Ent conditions for physiotherapists


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Ent conditions for physiotherapists

  1. 1. Ears  Hearing loss including BAHA(bone anchored hearing aid)  Ear discharge  Earache  Balance disorders  Tinnitus 
  2. 2. 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. 
  3. 3. Throat  Sore throat including tonsillitis  Snoring  Hoarse voice  Swallowing disorders  Tumours of the throat and larynx. 
  4. 4. Head and neck  Facial weakness  Neck swellings  Thyroid disorders  Salivary gland diseases 
  5. 5. Cosmetic Procedures  Rhinoplasty  Otoplasty  Children  Glue ear  Adenoidectomy  Tonsillectomy  Obstructive sleep apnoea 
  6. 6.          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.
  7. 7. paranasal sinuses  › › › › Frontal Maxillary Ethmoid Sphenoid  Acute/chronic sinusitis
  8. 8. Sinusitis Rhinitis Nasal congestion Nasal congestion Purulent rhinorrhea Rhinorrhea clear Postnasal drip Runny nose Headache Itching, red eyes Facial pain Nasal crease Anosmia Seasonal symptoms Cough, fever 12
  9. 9. Tobacco smoke Perfumes Cleaning solutions Burning candles Pollens House dust mite Allergic foods and beverages Cosmetics Car exhaust diesel fumes Hair spray
  10. 10.   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)
  11. 11.  Antihistamines recommended if allergy present › Oral or topical  Decongestants  Nasal steroid spray  Guafenesin  Decongestants  Steam inhalation  Nasal irrigation  Antibiotics with exacerbations › Oral or topical     Antibiotic when indicated (bacteria) Nasal irrigation Guaifenesin 200-400 mg q4-6 hrs Hydration
  12. 12.  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
  13. 13. 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 
  14. 14.  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.
  15. 15.         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.
  16. 16. Dull retracted TM  May show air-fluid level  Conductive hearing loss 
  17. 17. 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
  18. 18.        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
  19. 19.  Safe perforations may allow infection to enter the middle ear conductive 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
  20. 20. UNSAFE SAFE Source Cholesteatoma Mucosa Odour Foul Inoffensive Amount Usually scant, never profuse Can be profuse Nature Purulent Mucopurulent
  21. 21. Unsafe a)In the attic or b)In the posterior region. These are often linear rather than oval c)Or involve the eardrum margin Safe a) In the anterior region or b) In the inferior region c) And not involving the eardrum margin
  22. 22. 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.
  23. 23. 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 
  24. 24. 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. 
  25. 25.   Intracranial part Intratemporalpart Meatal Labyrinthine Tympanic, horizontal Mastoid, 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”
  26. 26.  Intratemporal part: › Idiopathic:   Central: › › › ›  › › › › Parotid gland CA Parotid gland surgery Parotid gland injury Neonatal facial nerve injury Congenital Möbius Syndrome ASOM CSOM Herpes Zoster Oticus -Ramsay Hunt syndrome › Trauma: › Acoustic neuroma Meningioma Metastatic CA Meningitis Extracranial part: Melkersson’s syndrome Infections:    Brain abscess Pontine glioma Poliomyelitis Multiple sclerosis Intacranial part: › › › ›  › › Bell’s palsy  Surgical: Mastoidectomy, Stapedectomy Accidental:# temporal bone › Neoplasms:  Glomus jugulare tumour  Facialnerveneuroma  Metastatic CA  Systemic: › › › › › › › › DM Hypothyroidism Uremia PAN Wegener’s granulomatosis Sarcoidosis Leprosy Leukemia
  27. 27.  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
  28. 28.  Nerve Excitability Test: NET  Maximum stimulation Test: MST  Electroneurography: ENoG  Electromyography: EMG  Pure-tune audiometry  Topodiagnostics:  Schirmer’s test:  Stapedial reflex:  Taste test:  Submandibular salivery flow test: Warton’s ducts  Bell's phenomenon
  29. 29. I II III Normal Normal tone and symmetry at rest Slight weakness on close inspection Good to moderate movement of forehead Complete eye closure with minimum effort Slight asymmetry of mouth with movement Normal tone and symmetry at rest Obvious but not disfiguring facial asymmetry Synkinesis may be noticeable but not severe +/- hemifacial spasm or contracture Slight to moderate movement of forehead Complete eye closure with effort Slight weakness of mouth with maximum effort IV Normal tone and symmetry at rest Asymmetry is disfiguring or results in obvious facial weakness No perceptible forehead movement Incomplete eye closure Asymmetrical motion of mouth with maximum effort V Asymmetrical facial appearance at rest Slight, barely noticeable movement No forehead movement Incomplete eye closure Asymmetrical motion of mouth with maximum effort
  30. 30. Residual paralysis  keratitis  Synkinesis  Tics and spasms  Crocodile tears  Frey’s syndrome “gustatory sweating”  Psychological and social stigma 
  31. 31. 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). 
