3. Ear
Hearing problem
s
Ear infection
s
Balance disorder
s
Tinnitu
s
Some cranial nerve disorders
Nose
Rhiniti
s
Problems with breathin
g
Problems with smellin
g
Sinuses disorder
s
Appearance of the nose
Throat
Diseases of the pharyn
x
Diseases of the laryn
x
Voice disorder
s
Swallowing disorders
3
What is Otorhinolaryngology?
It’s a medical speciality that focuses on medical and surgical treatment for
patients who have disorders of the nose, pharynx, larynx and ear.
4. To understand common ENT symptoms and to identify the diseases
you have to know anatomy and physiology of ENT-organs
4
6. • The nose is the organ of breath and smell
located in the middle of the face. The
internal part of the nose lies above the
roof of the mouth. The nose consists of:
• External meatus. Triangular-shaped
projection in the center of the face.
• External nostrils. Two chambers divided
by the septum.
What is the nose?
6
• Septum. Made up primarily of cartilage and bone and covered by mucous membranes. The
cartilage also gives shape and support to the outer part of the nose.
• Nasal passages. Passages that are lined with mucous membranes and tiny hairs (cilia) that help to
fi
lter the air.
• Sinuses. Four pairs of air-
fi
lled cavities, also lined with mucous membranes.
9. The nasal cavity has four functions:
• Warms and humidi
fi
es the inspired air
• Removes and traps pathogens and particulate matter from the inspired air
• Is responsible for sense of smell
• Drains and clears the paranasal sinuses and lacrimal ducts
9
10. The sinuses are:
• Are cavities, or air-
fi
lled pockets, near the nasal
passage
• Lined with mucous membrane continuous with that
of nasal cavity
• All communicate with nasal fossa through their
various ostia
• The sinuses are divided for Clinical Purposes into
two groups:
- Anterior
- Posterior
• The line of attachment of middle turbinate to lateral
wall of nose marks division between the two.
The Posterior Group draining at several locations above
the middle turbinate is made up of:
- Posterior Ethmoidal Cells
- Sphenoidal Sinuses
The Anterior Group draining below the middle
turbinate or near the infundibulum consists of:
- Frontal
- Maxillar
y
- Anterior and Middle Group of Ethmoidal cells
10
11. • Ethmoid sinus. This sinus is located inside the
face, around the area of the bridge of the nose. It
is present at birth, and continues to grow.
• Maxillary sinus. This sinus is located inside the
face, around the area of the cheeks. It is also
present at birth, and continues to grow.
• Frontal sinus. This sinus is located inside the face,
in the area of the forehead. It does not develop
until around 7 years of age.
• Sphenoid sinus. This sinus is located deep in the
face, behind the nose. It does not typically
develop until adolescence.
Types of sinuses:
11
12. • They may give resonance to voice
• Sound protection from transmission of one’s own speech to the ears
• They may have a role in air-conditioning of the inspired air
• They may reduce skull weight
• Provide protection to orbits
• An hitherto unexplained function of the PNS may be the supply of the fresh, uncontaminated
mucus to the middle meatus.
Functions of the
sinuses
12
13. • Nasolacrimal duct – acts to
drain tears from the eye. It opens
into the inferior meatus.
• Auditory (Eustachian) tube –
opens into the nasopharynx at
the level of the inferior meatus. It
allows the middle ear to equalise
with the atmospheric air
pressure.
In addition to the paranasal sinuses, other structures open into the nasal cavity:
13
14. Vasculature
The nose has a very rich vascular supply – this
allows it to e
ff
ectively change humidity and
temperature of inspired air.
The nose receives blood from both the internal and
external carotid arteries.
In addition to the rich blood supply, these arteries
form anastomoses with each other. It’s
particularly prevalent in the anterior portion of the
nose.
The veins of the nose tend to follow the arteries.
They drain into the pterygoid plexus, facial vein or
cavernous sinus.
In some individuals, a few nasal veins join with the
sagittal sinus (a dural venous sinus). This represents
a potential pathway by which infection can spread
from the nose into the cranial cavity.
Internal carotid branches:
• Anterior ethmoidal artery
• Posterior ethmoidal artery
• The ethmoidal arteries are branch of the
ophthalmic artery. They descend into the nasal
cavity through the cribriform plate
External carotid branches:
• Sphenopalatine artery
• Greater palatine artery
• Superior labial artery
• Lateral nasal arteries
14
16. • The innervation of the nose can be functionally
divided into special and general innervation.
