Ears, Nose and Throat

Diseases

Prepared By: Hannelli Belingon

 Topics
Review of anatomy and physiology of the Ear
Nose and Throat
Common ENT Problems:
– Cholesteatoma
– Ear Infection (Otitis Media)
– Meniere’s Disease
– Swimmer’s Ear (Otitis Externa)
– Tinnitus (Ringing in the Ears)
– Endolymphatic Hydrops
– Perforation of Tympanic Membrane
– Sinusitis
– Nasal Polyps
– Deviated Septum
– Tonsillitis
– Laryngitis
– Pharyngitis
 Anatomic and Physiologic
Overview of the Ear
The ears are a pair of complex sensory organs
located in the middle of both sides of the head
(that attaches to the temporal bone of cranium)
at approximately eye level.
Anatomic View of the Ear
The ear anatomy is divided into three parts, the
outer, middle, and inner ear.
• The outer ear consists of the parts you can see
outside the body, the auricle (also known as pinna),
the earlobe, and the ear canal up to the eardrum.
• The middle ear consists of the eardrum (tympanic
membrane) and the auditory bones (ossicles) - the
incus, malleus, and stapes.
• The inner ear consists of the fluid-filled
semicircular canals, snail-shaped
cochlea, vestibular nerve, and auditory nerve.
Common Ear Disorders
Cholesteatoma
Ear Infection (Otitis Media)
Meniere’s Disease
Swimmer’s Ear (Otitis Externa)
Tinnitus (Ringing in the Ears)
 Cholesteatoma

A cholesteatoma consists of
squamous epithelium that is
trapped within the skull base and
that can erode and destroy
important structures within the
temporal bone. Its potential for
causing central nervous system
(CNS) complications (eg, brain
abscess, meningitis) makes it a
potentially fatal lesion.
3 Types Of Cholesteatoma:
– Congenital cholesteatoma
– Primary acquired cholesteatoma
– Secondary acquired cholesteatoma
Cholesteatoma Symptoms

The hallmark symptom of a

cholesteatoma is a painless otorrhea,
either unremitting or frequently
recurrent. Other symptoms include the
following:
– Conductive hearing loss
– Dizziness: Relatively uncommon
– Drainage and granulation tissue in the ear
canal and middle ear: Unresponsive to
antimicrobial therapy
Cholesteatoma Symptoms

Occasionally, cholesteatoma initially

presents with symptoms of CNS
complications, including the
following:
• Sigmoid sinus thrombosis
• Epidural abscess
• Meningitis
Cholesteatoma Diagnosis

• Computed tomography (CT) scanning is the

diagnostic imaging modality of choice for
these lesions, owing to its ability to detect
subtle bony defects.
• Audiometry
• Magnetic Resonance Imaging
Cholesteatoma Treatment and Management

• Regular cleaning can help to control infection

and may slow growth of the cholesteatoma.
• Mastoidectomy
– Canal wall–up (closed) technique
 Highest probability of permanently ridding the patient of a
cholesteatoma
– Canal wall–down (open) technique
 Canal wall–up procedures have the advantage of
maintaining a normal appearance, but because the risk of
persistent or recurrent cholesteatomas is higher with this
operation, most surgeons advise an obligatory second-look
tympanomastoidectomy 6 months to 1 year after the initial
procedure
Drug therapy is not currently part of the standard of care
Drug therapy is not currently part of the standard of care
for cholesteatomas, being of little use even when the
for cholesteatomas, being of little use even when the
lesions become infected. Because a cholesteatoma has no
lesions become infected. Because a cholesteatoma has no
blood supply, systemic antibiotics cannot reach the center
blood supply, systemic antibiotics cannot reach the center
of the lesion.
of the lesion.

Topical antibiotics can often surround a cholesteatoma,

Topical antibiotics can often surround a cholesteatoma,
penetrating a few millimeters toward its center and
penetrating a few millimeters toward its center and
suppressing infection, but a large infected cholesteatoma
suppressing infection, but a large infected cholesteatoma
resists any type of antimicrobial therapy. Consequently,
resists any type of antimicrobial therapy. Consequently,
otorrhea either persists or recurs despite frequent
otorrhea either persists or recurs despite frequent
aggressive treatment with antibiotics.
aggressive treatment with antibiotics.
Postoperative Complications

• Postoperative stenosis
• Facial nerve damage
• Total neurosensory hearing loss
• Graft failure
• Balance Disturbance
• Chondritis and perichondritis
• Persistent Drainage
• Foreign bodies
• Altered taste
 Otitis Media

Otitis Media means inflammation

of the middle ear. The
inflammation occurs as a result
of a middle ear infection and
may occur in both ears.  It is a
most common cause of hearing
loss in children and can also
affect adults.
Subtypes of Otitis Media

Acute OM (AOM)
OM with effusion (OME)
Chronic suppurative OM
Adhesive OM
Otitis Media Symptoms

