Textbook Of Ear, Nose And Throat Diseases, 11th Edition
Textbook ofEar, Nose andThroat Diseases
Textbook ofEar, Nose andThroat DiseasesEleventh EditionMohammad MaqboolMBBS DLO MS FICSEx-Professor and HeadDepartment of OtorhinolaryngologyGovernment Medical CollegeSrinagar, J & KSuhail MaqboolMBBS MSAssistant ConsultantDepartment of ORLKing Fahad Medical CityKSAJAYPEE BROTHERSMEDICAL PUBLISHERS (P) LTDNew Delhi
Published byJitendar P VijJaypee Brothers Medical Publishers (P) LtdEMCA House, 23/23B Ansari Road, Daryaganj, New Delhi 110 002, IndiaPhones: 91-11-23272143, 91-11-23272703, 91-11-23282021, 91-11-23245672, Rel: 32558559Fax: 91-11-23276490, 91-11-23245683e-mail: jaypee@jaypeebrothers.com Visit our website: www.jaypeebrothers.comBranches 2/B, Akruti Society, Jodhpur Gam Road Satellite, Ahmedabad 380 015Phones: 91-079-26926233, Rel: 91-079-32988717, Fax: 91-079-26927094e-mail: ahmedabad@jaypeebrothers.com 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East, Bengaluru 560 001Phones: 91-80-22285971, 91-80-22382956, Rel: 91-80-32714073Fax: 91-80-22281761 e-mail: bangalore@jaypeebrothers.com 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon RoadChennai 600 008, Phones: 91-44-28193265, 91-44-28194897, Rel: 91-44-32972089Fax: 91-44-28193231 e-mail: chennai@jaypeebrothers.com 4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote Cross Road, Hyderabad 500 095Phones: 91-40-66610020, 91-40-24758498, Rel: 91-40-32940929Fax: 91-40-24758499 e-mail: hyderabad@jaypeebrothers.com No. 41/3098, B & B1, Kuruvi Building, St. Vincent Road, Kochi 682 018, KeralaPhones: 0484-4036109, 91-0484-2395739, 91-0484-2395740e-mail: kochi@jaypeebrothers.com 1-A Indian Mirror Street, Wellington Square, Kolkata 700 013Phones: 91-33-22451926, 91-33-22276404, 91-33-22276415, Rel: 91-33-32901926Fax: 91-33-22456075, e-mail: kolkata@jaypeebrothers.com 106 Amit Industrial Estate, 61 Dr SS Rao RoadNear MGM Hospital, Parel, Mumbai 400 012Phones: 91-22-24124863, 91-22-24104532, Rel: 91-22-32926896Fax: 91-22-24160828, e-mail: mumbai@jaypeebrothers.com “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science CollegeUmred Road, Nagpur 440 009 (MS)Phones: Rel: 3245220, Fax: 0712-2704275 e-mail: nagpur@jaypeebrothers.comTextbook of Ear, Nose and Throat Diseases 2007, Mohammad Maqbool, Suhail MaqboolAll rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any formor by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of theeditors and the publisher.This book has been published in good faith that the material provided by contributors is original. Every effort is made to ensureaccuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error(s). In caseof any dispute, all legal matters to be settled under Delhi jurisdiction only.First Edition : 1982Fifth Edition : 1991Ninth Edition : 2000Second Edition : 1984Sixth Edition : 1993Tenth Edition : 2003Eleventh Edition: 2007ISBN 81-8448-081-4Typeset at JPBMP typesetting unitPrinted at Gopsons Paper Ltd, NoidaThird Edition : 1986Seventh Edition : 1996Fourth Edition: 1988Eighth Edition: 1998
This Edition dedicated tothe original Author—a teacher to many,a guide to many more andto me all that and a loving father.
