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Contents

27 Complications of Functional Endoscopic Sinus

Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299

Shanmugam Ganesan, Emad Al Duhirat, Hamad Al Saey, Mansour Al Sulaiti, Maryam Abdulraheem, Raa Zahid, and Ahmed Shaikh

28 Neoplasms of the Sinonasal Cavity . . . . . . . . . . . . . . . . . . . . . . . . 317

Andrew Tassler, Charles A. Riley, Chetan Sa, and Michael G. Stewart

29 Cerebrospinal Fluid Rhinorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . 327

Hamad Al Saey, Ahmed Shaikh, Sara Ashkanani, Mansour Al Sulaiti, Emad Al Duhirat, and Shanmugam Ganesan

30 Anterior and Midline Central Skull Base Tumors . . . . . . . . . . . . 337

Sara Ashkanani and Abhishek Menon

31 Epistaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347

Ahmed Shaikh, Hamad Al Saey, Sara Ashkanani, Mashael Alhail, Mansour Al Sulaiti, Maryam Abdulraheem, Emad Al Duhirat, and Shanmugam Ganesan

32 The Nasal Septum and Turbinates . . . . . . . . . . . . . . . . . . . . . . . . 355

Mansour Al Sulaiti, Emad Al Duhirat, Hamad Al Saey, Shanmugam Ganesan, and Abdulaziz Al Jufairi

33 Pitfalls and Pearls in Endoscopic Sinus Surgery . . . . . . . . . . . . . 363

Omar M. Bargas and Ahmad AbuAlsoud

Part IV Head and Neck

34 Thyroid and Parathyroid Glands . . . . . . . . . . . . . . . . . . . . . . . . . 375

Hassan Haidar, Abdelrahman Alsaleh, Waheed Rahman, and Hussein Enezi

35 Diseases of the Salivary Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . 387

Hassan Haidar, Abhishek Menon, and Emad Al Duhirat

36 An Approach to Neck Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397

Suzan Saeed Mohamed, Abhishek Menon, and Waheed Rahman

37 Principles of Management of Head and Neck Cancers . . . . . . . . 409

Anil K. D’Cruz, Richa Vaish, and Harsh Dhar

38 Neoplasms of the Oral Cavity and Oropharynx . . . . . . . . . . . . . 427

Anil K. D’Cruz, Harsh Dhar, Khuzema Fatehi, and Richa Vaish

39 Neoplasms of the Larynx and Laryngopharynx . . . . . . . . . . . . . 449

Ismail Zohdi, Louay ElSharkawy, and Mahmoud ElBestar

xvi

40 Cancer of the Nasal Cavity and Paranasal Sinuses . . . . . . . . . . . 465

Ahmed Eldaly, Mohammed Hassab, and Ali Al Ansari

41 Nasopharyngeal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 479

Aisha Larem, Emad Al Duhirat, and Hassan Omer

42 Difficult Airway Management forENT Surgery

forNon-anesthesiologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487

Nabil A. Shallik, Odai Khamash, and Mohammad Al Nobani

Part V Laryngology and Esophagology

43 Physiology of the Voice and Clinical Voice Assessment . . . . . . . . 515

Mayed Radi Alkhafaji and Dina Emam

44 Inflammatory, Infectious, and Acquired Conditions

of the Larynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521

Aisha Larem, Nal Arimbrathodi, and Raa Zahid

45 Benign Lesions of the Vocal Folds . . . . . . . . . . . . . . . . . . . . . . . . . 531

Mayed Radi

46 Vocal Cord Paralysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539

Rashid Al-Abri and Suresh Pillai

Contents

47 Dysphagia Disorders Evaluation and Management . . . . . . . . . . 547

Mayed Radi Alkhafaji and Olfa Almannai

48 Esophageal Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553

Aisha Larem, Ma’in Ali Al Shawabkeh, and Khalil Sultan

Part VI General Otolaryngology

49 Pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567

Abdulsalam Al-Qahtani and Zaid Altamimi

50 Deep Neck Space Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575

Aisha Larem and Adham Aljariri

51 Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585

Medhat Shams and Hayam AlTaweel

52 ENT Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593

Aisha Larem, Adham Aljariri, Mouna Ghannam, Ahmed Aly, Shaban Mohammed, and Sara Shabana

