
- •In an adult by pulling the auricle upwards, outwards and backwards. Inconstant
- •Incudis in the aditus, and the annular ligament attaches the footplate of the
- •Inferior tympanic branches of the sympathetic plexus of the internal carotid
- •Via the cochlear aqueduct.
- •Internal Ear
- •Intensity of the stimulating source. These are known as cochlear microphonics
- •Inferior turbinate is a separate bone attached to the maxilla. Each turbinate
- •In the normal nose these parts can rarely be seen from the front. Between these
- •Venous drainage from the nasal cavity is through the sphenopalatine foramen to
- •Vasoconstriction and diminished secretion, arise from the superior cervical
- •Infection to the meninges.
- •In the adult. The lateral wall is contiguous with the internal carotid artery,
- •Immunoglobulin a (IgA), immunoglobulin m (IgM), and immunoglobulin g (IgG).
- •Vertebra.
- •Internal and external ligaments and membranes unite the cartilages and stabilise
- •Vein and for the internal branch of the superior laryngeal nerve which supplies
- •Internal laryngeal musculature. In addition, it provides sensation to the
- •Vital and Communicative Functions of the Larynx
- •Is therefore of interest to the otolaryngologist. Furthermore, endoscopic
- •Is held open by 16 to 20 horseshoe-shaped cartilaginous rings. The posterior
- •Vascular supply. The trachea is mainly supplied by the inferior thyroid artery
- •In combination with other non-pathogenic organisms. Less often Staphylococcus
- •Infection may be seen as a small, red, circumscribed and very tender swelling on
- •Injected along the upper wall of the meatus. Excessive force should not be
- •Infection entering the middle ear through the perforation from the external
- •It is in the upper respiratory tract that the source of infection will be found.
- •In all cases the aim of the treatment is to produce a safe, dry ear and, if
- •In addition the tympanic membrane and ossicles were removed, and the Eustachian
- •It is diseased, a homograft incus, to reconstitute the ossicular chain. Where
- •Incus are removed and, if this mobilizes the malleolar handle, the drum
- •Intramuscular injection starting with 1 million units (benzylpenicillin)
- •Incision is made, the mastoid bone is exposed and Shipo's triangle identified.
- •I.E. Cholesteatomatous erosion of the bony capsule of the labyrinth, usually the
- •Initial stages. Sedation with labyrinthine sedatives is required, dimenhydrinate
- •Intracranial complications. It is more common in the posterior than in the
- •Is associated with deep-seated boring pain, tenderness on tapping over the
- •Infections although more frequently in the latter. The local inflammation in the
- •Intervals between the rigors the patient is free from symptoms, although in
- •Is recommended. When active surgical intervention is required this consists of
- •Intracranial pressure. The patient's initial conscious level may be normal but
- •5Ml may be introduced is turbid. Surgery of the underlying ear disease should be
- •Venous system of the neck via the facial vein, but also drain via the angular
- •Initial catarrh occurs in influenza and infection with other types of viruses
- •Includes decongestant nose drops or oral decongestants. Antibiotics should only
- •Inflammation with gradual irreversible to the mucosa; infection in the sinuses,
- •Vascular-type face-aches arise.
- •Is a common problem, and rather than blindly instigating medical or surgical
- •Is affected, it can be removed locally. Only a very limited portion of the
- •Infection, particularly of the sinuses, should be sought and treated. Twenty
- •In more severe cases there is a vascular-type face-ache which throbs and becomes
- •Increasing around midday and decreasing in the afternoon. Sphenoidal sinusitis,
- •Inhalation of dust or fumes, is a further predisposing factor.
- •Infection, but is unlikely to be found unless the X-ray is carried out during an
- •1. Lavage of the sinus.
