Nausea, anxiety, and a general ill feeling are common due to the distorted balance signals that the brain receives from the inner ear. Recovery from acute labyrinthine inflammation generally takes from one to six weeks.

Labyrinthitis and Anxiety

Chronic anxiety is a common side effect of labyrinthitis, which can produce tremors, heart palpitations, panic attacks and depression. Often a panic attack is one of the first symptoms to occur as labyrinthitis begins. While dizziness can occur from extreme anxiety, labyrinthitis itself can precipitate a panic disorder.

Barotitis

Barotitis is caused by the changes in the barometric pressures, usually caused by the takeoff or landing of an airplane. Problems include ear pain, ringing, diminished hearing and, sometimes, dizziness. Alternate terms include aerotitis, aerotitis media, barotitis media, and otic barotrauma. Bacterial infections are treated with antibiotics in the form of eardrops or oral medications. The patients are encouraged to complete the entire course of therapy least the disease should recur. Blocked eustachian tubes are generally opened with medicated nasal drops. Severe or chronic otitis media requires an insertion of a plastic drainage tube to drain the pus or fluid. Ruptured eardrum is repaired with the procedure called tympanoplasty. Otitis externa or swimmer's ear is treated with antibiotic, antifungal, or corticosteroid ear drops.

Hearing Loss

A hearing impairment is a decrease in one's ability to hear (i.e. perceive auditory information). While some cases of hearing loss are reversible with medical treatment, many lead to a permanent disability (often called deafness). If the hearing loss occurs at a young age, it may interfere with the acquisition of spoken language and social development. Hearing aids and cochlear implants may alleviate some of the problems caused by hearing impairment, but are often insufficient. People who have hearing impairments, especially those who develop a hearing problem later in life, often require support and technical adaptations as part of the rehabilitation process.

Causes

There are five causes of hearing loss: long term exposure to environmental noise, genetic factors, disease processes affecting the ear, medication and physical trauma.

Types

There are three major types of hearing loss: neural/sensorineural, conductive, or a combination of both. Treatment depends upon the type of hearing loss that is present.

Sensorineural

Sensorineural hearing loss is caused by damage/malfunction of the inner ear (cochlea, eighth cranial nerve) or auditory brainstem. This can be divided further into a sensory hearing loss (inner ear) or a neural hearing loss (brainstem).

Conductive

Conductive hearing loss is caused by damage/malfunction of the middle or outer ear system (external ear canal, eardrum, or structures in the middle ear space including the malleus, incus and stapes bones).

Combination

Mixed hearing loss is caused by both conductive and sensorineural causes.

Quantification of hearing loss

The severity of hearing loss is measured by the degree of loudness, as measured in decibels a sound must attain before being detected by an individual. Hearing loss may be ranked as mild, moderate, severe or profound. It is quite common for someone to have more than one degree of hearing loss (i.e. mild sloping to severe). The following list shows the rankings and their corresponding decibel ranges:

· Mild:

· for adults: between 25 and 40 db

· for children: between 15 and 40 db

· Moderate: between 41 and 55 db

· Moderately severe: between 56 and 70 db

· Severe: between 71 and 90 db

· Profound: 90 db or greater

Unilateral hearing loss

People with unilateral hearing loss (single sided deafness/SSD) can hear normally in one ear, but have trouble hearing out of the other ear. Problems with this type of deficit is inability to localize sounds (ie. unable to tell where traffic is coming from) and inability to process out background noise in a noisy environment, such as in a restaurant.

Treatment

In order to treat the hearing loss, the physician prescribes a hearing aid if the loss is not severe. The type of hearing aid depends on the cause of the hearing loss. The patients are also trained in lip-reading. In some cases of otosclerosis, the surgery (stapedectomy) is performed to take out the malfunctioning stapes, and a prosthesis is inserted, which conducts sound vibrations to the inner ear.

Presbycusis

The tiny hair cells that line the cochlea degenerate with age. These cells are responsible for, sending the messages to the brain through the auditory nerves. Deterioration of these cells makes hearing difficult. This sensory-neural hearing loss is known as presbycusis. Hearing loss usually begins gradually after the age of sixty, and is usually more noticeable in men than women. Over time, the detection of high-pitched sounds becomes more difficult. Both ears tend to be affected.