53 Neck Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 605

Furat Abbas and Hossam Makki

54 ENT Manifestations in Systemic and Inflammatory

Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615

Aya Elderee, Ali Al Ansari, Hassan Haidar, and Mazin Al Khabouri

AL GRAWANY

Contents

xvii

Part VII Pediatrics

55 Anesthetic Considerations forPediatric ENT Surgeries

forNon-anesthesiologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627

Nabil A. Shallik, Ahmed Zaghw, Al Moataz Adham, and Sahar Mahadik

56 Adenoid and Tonsils . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647

Amr A. Elhakeem

57 Branchial Arch: Anatomy and Anomalies . . . . . . . . . . . . . . . . . . 655

Faisal Abdulkader, Francis J. Lannigan, and Mahmoud Taha

58 Evaluation of Pediatric Head and Neck Masses . . . . . . . . . . . . . . 663

Faisal Abdulkader and Niveen Eltigani Elmusharaf Mukhtar

59 Pediatric Head and Neck Vascular Anomalies and Tumors . . . . 671

Faisal Abdulkader and Niveen Eltigani Elmusharaf Mukhtar

60 Evaluation of Stridor and Wheezy Children . . . . . . . . . . . . . . . . 681

Amr A. Elhakeem

61 Managing the Stridulous Child . . . . . . . . . . . . . . . . . . . . . . . . . . . 689

Mai Elhassan

62 Congenital and Acquired Disorders of the Larynx . . . . . . . . . . . 695

Aisha Larem, Faisal Abdulkader, Zaid Altamimi, and Amr A. Elhakeem

63 ENT-Related Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707

Faisal Abdulkader and Mai Ahmed Mohamed Elhassan Ahmed

64 Congenital Anomalies of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . 719

Faisal Abdulkader, Francis J. Lannigan, and Mahmoud Taha

65 Cleft Lip and Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729

Dina Emam, Aya Elderee, and Abdelrahman Alsaleh

66 Pediatric Audiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 737

Abdulsalam Al-Qahtani, Reni K. Chandran, Khaled Abdulhadi, and Zaid Altamimi

Part VIII Facial Plastics

67 Facial Aesthetic Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 749

Rani Hammoud and Hassan Haidar

68 Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 759

Hassan Haidar and Rani Hammoud

69 Otoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 769

Rani Hammoud and Hassan Haidar

xviii

70 Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777

Maryam Abdulraheem, Rani Hammoud, Shanmugam Ganesan, and Alwyn D’Souza

71 Facelifting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 783

Rani Hammoud and Hassan Haidar

72 Fillers and Neurotoxins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 791

Maryam Abdulraheem, Rani Hammoud, Shanmugam Ganesan, and Alwyn D’Souza

Contents

AL GRAWANY

Part I

Audiology

General Audiology

Ma’inAliAl Shawabkeh, HassanHaidar, andKhaledAbdulhadi

1.1 Introduction

Audiological tests are essential in clinical practice as they can guide the management and determine the treatment option for patients. These tests should always be taken as a battery of tests and not relying on a single test, as this will help to give a whole picture of the patient.

1.2 Denitions

• Sound: It is the energy that travels in waves within a medium (like air). A sound wave is composed of compression (more dense) and rarefaction (less dense) waves. Two important terms related to sound are intensity and frequency.

• Frequency: It is the number of waves per sec- ond. Hertz (Hz) is the unit used for measurement of frequency. It is related to the pitch of the sound. The higher the frequency is, the more pitch the sound will be. Sound in nature is complex, which means it is composed of

M. A. Al Shawabkeh · K. Abdelhadi ENT Department, Hamad Medical Corporation, Doha, Qatar e-mail: Khadi@hmc.org.qa

H. Haidar (*) ENT Department, Hamad Medical Corporation, Doha, Qatar

Hamad Medical Corporation, Doha, Qatar

more than one frequency. Pure tone sound, that is, sound composed from single frequency, is rarely found in nature but usually used in audiometer for hearing assessment. Humans are capable of hearing sounds between 20 and 20,000Hz [1].