- •In the floor of the maxillary sinus if the cyst is small. When the cyst fills
- •Vary greatly in their tolerance of nasal obstruction, some complaining bitterly
- •In the young, but when it is successful a smooth, greyish-white, spherical mass
- •Inflammations of the pharynx
- •In localized forms, the disease is restricted to the tonsil, the nose, the
- •Injuring the major vessels of the neck. The incision is made parallel to the
- •If these measures fail and there is increasing dyspnea, the child must be
- •In addition to redness, this type displays a hypertrophy in the supraglottis and
- •Investigation is indicated, whose objective is shown in Table 1.
- •In appearance. The skin is coarse and pitted, and has an oily appearance due to
- •Intense headaches. In later disease pain is a prominent feature. Spread to lymph
- •Very least of maxillectomy with the fitting of an obturator, and before
- •If the soft tissues of the cheek are infiltrated by tumour, this area will have
- •Vessels. In later stages there is swelling of the lateral part and the face of
- •Immediately to further surgery if massive bleeding occurs.
- •Investigations. Radiography is not usually helpful except to see if there has
- •Vocal cord either on a pedicle or sessile. It is seroedematous and occasionally
- •Immunologic and antiviral treatment are used. Today there is no alternative to
- •Ventricles
- •Inherited Syphilis
- •Infiltration, dark red in colour, involving one or both sides of the septum.
- •Is found on the nasal septum syphilis should be suspected. The diagnosis is made
- •Venerologist. Local hygiene is necessary and the highly contagious nature of the
- •Is a rare complication of the pulmonary lesion. It is characterized by minute
- •It is, however, sound surgical practice to remove the tonsils from children who
- •If a hematoma is not treated, connective tissue organization, secondary
- •Into the bony labyrinth and the internal auditory meatus. In both cases the dura
- •View, tomograms, and possibly ct in patients with facial paralysis or csf
- •Vestibular provocation nystagmus in the presence of vertigo, and more rarely
- •Inflammatory diseases of the eustachian tube should be dealt with. These
- •In gunshot trauma there is a short stabbing pain in the ear, a marked continuous
- •Inevitably cause considerable soft-tissue swelling. This becomes marked very
- •Incisions are again made on both sides of the septum, the pus is removed and a
- •Vomiting, sialorrhea, and at times glottic edema and dyspnea. White corrosive
- •Introduced. Contraindications include shock and suspected perforation. Immediate
- •In any long-standing cases of nasal discharge
- •Impacted foreign bodies cause necrosis of the esophageal wall leading, depending
- •View should be obtained; the nose is less likely to be actively bleeding, and a
- •Is told to swallow it. At the moment at which he does so, just as the larynx is
- •Interesting point about it is that although it was first described over a
- •Is almost no evidence to support this theory. Allergy has been blamed,
- •Infections.
- •In nearly 50% of cases a history of deafness in the family can be obtained. The
- •Is likely to progress rapidly. Paracusis Willisii is frequently present,, I.E.
- •Include allergy, focal infection, biochemical disturbance, vitamin deficiency,
- •Is due to the inability to hear higher frequencies which means that consonant
Lecture 1KURSK STATE MEDICAL UNIVERSITY
Department of otorhinolaryngology
N.A. Konoplya
OTORHINOLARYNGOLOGY
SELECTED PROBLEMS
Textbook for Medical Students
Kursk – 2005
Printed according the decision
of the editorial-publishing
council of the KSMU
Konoplya N.A. Otorhinolaryngology Selected Problems. [Text] textbook for Medical
Students / Edited by professor S.Z. Piskounov, associate professor V.I.
Narolina. - Kursk: KSMU. - 2005. - 248 p.
The Textbook should be used by foreign students in reading up before practical
classes. The Textbook present anatomy and physiology of the nose, pharynx,
larynx and ear. It cover the problems of propedeutics, development, diagnostics,
treatment and prophylaxis of the ENT-diseases. The lectures are based on the
recent developments in otorhinolaringology.
Revised by Head of the Othorhinolaryngology Departament of the BSMU, doctor of
Medicine, Professor N.A. Arefyeva.