• Special sensory innervation refers to the ability of
the nose to smell. This is carried out by the
olfactory nerves. The olfactory bulb, part of the
brain, lies on the superior surface of the
cribriform plate, above the nasal cavity.
Branches of the olfactory nerve run through the
cribriform plate to provide special sensory
innervation to the nose.
• General sensory innervation to the septum and
lateral walls is delivered by the nasopalatine
nerve (branch of maxillary nerve) and the
nasociliary nerve (branch of the ophthalmic
nerve). Innervation to the external skin of the
nose is supplied by the trigeminal nerve.
Innervation
16
17. Nasal Secret
Goblet cells, serous and mucous glands produce a secret lining the surface of the airways (the
volume to 0.75 – 1,0 liters of mucus per day)
Humidi
fi
cation is carried out up to 95%
1. Hydration, lubrication of the epitheliu
m
2. Protection against the action of chemically aggressive substance
s
3. Adhesion weighted "dense" ingredient
s
4. Transport function (6-12 mm/sec
)
5. Eliminating up to 60% of microorganism
s
6. Antimicrobial activity (inhibition of colonization of ~ 2-6 hours) is during the slowing down of
mucus transport conditions for the development of Purulent in
fl
ammatory process
.
7. Filter-diffusion barrier
17
Functions
18. Mechanisms of the mucosa of upper respiratory tract protection
Respiratory epithelial layer – provides mechanical protection and mucociliary clearance,
produces a mucous secret
Slime – has adhesive properties and includes:
a) nonspeci
fi
c protective factors (lysozyme, interferon, lactoferrin, etc.
)
b) secretory immunoglobulin fraction (A, M)
;
Сolonization resistance of normal micro
fl
ora
;
The presence of lymphoid tissue – it gives immune protection (lymphoid
tissue associated with mucous shell - mucosal - associated lymphoid tissue).
18
19. Nose Pathology
1. Acute rhinitis
2. Chronic rhinitis
3. Septal deviation
4. Furuncle of external nose
20. • Check for in
fl
ammation, character of
secret, position of the septum, and
presence of polyps.
• A foreign body, usually accompanied by
an o
ff
ensive unilateral discharge, may be
seen inside the nose of a patient.
Anterior rhinoscopy
20
21. Symptoms:
runny nose
sneezing
congestion
postnasal drip,
cough
sometimes a low-grade fever
Acute rhinitis can be caused by a variety of viruses or bacteria.
It’s usually a part of the common cold.
Stages
:
I. Stage of irritatio
n
II. Stage of serous discharg
e
III. Stage of mucopurulent
discharge
21
Acute Rhinitis
22. I. Stage of irritatio
n
• Lasts a few hours (rarely 1-2 days
)
• Complaints: dryness in nose and nasopharynx,
feeling of burnin
g
• Malaise, chills, heaviness in the head and throa
t
• Body temperature could be 37 or higher
22
• Anterior rhinoscopy: hyperemia, mucosal vascular injection, no mucous
discharg
e
• Treatment
:
• Rest and warmth, warm drinking, sea-water solutions (eg.: Aqua Maris,
Aqualor)
23. II. Stage of serous discharg
e
• Complaints: nasal congestion, discharge from i
t
• Increased in
fl
ammation, transudate secretio
n
• Strengthening of the function of goblet cells and
mucous glands, the appearance of serous-mucous
discharge
• Violation of nasal breathin
g
• Redness of the skin around the nose, swellin
g
• Anterior rhinoscopy: hyperemia, mucosal vascular injection, no mucous discharg
e
• Mb lacrimation, conjunctivitis, a feeling of stuf
fi
ness in the ear
s
Treatment
:
Stage I + Decongestants (eg.: Xylometazoline, Indanazolinum, Naphazolinum)
23
Decongestants could be use
d
only for 3-5 days!