• Noise: It is a complex aperiodic sound; it can be a white noise if it composed of all the frequencies, a narrow-band noise if it is composed of certain frequencies (above and below specic frequency), or speech noise if it is composed of speech frequencies (i.e., 300–3000Hz).

• Intensity: It is the strength of the sound and consists of the amount of energy produced in an area per time. It correlates to the loudness of the sound. Decibel is the unit used to measure the intensity or loudness of sounds. The normal conversation usually is about 60dB, and the quiet countryside is about 30dB.One hundred and ten decibel can cause discomfort in the ear, and 130dB can cause pain in the ears [2].

• Decibel: It is a relative measure of the intensity of sound. It represents a logarithmic expression of two intensities ratios.

• Sound pressure level (SPL): It is related to the intensity of the sound and considered an absolute pressure reference level for the decibel. Zero dB SPL=0.0002dyn/cm

• Hearing level (HL): It is the most common reference used in audiometers. Zero dB HL means that normal human ears will perceive

https://doi.org/10.1007/978-3-030-54088-3_1

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M. A. AlShawabkeh et al.

the sound at any given frequency in 50% of the times.

• Sensation level (SL): Here, the reference is the threshold for an individual. Zero SL means that an individual can hear the sound at a given frequency in 50% of the times.

• Recruitment: It is the abnormal growth of loudness. It indicates a cochlear hearing loss. Patients with this condition are poor candidates for hearing aid.

• Most comfortable level: It is the intensity of the sound that is more comfortable to the patient.

• Loudness discomfort level: It is the intensity of the sound that will produce discomfort to the patient.

• Dynamic range: It is the range between the loudness discomfort level and the most comfortable level. Patients with recruitment will have a reduced dynamic range.

1.3 Assessment ofHearing

1.3.1 Clinical Tests

1.3.1.1 Tuning Fork Tests

There are different forks with each having specic frequencies. There are 128, 256, 512, 1024, 2048, and 4096Hz. Five hundred twelveHertz tuning fork is the most suitable one used for hearing assessment, because the one with low frequency will give a bone vibration sensation that means it is felt rather than heard, while the one with high frequencies will give a short decay time [3].

Weber test: It is the test of lateralization; the

tuning fork is put on the middle of the forehead after being activated, and then assess where the patient will hear the sound better.

• Normal hearing: there will be no lateralization of the sound (in the center).

• Unilateral Conductive hearing loss (CHL): he will lateralize the sound to the diseased ear.

• Unilateral Sensorineural hearing loss (SNHL): the patient lateralizes the sound to the normal ear.

Table 1.1 Interpretation of negative and positive Rinne

tests’ results of the different types of tuning forks

Degree of air-bone gap (AB

256Hz 512Hz 1024Hz Negative

Rinne Negative Rinne Negative Rinne

Positive Rinne Negative Rinne Negative Rinne

Positive Rinne Positive Rinne Negative Rinne

gap) (dB) 20–30

30–45

45–60

Rinne test: In this test, the tuning fork (after being activated) is put on the mastoid process for a given ear (it will assess the bone conduction (BC)) and then 2cm lateral to the external auditory canal of that ear (it will assess the air conduction (AC)), and the patient is asked which sound heard better.

• Normal hearing: It will give a positive Rinne,

which means AC is better than BC.

• CHL: It will give a negative Rinne, which

means BC is better than AC.

• SNHL: It will give a positive Rinne. Look at

Table 1.1, which gives an interpretation of

negative and positive Rinne tests’ results of

the different types of tuning forks.

For other tuning forks clinical tests, look at Table1.2.