Computer registration: Gavriliouk V.P.
© N.A. Konoplya, KSMU, 2005
Contents
Part 1.Anatomy and physiology of the ear……………………....7
Part 2.The nose, paranasal sinuses and pharynx………………24
Part 3.Anatomy and physiology of the larynx, trachea bronchial tree
and esophagus……………………………….....43
Part 4.Diseases of the ear…………………………………………55
Part 5.Complications of otitis media………………………………75
Part 6.Diseases of the nose and paranasal sinuses……………97
Part 7.Pharynx diseases…………………………………………..127
Part 8.Diseases of the larynx……………………………………...144
Part 9.Tumors and infectious granulomas of the upper
respiratory tract……………………………………………..157
Part 10.Traumas, foreign bodies, hemorrhages in the ear,
nose, pharynx, larynx, trachea, bronchi and esophagus and emergent aid in
these cases…………………………179
Part 11.Non-suppurative diseases of the ear……………………..212
Part 1
ANATOMY AND PHYSIOLOGY OF THE EAR
ANATOMY
The ear can be divided anatomically and clinically into three parts - the
external ear, the middle ear and the internal ear. The external and middle ears
are concerned primarily with the transmission of sound. The internal ear
functions both as the organ of hearing and as the part of the balance system of
the body.
THE EXTERNAL EAR
The external ear consists of the pinna or auricle and the external acoustic
meatus.
The Auricle
The auricle has lobule, tragus, antitragus, helix, antihelix, shapha, fossa
triangularis , cavum conchae (Fig. 1).
The auricle has two surfaces, lateral and medial. The underlying skeleton of the
auricle consists of a plate of yellow elastic cartilage, except for lobule which
is composed only of fat and fibro-areolar tissue. The skin on the lateral
surface is closely adherent to the perichondrium. The auricle is attached to the
side of the head by ligaments and the largely functionless anterior, superior
and posterior auricular muscles.
The External Acoustic Meatus
In adults the external acoustic meatus measures about 24 mm from the introitus
to the tympanic membrane, its medial limit. Since the tympanic membrane lies
obliquely at the inner end of the meatus, the anterior and inferior walls are
longer than the posterior and superior walls. At the junction of the inferior
wall with the tympanic membrane there is a depression, the inferior meatal
recess. This recess can be difficult to see and can contain an unsuspected
reservoir of debris in an infected ear.
The meatus is composed of two parts: an outer or lateral third, which has a
cartilaginous skeleton continuous with that of the auricle, and an inner or
medial two-thirds which has a bony skeleton (Fig. 2). The general direction of
the cartilaginous meatus is medially , upwards and backwards whilst that of the
bony meatus is medially, slightly downwards and forwards. There are two
constrictions in the canal, one at the junction of the cartilaginous and bony
part and the other in the osseous part. The meatus may be partially straightened
In an adult by pulling the auricle upwards, outwards and backwards. Inconstant
deficiencies of the cartilaginous meatus occur, known as the fissures of
Santorini, and they may provide a pathway for infections to spread from the
meatus to the parotid gland and superficial mastoid tissue or vice versa.
The skin lining the external meatus is continuous with that of the auricle. The
sebaceous glands, ceruminous glands and hair follicles are present only in the
cartilaginous portion. The skin is closely adherent to the underlying tissues,
and for this reason furuncles in the cartilaginous portion of the canal are
extremely painful owing to the increased tension in the tissue.
The anterior wall of the external meatus forms part of the temporomandibular
joint. The superior wall is a part of the base of the skull. It separates the
external acoustic meatus from the middle fossa of the skull. The inferior wall
is contiguous with the parotid gland. The posterior wall of the external
acoustic meatus is also the anterior wall of the mastoid process.