ForewordDear Reader,The eleventh edition of the Textbook of Ear, Nose and Throat Diseases is anexcellent overview for medical students and the general practitioners. Itis a comprehensive review of many of the specific ENT problems whichtrouble patients.ENT problems form a large segment of general practitioner’s patientevaluation and treatment. These doctors are the primary level of medicalcare.Many physician groups form the secondary level of ENT practice andthey are capable of proper evaluation and general surgical treatment of many disorders.These secondary level specialists will also sometimes refer to yet more highly trained, tertiaryENT sub-specialists who have become very skilled in a variety of relatively rare and challengingissues.Our hope and belief is that this compact volume, as it has throughout the history of itspublication and evolution, will continue to contribute to the knowledge of the wider medicalcommunity, so that ENT-specific problems can be rapidly and accurately identified and thesepatients either treated by their primary care providers, or appropriately referred.Dr William F HouseHouse Ear InstituteLA CaliforniaUSA
Preface to theEleventh EditionThrough the grace of almighty God and the continuous appreciation of previous editions bythe vast number of medical fraternities from all over the country, the eleventh edition is inthe hands of the readers.Efforts have been made to make this textbook more informative and update.A new Chapter on Headache has been added. A few new topics such as Neck masses,Tumours of Thyroid, Anthrax, etc. have also been incorporated. I am sure that the studentsboth undergraduate and postgraduate, interns and general practitioners, all will be benefitted.Any constructive and healthy criticism to make this textbook more informative will be highlyappreciated.I am highly thankful to my ex-students and colleagues Dr Rafiq Ahmad and Dr Qazi Imtiazfor their deep interest in the script and additions in the book.Thanks are due to Shri Jitendar P Vij, Chairman and Managing Director, Mr Tarun Duneja(General Manager, Publishing) and Mr PS Ghuman (Senior Production Manager) ofM/s Jaypee Brothers Medical Publishers Pvt. Ltd., New Delhi for their kind cooperation.Thanks are also due to Dr William F House for writing a foreword to this edition.Mohammad MaqboolSuhail Maqbool
Preface to theFirst EditionThough there are quite a few books on otorhinolaryngology now available in the country,omission of some important topics or common conditions is noticed in most of these books. Assuch, a student or a clinician feels handicapped and has to waste a lot of time in looking frombook to book for a particular topic or information. A humble effort has been made to preparea comprehensive Textbook of Ear, Nose and Throat Diseases which would provide all the necessarydetails and conception to the reader. I hope and pray that all the readers of this textbook,undergraduate and postgraduate students, academicians, and general practitioners will bebenefitted.I owe personal thanks to my departmental colleagues particularly to Dr Ab. Majid,Dr Ghulam Jeelani and Dr Rafiq Ahmad for their constant interest and contribution to the text.I must particularly thank Shri Jitendar P Vij of M/s Jaypee Brothers Medical PublishersPvt. Ltd., New Delhi for his help and cooperation. I would feel grateful for any suggestionsand healthy criticism from readers.Mohammad Maqbool
ContentsSECTION ONE: EAR1. Development of the Ear32. Anatomy of the Ear73. Physiology of the Ear234. History Taking with Symptomatology of Ear Diseases295. Examination of the Ear326. Congenital Diseases of the External and Middle Ear487. Diseases of the External Ear518. Diseases of the Eustachian Tube579. Acute Suppurative Otitis Media and Acute Mastoiditis5810. Chronic Suppurative Otitis Media6411. Complications of Chronic Suppurative Otitis Media7112. Nonsuppurative Otitis Media and Otitic Barotrauma7713. Adhesive Otitis Media8014. Mastoid and Middle Ear Surgery8215. Otosclerosis8816. Tumours of the Ear9417. Otological Aspects of Facial Paralysis10118. Ménière’s Disease and Other Common Disorders of the Inner Ear10619. Ototoxicity11120. Tinnitus11321. Deafness115
xivTextbook of Ear, Nose and Throat Diseases22. Hearing Aids and Cochlear Implant12423. Principles of Audiometry132SECTION TWO: NOSE24. Development and Anatomy of the Nose and Paranasal Sinuses14725. Physiology of the Nose and Paranasal Sinuses15526. Common Symptoms of Nasal and Paranasal Sinus Diseases15827. Examination of the Nose, Paranasal Sinuses and Nasopharynx16228. Congenital Diseases of the Nose16829. Diseases of the External Nose17130. Bony Injuries of the Face17531. Foreign Bodies in the Nose17832. Epistaxis18033. Diseases of the Nasal Septum18334. Acute Rhinitis19035. Chronic Rhinitis19236. Nasal Allergy, Vasomotor Rhinitis and Nasal Polyposis20137. Sinusitis20838. Tumours of the Nose and Paranasal Sinuses22639. Headache23640. Facial Neuralgia (Pain in the Face)238SECTION THREE: THROAT41. Oral Cavity and Pharynx24342. Common Symptoms of Oropharyngeal Diseasesand the Method of Examination24943. Common Diseases of the Buccal Cavity25244. Cysts and Fistulae of the Neck26045. Salivary Glands27446. Pharyngitis27947. Tonsillitis28348. Adenoids291