Otosclerosis

Otosclerosis is a hearing condition in which the stapes in the ear becomes attached to the surrounding bone by an abnormal bone growth. Sound transmission is progressively impaired so that hearing in the affected ear deteriorates.

Laryngitis

Laryngitis is an inflammation of the larynx. It causes hoarse voice or the complete loss of the voice because of irritation to the vocal folds (vocal cords). It is categorized as acute if it lasts less than a few days. Otherwise it is categorized as chronic.

Laryngitis is often caused by a virus or by bacteria.

Other causes include smoking, various allergies, reflux and straining the voice through singing or shouting.

Home treatments

· Ibuprofen and aspirin may help alleviate fever and some of the discomfort associated with laryngitis

· Avoid speaking when possible. Speak softly, but do not whisper

· Drink warm liquids such as tea or a honey-lemon drink.

· Take cough drops/throat lozenges. If unavailable, suck on hard candy.

· Stay hydrated, drink plenty of liquids; water, orange juice, etc.

· Humidifiers and warm showers can also help alleviate some symptoms.

· Avoid airborne irritants such as smoke and allergens.

· Gargle with a salt-water rinse; avoid mouth rinses containing alcohol which can dry the throat (however, these can be helpful when the cause of the infection is bacterial).

Ménière’s Disease

Ménière's disease (or syndrome, since its cause is unknown) was first described by French physician Prosper Ménière in 1861. It is a balance disorder of the inner ear.

The symptoms of Ménière’s are variable; not all sufferers experience the same symptoms. However, four symptoms are considered to comprise so-called "classic Ménière’s”:

· periodic episodes of rotary vertigo (the abnormal sensation of movement) or dizziness

· fluctuating, progressive, unilateral (in one ear) or bilateral (in both ears) hearing loss, often in the lower frequency ranges

· unilateral or bilateral tinnitus (the perception of noises, often ringing, roaring, or whooshing), sometimes variable

· a sensation of fullness or pressure in one or both ears

Ménière’s often begins with one symptom, and gradually progresses. A diagnosis may be made in the absence of all four classic symptoms.

Cause

The exact cause of Ménière's disease is not known, but it is believed to be related to endolymphatic hydrops or excess fluid in the inner ear. It is thought that endolymphatic fluid bursts from its normal channels in the ear and flows into other areas causing damage. This may be related to swelling of the endolymphatic sac or other issues in the vestibular system of the inner ear, which is responsible for the body's sense of balance. The symptoms may occur in the presence of a middle ear infection, head trauma or an upper respiratory tract infection, or by using aspirin, smoking cigarettes or drinking alcohol.

Treatment

The patient is asked to restrict fluid intake and take a diuretic to lower the level of the body fluid. In some cases, electrocochleography may also be per-formed in which a probe is inserted under local anesthesia through the eardrum to mea-sure the eardrum to measure the electrical activity. Medical treatment includes usage of antihistamines (Benadryl, Antivert, Valium), antinausea drugs (dimenhydrinate, Transderm), or steroids (prednisone) to alleviate the episodes of Meniere Disease. Sometimes surgery may also be recommended. Another treatment is chemical labyrinthectomy, in which a drug (such as gentamicin) that "kills" the vestibular apparatus is injected into the inner ear. Lipoflavonoid is also recommended for treatment by some doctors.

Pharyngitis

Pharyngitis is a painful inflammation of the pharynx, and is colloquially referred to as a sore throat. Infection of the tonsils, tonsillitis (American English: tonsillitis) may occur simultaneously.

The major cause is infection, of which 90% are viral, the remainder caused by bacterial infection and rarely oral thrush (fungal candidiasis e.g. in babies). Some cases of pharyngitis are caused by irritation from agents such as pollutants, chemicals, or smoke.

Pharyngitis is generally treated with broad-spectrum antibiotics, which may range penicillin, azithromycin, erythromycin, doxycycline, and ceftriaxone.

Types

Viral sore throats

These comprise about 90% of all infectious cases and can be a feature of many different types of viral infections.