The auricle and external meatus are supplied by branches of the
Vth(auriculotemporal n.), VIIth(temporal branches) and Xth(auricular branches)
cranial nerves. The medial or posterior surface of the auricle is supplied by
fibres of the great auricular nerve (C2 and C3) and the lesser occipital nerve
(C2).
The blood supply of the auricle comes from the superficial temporal(E.C.A.) and
posterior auricular (E.C.A.) arteries. The meatus is also supplied by these
vessels but it receives a further supply in its inner part from the deep
auricular branch of the maxillary artery(E.C.A.). The veins accompany the
arteries.
The lymphatics of the auricle and external meatus drain anteriorly into the
pre-auricular (parotid) glands, inferiorly into the superficial cervical nodes
along the external jugular vein, and posteriorly into the retroauricular
(mastoid) glands. The retro-auricular glands also drain adjacent areas of the
scalp, infection of which may produce swelling and tenderness of the mastoid
area. This can lead to an erroneous diagnosis of acute mastoiditis.
Tympanic Membrane
The tympanic membrane, or drumhead (Fig. 3), separates the external meatus from
the middle ear and functionally is the part of the middle ear. The rim of the
tympanic membrane consists of a fibrocartilage ring deficient in its superior
part. This ring sits in a bony sulcus, the tympanic annulus, which lies at the
medial end of the external meatus. There is a deficiency superiorly of both the
cartilaginous annulus and the bony annulus known as the notch of Rivinus. It
lies medial to the pars flaccida of the drum. The tympanic membrane is thin and
when examined with an auriscope has a pearly grey colour with a triangular
bright area, the cone of light, extending from the centre (the umbo) downwards
and forwards. The membrane has an outer layer of squamous epithelium continuous
with that of the meatus, a middle layer of fibrous tissue which has radiating
and circular fibres, and an inner layer of mucous membrane continuous with the
lining of the tympanic cavity. The fibrous tissue layer is deficient in the area
of membrane bounded by the notch of Rivinus which, being less tense, is known as
the pars flaccida or Shrapnell's membrane. The lower margins of this part are
thickened and extend from the ends of the notch of Rivinus to the lateral (or
short) process of the malleus forming the anterior and posterior folds of the
membrane. The rest of the tympanic membrane is known as the pars tensa. The
prominence between umbo and lateral process of the malleus is a handle of the
malleus.
The nerve supply of the outer surface of the drum is similar to that of the
adjacent external meatus. The anterior portion is therefore supplied by the
auriculotemporal branch of mandibular nerve, and the posterior portion is
supplied by the auricular branch of the vagus. The inner surface is supplied
from the tympanic branch of the glossopharyngeal nerve.
The outer surface of the tympanic membrane has a blood supply from the deep
auricular branch of the maxillary artery. The inner surface receives branches
from the posterior auricular artery and from the maxillary artery through its
tympanic branch.
THE MIDDLE EAR
The middle-ear cleft in the temporal bone includes the Eustachian tube, the
tympanic cavity, and the aditus which leads posteriorly to the mastoid antrum
and air cells. Anteriorly the Eustachian tube opens into the nasopharynx from
which the cleft develops in early fetal life.
The Tympanic Cavity
The tympanic cavity, lies between the tympanic membrane laterally and the
labyrinth medially. Its upper part extending above the tympanic membrane is
known as the epitympanic recess or attic, the lower part extending below the
level of the floor of the external auditory meatus is referred to as the
hypotympanum, the middle part is known as the mesotympanum (Fig. 4).
The cavity may be described as a 6-sided box, frequently likened in shape to a
match-box standing on end with its vertical length greater than its breadth, but
narrow in depth, particularly portion where the basal turn of the cochlea forms
a bulge on the medial wall. The roof of the cavity is formed by a thin plate of
bone (the tegmen tympani), formed partly by the petrous part of the temporal
bone and the squamous part. This plate of bone also forms the roof of the
mastoid antrum and separates the tympanic cavity and antrum from the middle
fossa of the skull. The floor, which is also thin, separates the cavity from the
bulb of the internal jugular vein which may be exposed by bony deficiensy. The
tympanic branch of the glossopharyngeal nerve enters the cavity through the
floor.