Contentsxv49. Pharyngeal Abscess29450. Tumours of the Pharynx29651. Miscellaneous Conditions of the Throat30352. Larynx and Tracheobronchial Tree30753. Physiology of the Larynx31454. Common Symptoms of Laryngeal Diseases31655. Examination of the Larynx31856. Stridor32457. Acute Laryngitis33058. Chronic Laryngitis33259. Laryngeal Trauma33760. Laryngocele33961. Oedema of the Larynx34062. Foreign Body in the Larynx and Tracheobronchial Tree34463. Laryngeal Paralysis34664. Tracheostomy35165. Disorders of Voice35666. Tumours of the Larynx35867. Block Dissection of the Neck37268. Thyroid37569. Bronchoscopy38070. Oesophagus38371. Common Oesophageal Diseases in ENT Practice38572. Oesophagoscopy39373. Laser Surgery in ENT39574. Principles of Radiotherapy39775. Syndromes in Otorhinolaryngology40176. Common ENT Instruments421Index427
IntroductionPRELIMINARY CONSIDERATIONS INEXAMINATIONHistory TakingBefore proceeding to the examination of apatient, a detailed and proper history takingis a must. The relevant points to be noted mayvary from one organ to another, hence aredescribed at the beginning of each section.The examination room should be reasonably large and noise free.Most of the ear, nose and throat areas lendthemselves to direct visualisation and palpation but a beam of light is needed for propervisualisation of the inside of the cavities.Hands should be free for any manipulation. This is achieved, if a beam of light isreflected by a head mirror or head light.Usually the head mirror is used. The headlight serves the same purpose in the operation theatre.Head MirrorThis consists of a concave mirror on a headband with a double box joint. The head mirrorshould be light as it is worn for long periodsof time and may cause headache. The purposeof the double box joint is to enable the mirrorto be as close to the examiner’s eye aspossible. The centre of the mirror has a holeabout 2 cm in diameter.The focal length of the head mirror isgenerally 8 to 9 inches (25 cm). It is the distanceat which the light reflected by the mirror issharply focussed and looks brightest. It is alsothe distance where most people can see andread clearly.The head mirror is worn in such a way thatthe mirror is placed just in front of the righteye (in right handed persons). The examinerlooks through the hole in the mirror and thusbinocular vision is retained.Light SourceThe light is provided from an ordinary lampfixed in a metallic container with a big convexlens and fitted on a movable arm whichslides on a rod with a firm base (bull’s eyelamp) or a revolving light source providedwith ENT treatment unit (Fig. I.1). This lightsource is kept behind and at the level of thepatient’s left ear. Light from this source isreflected by the head mirror worn by theexaminer.
xviiiTextbook of Ear, Nose and Throat DiseasesFig. I.1: ENT treatment unitFig. I.2: Mother holding child for examinationFig. I.3: Position of the patient for ENT examinationFig. I.4: Common instruments used inENT outdoor examinationPosition of the PatientThe patient should remain comfortablyseated. Young children usually do not permitthe examination in this position and needassistance. The assistant sits in front of theexaminer and holds the child in his/her lap(Fig. I.2). The legs of the child are held inbetween the thighs of the assistant. One handof the assistant holds the child’s hands acrosshis chest while the other hand stabilises thechild’s head.Position of the ExaminerThe examiner sits in front of the patient on astool or revolving chair (Fig. I.3). The legs ofthe examiner should be on the right side ofthe patient’s legs.Examination EquipmentThe following are the instruments routinelyused for ENT examination (Fig. I.4).1. Tongue depressor2. Nasal specula3. Ear specula4. Holm’s sprayer5. Laryngeal mirrors6. Postnasal mirrors7. Seigle’s speculum8. Eustachian catheter
IntroductionContents9. Ear forceps10. Nasal forceps11. Tuning forks12. Probes13. Ear syringe14. Auroscope.Besides, a sterilizer, Cheatle’s forceps,spirit lamp and few small labelled bottlescontaining the commonly used solutions,paints and ointments are also needed.xixSuction ApparatusA suction apparatus with suction tubes andcatheters of various sizes is very helpful forcleaning the discharges to allow properexamination. It is also used for removing waxfrom the ears of the patients who have waxalong with CSOM, where water should notbe syringed in.