• Acute Otitis Media implies rapid onset of disease

associated with one or more of the following symptoms:
 Otalgia
 Otorrhea
 Headache
 Fever
 Irritability
 Loss of appetite
 Vomiting
 Diarrhea
Otitis Media Symptoms

• Otitis Media with Effusion (OME) often follows

an episode of AOM. Symptoms that may be
indicative of OME include the following:
 Hearing loss
 Tinnitus
 Vertigo
 Otalgia
Otitis Media Symptoms

• Chronic suppurative otitis

media is a persistent ear
infection that results in tearing
or perforation of the eardrum.
• Adhesive otitis media occurs
when a thin retracted ear drum
becomes sucked into the middle
ear space and stuck.
Otitis Media Causes

• Blockage of the eustachian tube

during a cold, allergy, or upper
respiratory infection and the presence
of bacteria or viruses leading to an
accumulation of fluid (a build-up of
pus and mucus) behind the eardrum.
• The build-up of pressurized pus in the
middle ear.
Otitis Media Diagnosis

• Pneumatic otoscopy remains the standard

examination technique for patients with
suspected OM. 
• Tympanometry which measures changes in
acoustic impedance of the TM/middle ear
system with air pressure changes in the
external auditory canal, and acoustic
reflectometry, which measures reflected sound
from the Tympanic Membrane; the louder the
reflected sound, the greater the likelihood of
an Middle Ear Effusion.
Workup of Otitis Media

 Contrast-enhanced computed tomography (CT) of the

temporal bones.
 Magnetic resonance imaging (MRI) is more helpful in
depicting fluid collections, especially small middle-ear
collections. MRI is usually performed after CT if further
information is needed for definitive diagnosis.
 Tympanocentesis to determine the presence of middle-
ear fluid, followed by culture of the fluid to identify
causative pathogens.
 Tympanometry may help with diagnosis in patients who
OME. Some practitioners also use acoustic reflectometry
to evaluate for middle ear effusion (MEE) in patients with
OM.
Otitis Media Treatment and Management
Surgical Care:

• Tympanocentesis
Indications for tympanocentesis are as follows:
– OM in patients who have severe otalgia, who are seriously
ill, or who appear toxic
– Unsatisfactory response to antimicrobial therapy
– Onset of AOM in a patient receiving antimicrobial therapy
– OM associated with a confirmed or potential suppurative
complication
– OM in a newborn, sick neonate, or patient who is
immunologically deficient, any of whom may harbor an
unusual organism
• Tympanostomy tubes

Guideline recommendations include the following:

– Many children with OME improve spontaneously, especially
when effusion is present for less than 3 months; children with
a single OME episode lasting less than 3 months should not
undergo TT insertion
– Age-appropriate hearing evaluation is recommended before
surgery and for all children with persistent OME lasting 3 or
more months
– Clinicians should offer TTs to children with impaired hearing
and bilateral OME for 3 or more months
– Clinicians may perform TT placement in children with
unilateral or bilateral OME lasting 3 or more months and
associated symptoms, such as vestibular symptoms, school or
behavioral problems, ear discomfort, or lowered quality of life
– Children with recurrent acute OM without MEE should not
undergo TT placement, but TT placement should be
considered for children with MEE to prevent most future AOM
episodes and to facilitate treatment of AOM with ear drops
instead of oral antibiotics
– When unilateral or bilateral OME is unlikely to resolve quickly,
children at risk for developmental difficulties (including those
with permanent hearing loss; speech, language, or
developmental delay or disorder; autism spectrum disorder;
Down syndrome; craniofacial disorders; or cleft palate) may
benefit from TTs
– Children with TTs who develop ear infections, including
uncomplicated acute TT otorrhea, should be treated with
topical antibiotic ear drops [31] rather than systemic antibiotics
– Children with TTs can usually swim or bathe without specific
precautions such as earplugs or headbands
Surgery for children with cleft palate
• Myringotomy and Tympanostomy
Tube placement are warranted in
most children with cleft palate
because of inherent Eustachian Tube
dysfunction (ETD) and increased risk
of OM.
Surgery for children with Down
Syndrome
• The essential elements of care in
these patients include close
monitoring, appropriate surgical
interventions for external auditory
canal enlargement, and repetitive
Tympanostomy Tubes placements.
Medications:
• Antimicrobial Agents
– Amoxicillin
– Cefaclor
– Cefprozil
– Cefuroxime
– Cefixime
– Ceftriaxone
– Cefpodixime
– Cefdinir
– Clarithromycin
– Azithromycin
– Trimethoprim
– Erithromycin
Prevention of Otitis Media
• Elimination of risk factors
– Tobacco smoke exposure
– Pacifier use
– Breastfeeding for less than 3 months
• Passive and active immunizations
– Passive immunization with Respiratory Syncytial
Virus-Immunoglobulin IV in selected infants
– Pneumococcal vaccine
– Influenza vaccine
• Antibiotic Prophylaxis
 Meniere’s Disease
Ménière disease is a disorder of
the inner ear that is also known as
idiopathic endolymphatic hydrops.
It is also defined by spontaneous
vertigo attacks (each lasting 20
minutes to 12 hours) with
documented low- to mid frequency
sensorineural hearing loss in the
affected ear before, during, or after
one of the episodes of vertigo.
Meniere’s Disease Symptoms
• fluctuating hearing loss
• occasional episodic vertigo
(usually a spinning sensation,
sometimes violent)
• tinnitus or ringing in the ears
(usually low-tone roaring)
• aural fullness (eg, pressure,
discomfort, fullness sensation
in the ears)
Diagnostic Criteria
Definite MD:
• Two or more spontaneous attacks of vertigo, each
lasting 20 minutes to 12 hours
• Audiometrically documented fluctuating low- to
midfrequency sensorineural hearing loss in the
affected ear on at least 1 occasion before, during, or
after 1 of the episodes of vertigo
• Fluctuating aural symptoms (hearing loss, tinnitus, or
fullness) in the affected ear
• Other causes excluded by other tests
Probable MD:
• At least 2 episodes of vertigo or dizziness
lasting 20 minutes to 24 hours
• Fluctuating aural symptoms (hearing loss,
tinnitus, or fullness) in the affected ear
• Other causes excluded by other tests
Workup of Meniere’s Disease
No blood test is specific for Ménière disease. However, the following
studies may be ordered to exclude obvious metabolic disturbances,
infections, or hormonal imbalances:
• Thyroid-stimulating hormone (TSH), T4, and T3 to rule out
hyperthyroidism and hypothyroidism
• Glucose level to rule out diabetes
• Erythrocyte sedimentation rate (ESR) and antinuclear antibody (ANA) test
to rule out autoimmune disorders
• Urinalysis to rule out proteinuria and hematuria and indicators of otorenal
syndrome
• Complete blood count (CBC) to rule out anemia and leukemia
• Electrolyte levels to rule out salt/water imbalance
• Venereal Disease Research Laboratory test (VDRL) and fluorescent
treponemal antibody (FTA-ABS) to rule out neurosyphilis and Lyme disease
• Allergy testing for allergy-mediated Ménière syndrome
• C-reactive protein (CRP)
• MRI or CT to identify or exclude other
potential disease processes
• Audiometry
• Electrocochleography (ECOG) is an
electrophysiological test that reflects
elevation of inner ear pressure
• Electronystagmography (ENG) is a test
of inner ear function (particularly the
horizontal semicircular canals). The test
determines inner ear responsiveness to
movement and caloric stimulation.
Meniere’s Disease Treatment and
Management
• Pharmacological Therapy
– Vestibulosuppressants
– Diuretics and diuretic-like medications
– Steroids
– Aminoglycosides
– Histamine agonists
• Meniett Device
– Delivers pulses of pressure to the
inner ear via the tympanostomy tube
• Surgical management
– Endolymphatic sac decompression or shunt
placement Vestibular nerve section (decreases
endolymph pressure accumulation by removing some of
the mastoid bone, which encases the endolymph
reservoir)
– Vestibular Nerve Section (opens the internal auditory
canal)
– Labyrinthectomy (involves ablation of the diseased
inner ear organs)
– Cochlear Implant
– Intratympanic injection of medications such as
gentamicin  or steroids 
 Otitis Externa

Otitis externa (OE) is an

inflammation or infection of
the external auditory canal
(EAC), the auricle, or both. This
condition can be found in all
age groups.
Signs and Symptoms of Otitis Externa

• Pain upon palpation of the tragus (anterior to

ear canal) or application of traction to the
pinna (the hallmark of OE).
• Otalgia - Ranges from mild to severe, typically
progressing over 1-2 days
• Hearing loss
• Ear fullness or pressure
• Erythema, edema, and narrowing of the EAC
• Tinnitus
• Fever (occasionally)
• Itching (especially in fungal OE or chronic OE)
• Severe deep pain - Immunocompromised
patients may have necrotizing (malignant) OE
• Discharge - Initially, clear; quickly becomes
purulent and foul-smelling
• Cellulitis of the face or neck or lymphadenopathy
of the ipsilateral neck (occasionally)
• Bilateral symptoms (rare)
• History of exposure to or activities in water
(frequently) (eg, swimming, surfing, kayaking)
• History of preceding ear trauma (usually) (eg,
forceful ear cleaning, use of cotton swabs, or
water in the ear canal)
Otitis Externa Diagnosis