24. III.Stage of mucopurulent discharg
e
• Complaints: nasal congestion, numerous
varicoloured discharge from i
t
• Begins 4-5 days from the onset of the diseas
e
• Thick mucopurulent discharg
e
• Gradually the amount of discharge decreases, the
edema of the mucous membrane decreases, the
function of nasal breathing is restored, the general
condition improve
s
• After 8-12 days, the acute rhinitis stops
24
Treatment
:
Stage II + Mucolitics (eg.: Bromhexinum, Acetylcysteinum, Ambroxolum)
25. Physiological e
ff
ects:
1. Liquefy viscous mucus, soften crusts
2. Normalise mucus production
3. Stimulate the function of the ciliated
epithelium
4. Mechanically wash out foreign particles
5. Reduce microbial contamination
6. Micro- and macro-regenerating e
ff
ect
Marimer, Aqua Maris, Physiomer, Saline,
Rinolayf, Humer, Dolphin
Isotonic saline (sea-water) sprays for endonasal application
25
26. Nasal decongestants
A group of drugs that cause vasoconstriction of vessels and cavernous bodies of nasal
mucosa by adrenomimetic action.
Physiological effect
s
Reversible spasm of blood vessels and corpus cavernous of mucosa:
• Signi
fi
cant reduction in blood supply vessels and cavernous bodies
• Decrease of mucosal edema
• Decrease of mucus hypersecretion
• Restoration of nasal breathing, ventilation and self-puri
fi
cation of the paranasal
sinuses, the auditory tube and middle ear cavity
• Prevention of bacterial complications
26
27. 1. Transient sensation of burning, dryness in the nasal cavity and
nasopharynx
2. Rebound syndrome (compensatory plethora)
3. Development of tachyphylaxis ("addiction")
4. Violation of vegetative regulation of vessels and glands of the nasal
cavity with the development of nasal-hyperreactive, e.g.: medical rhinitis
5. Inhibition of secretory function and microcirculation, development of
atrophic rhinitis
6. Systemic sympathomimetic e
ff
ects (headache, insomnia, nausea,
tachycardia, increased blood pressure, tremor, increased intraocular
pressure)
7. Allergic reactions
Contraindications:
1. Atrophic rhinitis
2. Medical rhinitis
3. Hypertension
4. Severe atherosclerosis
5. Glaucoma
6. Surgery on the
conchae in history
7. Allergic intolerance to the
drug
8. Age restrictions are
speci
fi
c to each drug
9. Pregnancy and Lactation
27
Side and unwanted effects of nasal decongestants
28. Examples with doses
• Decongestants
Polydexa with phenylephrine – 1 dose into each 1/2 of the nose 3-5 times a day – 3
days
Xylometazoline – 1-2 doses into each 1/2 of the nose 2-3 times a day – 3 days
• Analgesics or non steroidal anti-in
fl
ammatory drugs
Ibuprofen – 0,2 gr 2 times a day - in case of high temperature of moderate pain
• Mucolytics
Ambroxol 0,03 3 times a day – 2-3 days, then 0,03 2 times a day – 2 days
29. Non-allergic chronic rhinitis:
1. Chronic catarrhal rhinitis
2. Chronic hypertrophic rhinitis (di
ff
use or local)
3. Chronic atrophic rhinitis
4. Vasomotor rhinitis (neurovegetative)
Allergic rhinitis
29
– is a chronic in
fl
ammation of mucosa and sometimes bone walls of nasal cavity
Classi
fi
cation
Chronic rhinitis
30. Differential diagnostic
• Anamnesis and complaints
• Examination and anterior rhinoscopy
• Microbiological research: de
fi
nition of microorganism and its’ sensitivity to
antibiotics
• Anemisation
• CT of paranasal sinuses
+ research of other organs and systems, other specialists consultation to
fi
nd
the reason of the disease
30
31. Only once examined patient you can’t correctly
de
fi
ned the kind of chronic rhinitis.
You have to prescribe drugs to treat an acute stage
and ask person to come again for next inspection and
examination. Later you could change treatment if it’s
needed.
31
32. 1. Chronic catarrhal rhinitis
- di
ffi
culty in nasal breathing, nasal discharge (moderate amount)
- problems in breathing usually at cold temperature
- during the exacerbation – purulent profuse discharge
- could be impaired sense of smell while the amount of mucus increases
32
• pastiness, swelling of mucosa, slight thickening mainly in the area of
the inferior turbinate and
the anterior end of the middle turbinate.
