Acute otitis media (急性中耳炎) Aetiology: Acute infection of the middle ear cleft, common in young children. This usually occurs as part of an upper respiratory tract infection, with Haemophilus influenzae and Pneumococcus being the most common pathogens. Clinical features: Presents as severe otalgia and deafness. The tympanic membrane is red and bulging. Rupture may occur leading to purulent otorrhoea. Management: Treat with oral antibiotic therapy (amoxicillin, cotrimoxazole or erythromycin) and adequate analgeria.
Aetiology: Middle ear effusion is often associated with Eustachian tube obstruction, either acute during upper respiratory infections or chronic as in childhood adenoid hypertrophy. In adults middle ear effusion may result from Eustachian tube obstruction by a nasopharyngeal neoplasm. Changes in atmospheric pressure occurring during flight or diving may also result in effusions: otitic barotrauma. Incidence: Middle ear effusion is a common pediatric problem, particularly in the 4-7age group. Clinical features: On otoscopy the tympanic membrane is dull with a loss of light reflex. Small vessels are often seen radiating from the handle of the malleus and occasionally a fluid level is seen. Deafness in children may lead to poor language development and educational performance. Diagnosis may be confirmed by impedance audiometry in which the compliance of the tympanic membrane is measured in response to pressure changes in the external auditory meatus. Management: Medical treatment – consists of the use of topical and systemic decongestants. Surgical treatment – consists of myringotomy and insertion of a ventilation tube into the affected tympanic membrane. Children may also require an adenoidectomy whilst in adults a nasopharyngeal tumor must be excluded.
Presents as a persistent frontal headache or, if a mucocele develops, a unilateral proptosis. A pyocele may result from secondary infection of a mucocele. X-rays show an opaque sinus, often with hazy, indistinct edges. A CT scan will show a soft tissue mass filling the sinus.
Surgical treatment is aimed at re-establishing aeration of the frontal sinus. The area of the frontal recess leading into the frontal sinus can be approached either endoscopically through the nasal cavity or via an external incision. Obliteration of the frontal sinus via an osteoplastic flap approach is a radical procedure very rarely required.
Disease is commonly bilateral unless there is an underlying septal deviation, unilateral polyp or history of maxillary trauma. A past history of dental treatment may be relevant.
Usually presents with chronic facial pain or upper jaw toothache. Other presentations include a purulent postnasal drip, chronic laryngitis or otitis media. Examination is often normal but paranasal sinus X-rays usually demonstrate antral disease, in the form of mucosal thickening, a persistent fluid level or total opacification.
Treatment involves the creation of intranasal antrostomies to ventilate and drain the antra. Antrostomies are now normally performed endoscopically through the middle meatus. In severe cases a Caldwell-Luc approach can be used to remove diseased antral mucosa.
Aetiology: Stasis and acute infection of sinus secretions may result from any pathological or anatomical abnormality obstructing free sinus drainage. The common cold is the most frequent cause. Acute maxillary sinusitis can also result from apical infection of an upper tooth root. The causative organism is usually Pneumococcus, Streptococcus viridans or Haemophilus influenzae. Complications: Left untreated, acute sinusitis can rarely lead to orbital cellulitis, cavernous sinus thrombosis or intracranial abscess formation. Chronic sinusitis is a far more common sequela. Maxillary sinusitis Clinical features: Most common type overall. Facial or dental pain may occur, as may referred otalgia. Nasal obstruction and purulent rhinorrhea are also frequent. Local tenderness may be the only physical sign. An occipitomental X-ray usually shows a fluid level on one or both sides, but this investigation is increasingly being replaced by CT scanning. Management: Treat with antibiotics and topical nasal decongestants. An antral washout through the inferior meatus may be necessary if resolution with antibiotics does not occur, but this form of treatments is decreasing in popularity with the advent of endoscopic management of sinusitis. Ethmoiditis Incidence: Most common in young children who have poorly developed maxillary sinuses. Clinical features: Usually presents as persistent headache and orbital cellulitis following a cold. Untreated, an orbital abscess and blindness may occur. Management: Treatment requires hospital admission. Antibiotics are given and the maxillary sinuses washed out if also infected. Rarely, an external ethmoidectomy may be necessary. A CT scan should be performed if there is any question of an orbital abscess. Frontal sinusitis Potentially the most serious acute sinusitis. The long course of the frontonasal duct makes it particularly prone to obstruction by mucosal oedema. Clinical features: Presents as frontal headache after an upper respiratory tract infection. Local tenderness is common, but may be the only sign. A sinus CT scan usually shows a fluid level or complete opacification in one or both sinuses. Management: Treatment is with antibiotics, but sinus trephine and insertion of drainage tubes is undertaken if rapid resolution does not occur. Sphenoiditis Clinical features: This rare form of sinusitis may present as a deep central, reto-orbital or vertex headache. Diagnosis is confirmed by a lateral X-ray or CT scan. Sinus drainage may be necessary if there is not a quick response to antibiotic therapy.