• Laboratory Testing
– Gram stain and culture of any discharge from the
auditory canal
– Blood glucose level
– Urine dipstick
• High-resolution computed tomography (CT) -
Preferred; better depicts bony erosion 
• Radionucleotide bone scanning
• Gallium scanning
• Magnetic resonance imaging (MRI) - Not used as
often as the other modalities; may be
considered secondarily or if soft-tissue extension
is the predominant concern 
Otitis Externa Treatment and Management

• Pharmacotherapy
– Topical medications (eg, acetic acid in aluminum acetate,
hydrocortisone and acetic acid otic solution, alcohol vinegar
otic mix)
– Analgesic agents (eg, acetaminophen, acetaminophen and
codeine)
– Antibiotics (eg, hydrocortisone/neomycin/polymyxin B, otic
ofloxacin, otic ciprofloxacin, otic finafloxacin, gentamicin
0.3%/prednisolone 1% ophthalmic,
dexamethasone/tobramycin, otic ciprofloxacin and
dexamethasone, otic ciprofloxacin and hydrocortisone
suspension)
– Oral antibiotics (eg, ciprofloxacin)
– Antifungal agents (eg, otic clotrimazole 1% solution, nystatin
powder)
• Surgery
– Surgical debridement of the ear canal -
Usually reserved for necrotizing OE or
for complications of OE (eg, external
canal stenosis); often necessary in more
severe cases of OE or in cases where a
significant amount of discharge is
present in the ear; mainstay of
treatment for fungal infections
– Incision and drainage of an abscess
 Tinnitus

A ringing, swishing, or other noise in the ears or head

when no external sound is present is called tinnitus.
Usually, it's more of a nuisance than a serious
medical problem. In rare cases, it can be a sign of an
underlying medical condition that needs attention. 
The sounds can vary in pitch from a low roar to a high
squeal or whine. They can be present in one ear or
both. The ringing may be occasional or constant.
Causes of Tinnitus

• Fluid, infection, or disease of the middle ear bones or ear

drum (tympanic membrane)
• Damage to the microscopic endings of the hearing nerve in
the inner ear, which can also occur with advanced age
• Loud noise exposure, such as from firearms, or music at a
concert
• Medications
• Meniere's syndrome
• In rare cases, tinnitus can be a symptom of a serious medical
problem such as a brain aneurysm or acoustic nerve tumor.
Treatment for Tinnitus

Treatment for tinnitus depends on the underlying cause and may

include medications in addition to home remedies.

Tinnitus may disappear on its own or the person may need to

learn to cope with it. Medications may be prescribed in some
cases but there is no clear solution in most individuals.
Medications may often be used to treat the psychological effects
of anxiety or depression that may accompany the tinnitus. In
these cases selective serotonin reuptake inhibitor (SSRI)
antidepressants such as sertraline (Zoloft) and paroxetine (Paxil),
or a benzodiazepine such as alprazolam (Xanax) may be
prescribed.
Some home remedies may be helpful for some people:
• Reduce or avoid caffeine and salt.
• Quit smoking.
• Melatonin may help those who suffer with tinnitus,
particularly those with disturbed sleep due to
tinnitus.
• Successful behavioral and cognitive therapies
include retraining therapy, masking, and behavioral
therapy.
Tinnitus Prevention

1. Cotton swabs (Q-tips) should never be used to clean the

inside of the ear. Pushing a swab into the ear can cause the
wax in the ear canal to become impacted against the
eardrum, causing tinnitus.
2. If you work in an environment that is noisy, protect your
hearing in the workplace. Occupational Safety & Health
Administration (OSHA) regulations have recommendations
to protect hearing that include wearing earplugs or
earmuffs. Follow any hearing protections set by your
employer.
3. Many recreational events such as concerts, sports, or
hunting may come with loud noise that can bother the
ears. Wear earplugs or earmuffs in these loud situations.
Do not use tissue or cotton in the ears as these not only do
not offer adequate protection against certain loud or high-
pitched noises, they may become lodged in the ear canal.
4. Keep the volume of music headphones
at a reasonable level. If others can hear
your music, or you are unable to hear the
noise around you, the volume is too high.
5. Many everyday noises may bother your
ears. Even blow-dying your hair or mowing
the lawn may require earplugs or earmuffs.
6. Avoid or moderate use of alcoholic or
caffeinated beverages. Don't smoke and
avoid secondhand smoke. Nicotine in
tobacco products may reduce blood flow
to the structures of the ear, leading to
tinnitus.
7. Maintain a healthy weight. Excess weight can
cause high blood pressure. Elevated blood
pressure can cause sensitivity to noise and
tinnitus. Exercise regularly and eat a balanced
diet.
 Perforation of the Tympanic Membrane

• Tympanic membrane perforations (TMPs)

can result from disease (particularly
infection), trauma, or medical care.
Perforations can be temporary or persistent.
Effect varies with size, location on the drum
surface, and associated pathologic condition.
• Infection is the principal cause of tympanic
membrane perforation (TMP). Traumatic
perforations occur from blows to the ear,
severe atmospheric overpressure, exposure
to excessive water pressure (eg, in scuba
divers), and improper attempts at wax
removal or ear cleaning.
Symptoms of a Perforated Tympanic Membrane