1.3.2 Audiometric Tests

1.3.2.1 Pure Tone Audiometry

The audiometer is a device used for hearing assessment. It can measure the threshold for air conduction and bone conduction. In AC, 250, 500, 1000, 2000, 4000, and 8000 Hz are used, while in BC, 8000Hz is not measured. Pure tone average (PTA) is the average threshold of AC.Table1.3 shows the different symbols used in an audiogram.

Hearing assessment can show:

(a) Normal hearing: if all threshold within the

normal level.

1 General Audiology

Table 1.2 Other tuning forks clinical tests

Test How to perform the test Normal hearing CHL SNHL Bing test The tuning fork is put on the

Schwabach test

Absolute bone conduction

Note: In Gelle test, the tuning fork is put on the patient’s mastoid process, and then a different amount of pressure level is applied to the tympanic membrane (TM). Patients with normal TM and ossicles will notice a decrease of sound while the pressure is increased, while patients with ossicular discontinuity or xation will appreciate no change in sound. It was used before to detect patients with otosclerosis

mastoid process of the ear, and the examiner closes and opens the patient’s ear canal by his nger The tuning fork is put on the mastoid process of the patient till the sound will stop, then the examiner will put that fork to his mastoid process The tuning fork is put on the patient’s mastoid process and then on the examiner’s mastoid process. The external auditory canal of the patient and the examiner should be occluded

Positive Bing, which means the patient will hear the sound louder when the ear is occluded

Normal Schwabach; The patient will stop hearing the sound same as the examiner (given that the examiner has a normal hearing) Both the patient and the examiner will hear the sound for the same period

Negative Bing; there will be no change in the appreciation of the sound while the ear is opened or closed Prolonged Schwabach; the patient will hear the sound for a more extended period than the examiner Both the patient and the examiner will hear the sound for the same period

Positive Bing

Diminished Schwabach; the patient will stop hearing the sound before the examiner

The patient will hear the sound for a shorter period

Table 1.3 Different symbols used in an audiogram

Interpretation Right ear Left ear

Unmasked AC X

Masked AC

Unmasked BC < >

Masked BC [ ]

No response

Soundfield S S

(b) CHL: if BC within normal threshold but AC

shows some hearing loss.

degree of hearing loss.

(d) Mixed: Both AC and BC show a hearing loss,

but AC has more severe hearing loss than BC.

• Low-frequency SNHL: found in endolym-

phatic hydrops.

• High-frequency SNHL: found in presbycusis

and ototoxicity.

• Carhart notch: found in otosclerosis.

• 4kHz Notch: found in noise-induced hearing

loss.

• Cookie Bit (U-shaped): found in hereditary

Look at Fig. 1.1 that represents a different

hearing loss.

type of audiograms.

Masking

Note

• Maximal CHL is 60 dB, and it is found in cases of an intact TM with ossicular discontinuity.

Interaural attenuation is the amount of sound needed to make it cross to the contralateral ear (non-tested ear); because of that, the tested sound should not exceed that level to prevent

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Frequency in hertz (hz)

Hearing threshold level in descibels (db)

120

8000

Frequency in hertz (hz)

M. A. AlShawabkeh et al.

125 250 500 1000 2000 4000 8000

100

110

120

Hearing threshold level in descibels (dB)

100

110

120

[

125 250 500 1000 2000 4000 8000

[

]]

[

Frequency in hertz (Hz)

[

]]

XX X

[

]

125 250 500 1000 2000 4000

Hearing threshold level in descibels (db)

100

110

120

Hearing threshold level in descibels (db)

100

110

[

125 250 500 1000 2000 4000 8000

[

Frequency in hertz (hz)

[

]

[[

[

]

[

]

[

]

[

]

Fig. 1.1 Different types of audiograms. (a) Normal hearing in the right ear, (b) mild SNHL in the right ear, (c) bilateral

CHL, (d) bilateral mixed hearing loss

crossover, otherwise masking is needed. In AC testing, the interaural attenuation for stimuli delivered via headphones ranges from 35 to 50 dB, and it is 60 to 65 dB for the stimuli delivered via the earphones. In BC testing, it is 0dB [4].