A ball of keratinizing stratified squamous epithelium in the middle ear cleft or mastoid which enlarges and can destroy or erode local structures. It is a feature of the unsafe type of chronic middle ear disease. Aetiology: The most widely accepted theory of its development is the immigration-retraction pocket theory: in response to Eustachian tube obstruction and negative middle ear pressure an inward retraction of the tympanic membrane occurs, usually in the attic region. Desquamated epithelium normally shed from the membrane into the meatus collects in the pocket, the continued enlargement of which results in the formation of a cholesteatoma sac. Congenital cholesteatoma is very rare and results from congenital squamous cell rests within the temporal bone. Clinical features: Presents as progressive conductive hearing loss with purulent, and often offensive, otorrhoea. Pain or vertigo due to bong erosion may also occur. Otoscopy reveals a retraction pocket or perforation in the attic or posterior marginal region of the tympanic membrane with flaky white debris visible in the defect. Nystagmous and other evidence of neurological involvement should be sought. Management: Radical mastoidectomy involves removal of the cholesteatoma, middle ear structures and bone of the bony external meatus, producing a smooth exteriorized mastoid cavity accessible for inspection. The operation may be modified in order to conserve hearing by retaining part of the ossicular chain and tympanic membrane.
Otogenic vertigo is an hallucination or a false sensation of movement. Disease affecting the vestibular apparatus may produce rotatory vertigo accompanied by horizontal nystagmus.
Involves stimulating the vestibular apparatus by irrigating the external meatus with water at varying temperatures; the duration of induced nystagmus is recorded, allowing comparison between the two sides.
Vertigo provoked by head movements may be a feature of inner ear disease, cervical spondylosis or disease affecting central vestibular pathways in the brainstem.
Unknown. Maybe due to imbalance between production and absorption of inner ear endolymph or disturbance of inner ear immunity.
Episodic rotatory vertigo, tinnitus and sensorineural deafness may be present. Unilateral in early stages.
Vestibular sedatives for acute attacks. Surgery may be conservative (endolymphatic sac decompression) or destructive (labyrinthectomy or vestibular neurectomy). Intratympanic gentamicin is also an option.
Sudden unilateral vestibular failure
Unknown aetiology. Viral infection, ischaemia and inner ear membrane rupture have been postulated.
Presents with sudden onset of vertigo. Recovery takes place by central compensation.
Vestibular sedatives are useful in the acute phase.
Other causes of vertigo are syphilis, suppurative labyrinthitis, temporal fractures and ototoxic drugs.
Disruption of the lower motor neurone facial nerve can occur at any point between its brainstem nucleus and the facial musculature. Bellis (idiopathic) Palsy Clinical features: Most common palsy with no identifiable cause although a viral or vascular aetiology postulated. Palsy may be partial or complete. Management: Total recovery occurs in 90% of cases. Treatment with steroids or surgical decompression controversial. Ramsay Hunt Syndrome Clinical features: Herpes zoster involvement of the facial nerve with herpetic vesicles on the tympanic membrane, pinna or palate. May present with severe otalgia alone. Auditory and trigeminal nerves may be affected. Management: Recovers fully in about 60% of cases. If given early, the antiviral agent aciclovir may enhance recovery. The value of steroids or surgical decompression of the nerve remains unproven. Temporal bone fracture Clinical features: Longitudinal fractures (80%) are associated with a facial palsy in 20% of cases and a conductive deafness. Transverse fractures (20%) are associated with a facial palsy in 50% of cases and a sensorineural deafness. Diagnosis is confirmed by CT scan. Management: Exploration of the nerve may be indicated in cases of immediate, complete paralysis but is likely to be followed by deafness.
Aetiology Simple nasal polyps are pedunculated areas of oedematous mucosa occurring in the nasal cavity and paranasal sinuses. Their aetiology is unknown although chronic sinus infection and mucosal allergy have been suggested. Most polyps arise from the ethmoid sinuses with the maxillary antrum being a less common source. Nasal polyps can be associated with asthma and aspirin sensitivity (aspirin triad). In children, nasal polps may be a manifestation of cystic fibrosis. Clinical features Presents as progressive nasal obstruction and rhinorrhea. On inspection of the nasal cavity, polyps are seen as pale grey, smooth swellings, which can fill the nasal cavity. Most cases are bilateral but in unilateral cases a neoplasm must be excluded by biopsy. An antrochoanal polyp passes from the maxillary sinus via its ostium posteriorly into the nasal cavity to occupy the posterior choana where it can be seen on posterior rhinoscopy and its presence confirmed by lateral radiography. Management Medical treatment: Topical steroid drops or spray administered correctly can cause considerable diminution in polyp size. Surgical treatment: Intranasal polypectomy may have to be repeated as recurrence after polyp removal is common. Many surgeons use endoscopic ethmoidectomy techniques to remove polyps from the ethmoid sinuses.