• Discharge from the ear

• Ear ache (otalgia)
• Change in hearing
• Bleeding or pus from the ear may
indicate the presence of a
perforation.
Prevention of Perforated Tympanic Membrane

• Never try to remove an object which

is lodged in your ear canal.
• Do not use objects such as cotton
swabs or paper clips in your ears in
an attempt to clean them.
• Do your best to avoid contact with
persons who have colds of a flu-like
illness.
Workup of Perforated Tympanic Membrane

Otoscopy Otomicroscopy

Tympanometry Audiometry
Perforated Tympanic Membrane Treatment and Management

• Ofloxacin Otic Drops

• Antibiotics (eg, trimethoprim-
sulfamethoxazole, amoxicillin)
• Hearing aid - may prove the only
necessary treatment for patients with
symptomatic hearing loss but no
infection or swimming history
• Paper-patch method
• Tympanoplasty
 Anatomic and Physiologic
Overview of the Nose

The nose serves as the only means of bringing warm

humidified air into the lungs. It is the primary organ for
filtering out particles in inspired air, and it also serves
to provide first-line immunologic defense by bringing
inspired air in contact with mucous-coated membranes
that contain immunoglobulin A (IgA). Inspired air is
brought high into the nasal cavity to come in contact
with the olfactory nerves, thereby providing the sense
of smell, which is intimately associated with the taste
sensation. Dysfunction of any of these systems can
lead to symptoms of nasal dysfunction (eg, congestion,
postnasal drainage, facial pressure, headaches, sinus
infections).
The external nose consists of
paired nasal bones and upper and
lower lateral cartilages. Internally,
the nasal septum divides the nasal
cavity into a right and left side. The
lateral nasal wall consists of inferior
and middle turbinates and
occasionally a superior or supreme
turbinate bone. The opening of the
sinuses also is found under the
middle turbinates on the lateral
nasal wall. The lacrimal system
drains into the nasal cavity below
the anterior inferior aspect of the
inferior turbinates.
Common Nose Disorders
 Acute Sinusitis
 Nasal Polyps
 Deviated Septum
 Sinusitis
Sinusitis is characterized by inflammation of the
lining of the paranasal sinuses. Because the nasal
mucosa is simultaneously involved and because
sinusitis rarely occurs without concurrent rhinitis,
rhinosinusitis is now the preferred term for this
condition.