• the mucous membrane is hyperemic with a cyanotic shade
• the turbinates are swollen, but the nasal passages do not completely close
• the walls of the nasal cavity are covered with mucus (or mucopurulent discharge), the discharge
accumulates at the bottom of the nasal cavity, is easily removed
Complaints:
Anterior rhinoscopy:
33. • Healthy lifestyle
• Household modi
fi
cation (wet cleaning, airing)
• Cleaning the nose cavity using saline solutions
• Topical cocorticoisteroids*
• Antiseptic solutions
Treatment:
33
• Topical antibacterial treatment at acute stage (Polydexa with phenylephrine)
• Systemic antibacterial treatment – if microorganism and its sensitivity were
determined
34. Topical corticsteroids – nasal sprays
• Could be used for a long time
• Are indicated for conditions characterized by in
fl
ammation, hyperproliferation, and immunological
involvement
• In ENT such TCR as Mometasone, Budesonide, Beclometasone could be used:
• For example: Mometasone 200 mg 2 doses into each nostril 2 times a day
Nasonex
(Mometasone)
Nasoferon
(Mometasone)
Dezrinit
(Mometasone)
Taken Nasa
l
(Budesonide)
Nasobek
(Beclometasone)
35. 2. Chronic hypertrophic rhinitis
- di
ffi
culty in nasal breathing
- hypertrophied areas of the turbinates can squeeze the pharyngeal
fi
stulas of the auditory
tubes, the opening of the nasolacrimal canal, press on the nasal septum - all this leads to the
occurrence of certain symptoms and the appearance of complaints.
35
• enlargement of turbinates - di
ff
use or local
• overgrowth and thickening of mucosa mainly in the area of
inferior turbinates and lessly middle
turbinates
• mucosa is full-blooded, slightly cyanotic or purple-cyanotic, covered with mucus
Complaints:
Anterior rhinoscopy:
36. • Healthy lifestyle
• Household modi
fi
cation (wet cleaning,
airing)
• Cleaning the nose cavity using saline
solutions
• Topical cocorticoisteroids
Treatment:
36
Surgical treatment to delete hypertrophied tissues:
• Plastic of turbinates or
• submucosal conchotomy
37. 3. Chronic atrophic rhinitis
- mucous or mucopurulent discharge, crusts in the nose
- dryness in the nose and throat
- decreased sense of smell
- itching (arising from crusts), due to exposure - damage to the mucosa in the anterior region (up to
ulceration and perforation)
- nosebleeds (usually from the Kisselbach zone)
- in some cases – an unpleasant smell from the nose
37
• the nasal passages are too wide, the nasal conchas are reduced, covered with pale dryish mucosa,
in some places - crusts or viscous mucus
• crusts also could be brownish, yellow-green,
fi
ll the entire nasal cavity, can spread to the pharynx
Complaints:
Anterior rhinoscopy:
38. • Healthy lifestyle
• Household modi
fi
cation (wet cleaning, airing)
• Topical cocorticoisteroids
• Antiseptic solutions
• Cleaning the nose cavity using saline solutions – at ENT o
ffi
ce
• Group B vitamins
• Surgical treatment – to make nose cavity more physiological
• After surgery – the use of various gels and ointments with a
regenerating e
ff
ect (eg.: Dexpanthenol, Solkoseril, Actovegin)
Treatment:
38
39. 4. Vasomotor rhinitis
- profuse watery or mucous discharge
- di
ffi
culty in nasal breathing
- in some patients - sleep disturbance and deterioration in general condition
39
• pu
ffi
ness, pallor mucosa, cyanotic spots on mucosa
• the inferior turbinates are enlarged, they contract poorly during anemization
• outside the attack, the rhinoscopy picture may be normal
Complaints:
Anterior rhinoscopy:
40. Treatment:
40
• Healthy lifestyl
e
• Household modi
fi
cation (wet cleaning, airing
)
• Elimination of pathogenetic factors – cancelling
vasoconstrictor drops, bad habit
s
• For diseases of the nervous system – treatment together
with a neurologis
t
• Topical corticosteroid
s
• Surgical treatment: submucosal vasotomy of the inferior
turbinates, destruction of vascular connections, etc
41. 5. Alergic rhinitis
- frequent sneezing
- profuse watery or mucous discharge
- nasal congestion
- some patients have a decreased sense of smell (eg, when combined with polyposis sinusitis)
41
• swelling of mucosa varying degrees of severity, pallor of mucosa (sometimes with a bluish tinge)
• discharge watery or foamy
• polypoid hyperplasia of the middle turbinate can be determined
Complaints:
Anterior rhinoscopy:
42. • Consultation of an allergist, treatment can be selected
together
• System antihistamines: cetirizine (Zyrtec, Cetrin, Zodak),
deslortadine (Erius, Desal. Lordestin)
For example: Desloratadini 0,005 at evening - 5-7 days
• Local antihistamines:
Treatment:
42
• Azelastine + mometasone (Momat), dimethindene + phenylephrine (Vibrocil)
• Vasoconstrictor drops (short course): xylometazoline, naphazoline, oxymetazoline
• Mast cell membrane stabilizers (cromones): Cromogen
43. • When a deviated septum is severe, it can block one
side of the nose and reduce air
fl
ow, causing di
ffi
culty
breathing and other symptoms like dryness,
contribution to crusting, bleeding, etc.