· Adenovirus

· Orthomyxoviridae which cause Influenza

· Infectious mononucleosis ("glandular fever") caused by the Epstein-Barr virus. Herpes simplex virus can cause multiple mouth ulcers.

· Measles

Bacterial sore throat-The most common bacterial agent is streptococcus.

Diphtheria-Diphtheria is a potential life threatening upper respiratory infection caused by Corynebacterium diphtheriae which has been largely eradicated in developed nations since the introduction of childhood vaccination programs, but is still reported in the Third World and increasingly in some areas in Eastern Europe. Antibiotics are effective in the early stages, but recovery is generally slow.

Treatment

The treatment of pharyngitis will vary according to the cause.

· Iodine compounds sold as Betadine or TCP can be gargled to shorten the duration of the infection. These compounds are effective anti-viral agents.

· Antibiotics are only helpful when a bacterial infection is the cause of the sore throat. For bacterial sore throats, antibiotics have been shown to only affect the degree of pain by day 4 and shorten the average natural duration by 16 hours overall (14 people need be treated for a week to reduce the duration by one day.)

Symptomatic

· Lozenges (cough medicine) are often used for short-term pain relief.

· Gargling with warm salty water is a popular household remedy, although there is only anecdotal evidence this gives other than temporary relief and likewise for the use of aspirin gargles.

· Warm tea can help temporarily alleviate the pain of a sore throat.

· Analgesics such as NSAIDs can help reduce the pain associated with a sore throat.

Sinusitis

Sinusitis is inflammation, either bacterial, fungal, viral, allergic or autoimmune, of the paranasal sinuses.

By location

Sinusitis is classified by the sinus cavity, which it affects:

Maxillary sinusitis-causes pain in the maxillary area (e.g., toothache, headache)

Frontal sinusitis-causes pain in the frontal sinus cavity (located behind/above eyes), headache

Ethmoid sinusitis-causes pain between and/or behind eyes, headache

Sphenoid sinusitis-causes less generalized pain, headache

Acute vs. chronic

Sinusitis can be acute (going on less than four weeks), subacute (4-8 weeks) or chronic (going on for 8 weeks or more).

Both types of sinusitis have similar symptoms, and are thus often difficult to distinguish.

Acute sinusitis

Acute sinusitis is often brought on by bacteria, such as Haemophilus influenzae, streptococci, or staphylococci.

It is usually precipitated by an earlier upper respiratory tract infection, generally of the viral type.

Chronic sinusitis:

Chronic sinusitis is one of the most common complications of the common cold.

Symptoms include nasal congestion; facial pain; headache; fever; general malaise; thick green or yellow discharge; feeling of facial 'fullness' worsening on bending over.

In a small number of cases, chronic maxillary sinusitis can also be brought on by the spreading of bacteria from a dental infection. Chronic hyperplastic eosinophilic sinusitis is a noninfective form of chronic sinusitis.

Treatment

Therapeutic measures include simple painkillers (aspirin, paracetamol (acetaminophen) or similar), inhaling steam, nasal irrigation or jala neti using a warm saline solution, hot drinks including tea and chicken soup, over-the-counter decongestants, and getting plenty of rest. If sinusitis doesn't improve within 48 hours, or is causing significant pain, one should see a doctor, who may prescribe antibiotics or nasal steroids. If the recommended doses and duration of antibiotic treatment(s) are ineffective, one should consult a doctor; who may suggest further treatment by a qualified specialist.

If left untreated, sinusitis can lead to bronchitis and pneumonia.

A recent advance in the treatment of sinusitis is a type of surgery called FESS - functional endoscopic sinus surgery, whereby normal clearance from the sinuses is restored by removing the anatomical and pathological obstructive variations that predispose to sinusitis. This replaces the less effective Caldwell-Luc surgery.

Tinnitus

Tinnitus is a phenomenon of the nervous system connected to the ear, characterized by perception of a ringing or beating sound (often perceived as sinusoidal) with no external source. This sound may be a quiet background noise, or loud enough to drown out all outside sounds. It is sometimes referred to as "the club disease" as many people get temporary tinnitus at loud clubs or concerts.