Rhinosinusitis may be further classified according

to the anatomic site (maxillary, ethmoidal, frontal,
sphenoidal), pathogenic organism (viral, bacterial,
fungal), presence of complication (orbital,
intracranial), and associated factors (nasal
polyposis, immunosuppression, anatomic variants).
Signs and Symptoms
Clinical findings in acute sinusitis may include the following:
• Pain over cheek and radiating to frontal region or teeth, increasing
with straining or bending down
• Redness of nose, cheeks, or eyelids
• Tenderness to pressure over the floor of the frontal sinus immediately
above the inner canthus
• Referred pain to the vertex, temple, or occiput
• Postnasal discharge
• A blocked nose
• Persistent coughing or pharyngeal irritation
• Facial pain
• Hyposmia
Symptoms of acute bacterial rhinosinusitis include the following:
• Facial pain or pressure (especially unilateral)
• Hyposmia/anosmia
• Nasal congestion
• Nasal drainage
• Postnasal drip
• Fever
• Cough
• Fatigue
• Maxillary dental pain
• Ear fullness/pressure
The following signs may be noted on physical
examination:
• Purulent nasal secretions
• Purulent posterior pharyngeal secretions
• Mucosal erythema
• Periorbital edema
• Tenderness overlying sinuses
• Air-fluid levels on transillumination of the sinuses
(60% reproducibility rate for assessing maxillary
sinus disease)
• Facial erythema
Workup of Sinusitis
• CBC
• Tests for immunodeficiency are indicated if history findings indicate recurrent
infection, to include the following:
– Immunoglobulin studies
– HIV serology
• Nasal cytology
• Sweat Chloride Test
• Cultures of Nasal Secretions (patient in ICU or immunocompromise)
• Computed Tomography
• CT scanning (preferred imaging method for rhinosinusitis)
• Radiography
• Magnetic Resonance Imaging (useful only if fungal infection or a tumor is
suggested)
• Ultrasonography
• Paranasal biopsy (used to help exclude neoplasia, fungal disease, and
granulomatous disease)
• Fiberoptic sinus endoscopy (used to visualize posterior sinonasal structures)
Treatment of Sinusitis
• Symptomatic or adjunctive therapies may
include the following:
– Humidification/vaporizer
– Warm compresses
– Adequate hydration
– Smoking cessation
– Balanced nutrition
– Nonnarcotic analgesia
• Sinus puncture and irrigation
(medical or surgical)
– topical and systemic vasoconstrictors
(medical)
 Oral alpha-adrenergic vasoconstrictors (eg,
pseudoephedrine, and phenylephrine) for
10-14 days
 Topical vasoconstrictors (eg, oxymetazoline
hydrochloride) for a maximum of 3-5 days
– removal of thick purulent sinus
secretions
• Antimicrobial therapy is the mainstay of medical
treatment in sinusitis. The choice of antibiotics
depends on whether the sinusitis is acute, chronic,
or recurrent.
– Adults with mild disease who have not received
antibiotics: Amoxicillin/clavulanate, amoxicillin (1.5-3.5
g/day), cefpodoxime proxetil, or cefuroxime is
recommended as initial therapy.
– Adults with mild disease who have had antibiotics in the
previous 4-6 weeks and adults with moderate disease:
Amoxicillin/clavulanate, amoxicillin (3-3.5 g),
cefpodoxime proxetil, or cefixime is recommended.
– Adults with moderate disease who have received
antibiotics in the previous 4-6 weeks:
Amoxicillin/clavulanate, levofloxacin, moxifloxacin, or
doxycycline is recommended.
• Functional endoscopic sinus surgery
(FESS)
 Nasal Polyps
Nasal polyps are abnormal lesions that
originate from any portion of the nasal
mucosa or paranasal sinuses. Polyps are
an end result of varying disease
processes in the nasal cavities. The most
commonly discussed polyps are benign
semitransparent nasal lesions that arise
from the mucosa of the nasal cavity or
from one or more of the paranasal
sinuses, often at the outflow tract of the
sinuses.
The following conditions are associated with multiple benign
polyps:
• Bronchial asthma - In 20-50% of patients with polyps
• CF - Polyps in 6-44% of patients with CF [1]
• Allergic rhinitis
• AFS - Polyps in 85% of patients with AFS
• Chronic rhinosinusitis
• Primary ciliary dyskinesia
• Aspirin intolerance - In 8-26% of patients with polyps
• Alcohol intolerance - In 50% of patients with nasal polyps
• Churg-Strauss syndrome - Nasal polyps in 50% of patients with
Churg-Strauss syndrome
• Young syndrome (ie, chronic sinusitis, nasal polyposis,
azoospermia)
• Nonallergic rhinitis with eosinophilia syndrome (NARES) - Nasal
polyps in 20% of patients with NARES
Signs and Symptoms of Nasal Polyps
• Patients with massive nasal polyposis typically
present with:
– increasing nasal congestion
– hyposmia to anosmia
– changes in sense of taste
– persistent postnasal drainage
– Headaches and facial pain and discomfort (are not
uncommon and are found in the periorbital and
maxillary regions)
– *a patient with completely obstructing nasal
polyposis presents with symptoms of obstructive
sleep apnea.
• Patients with solitary polyps frequently present
with only symptoms of nasal obstruction, which
may change with a shift in position.
Workup of Nasal Polyps
• Coronal sinus CT
scanning (imaging study of
choice in the evaluation of
patients with nasal polyposis)
• Nasal Endoscopy (helpful in the
diagnosis and evaluation of nasal
polyps)
Treatment of Nasal Polyps
• Corticosteroids are the treatment of
choice
– Oral steroids are the most effective
medical treatment for nasal polyposis.
In adults, most authors use prednisone
(30-60 mg) for 4-7 days and taper the
medicine for 1-3 weeks. Dosage varies
for children, but the maximum dosage is
usually 1 mg/kg/day for 5-7 days, which
is then tapered over 1-3 weeks. 
• Simple Polypectomy - is effective
initially to relieve nasal symptoms,
especially for isolated polyps or small
numbers of polyps.
• Endoscopic sinus surgery (ESS) - for
nasal polyposis without coexisting
medical conditions.
 Deviated Septum
• A deviated septum is a condition of the
nose where the thin wall of bone and
cartilage that separates your left and right
nasal cavities is displaced to one side, or
crooked. This thin wall is referred to as your
nasal septum and when it’s displaced,
crooked, or deviated, it can make one of the
nasal passages smaller than the other.
• A deviated septum may be present at birth,
may become crooked during growth, or may
be caused by injury to the nose and face.
Symptoms of Deviated Septum
• Difficulty breathing
• Significant congestion in one nostril (versus
less significant congestion in the other nostril)
• Repeated Sinus infections
• Chronic post nasal drip leading to sore throat
or ear pressure
• Nosebleeds
• Facial pain
• Headaches
• Snoring, loud breathing during sleep, or sleep
apnea
Treatment of Deviated Septum
• Some symptoms such as a stuffy
nose or postnasal drip may be
alleviated with medication,
including:
 Decongestants
 Antihistamines
 Nasal sprays
In many cases, medications are tried
before surgery is recommended.
• If medications does not provide
the necessary relief, the following
surgeries are recommended:
– Septoplasty
– Septorhinoplasty (Rhinoplasty and
Septoplasty Combined)
– Turbinoplasty
 Anatomic and Physiologic
Overview of the Throat
The throat is part of both the digestive
and respiratory systems and is
responsible for coordinating the
functions of breathing and swallowing.
From superior to inferior, the throat is
subdivided into 3 sections: oropharynx,
hypopharynx, and larynx. Together, the
oropharynx, hypopharynx, and larynx
function to sense and propel a food
bolus from the mouth to the esophagus
in a coordinated fashion while
protecting the airway.
Common Throat Disorders
 Tonsillitis
 Laryngitis
 Pharyngitis
 Tonsillitis