• It also plays role in many ENT diseases such as acute
and chronic rhinitis, sinusitis, otitis, tonsillitis, its.
43
A deviated septum occurs when the nasal septum is
displaced from the central line, so it makes one nasal
passage smaller.
Septal Deviation
44. Complaints
• Di
ffi
culty in nasal breathing: obstruction of one
or both nostrils
• Nasal congestion
• Crusts and/or bleeding
• Noisy breathing during sleep
• Frequent viral infections, rhinitis, sinusitis, etc
1. Anamnesis and
complaint
s
2. Physical examinatio
n
3. ENT-organs
examinatio
n
4. CT of paranasal
sinuses
Diagnostic:
44
45. 45
Axial CT scan demonstrating
severe septal deviation.
Note left-sided de
fl
ection of
caudal septum and right-sided
nasal airway obstruction due to
bony and cartilaginous
posterior deviation
.
Any other abnormalities?
46. Indications to septoplasty
• Deviation of the nasal septum in combination with impaired nasal breathing
through one or two nostrils
• Deviation of the nasal septum in combination with chronic recurrent sinusitis,
otitis media
• Deviation of the nasal septum in combination with chronic dacryocystitis,
impaired out
fl
ow of lacrimal
fl
uid
• Deformation of individual parts of the septum, making it di
ffi
cult for intranasal
surgical access to the sinuses or lacrimal sac
46
47. 47
One technique of incising the septal
cartilage involves removing thin wedges
from the convex side of the deviated
septum to encourage midline
repositioning.
Excess and displaced septal cartilage
along a hypertrophied maxillary crest can
be excised. A straight osteotome may
facilitate removal of the bony portion.
48. • Diabetes
• Problems with the immune system
• Poor nutrition
• Poor hygiene
• Exposure to harsh chemicals that irritate the skin
– is an acute infection of hair follicle by Staphylococcus aureus.
These health problems make people more susceptible to skin infections:
48
External nose boil (furuncle)
49. Oh, that hurts!
A boil starts as a hard, red, painful lump usually about half an inch in size. Over
the next few days, the lump becomes softer, larger, and more painful. Soon a
pocket of pus forms on the top of the boil.
The condition is exquisitely painful as the vestibular skin is tightly bound to
the underlying cartilages. This condition is considered more serious because
it can lead to cellulitis, a rapidly spreading skin infection that can get into
your bloodstream. The condition causes skin dimpling, swelling, and red
areas of in
fl
ammation. In some instances, cellulitis can be deadly.
49
Symptoms
50. Signs of a severe infection:
• The skin around the boil becomes infected. It turns red, painful, warm, and
swollen
• More boils may appear around the original one
• A fever may develop
• Lymph nodes may become swollen
Local cleaning and systemic antibiotics should be given and the possibility
of a cavernous sinus thrombosis considered.
50
51. Stages and treatment
1. in
fi
ltration
2. pustule stage – the formation of
a purulent necrotic core
3. recovery or the formation of
complications
During the 1st stage – cleaning of the skin around the boil
using antiseptic solutions (alcohol- containing) e.g.,
chlorhexidine, boric acid; nonsteroidal anti-in
fl
ammatory
drugs – to treat the pain, fever, in
fl
ammation.
The 2nd stage – Furuncle opening and removal of
purulent-necrotic core using local anesthesia.
The 3rd stage – could occur with no treatment, but you
also could use some healing ointments and gels like
Dexpanthenol.
It’s important to remember that the treatment depends
on the stage of furuncle!
51
Nose furuncle should be
treated like the other furuncles
as it has the same stages:
52. Possible complications
- abscess or ascending boil
- thrombophlebitis of small veins of the face
- reactive swelling of the soft tissues of the face – intracranial and intraorbital
spread of infection
52
