• Clinical science

Miscellaneous ear, nose, and throat disorders

Abstract

This learning card provides an overview of ear, nose, and throat conditions not discussed elsewhere, including common ones (e.g., deviated nasal septum) as well as uncommon ones (e.g., decompression sickness, ear barotrauma, auricular hematoma).

For an overview of differential diagnoses for hearing loss, see the corresponding learning card.

Deviated nasal septum

  • Definition: significant deviation of the nasal septum from midline; which often leads to obstruction of nasal breathing.
  • Etiology
  • Clinical findings
    • Difficulty breathing (typically in only one nostril)
    • Nasal congestion
    • Snoring or noisy breathing during sleep
    • Headaches or facial pain
    • Epistaxis (nosebleeds)
  • Diagnostics
    • Anterior rhinoscopy: A nasal speculum and external light source are used to visualize the septum.
    • Nasal endoscopy
    • CT scan
    • Further tests
      • Rhinomanometry: diagnostic tool used to measure the air flow of the nose or objective nasal patency
        • Procedure of active anterior rhinomanometry
          • Application of an airtight pressure sensor in the nostril of the side that is not to be measured
          • Application of an airtight face mask; the air supply is equipped with a probe for measuring airflow
          • The patient is asked to breathe calmly
          • Depending on the issue, an allergen or a nasal decongestant can be administered and measurement can be repeated after a period of 15–20 minutes.
        • Evaluation: a computer calculates a pressure-volume curve, which is subsequently assessed.
        • Acoustic rhinometry: a diagnostic tool for calculating the cross-sectional area of the nasal cavity using an acoustic signal. This measurement allows determination of the location of flow obstruction.
          • Procedure
            • A probe with an airtight seal is inserted into the nostril.
            • An acoustic signal is transmitted through the probe and the signal is picked up via a microphone.
          • Evaluation: The cross-sectional area (in cm2) is calculated based on impedance changes of the acoustic signal that was transmitted
  • Treatment
    • Septoplasty; to correct the deviation is indicated if there are significant symptoms.
    • This procedure can be combined with rhinoplasty (to change the external appearance of the nose) or sinus surgery (if sinus symptoms are present).
  • Complication of surgery
    • Nasal septum perforation
      • Etiology: sequela of septal hematoma (e.g., due to nasal fracture, septoplasty, or rhinoplasty)
      • Clinical features: nasal whistling sound with breathing
      • Diagnostics
        • Anterior rhinoscopy: to directly visualize abnormalities of the anterior to middle part of the septum
        • Posterior rhinoscopy: to directly visualize abnormalities of the middle to posterior part of the septum (via endoscopy)
        • CT: for more detailed evaluation of the nasal septum (and adjacent structures)
      • Treatment: surgical restoration of physiologic configuration/structure (septoplasty)

References:[1][2][3]

Temporomandibular joint dysfunction

  • Definition: pain and dysfunction of the temporomandibular joint (TMJ) due to musculoskeletal, psychological and/or neuromuscular factors
  • Peak incidence: 20–40 years
  • Clinical features
    • Pain
      • Can spread to the ear, temporal regions, periorbital regions, or the mandible
      • Often episodic and sharp
      • Worsened by jaw motion (chewing)
      • On palpation of the TMJ
    • Ear discomfort
    • Headache
    • Cracking or grinding of the TMJ
    • Limited jaw opening (occasionally painful)
    • Nocturnal teeth grinding (bruxism)
  • Diagnosis: clinical diagnosis
  • Treatment
    • Consider further evaluation and referral to dentist or maxillofacial surgeon if there is:
      • Recent trauma and/or infection//
      • Pre-existing dislocation and/or malocclusion
      • Previous attempt with conservative treatment was unsuccessful
    • Indications
      • Pain with palpation, jaw movement, or biting/chewing
      • Masticatory muscle spasms
    • Modalities

Symptoms resolve spontaneously in approx. 40% of patients!

References:[4][5][6]

Decompression sickness

  • Definition: formation of air embolisms as a result of a rapid decline of barometric pressure within the body
  • Etiology
  • Pathophysiology (in diving)
    • The pressure increases as the diver dives deeper → more oxygen and nitrogen are dissolved in the blood.
    • During normal ascent → pressure decreases and the tension of gas in the blood exceeds the surrounding pressure → dissolved nitrogen changes back into its gaseous form → the gas is exchanged with the lungs and breathed out.
    • In rapid ascent → formation of nitrogen gas bubbles within the blood vessels → insufficient time for the gas to be released via the lungs → gas bubbles remain in circulation and obstruct proper blood flow → air embolism
  • Clinical features
  • Treatment
    • Hyperbaric, 100% oxygen
    • Hydration
    • Positioning maneuvers; (left lateral decubitus and lowering the head zone of the bed)
  • Prevention
    • Avoid situations with rapid decline of barometric pressure
    • Follow diving safety guidelines

References:[7][8][9]

Ear barotrauma (barotitis media, aerotitis media)

References:[8][10]

Auricular hematoma

  • Definition: hematoma of the auricle
  • Etiology: Trauma to the ear
    • Blunt: blow/s to the ear (e.g., in boxers/wrestlers)
    • Penetrating: lacerations of the ear (less common)
  • Clinical features
    • Sudden tense, tender, fluctuant swelling of the pinna and loss of normal anatomy/landmarks of the anterosuperior aspect pinna
    • Overlying skin is ecchymotic
  • Treatment
    • Small auricular hematomas; , < 2 days old: needle aspiration
    • Large auricular hematomas; or those > 2 days old: incision, drainage, placement of a draining wick
    • Post-procedure formed pressure packing of the pinna
    • Re-assess in 48 hours to check for re-accumulation
  • Complications

Surgical drainage is always indicated!

References:[11][11][12][13]

Obstruction in nasal turbinate hypertrophy

  • Definition: Hypertrophy of the nasal turbinates which often leads to obstruction in nasal breathing.
  • Etiology
  • Clinical findings
  • Diagnostics
    • Anterior rhinoscopy
    • Nasal endoscopy
    • CT scan
  • Treatment:
    • First-line therapy: combination of intranasal steroid sprays, nasal and/or oral decongestants, and antihistamines
    • Surgical therapy: persistent symptoms despite medical management
      • Turbinate reduction of the bone or mucosa with cryosurgery, thermal ablation, or radiofrequency ablation

References:[14]

Patulous eustachian tube

  • Definition: chronically patent (open) eustachian tube
  • Etiology
  • Clinical features
    • Usually asymptomatic
    • Autophony: hallmark of patulous eustachian tube; unusually loud hearing and booming of one's own voice
    • Hearing one's own breathing
    • No hearing loss
    • Symptoms disappear when the affected individuals lye down or when abdominal pressure increases.
  • Otoscopy: synchronous movement of the eardrum during respiration
  • Treatment:
    • Often not required as the condition does not generally cause ear complications. Medical management, such as hydration, is initially considered. Weight gain is not effective.
    • Surgical management is reserved for severe cases.

References:[15]