Table Of ContentT. Metin Önerci
Zeynep Önerci Altunay
Diagnosis in
Otorhinolaryngology
An Illustrated Guide
Second Edition
123
T. Metin Önerci • Zeynep Önerci Altunay
Diagnosis in Otorhinolaryngology
T. Metin Önerci
Zeynep Önerci Altunay
Diagnosis in
Otorhinolaryngology
With 558 Figures and 74 Tables
Second Edition
T. Metin Önerci Zeynep Önerci Altunay
Department of Otorhinolaryngology Department of Otorhinolaryngology
Hacettepe University Faculty of Medicine University of Health Sciences
Ankara Haseki Training and Research Hospital
Turkey İstanbul
Turkey
ISBN 978-3-030-64037-8 ISBN 978-3-030-64038-5 (eBook)
https://doi.org/10.1007/978-3-030-64038-5
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
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Contents
Chapter 1 Ear 2.5 Sinusitis 101
2.6 Complications of Sinusitis 110
1.1 Ear Anatomy 3 2.7 Nasal Polyposis 119
1.2 Vestibular Anatomy 12 2.8 Nasal Obstruction 125
1.3 ENT Examination 17 2.9 Septum 131
1.4 The Pinna 24 2.10 Epistaxis 136
1.5 External Ear Canal 28 2.11 Traumas 140
1.6 Otitis Media with Effusion 35 2.12 Nasolacrimal Obstructions 149
1.7 Acute Otitis Media 39 2.13 Optic Neuropathy 156
1.8 Chronic Otitis Media 45 2.14 Tumors 160
1.9 Facial Nerve Paralysis 55
1.10 Complications of Otitis Media 61
1.11 Hearing Loss 63 Chapter 3 Throat and Neck
1.12 Otalgia 69
1.13 Temporal Bone Fractures 71 3.1 Acute Tonsillopharyngitis 176
1.14 Tinnitus 73 3.2 Adenoids 180
1.15 Vertigo 75 3.3 Snoring 183
1.16 Eustachian Tube 82 3.4 Temporomandibular Joint 194
3.5 Airway Obstructions 196
3.6 Hoarseness 200
Chapter 2 Nose 3.7 Larynx CA 207
3.8 Cysts 213
2.1 The Common Cold and the Flu 86 3.9 Salivary Gland Tumors 216
2.2 Rhinitis 88 3.10 Oral Cavity 220
2.3 Allergic Rhinitis 93 3.11 Neck Masses 228
2.4 Nasal Vestibulitis, Nasal Furunculosis and 3.12 Neck Malignancies 237
Mucormycosis 97
v
Chapter 1
E A R
C O N T E N T S
1.1 Ear Anatomy 3
1.2 Vestibular Anatomy 12
1.3 ENT Examination 17
1.4 T he Pinna 24
1.5 External Ear Canal 28
1.6 Otitis Media with Effusion 35
1.7 Acute Otitis Media 39
1.8 Chronic Otitis Media 45
1.9 Facial Nerve Paralysis 55
1.10 Complications of Otitis Media 61
1.11 Hearing Loss 63
1.12 O talgia 69
1.13 Temporal Bone Fractures 71
1.14 Tinnitus 73
1.15 Vertigo 75
1.16 Eustachian Tube 82
© The Author(s), under exclusive license to Springer Nature 1
Switzerland AG 2021
T. M. Önerci, Z. Önerci Altunay, Diagnosis in Otorhinolaryngology,
https://doi.org/10.1007/978-3-030-64038-5_1
2 Chapter 1 Ear
1.1 Ear Anatomy 3
1.1 covered by skin. The shape of the cartilage is very impor- E
tant since it gives the shape of the auricle. Any necrosis of A
Ear Anatomy the cartilage may lead to cosmetic deformity. The external R
auditory canal measures approximately 25 cm. The outer
one-third is cartilaginous and the inner two-thirds is bony.
The ear is divided into three compartments: external, There is a narrowing at the bone–cartilage junction which
middle, and inner. The pinna is composed of cartilage causes foreign bodies to get stuck in this area. The skin of N
O
S
a c d E
T
H
R
O
A
T
A
N
D
b
N
E
C
K
Fig. 1.1.1 (a) The ear is divided into three compartments: external, part of the ear) into the auditory canal (pink) toward the eardrum.
middle, and inner. The pinna is composed of cartilage covered by The eardrum transmits the vibrations to three tiny bones—the mal-
skin. The shape of the cartilage is very important since it gives the leus, incus, and stapes—in the middle ear. The stapes passes the
shape of the auricle. Any necrosis of the cartilage may lead to cos- vibrations to the inner ear structures (purple), the semicircular canals
metic deformity. The external auditory canal measures approxi- and the cochlea (spiral). Auditory sensations are picked up by the
mately 2.5 cm. The outer one-third is cartilaginous and the inner cochlear nerve (yellow) and transmitted to the medulla (brainstem),
two-thirds is bony. There is a narrowing at the bone–cartilage junc- the thalamus, and ultimately the cerebral cortex (visual photos).
tion which causes foreign bodies to get stuck in this area. The skin of (c, d) The external and middle ear develop from the branchial appa-
the bony part is very thin lying on the periosteum and does not con- ratus. The middle ear cavity is derived from the endodermal first
tain glands, hair follicles, and any adnexal structures. There are two or branchial cleft. The inner ear develops from the otic placode. The first
three fissures in the cartilaginous external auditory canal which are arch, or Meckel’s cartilage, contributes to the malleus and the incus.