Tinnitus can be objective (the sound, e.g., a bruit, can be perceived by a clinician) or subjective (perceived only by the patient).

Causes

Causes of tinnitus include:

· A sudden loud noise, prolonged exposure to loud music through PA systems or personal stereos, exposure to an excessively noisy work environment without ear protection, (Eg. industrial)

· Hearing loss (20 per cent of cases: chronic noise damage and presbycusis)

· Head injury (especially basal skull fracture)

· Drugs: aspirin overdose, loop diuretics, aminoglycoside, quinine

· Temporomandibular and cervical spine disorders

· Suppurative otitis media (also chronic infection and serous OM)

· Otosclerosis

· Ear wax

· Ménière’s disease

· Impacted wisdom teeth

· Hypertension and atherosclerosis

· Acoustic neuroma

· Palatal myoclonus (objectively detectable)

· Arteriovenous fistulae and arterial bruits (objectively detectable)

· Severe anemia and renal failure

· Glomus jugulare tumors (objectively detectable)

· Lyme Disease

· Stress and depression

· Thyroid disorders, such as hyperthyroidism or hypothyroidism

The treatment involves curing the patient of the underlying disease, changing the drug regimen, and using a hearing aid or tinnitus masker.

Vertigo

Vertigo, sometimes called a headrush, is a major symptom of a balance disorder. It is the sensation of spinning while the body is stationary. With the eyes shut, there will be a sensation that the body is in movement, called subjective vertigo; if the eyes are open, the surroundings will appear to move past the field of vision, called objective vertigo.

The effects may be slight. It may cause nausea or, if severe, may give rise to difficulty with standing and walking. Vertigo is usually associated with a problem in the inner ear balance mechanisms (vestibular system), in the brain, or with the nerve connections between these two organs. The most common cause is benign positional vertigo.

We are able to maintain our equilibrium and balance in space with the help of vision, touch, hearing, and the vestibular system in the inner ear. Many areas of the brain also contribute to our sense of equilibrium. Disturbance or malfunctioning in any of these areas can result in the diseases of dizziness, such as vertigo, disequilibrium, or lightheadedness. True vertigo (an illusion of motion) often comes with a feeling of nausea and vomiting, and the person feels that the room is moving around him or as if he himself is moving around the room. The vertigo may originate in the vestibular region of the Inner ear or in the brain itself. There can be many reasons for vertigo, e.g. tumors, head injuries, Meniere disease, allergic rhinitis inner ear infection, or extremely high doses of certain medicines.

Disequilibrium is a slightly less severe from of imbalance and can result from the degeneration of the nerve. It is an unsteady feeling of falling and can result of alcoholism as well.

Important:

· Vertigo should not be confused with dizziness. Dizziness is an unpleasant feeling of light-headedness, giddiness or fuzziness often accompanied by nausea.

· Vertigo is often used, incorrectly, to describe a fear of heights.

· Vertigo is often experienced when breathing helium, as a result of helium flow instead of oxygen to the brain.

Based upon the cause of dizziness, a physician may prescribe dimenhydrinate (Hydrate) or meclizine (Antivert). Inner ear infections are treated by the antibiotics. In case the vertigo is the result of some other underlying disease, treatment of that disease contributes to the final treatment of vertigo.

Procedures

Audiometry

Audiometry is the testing of hearing ability. Typically, audiometric tests determine a subject's hearing levels, but may also measure ability to discriminate between different sound intensities, recognize pitch, or distinguish speech from background noise. Acoustic reflex and otoacoustic emissions may also be measured. There are different kinds of auditory tests, viz., automatic audiometry, behavioral observation audiometry, cortical audiometry, and diagnostic audiometry. Results of audiometric tests are used to diagnose hearing loss or diseases of the ear. They also determine the kind of impairment, i.e. conductive, sensorineural, or mixed.

Heimlich Maneuver

The Heimlich Maneuver, also known as abdominal thrusts, is a first aid procedure for clearing an obstructed airway. It is an effective lifesaving measure in cases of choking. Dr. Henry Heimlich also has promoted it as a treatment for drowning and asthma attacks, but the practice of using the maneuver for these afflictions has not gained wide acceptance. Briefly, a person performing the Heimlich maneuver uses their hands to exert pressure on the bottom of the diaphragm. This compresses the lungs and exerts pressure on any object lodged in the trachea, hopefully expelling it. This amounts to an artificial cough. (The victim of an obstructed airway, having lost the ability to draw air into the lungs, has lost the ability to cough on their own.)