  32. 32. smoke  drink large quantities of alcohol  allergies  habitually fatigued  extreme stress  aspirin 
  33. 33.      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
  34. 34.         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.
  35. 35.    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 BrandtDaroff exercises. Functional retraining - including postural control, relaxation, and balance training.
  36. 36. 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 
  37. 37. Primary metabolic bone disease of the otic capsule and ossicles Results in fixation of the ossicles and conductive hearing loss May have sensorineural component if the cochlea is involved Osseous dyscrasia Resorption and formation of new bone Limited to the temporal bone and ossicles Hereditary, endocrine, metabolic, infectious, vascular, autoimmune, hormonal
  38. 38. 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)
  39. 39. labyrinthine otosclerosis /Cochlear Otosclerosis May cause SNHL via  Toxic metabolites  Decreased blood supply  Direct extension  Disruption of membranes
  40. 40.  Associated symptoms › Dizziness › Otalgia › Otorrhea › Tinnitus  Vestibular symptoms › Most commonly dysequilibrium › Occasionally attacks of vertigo with rotatory nystagmus
  41. 41.  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
  42. 42.  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.
  43. 43. 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, AC > BC maintaining the relative difference of bone and air conductions positive Rinne In sensorineural hearing loss patients there may AC < BC be a false negative Rinne negative Rinne
  44. 44. Weber without lateralization Rinne both ears AC>BC Normal/bilateral Sensorineural sensorineural loss loss in right Rinne left BC>AC Conductive loss in left Weber lateralizes right Sensorineural loss in left Combined loss : conductive and sensorineural loss in left Combined loss : conductive and Conductive loss sensorineural loss in right in right Rinne right BC>AC Rinne both ears BC>AC Weber lateralizes left Conductive loss in both ears Combined loss in right and conductive loss on left Combined loss in left and conductive loss on right
  45. 45. The Hearing in Noise Test (HINT)  Tympanogram  Acoustic reflex  Audiometer hearing test  speech tests  Whisper test  Watch test 
  46. 46. ENT surgeons diagnose and treat conditions of the ears, nose, throat, head and neck, and undertake some cosmetic procedures.
  47. 47. Cochelar Implant  Tymanoplasty - Ear Drum Repair  Stapedectomy  Larygectomy  Sinus surgery  Ossiculoplasty  Bronchoscopy  Grommet insertion  Grommet RemovalMyringotomy  Parotid Gland Removal - Parotidectomy  Nasal Polyp Removal  Septoplasty  Submucous Resection - SMR  Tonsillectomy  Turbinates of Nose - Resection 
  48. 48. 70
  49. 49. Voice changes-hoarseness,puberphonia,vocal asthenia&functionalaphonia  Stridor-noisy respiration  Dysnoea  Weak cry  Dry cough  Painful swallowing 
  50. 50. Complete Laryngectomy Partial Laryngectomies Supraglottic laryngectomy Vertical hemilaryngectomy  Carcinoma supraglottic / subglottic / glottic 72
  51. 51.  Sorenson’s incision  Gluck’s incision 73
  52. 52. 74
  53. 53. 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 monitoring  Mobility/pulmonary care  Stitches removed on 7-10 days  Speech Rehabilitation  Esophageal speech  Electro larynx.  Tracheo esophageal puncture (neoglottis formation)  75
  54. 54. Cardiac arrest  Hemorrhage  Pulmonary embolism  Pulmonary pneumonia  Atelectasis  Fistula  76
  55. 55. Partial/total with laryngectomy  Repair and reconstructive surgeries 
  56. 56. Lobectomy and isthmusectomy  Bilateral subtotal thyroidectomy  Near total thyroidectomy  Total thyroidectomy  78
  57. 57. 79
  58. 58. 80
  59. 59. Carcinoma  Large nodular thyroid compressing the airway  81
  60. 60.     Recurrent laryngeal nerve paralysis Bleeding Hypo parathyroidism Infection 82
  61. 61.   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.
  62. 62. 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 
  63. 63. 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. 
  64. 64.   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
  65. 65.       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