• Tonsillitis is an inflammation
(swelling) of the tonsils.
Sometimes along with tonsillitis,
the adenoids are also swollen.
• The cause of tonsillitis is usually
a viral infection. Bacterial
infections such as strep
throat can also cause tonsillitis.
Types of Tonsillitis
• Acute tonsillitis
– The symptoms usually last 3 or 4 days but can last
up to 2 weeks.
• Recurrent tonsillitis
– This is when you get tonsillitis several times in a
year.
• Chronic tonsillitis
– This is when you have a long-term tonsil infection.
Symptoms of Tonsillitis
• Red, swollen tonsils
• White or yellow coating or patches on the tonsils
• Sore throat
• Difficult or painful swallowing
• Fever
• Enlarged, tender glands (lymph nodes) in the neck
• A scratchy, muffled or throaty voice
• Bad breath
• Stomachache, particularly in younger children
• Stiff neck
• Headache
Symptoms of Tonsillitis
• In young children who are unable to
describe how they feel, signs of
tonsillitis may include:
– Drooling due to difficult or painful
swallowing
– Refusal to eat
– Unusual fussiness
Diagnosis of Tonsillitis
• Throat Swab
• CBC
Complications of Tonsillitis
• Inflammation or swelling of the tonsils from
frequent or ongoing (chronic) tonsillitis can
cause complications such as:
• Difficulty breathing
• Disrupted breathing during sleep (obstructive
sleep apnea)
• Infection that spreads deep into surrounding
tissue (tonsillar cellulitis)
• Infection that results in a collection of pus
behind a tonsil (peritonsillar abscess)
Complications of Tonsillitis
• If tonsillitis caused by group A streptococcus
or another strain of streptococcal bacteria
isn't treated, or if antibiotic treatment is
incomplete, an increased risk of rare
disorders may occur such as:
– Rheumatic fever, an inflammatory disorder that
affects the heart, joints and other tissues
– Post streptococcal glomerulonephritis, an
inflammatory disorder of the kidneys that
results in inadequate removal of waste and
excess fluids from blood
Treatment for Tonsillitis
• Antibiotics (if the cause is bacterial, if the
cause is a virus, there is no medicine to treat
it)
• Tonsillectomy (to remove tonsils)
 Laryngitis
• Laryngitis, an inflammation of the larynx,
manifests in both acute and chronic forms.
 Acute laryngitis - has an abrupt onset and is usually
self-limited.
 Chronic laryngitis - If a patient has symptoms of
laryngitis for more than 3 weeks.

The etiology of acute laryngitis includes vocal misuse,

exposure to noxious agents, or infectious agents
leading to upper respiratory tract infections. The
infectious agents are most often viral but sometimes
bacterial.
Symptoms of Laryngitis
• Fever
• Cough 
• Rhinitis
• Dysphonia or a hoarse voice (A hoarse voice is defined as one that
has the components of breathiness and tension) 
• Patients with laryngitis may also experience odynophonia,
dysphagia, odynophagia, dyspnea, rhinorrhea, postnasal discharge,
sore throat, congestion, fatigue, and malaise. 

The patient's vocal symptoms usually last 7-10 days. If symptoms

persist longer than 3 weeks, a workup for chronic laryngitis should be
performed.
Management of Laryngitis
The following measures can help to lessen the intensity
of laryngitis:
• Inhaling humidified air promotes moisture of the
upper airway, helping to clear secretions and exudate
• Complete voice rest is suggested, although this
recommendation is nearly impossible to follow; if the
patient must speak, soft sighing phonation is best;
avoidance of whispering is best, as whispering
promotes hyperfunctioning of the larynx
• A patient who smokes must cease smoking in
order to promote timely resolution of the
acute laryngitis. If the patient's laryngitis is
from an infectious etiology, continued
smoking delays prompt resolution of the
disease process.
• The treatment for gastroesophageal reflux disease
(GERD)–related laryngitic conditions includes
dietary and lifestyle modifications, as well as
antireflux medications. Antacid medications that
suppress acid production, such as H2-receptor and
proton pump blocking agents, are highly effective
against gastroesophageal reflux. Of the various
classes of medicines available to treat GERD, the
proton pump inhibitors are the most effective
• Dietary restrictions are recommended for
patients with GERD. These include avoidance
of caffeine, fatty foods, chocolate,
peppermint, and late meals (ie, < 3 h before
retiring). The patient should maintain
hydration and fluid intake at a stress level to
support requirements during the illness. The
patient should drink at least 6-8 glasses (8 oz
each) of water per day.
 Pharyngitis
• Pharyngitis is defined as an
infection or irritation of the
pharynx or tonsils.
• The etiology is usually infectious,
with most cases being of viral
origin and most bacterial cases
attributable to group A
streptococci (GAS). Other causes
include allergy, trauma, toxins,
and neoplasia.
Signs and Symptoms of Pharyngitis