called “Santorini fissures.” These fissures provide a potential route for The tensor tympani muscle derives from the first branchial arch and
the spread of infection from the external ear to the parotid area or is innervated by the nerve of the first branchial arch, which is the
infratemporal fossa and also of tumors from the parotid area to the mandibular branch of the trigeminal nerve. The second branchial
external ear. The Eustachian tube connects the middle ear to the arch, or Reichert’s cartilage, contributes to the suprastructure of the
nasopharynx. The posterior one-third of the adult Eustachian tube is stapes. The stapes muscle is innervated by a facial nerve, which is the
bony and lies within the petrous portion of the temporal bone. The nerve of the second branchial arch. The chorda tympani nerve, a
anterior two-thirds is cartilaginous. In adults, the tube lies at an angle branch of the facial nerve (second arch nerve), joins the first arch
of 45° in relation to the horizontal plane, whereas this inclination is nerve to the mandibular lingual nerve. The footplate of the stapes is
only 10° in infants. The tube is longer in the adult than in the infant derived from the otic capsule. Thus, a congenital abnormality can
and young child. (b) Illustration showing the organs of hearing and occur in one part while the other parts may develop normally
the cerebellum. Sound waves are channeled by the pinna (visible
4 Chapter 1 Ear
a
Helix
Fossa triangularis
Cymba concha Antihelix
Scafa
Tragus
Cavum concha
Antitragus
b
Fig. 1.1.2 The anatomy of the auricle
Light cone
c
Fig. 1.1.4 (a, b) The tympanic membrane is elliptical and slightly
Fig. 1.1.3 The external auditory canal is not straight. To see the tym- conical in shape. The apex of this cone, the umbo, marks the inferior
panic membrane, the ear canal should be straightened by pulling the part of the manubrium. The diameter of the tympanic membrane
auricle posteriorly and superiorly in adults (but inferiorly in infants) measures approximately 9 mm (9–10 vertical; 8–9 horizontal). The
surface area is 85–90 mm2. The tympanic membrane is composed of
three layers: an outer epidermal layer, an inner mucosal layer, and a
middle fibrous layer. The area above the short process of the malleus
the bony part is very thin lying on the periosteum and
is known as pars flaccida and the area below as pars tensa. The pars
does not contain glands, hair follicles, and any adnexal flaccida does not have a middle fibrous layer therefore it is flaccid.
structures. There are two or three fissures in the cartilagi- The pars tensa thickens peripherally forming the tympanic annulus.
The tympanic annulus does not exist superiorly around the pars flac-
nous external auditory canal which are called “Santorini
cida. There is a light triangle in the anterior–inferior quadrant of the
fissures.” These fissures provide a potential route for the
tympanic membrane. The position of this triangle changes superiorly
spread of infection from the external ear to the parotid and becomes shorter when the tympanic membrane is retracted.
area or infratemporal fossa and also of tumors from the (c) Endoscopic view of left tympanic membrane (A pars flaccida, B
posterior malleolar fold, C chorda tympani, D pars tensa, E fibrous
parotid area to the external ear.
anulus, F light cone, G umbo, H manubriu m mallei, I -short process of
malleus, K -anterior malleolar fold)
1.1 Ear Anatomy 5
E
A
R
N
O
S
E
T
H
R
O
A
T
A
Fig. 1.1.5 Three smallest bones in the human body responsible for N
conduction of sound waves in the middle ear. At the top right is the Fig. 1.1.6 Due to the differences in the physical properties of air and
D
malleus (hammer), which strikes the incus (anvil—left of malleus); water, sound vibrations in the air are largely reflected away from the
the incus is joined to the stapes (stirrups), which conducts sound surface of the water (99.9% of the energy of air-borne sound is N
toward the inner ear. Sound waves enter the ear through the external reflected away), with only 0.1% entering the water. Although the sur-
E
auditory meatus and cause the eardrum to vibrate. Vibrations from face area of the tympanic membrane is 85–90 mm2, the effective
C
the eardrum are passed to the malleus and then the stapes via the vibrating area of the tympanic membrane is 55 mm2. The surface area
K
incus. The stapes transmits the vibrations to the fluid-filled cochlea of of the footplate is 3.2 mm2. The ratio of the surface areas of the tym-
the inner ear where the vibrations are converted to nerve impulses. panic membrane and the footplate is 55/3.2 = 17.1. This represents
Lever effect: the manubrium mallei is 1.3 times longer than the long the hydraulic ratio of the tympanic membrane and stapes footplate,
process of the incus. This difference in the lengths of the manubrium producing an increased force at the oval window of 17 times for the
mallei and long process of the incus contributes a lever factor of 1.3 human ear since the sound pressure level is equal to the force divided
to increase the intensity of the sound (visual photos) (With kind per- by the surface area (P = F/a). The final transformer ratio of the human
mission of TESAV) tympanic membrane and ossicular chain is the product of the lever
ratio of 1.3 times the hydraulic ratio of 17, which equals 22. This gain
compensates the loss due to the air-bone difference
Incus
Fulcrum
Rotation axis
P
Malleus V
Stapes
A Piston
FP
Stapes
L
suprastructure
A
U TM
P
EC
TM
Piston Rotation axis
Fig. 1.1.7 The lever effect of the ossicular chain is of 1.3 to 1