Rinne Test

Rinne test is performed to determine the smooth functioning of the sound conduction mechanism. By virtue of a normal sound conduction mechanism through the middle ear, air conduction will be greater than the bone conduction. To determine the sound conduction mechanism, a vibrating tuning fork is placed by the skull until the sound is lost. The prongs are then placed near the auditory orifice and a faint sound is again heard. A disorder of the sound conduction mechanism will make bone conduction greater than air conduction.

In short, Rinne test of hearing compares perception of sounds, as transmitted by air or by sound conduction through the mastoid.

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

AC > BC, positive Rinne.

In conductive hearing loss, bone conduction is better than air

BC > AC, negative Rinne.

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

AC > BC, positive Rinne.

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

BC > AC,

If the normal ear is not masked, and bone conduction heard in the normal ear is reported as louder by the patient.

Weber Test

In the Weber test of hearing, a tuning fork is struck and placed on the patient's forehead. The patient is asked to report in which ear the sound is heard louder.

A normal patient would report that the sound is heard equally in both ears. A patient with a conductive hearing loss would hear the sound louder in the affected ear. This is because the affected ear cannot hear ambient noises as well because of its conductive hearing loss and so is effectively masked to these noises and able to focus more on the sound conducted through the skull. You can replicate this yourself by plugging one ear with your finger (i.e. mimicking a conductive hearing loss) and performing the Weber test on yourself.

A patient with a sensorineural hearing loss would hear the sound louder in the normal ear, because the affected ear is less effective at picking up sound even if is transmitted directly by conduction into the cochlea.

Pharmacology

Aural preparations

Drugs for the ears can be classified under four different categories: antibacterial, antifungal, anti-inflammatory, and anti-infective combinations, and drugs for wax removal. Antibacterial preparations are generally used in the treatment of inflammations in the external ear. Examples of such drugs are gentamicin and ciprofloxacin. Antifungal drugs are also known as antimycotic and they are antagonists to fungi. Clotrimazole is such an antimycotic, which is used in the treatment of otomycosis. Wax is a natural secretion in the ear. Sometimes, excess wax in the ear can cause deafness or block the view of the tympanic membrane. In such cases, removal of wax becomes a necessity. Ceruminolytic agents like Cerumenex are instilled, which emulsify and remove the wax.

Nasal Preparations

Nasal preparations can be divided into three broad categories: topical nasal decongestants, nasal anti-infectives, and nasal antiallergics. Topical nasal decongestants, like ephedrine are used to provide symptomatic relief from the nasal congestion. They act by achieving vasoconstriction and thereby relieving the congestion. Nasal antiallergics, mostly corticosteroids, exert their action by the stabilization of the mast cel1s.

Oropharyngeal Preparations

Pathological conditions such as gingivitis, stomatitis, pharyngitis, tonsillitis, and oral candidal infections require oropharyngeal preparations to get healed. Drugs like Hibiclens, Peridex, and Betadinegargles are used for this purpose.

Abbreviations

ABR: auditory brainstem response
AC: air conduction
AD: right ear (auris dextra)
AOM acute otitis media
AS: left ear (auris sinistra)
AU: both ears (auris uterque)
db: decibel (unit for expressing sound)
ENT: ears, nose, and throat
HEENT: head, eyes, ears, nose, and throat
PE tubes: pressure-equalizing tubes
PND: postnasal drainage; paroxysmal nocturnal dyspnea
T &A: tonsillectomy and adenoidectomy
TM: tympanic membranes
UPPP: uvulopalatopharyngoplasty
URI: upper respiratory infection