The anterior wall in its lower portion is formed by a thin plate of bone
separating the cavity from the internal carotid artery. The upper portion has
two openings, the lower one being the auditory (pharyngotympanic or Eustachian)
tube and above it lies the canal for the tensor tympani muscle.
The posterior wall is wider than the anterior wall and its upper part the aditus
connects the epitympanic recess (attic) with the mastoid antrum. Below the
aditus a bony projection, the pyramid, gives exit to the tendon of the stapedius
muscle. Just above the pyramid the fossa incudis gives attachment for the short
process of the incus. Below the pyramid is a depression, the sinus tympani,
which runs deep to the facial nerve and is continuous inferiorly with the
hypotympanum. The facial nerve bends downwards at the level of the floor of the
aditus and lies in close relation to the posterior wall. Posterolaterally to the
Fallopian canal in the aditus lies the rounded prominence of the bony wall of
the horizontal semicircular canal.
The lateral wall (Fig. 5) is formed mainly by the tympanic membrane and the
outer bony wall of the epitympanic recess (attic). The medial wall is also the
lateral wall of the internal ear. There are two openings in it, the upper of
which is the oval window (fenestra vestibuli) and below it is the niche leading
to the round window (fenestra cochleae), which is closed by the secondary
tympanic membrane. In front of and between these two windows lies the
promontory. The surface of this bony covering of the basal coil of the cochlea
is grooved for the nerve fibres of the tympanic plexus. The horizontal portion
of the facial nerve is enclosed in a bony canal (the canal of Fallopius), which
is sometimes deficient, and which crosses the medial wall above the oval window
before turning vertically downwards at the posterior end of the window. The
processus cochleariformis, containing the tendon of the tensor tympany, is
situated on the anterior and superior part of the medial wall in front of the
point of entry of the facial nerve from the inner ear.
The mucosal or epithelial lining of the tympanic cavity is of columnar ciliated
epithelium in that part derived from the tubotympanic recess, but in a
posterosuperior direction there is a transition to cuboidal epithelium and
finally to a flattened single-layer epithelium lining the mastoid antrum and air
cells.
The Ossicles
The three ossicles, clothed in mucosa and supported by ligaments, form an
articulated connection between the tympanic membrane and the oval window. The
malleus consists of a head, neck, anterior and lateral processes and handle. The
handle is attached to the drumhead and the head is situated in the attic
articulating with the body of the incus, the short process of which has a
ligamentous attachment to the floor of the aditus. The long process of the incus
extends downwards and its lentiform process articulates with the head of the
stapes. The stapes, suitably named from its stirrup-shaped appearance, has a
head, a neck, two crura or limbs, and a footplate which is fixed to the margins
of the oval window by an annular ligament.
The tensor tympani muscle arises from the cartilaginous part of the auditory
tube, from the adjacent part of the greater wing of the sphenoid and from the
bony canal in which it lies. Its tendon bends laterally around the processus
cochleariformis and is inserted into the medial surface of the malleus near the
neck. The nerve supply is from the motor division of the trigeminal nerve,
through the otic ganglion, and its action is to tense the tympanic membrane by
drawing it medially. The tendon of the stapedius muscle, after emerging from the
pyramid, is inserted into the neck of the stapes. It has an action of damping
the movement of the stapes by tilting outwards the anterior end of the
footplate, and it is supplied by the facial nerve.
Tympanic Ligaments and Spaces
The anterior and posterior ligaments of the malleus surround its neck and
jointly form the axis ligament attached to the anterior and posterior ends of
the tympanic notch. From the head of the malleus and the body of the incus a
superior ligament suspends each from the roof of the attic. The posterior
ligament of the incus attaches the short process of the incus to the fossa