Miscellaneous ear, nose, and throat disorders

This article covers various ear, nose, and throat conditions, including auricular hematoma, external auditory canal atresia, cerumen impaction, ear foreign body, ear barotrauma, deviated nasal septum, nasal septal ulcers and perforation, nasal turbinate hypertrophy, patulous eustachian tube, and temporomandibular joint dysfunction.

• Etiology
  • Blunt trauma: blows to the ear (e.g., during boxing or wrestling)
  • Penetrating trauma: lacerations and/or perforation of the ear (e.g., due to earring misplacement, ear piercing)
• Pathophysiology: trauma to the ear → bleeding from the perichondral vessels → accumulation of blood and serous fluid between the perichondrium and the cartilage → subperichondrial hematoma≤≥
• Clinical features
  • Sudden tense, tender, and fluctuant swelling of the auricle
  • Loss of normal anatomical landmarks of the anterosuperior aspect of the auricle
  • Ecchymosis
• Management
  • Small (≤ 2 cm) auricular hematomas ≤ 2 days old: needle aspiration
  • Large auricular hematomas (> 2 cm), and auricular hematomas 2–7 days old: incision, drainage, and placement of a compression dressing (to prevent reaccumulation)
  • Hematomas > 7 days old: referral to otolaryngology or plastic surgery
  • Daily follow-up for 3–5 days to monitor for reaccumulation
  • Prophylactic administration of levofloxacin for 7–10 days after drainage
  • Patients can return to sports after 7 days if the hematoma does not reaccumulate.
• Complications
  • Cauliflower ear: a permanent deformity of the ear caused by an untreated or inadequately drained auricular hematoma
  • Perichondritis

Drainage or aspiration of auricular hematomas is always indicated.

References:^[1][2]

• Definition: : the buildup of tightly packed cerumen in the outer ear
• Risk factors
  • Anatomic deformity and/or increased number of hairs in the external auditory canal
  • The use of items that increase the risk of cerumen impaction (e.g., cotton swabs)
• Clinical findings
  • Conductive hearing loss
  • Ear discomfort
  • Cerumen plug in the auditory canal
• Diagnostics: otoscopy for direct visualization
• Treatment
  • Irrigation; (e.g., with warm saline containing a bacteriostatic substance)
  • Cerumenolytics (e.g., docusate sodium)
  • Mechanical removal (e.g., with forceps, a curette, or suction)

Cerumen impaction should always be considered in individuals presenting with hearing loss.

References:^[3]

• Definition: the presence of a foreign body in the external auditory canal; commonly impacted at the bony-cartilaginous junction
• Epidemiology: most often occurs in children < 8 years of age ^[4]
• Etiology
  • Children: mostly toys (e.g., beads, marbles)
  • Adolescents and adults: cotton balls (e.g., from cotton swabs), jewelry (e.g., earrings), insects
• Clinical features
  • Often asymptomatic
  • Ear fullness (most common)
  • Hearing loss
  • Pruritus
  • Otalgia
  • Otorrhea (hematic or purulent)
  • Cough (via the Arnold ear-cough reflex)
• Diagnostics
  • Otoscopy
  • CT scan if bony erosion, ossicular lesions, or other complications are suspected
• Management
  • Removal of the foreign body
    • Removal techniques: forceps, water irrigation, suction
    • Special considerations
      • Batteries require immediate removal as their contents can cause tissue necrosis.
      • Removal by water irrigation is contraindicated if the foreign body is a vegetable or another item that might expand, or a battery (to avoid creating an electrical current).
      • Insects should be killed before removal is attempted.
  • Topical antibiotics (e.g., ofloxacin): indicated in patients with concurrent otitis externa or if canal lacerations are present
  • Indications for ENT referral ^[4]
    • Presence of objects that require specialized removal techniques (e.g., batteries, sharp foreign bodies, objects lodged against the tympanic membrane)
    • Sedation required
    • Trauma to the external auditory canal or tympanic membrane
    • Unsuccessful removal attempts
• Complications
  • Risk factors
    • Sharp foreign bodies
    • Successive failed attempts at removal
    • Increased duration of foreign body impaction
  • Bacterial superinfection of the external auditory canal
  • Hearing loss
  • Tympanic membrane perforation
  • Acute otitis media
  • Skin necrosis
  • External auditory canal laceration and bleeding

In individuals with ear foreign bodies, the other ear canal and both nostrils should also be inspected, as it is common for multiple foreign bodies to be present.

References:^[5][6]

• Definition: significant displacement of the nasal septum from the midline that often leads to nasal airway obstruction
• Etiology
  • Congenital (e.g., due to growth disturbances or intrauterine conditions resulting in pressure on the facial bones)
  • Trauma (e.g., septal hematoma due to facial and/or nasal fractures)
  • Iatrogenic (septoplasty/rhinoplasty, obstetric forceps delivery)
• Clinical features
  • Difficulty breathing (typically only in one nostril)
  • Nasal congestion
  • Snoring
  • Headaches and/or facial pain
  • Epistaxis
• Diagnostics
  • Anterior rhinoscopy and/or nasal endoscopy: visualization of the deviated septum
  • CT scan of the sinuses
    • Preoperative planning and identification of ancillary sinonasal pathologies (e.g., sinusitis)
    • Evaluation of potentially damaged adjacent structures after trauma to the nose (e.g., bone fractures)
• Treatment: septoplasty (a surgical procedure that corrects a deviation of the bone or cartilage of the nasal septum)
• Complications (mainly due to surgery)
  • Nasal septal perforation (see below)
  • Nasal septal hematoma
  • Intranasal synechia