Vocabulary

Acusis: normal hearing
Adenectomy: excision of adenoids
Adenitis: inflammation of the lymph node or gland
Adenocarcinoma: a malignant neoplasm. Of epithelial cells in a glandular pattern
Adenoid: gland-like appearance
Adenopathy: disease of the lymph nodes
Ala nasi: outer flaring wall of each nostril; wing of the nose
Anacusis: total loss or absence of ability of hearing
Annulus: a ring; circular structure
Arytenoid: .cartilage and muscles of larynx
Audiology: study of hearing disorders through identification and measurement of hearing loss
Audiometry: test for measuring hearing levels with the help of an audiometer
Auditory: related to the sense of hearing
Aural: related to the ear
Auricle: external ear
Cerumen: a waxy secretion of external auditory canal; earwax
Cholesteatoma: a tumor-like mass of squamous epithelium and cholesterol in the middle ear
Cochlea: a spiral, cone-shaped cavity in the internal ear
Conchae: a shell-shaped structure in the anatomy for example, auricle of the ear
Conduction: transmission from one point to another of energy forms of energy without evident movement in the conducting body
Conductive deafness: impairment of hearing caused due to obstruction or interference with sound waves transmission through the external ear, the middle ear. And auditory ossic1es
Coryza: acute rhinitis; inflammation of the mucous lining of nose marked by sneezing, lacrimation, and secretion of a watery mucus discharge
Cricoid: ring-shaped: lowermost laryngeal cartilage
Dysacusia: difficulty in processing sound; difficulty in hearing
Dysosmia: altered sense of smell: difficulty in processing smell
Dysphagia: difficulty swallowing
Epiglottic: related to the epiglottis
Epiglottis: an elastic cartilage at the roof of tongue, which covers the opening of windpipe during swallowing to prevent it getting choked .
Epiglottitis : inf1ammation of the epiglottis, can cause fatal respiratory obstruction, especially in small children
Epistaxis: bleeding from the nose
Erythema: redness of skin
Eustachian tube: the tube that leads from the middle ear to the nasopharynx and equalizes the pressure on both sides of the tympanic membrane
Exudate: any fluid that has seeped out of a tissue, due to any inflammation or injury
Fenestra: an opening in anatomy; window
Fenestra ovalis: an oval opening in the wall of the tympanic cavity and the vestibule, closed by base of stapes
Foramen: an opening or aperture, especially in a l)(me or membrane
Glossoepiglottic: relating to tongue and epiglottis
Glossopharyngeal: related to tongue pharynx
Helical: relating to helix
Helix: the folded margin of the external ear
Hyperacusis/hyperacusia: hearing acuteness due to irritability of the sensory and neural mechanism of the ear
Incus: the middle of the three ossicles in middle ear; anvil
Jugular: relating to neck or throat
Keratoid: horny
Labyrinth: an anatomical structure composed of many intercommunicating canals and cavities. For example, the inner ear
Labyrinthitis: inflammation of the labyrinth
Laryngeal: relating to the larynx
Laryngectomy: excision of the larynx
Laryngitis: inflammation of mucous membrane of the larynx
Laryngograph: an instrument used for tracing activity of larynx, vocal cord
Laryngoparalysis: paralysis of the larynx
Laryngopharyngeal: relating to both the larynx and the pharynx
Laryngopharyngectomy: excision of both the larynx and the pharynx
Laryngoplasty: surgical repair of the larynx
Laryngoscope: an endoscope used to examine the interior of the larynx
Laryngostomy: forming an opening from the neck into the larynx
Laryngotomy: a surgical incision of the larynx
Laryngotracheal: relating to both the larynx and the trachea
Larynx: an organ of voice production located between the pharynx and the trachea
Malleus: largest of the three ossicles of the ear
Meatus: a passage, especially an external opening
Meniere disease: disease of inner ear characterized by vertigo, nausea, vomiting, tinnitus, and progressive deafness
Myringectomy: excision of the tympanic membrane
Myringitis: inflammation of the tympanic membrane
Myringoplasty: surgical repair of the tympanic membrane