Development of the Ear Anatomy of the Ear Physiology of the Ear History Taking with Symptomatology of Ear Diseases Examination of the Ear Congenital Diseases of the External and Middle Ear Diseases of the External Ear Diseases of the Eustachian Tube Acute Suppurative Otitis Media and Acute Mastoiditis Chronic Suppurative Otitis Media Complications of Chronic Suppurative Otitis Media Nonsuppurative Otitis Media and Otitic Barotrauma Adhesive Otitis Media Mastoid and Middle Ear Surgery Otosclerosis Tumours of the Ear Otological Aspects of Facial Paralysis Ménière's Disease and Other Common Disorders of the Inner Ear Ototoxicity Tinnitus Deafness Hearing Aids and Cochlear Implant Principles of Audiometry
1Development of the EarThe knowledge of the development of the earis important for the diagnosis and therapy ofthe various diseases of the ear. It is also necessary to know the various anatomical variationsthat the surgeon may encounter on the table.The two functional parts of the auditorymechanism have different origins. The soundconducting mechanism takes its origin fromthe branchial apparatus of the embryo, whilethe sound perceiving neurosensory apparatus of the inner ear develops from theectodermal otocyst.Development of the Externaland Middle EarThe structures of the outer and middle eardevelop from the branchial apparatus (Figs 1.1and 1.2). During the sixth week of intrauterinelife, six tubercles appear on the first andsecond branchial arches around the first branchial groove. These tubercles fuse together toform the future pinna.The first branchial groove deepens tobecome the primitive external auditorymeatus, while the corresponding evaginationfrom the pharynx, the first pharyngeal pouch,grows outwards. By the end of the secondfoetal month, a solid core of epithelial cellsFig. 1.1: Visceral arches, clefts andpharyngeal pouchesgrows inwards from the primitive funnelshaped meatus towards the epithelium of thepharyngeal pouch. By the seventh month ofembryonic life, the cells of the solid core ofepithelium split in its deepest portion to formthe outer surface of the tympanic membraneand then extend outwards to join the lumenof the primitive meatus. Thus, congenitalatresia of the meatus may occur with anormally formed tympanic membrane andossicles, or with their malformation depending upon the age at which development getsarrested.The first pharyngeal pouch becomes theeustachian tube, middle ear cavity and inner liningof the tympanic membrane. The cartilages of the
4Textbook of Ear, Nose and Throat DiseasesFig. 1.2: Development of the pinna: A. Primordial elevations on the first and second arches. B and C. Progressof embryonic fusion of the hillocks. D. Fully developed configuration of the auriclefirst and second branchial arches proceed toform the ossicles.The malleus and incus basically developfrom the Meckel’s cartilage of the first branchialarch. From the second branchial arch developthe stapes, lenticular process of the incus and thehandle of malleus.The foot plate of the stapes is formed by thefusion of the primitive ring-shaped cartilageof the stapes with the wall of the cartilaginousotic capsule. The ossicles are fully formed atbirth.As the ossicles differentiate and ossify, themesenchymal connective tissue becomeslooser and allows the space to form the middleear cavity. The air cells of the temporal bonedevelop as out-pouchings from the tympanum, antrum and eustachian tube. The extentand pattern of pneumatisation vary greatlybetween individuals. Failure of pneumatisation or its arrest is believed to be the resultof middle ear infection during infancy. Themastoid process is absent at birth and begins todevelop during the second year of life by thedownward extension of the squamous andpetrous portions of the temporal bone. This isof importance in infants where the facial nerveis likely to be injured during mastoidectomythrough the postaural route. In order to avoidinjury to the facial nerve, the usual postauralincision is made more horizontally.Points of Clinical Importance1. Hearing impairment due to congenitalmalformation usually affects either onlythe sound conducting system or only thesensorineural apparatus because of theirentirely different embryonic origin, butoccasionally both can be affected.2. The particular malformation present ineach case depends upon the time in embryonic life, at which the normal development was arrested, as well as upon theportion of the branchial apparatus affected.3. Failure of fusion of the auricle tuberclesleads to the development of an epitheliallined pit called preauricular sinus.4. Failure of canalisation of the solid core ofepithelial cells of the primitive canal leadsto atresia of the meatus.