To prevent crossover, masking should be used

ear is more than 70dB the BC in the non-tested ear for the insert earphones. Masking also should be used in the BC test if the AB gap in the tested ear is more than 10dB.

While testing a dead ear, sound can cross to

the non-test ear giving a shadow curve.

For degree of hearing loss, look at Table1.4. in the non-test ear. Masking is a narrow-band noise for pure tone audiometry or wideband noise for speech audiometry. Masking should be used while doing AC test in cases where the AC in the tested ear is more than 40dB the BC in the nontested ear for the headphones, or AC in the tested

1.3.2.2 Speech Audiometry

Here the stimulus is the spoken words; it can be either Speech Reception Threshold (SRT) or Word Recognition Score (WRS) (Speech Discrimination Score):

1 General Audiology

Table 1.4 Degree of hearing loss

0–25dB HL Normal 26–40dB HL Mild 41–55dB HL Moderate 56–70dB HL Moderately severe 71–90dB HL Severe Above 91 Profound

Table 1.5 The interpretation of WRS results

WRS (%) Interpretation 90–100 Normal 76–88 Slight difculty 60–74 Moderated difculty 40–58 Poor 40 Very poor

Note: In normal individuals, as the intensity of the sound at which PB words are presented increases, the score will increase until it reaches 100%. In SNHL of cochlear origin, it will reach a plateau at which the WRS score will not increase. However, in SNHL of retrocochlear origin, as sound’s intensity increases, WRS will not maintain that plateau and then it will fall down; this condition is called RollOver Phenomenon. Look at Fig.1.2

(a) SRT: the stimulus is spondee words (i.e.,

two-syllable words that have the same stress on each syllable as in “eardrum”). The threshold is the lowest intensity at which the patient repeats the words in 50% of the time. SRT should be within 10dB of the measured PTA.

(b) WRS: the stimulus is phonetically balanced

(PB) words, which are presented to the patient at 30–40 dB above SL. The patient will hear 50 words. The result is the percentage of the words that the patient will repeat correctly. The interpretation of the results is shown in Table1.5.

1.3.2.3 Immittance/Impedance Test

objective one, and it can measure ear canal volume of the tested ear and the compliance of its TM at different pressure levels, which will be shown on a chart called tympanogram. A normal test will show a type A graph; in adults, the peak compliance will be 0.3–1.4 (mean 0.8), the peak will be at average 0mm H

O pressure (between

−50mm H2O till +50mm H2O is considered nor- mal), and ear canal volume is 0.6–1.5mL (mean

1.1). In pediatrics, the peak compliance will be

0.2–0.9 (mean 0.5), the peak will be at average 0mm H2O pressure (between −50mm H2O till +150 mm H

O is considered normal), and ear

canal volume is 0.4–1.0 mL (mean 0.7). There are ve types of tympanogram graphs:

1. Type A: is the normal one and discussed above.

2. Type B: a at one, and it can indicate either: (a) Fluid behind the TM: the volume of the

ear canal will be normal.

(b) TM perforation: the volume of the ear

canal will be high.

wax: the volume of the ear canal will be low.

3. Type C: the peak will be at negative pressure, and this will indicate Eustachian tube dysfunction.

4. Type As: The peak will be shallow, and this can indicate wither: (a) Otosclerosis. (b) Tympanosclerosis. (c) Malleus xation.

5. Type Ad: The peak will be high, and this indicates either: (a) Flaccid TM. (b) Ossicular discontinuity.

Tympanometry

This device is composed of a probe inserted in the tested ear canal. It has three channels, the rst will deliver a 226Hz tone, this tone will go to TM and then either get reected or absorbed, the second channel will collect the reected sound, and the last channel will make changes of the pressure inside the ear canal. A compliant TM will reect less sound than a stiff TM.This test is an

Look at Fig.1.3 which shows different types

of tympanograms.

Acoustic Reex

In the case where there is an exposure to a highintensity sound, there will be a reective contraction of the bilateral stapedial muscle making the TM stiffer; this is a protective mechanism of the ear against high-intensity sounds. This reex is

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