Myringotomy: surgical incision into the tympanic membrane
Naris: nostril
Nasofrontal: relating to the nose and the forehead
Nasogastric: involving the nasal passages and the stomach
Nasogastric tube: a tube passed into the stomach through the nose
Nasolabial: related to the nose and upper lip
Naso-oral : related to the nose and mouth
Nasopharyngeal: related to the nose and the pharynx
Nasopharynx: part of pharynx that line above the soft palate
Nasotracheal intubation: intubation of the trachea through the nose
Naode: a small knot of lump of tissue
Obtund: dull or blunt
Obturation: obstruction
Odynacusis : acute pain on hearing any sound
Odynophagia: pain on swallowing
Odynophonia: pain while speaking
Olfactory: related to sense of smell
Ossicle: a small bone
Otalgia: earache
Otitis: inflammation of the ear
Otodynia: earache
Otolaryngology: study of the ear and larynx
Otopathy: any disease of the ear
Otorrhea : discharge from the ear
Otoscope: an instrument used for inspecting the eardrum
Palate: roof of the mouth
Periauricular : around the ear
Pharyngeal: related to the pharynx
Pharyngitis: inflammation of the pharynx
Pharyngoglossal: relating to the pharynx and the tongue
Pharyngoplegia: paralysis of muscles of the pharynx
Pharynx: throat
Pinna: auricle, external ear
Presbycusis: progressive loss of ability of hearing due to again
Purulent: containing pus
Rhinitis: inflammation of nasal mucous membranes
Rhinopathy : disease of the nose
Rhinoplasty : surgical repair of the nose
Rhinorrhea: discharge from the nose or nasal passages
Salpingitis: inflammation of eustachian tube or fallopian tubes
Salpinx: auditory or eustachian tube; fallopian tubes
Septectomy: excision of septum, pan or whole
Septum: a wall partition between two cavities or two masses of soft tissue
Serosanguineous: discharge containing serum and blood
Shotty: rubbery type of feel to touch
Sinus: a passageway or hollow space in bone or other tissue
Sinusitis: inflammation of the sinus
Sinusoid: resembling sinus
Snuff: to inspire forcibly through the nose
Stapedectomy: excision of stapes
Stapes: smallest auditory ossicle; stirrup
Strep: short form for streptococcus
Streptococcal: caused by streptococcus
Tinnitus: noises in the ear, such as ringing and whistling
Trachea: windpipe
Tracheitis: inflammation of membrane lining the trachea
Tracheobronchial: related to the trachea and the bronchi
Tracheostomy: forming an opening into the trachea
Tragus: a small projection of cartilage in front of external auditory meatus
Tympanectomy: excision of the tympanic membrane
Tympanic: related to the tympanic membrane
Tympanoeustachian: related to tympanic membrane and eustachian tube
Uvula: a conical fleshy projection from the middle of the soft palate in the mouth
Uvulitis: inflammation of the uvula 132, 1l\1.1iopalatopharyngoplasty: a surgical treatment in which unnecessary uvula and palatal tissue and the oropharyngeal tissue is resected for patients with sleep apnea
Vertigo: dizziness; a sensation of spinning motion
Vestibule: a small cavity or space at the entrance of the canal
Vestibulocochlear: related to vestibule and cochlea of the ear
Vibrissae: hair growing at the nares; nose hair
Xerostomia: Dryness of the mouth

Combining Forms

acous/o: hearing

aden/o: gland

audi/o: hearing

myring/o: tympanic membrane

nas/o: nose

ot/o: ear

pharyng/o: pharynx

laryng/o: larynx

rhin/o: nose

salping/o: eustachian tube

seler/o: hardening

thyroid/o: thyroid

tympan/o: tympanic membrane

Suffix

-ectomy: excision

-itis: inflammation

-logist: specialist in the study of

-logy: study of

-scope: instrument to view

-stenosis: stricture

-stomy: forming an opening

-tomy: incision

Prefix

dys-: difficult

a-: without

hyper-: excessive

IOL	Intraocular lens.
IOP	Intraocular pressure.
OD	(Oculus dexter) right eye.
OS	(Oculus sinister) left eye.
OU	(Oculus uterque) each eye.
PERRLA	Pupils equally round and reactive to light and accommodation.
VA	Visual acuity.
VF	Visual field, field of vision.
AD	Auris dextra (right ear).
AS	Auris sinistra (left ear).
AU	Auris unitas (both ears).
EENT	Ear, eye, nose and throat.
ENT	Ear, nose, and throat.
PE tube	Pressure equalization tubes.