Development of the Ear5. At birth, only the cartilaginous part of theexternal auditory canal is present and thebony part starts developing from thetympanic ring which is incompletelyformed at that time.The best indication of the degree of middleear malformation in cases of congenital atresiais the condition of the auricle. As the auricleis well formed by the third month of foetallife, a microtia indicates arrest of development of the branchial system earlier inembryonic life with the possibility of absenttympanic membrane and ossicles.Development of the Inner EarAt about the third week of intrauterine life aplate-like thickening of the ectoderm calledotic placode develops on either side of the headnear the hindbrain. The otic placode invaginates in a few days to form the otic pit. By thefourth week of embryonic life, the mouth ofthe pit gets narrowed and fused to form theotocyst that differentiates as follows (Fig. 1.3):i. At four and a half weeks the oval-shapedotocyst elongates and divides into twoportions—endolymphatic duct and sacportion, and the utriculosaccular portion.ii. By the seventh week arch-like outpouchings of the utricle form the semicircular canals. Between the seventh andeighth weeks, a localised thickening ofthe epithelium occurs in the saccule,utricle and semicircular canals to formthe sensory end organs.Evagination of the saccule forms thecochlea, which elongates and begins to coil bythe eleventh week. A constriction between theutricle and saccule occurs and forms theutricular and saccular ducts, which join to formFig. 1.3: Development of the inner earthe endolymphatic duct.The mesenchyme surrounding the otocystbegins to condense at the sixth week andbecomes the precartilage at the seventh weekof embryonic life. By the eighth week theprecartilage surrounding the otic labyrinthchanges to an outer zone of true cartilage toform the otic capsule. The inner zone loosensto form the perilymphatic space.The perilymphatic space has three prolongations into surrounding osseous oticcapsule, viz. the perilymphatic duct, the fossulaante fenestram, and the fossula post fenestram.Development
The eleventh edition of the Textbook of Ear, Nose and Throat Diseases is an excellent overview for medical students and the general practitioners. It is a comprehensive review of many of the specific ENT problems which trouble patients. ENT problems form a large segment of general practitioner’s patient
Furuncle of external ear. H60.00 Abscess of external ear, unspecified ear. H60.01 Abscess of right external ear. H60.02 Abscess of left external ear. H60.03 Abscess of external ear, bilateral. H60.1 Cellulitis of external ear. Cellulitis of auricle Cellulitis of external auditory canal. H60.10 Cellulitis of external ear, unspecified ear
whole middle ear space is the ear drum and the tympanic membrane the drum skin. 2.2.2. The Middle Ear The middle ear is an air filled space connected to the back of the nose by a long, thin tube called the Eustachian tube. The middle ear space houses three little bones, the hammer, anvil and
Care of Ear Cleaning Equipment 7. Ear Cleaning Equipment Single-use [(e.g. Tips (Elephant Ear Washer tips , Otoclear tips)], Syringes) Multi-patient reusable Patient owned or dedicated to a single patient (e.g. Elephant Ear Washer or Rhino Ear Washer ) (e.g. Elephant Ear Washer , Rhi
H53.10 Unspecified subjective visual disturbances H53.1 1 Day blindness Ear Diseases H61 .20 Impacfed cerumen, unspecified ear H61 .2t Impacted cerumen, right ear H6t 22 Impacted cerumen left ear H61 23 Impacted cerumen bilatera H60.00 Abscess of external ear, unspecified ear H60.01 Abscess of right external ear
Massachusetts Eye and Ear (Mass. Eye and Ear) is a specialty hospital dedicated to excellence in the care of disorders that affect the eye, ear, nose, throat, and adjacent regions of the head and neck. Mass. Eye and Ear also provides primary care and serves as a referral center for outpatient and inpatient medical and surgical care.
problems in the middle ear. It’s possible for infection to spread from the nose and throat area through the Eustachian tube to the middle ear, which is one of the causes of middle ear infections. The third part of the auditory system is the inner ear. The inner ear has two sections: one that is responsible for balance and the other for hearing.
Ear Cough on scratching the external auditory canal is due to auricular branch of vagus nerve (Arnold’s nerve) Nerve responsible for referred otalgia:- Glossopharyngeal nerve Reference: Diseases of Ear, Nose and Throat, Dhingra (Pg 3, 15 ) Textbook of Ear, Nose and Throat, BS Tuli (Pg 3, 19) [NEET118T [MEET 2020]
1. The ear is the sense organ that is sensitive to sound stimuli produced by vibrating object. 2. A human ear has three main part. i. the outer ear, filled with air. ii. The middle ear, filled with air. iii. The inner ear, filled with liquid Draw figure 1.15, page 14 3. Function of the different parts of the human ear. Salin table 1.4, page 15
