Miscellaneous ear, nose, and throat disorders

This article provides an overview of ear, nose, and throat conditions not discussed elsewhere, including common ones (e.g., deviated nasal septum) as well as uncommon ones (e.g., decompression sickness, ear barotrauma, auricular hematoma).

For an overview of differential diagnoses for hearing loss, see the corresponding article.

• Definition: significant deviation of the nasal septum from midline; which often leads to obstruction of nasal breathing.
• Etiology
  • Prenatal: growth disturbances or intrauterine conditions that lead to pressure on the facial bones
  • Birth trauma (e.g., from forceps)
  • Trauma (e.g., fall onto the facial bones)
• Clinical findings
  • Difficulty breathing (typically in only one nostril)
  • Nasal congestion
  • Snoring or noisy breathing during sleep
  • Headaches or facial pain
  • Epistaxis (nosebleeds)
• Diagnostics
  • Anterior rhinoscopy: A nasal speculum and external light source are used to visualize the septum.
  • Nasal endoscopy
  • CT scan
• Treatment
  • Septoplasty to correct the deviation is indicated if there are significant symptoms.
• Complication of surgery
  • Nasal septum perforation
    • Etiology: sequela of septal hematoma (e.g., due to nasal fracture, septoplasty, or rhinoplasty)
    • Clinical features: nasal whistling sound with breathing
    • Diagnostics
      • Anterior rhinoscopy: to directly visualize abnormalities of the anterior to middle part of the septum
      • Posterior rhinoscopy: to directly visualize abnormalities of the middle to posterior part of the septum (via endoscopy)
      • CT: for more detailed evaluation of the nasal septum (and adjacent structures)
    • Treatment: : surgical restoration of physiologic configuration/structure (septoplasty)

References:^[1][2][3]

• Definition: pain in and dysfunction of the temporomandibular joint (TMJ) and muscles of mastication due to musculoskeletal, psychological and/or neuromuscular factors
• Peak incidence: 20–40 years
• Etiology: multifactorial ^[4]
  • Behavioral factors (e.g., poor head and/or cervical spine posture; , bruxism)
  • Psychological factors (e.g., depression, anxiety, stress)
  • Trauma to the TMJ (e.g., cervical spine or jaw injuries)
  • Occlusal abnormalities (e.g., overbite, cross-bite)
  • Abnormal processing of trigeminal nerve pain (e.g., sensitization)
• Clinical features
  • Pain
    • Constant, dull, and unilateral
    • Intervals of sharp pain
    • Can spread to the ear, temporal regions, periorbital regions, or the mandible
    • Worsened by jaw motion (chewing)
    • On palpation of the TMJ
  • Ear discomfort
  • Headache
  • Cracking or grinding of the TMJ
  • Limited jaw opening (occasionally painful)
  • Nocturnal teeth grinding (bruxism)
• Diagnostics: clinical diagnosis
• Treatment
  • Indications
    • Pain with palpation, jaw movement, or biting/chewing
    • Masticatory muscle spasms
  • Modalities
    • Behavioral therapy to avoid triggers
    • Pain relief (NSAIDs, tricyclic antidepressants, benzodiazepines, and/or muscle relaxants)
    • Occlusal splints for bruxism

References:^[5][6][7]

• Definition: formation of air embolisms as a result of a rapid decline of barometric pressure within the body
• Etiology
  • Divers during rapid ascent
  • Risk factors: insufficient diving experience, recent air travel soon after a dive, pre-existing right-to-left shunt (e.g., patent foramen ovale)
• Pathophysiology (in diving)
  • The pressure increases as the diver dives deeper → more oxygen and nitrogen are dissolved in the blood.
  • During normal ascent → pressure decreases and the tension of gas in the blood exceeds the surrounding pressure → dissolved nitrogen changes back into its gaseous form → the gas is exchanged with the lungs and breathed out.
  • In rapid ascent → formation of nitrogen gas bubbles within the blood vessels → insufficient time for the gas to be released via the lungs → gas bubbles remain in circulation and obstruct proper blood flow → air embolism
• Clinical features
  • Prodromal stage: malaise, fatigue, anorexia, headaches
  • Later stages
    • Muscle and joint pain
    • Pruritus
    • Cutis marmorata (a mottling, reticular skin rash)
    • Neurological defects
    • Chest pain and dyspnea
    • Can be lethal
• Treatment
  • Hyperbaric, 100% oxygen
  • Hydration
  • Positioning maneuvers (left lateral decubitus and lowering the head zone of the bed)
• Prevention
  • Avoid situations with rapid decline of barometric pressure
  • Follow diving safety guidelines

References:^[8][9][10]

• Definition: failure to equalize the pressure of the middle ear with the ambient pressure, resulting in injury to structures of the inner and/or middle ear
• Etiology
  • Flying (most common)
  • Diving
  • Increased risk with concurrent rhinogenic infection
• Clinical features
  • Acute onset of symptoms
  • Feeling of pressure and/or stabbing ear pain
  • Hearing loss
  • Tinnitus, nausea, and vertigo
  • Bleeding from the ear canal (if the tympanic membrane is ruptured)
• Diagnostics
  • Otoscopy: hematotympanum ; in rare cases, ruptured eardrum
  • Tympanometry: high negative pressure in the middle ear suggests eustachian tube dysfunction, tympanic membrane perforation would result in a large canal volume
  • Hearing test (tuning fork, audiogram)
    • Evidence of conductive hearing loss
• Treatment
  • Conservative
    • Valsalva maneuver
    • Decongestant nose drops
    • Analgesics
  • Surgical
    • Indication: persistent negative pressure, effusion, strong pain
    • Procedure: myringotomy with or without tube placement
• Prognosis
  • Without inner ear involvement: good → full recovery
  • With inner ear involvement: possible persistent hearing loss, vertigo, tinnitus
• Prevention
  • Valsalva maneuver
  • Decongestant nose drops
  • Antihistamines

References:^[9][11]

• Definition: hematoma of the auricle
• Etiology: trauma to the ear
  • Blunt: blow/s to the ear (e.g., in boxers/wrestlers)
  • Penetrating: lacerations of the ear (less common)
• Clinical features
  • Sudden tense, tender, fluctuant swelling of the pinna and loss of normal anatomy/landmarks of the anterosuperior aspect pinna
  • Overlying skin is ecchymotic
• Treatment
  • Small auricular hematomas: needle aspiration
  • Large auricular hematomas: incision, drainage, placement of a draining wick
  • Post-procedure formed pressure packing of the pinna
  • Re-assess in 48 hours to check for re-accumulation
• Complications
  • Cauliflower ear (wrestler's ear): permanent deformity of the pinna due to an inadequately drained auricular hematoma
  • Perichondritis: infection and inflammation of the perichondrium (connective tissue that envelops cartilage)

Surgical drainage is always indicated!

References:^{[12][12][13][14]}

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