It is difficult to distinguish viral and bacterial causes of pharyngitis on

the basis of history and physical examination alone. Nevertheless, the
following factors may help rule out or diagnose GAS pharyngitis:
• GAS infection is most common in children aged 4-7 years
• Sudden onset is consistent with GAS pharyngitis; pharyngitis after
several days of coughing or rhinorrhea is more consistent with a
viral etiology
• Contact with others who have GAS or rheumatic fever with
symptoms consistent with GAS raises the likelihood of GAS
pharyngitis
• Headache is consistent with GAS infection
• Cough is not usually associated with GAS infection
• Vomiting is associated with GAS infection, though not exclusively so
• Recent orogenital contact suggests possible gonococcal pharyngitis
• A history of rheumatic fever is important
Signs and Symptoms of Pharyngitis

• The Centor criteria have been used

in the past as a way to diagnose and
treat GAS pharyngitis. These include
the following:
– Fever
– Anterior cervical lymphadenopathy
– Tonsillar exudate
– Absence of cough
Signs and Symptoms of Pharyngitis

• Physical examination includes the following:

– Assessment of airway patency
– Temperature
– Hydration status
– Head, ears, eyes, nose, and throat – Conjunctivitis,
scleral icterus, rhinorrhea, tonsillopharyngeal/palatal
petechiae, tonsillopharyngeal exudate,
oropharyngeal vesicular lesions
– Lymphadenopathy (cervical or generalized)
– Cardiovascular evaluation
– Pulmonary assessment
– Abdominal examination
– Skin examination
Diagnosis of Pharyngitis

• Laboratory studies that may be helpful include the following:

– Group A beta-hemolytic streptococcal rapid antigen detection test
(preferred diagnostic method in emergency settings)
– Throat culture (criterion standard for diagnosis of GAS infection [90-
99% sensitive])
– Mono spot (up to 95% sensitive in children; less than 60% sensitive in
infants)
– Peripheral smear
– Gonococcal culture if indicated by the history
– A throat swab
• Imaging studies generally are not indicated for uncomplicated
viral or streptococcal pharyngitis. However, the following may
be considered:
– Lateral neck film in patients with suspected epiglottitis or airway
compromise
– Soft-tissue neck CT if concern for abscess or deep-space infection
exists
Treatment & Management of Pharyngitis
• Prehospital care usually is not necessary for
uncomplicated pharyngitis unless airway
compromise is an issue.
• Intubation should not be attempted unless the
patient stops breathing spontaneously.
Treatment & Management of Pharyngitis
• Prehospital care usually is not necessary for
uncomplicated pharyngitis unless airway
compromise is an issue. Intubation should
not be attempted unless the patient stops
breathing spontaneously.
– Emergency measures may include the
following:
• Assess and secure the airway, if necessary
• Assess the patient for signs of toxicity, epiglottitis, or
oropharyngeal abscess
• Evaluate hydration status, and rehydrate as
necessary
• Assess for GAS infection if clinically suspected
Treatment & Management of Pharyngitis
• Do not treat patients without a positive culture or positive
rapid antigen detection test result
• Perform a rapid antigen detection test if GAS is clinically
suspected on the basis of the history and physical examination;
if test results are positive, begin antibiotic therapy
• Patients who are positive for all 4 Centor criteria can often be
treated with antibiotics without antigen testing or cultures
• Household contacts of patients with GAS infection or scarlet
fever should be treated for a full 10 days of antibiotics without
testing only if they have symptoms consistent with GAS;
asymptomatic contacts should not be treated
• If the diagnosis is in doubt or the above criteria are not met,
initiation of antibiotic therapy should await rapid antigen test
or culture results
Treatment & Management of Pharyngitis
• Antibiotics
– Penicillin G (drug of choice for GAS pharyngitis)
– Amoxicillin
– Cephalexin
– Azithromycin
– Erythromycin
– Clindamycin
– Ceftriaxone
• Corticosteroids
– Dexamethasone
– Prednisone
• Antifungals
– Nystatin
– Fluconazole