References:^[7][8]

• Definition: pain in and dysfunction of the TMJ and muscles of mastication
• Epidemiology: peak incidence is in individuals 20–40 years of age ^[12]
• Etiology (multifactorial) ^[13]
  • 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)
  • Abnormal processing of trigeminal nerve pain (e.g., sensitization)
  • Substance related (e.g., from the use of cocaine, MDMA)
  • Occlusal abnormalities (e.g., overbite, crossbite)
• Clinical features
  • Pain
    • Constant, dull, and unilateral
    • Intervals of sharp pain
    • Can spread to the ear, temporal regions, periorbital regions, and/or the mandible
    • Worsened by jaw motion (e.g., chewing)
    • On palpation of the TMJ
  • Ear discomfort
  • Headache
  • Cracking or grinding of the TMJ
  • Limited jaw opening (occasionally painful)
  • Bruxism: teeth grinding and/or jaw clenching; can occur while awake (often unconsciously) or while asleep
• Diagnostics: clinical diagnosis
• Management ^[12][14]
  • Conservative management
    • General measures
      • Soft diet, moist warm compresses
      • Physical therapy and passive stretching exercises
      • Patient education and behavior modification (e.g., stress reduction, avoiding bruxism and excessive opening of the mandible when yawning)
      • Occlusal splints
    • Pharmacological therapy
      • NSAIDs (naproxen): first-line agents
      • Muscle relaxants (cyclobenzaprine): generally reserved for patients with evidence of a muscular component (e.g., muscle spasms, tenderness to palpation)
      • Tricyclic antidepressants (amitriptyline): generally reserved for patients who do not respond to NSAIDs after 2–3 weeks of treatment
      • Other agents: anticonvulsants (gabapentin), benzodiazepines (diazepam)
  • Invasive management: recommended if conservative management is unsuccessful and in patients with severe acute exacerbations
    • Intraarticular corticosteroid injection
    • Other injectable agents: intraarticular hyaluronic injections, botulinum toxin injections
    • Surgery (rarely required)
      • Indications: if conservative measures and intraarticular injections are unsuccessful and in patients with a history of recent trauma
      • Procedures: arthroscopy, discectomy, total joint replacement

References:^[15][16]

• Definition: a chronically patent (open) eustachian tube
• Etiology
  • Severe weight loss (causing a loss of fatty tissue surrounding the eustachian tube)
  • Mucosal scarring and/or atrophy
  • Neuromuscular disorders (causing muscle atrophy)
• Clinical features
  • Usually asymptomatic
  • Autophony: abnormally loud hearing of one's own voice (hallmark of patulous eustachian tube)
  • Aerophony: hearing of one's own breathing (most specific symptom)
  • Symptoms disappear when patients lie down and with increasing abdominal pressure.
• Diagnostics
  • Otoscopy: detection of tympanic membrane movement that is synchronous with respiration
  • Nasal endoscopy: direct visualization of a continuously open eustachian tube and/or defect in the tubal valve
  • Tympanometry: detection of tympanic membrane movement that is synchronous with respiration
• Management ^[17]
  • Often not required, as the condition does not generally cause ear complications
  • General measures
    • Sufficient hydration
    • Nasal application of distilled water
    • Discontinuation of nasal decongestants and nasal steroids
    • Nasal application of pharmacological agents (e.g., anticholinergics and/or estrogens)
    • Oral potassium iodine (used if hydration and topical therapy are not effective)
  • Surgery
    • Indication: patients with severe symptoms that diminish their quality of life who do not respond to pharmacological treatment
    • Procedure: tympanic membrane manipulation techniques (e.g., tympanostomy tube insertion) and eustachian tube occlusion techniques (e.g., eustachian tube reconstruction or plugging, injection of bulking agents at its nasopharyngeal orifice)

Although severe weight loss may cause patulous eustachian tube, weight gain is generally not effective at reversing the condition and, therefore, is not recommended.

References:^[18][19]

• Definition: hypertrophy of the nasal turbinates
• Etiology
  • Allergic rhinitis
  • Infection (e.g., nasopharyngitis)
  • Deviated nasal septum
  • Rhinitis medicamentosa
• Clinical features
  • Nasal congestion with difficulty breathing through the nose
  • Acute or recurrent sinusitis
  • Snoring
  • Headaches and facial pain
• Diagnostics
  • Anterior rhinoscopy and nasal endoscopy: turbinate hypertrophy
  • CT scan of the sinuses: indicated if rhinoscopy and nasal endoscopy are inconclusive
• Treatment
  • Pharmacological treatment (first-line therapy): combination of intranasal steroid sprays, nasal and/or oral decongestants, and antihistamines
  • Surgical therapy
    • Indication: persistence of symptoms despite pharmacological treatment
    • Procedure: reduction of the turbinate bone or mucosa using cryosurgery, thermal ablation, or radiofrequency ablation

References:^[20][21][22]

• Definition: an absent or stenotic external auditory canal
• Epidemiology: ♂ > ♀ (2.5:1) ^[23]
• Etiology ^[24]
  • Congenital (most common) ^[25]
    • Unilateral atresia > bilateral atresia (4:1)
    • The right ear is most commonly affected
  • Acquired
    • Trauma (e.g., from a motor vehicle accident, gunshot wound)
    • Neoplasia (e.g., cutaneous carcinomas)
• Clinical features
  • Underdeveloped ear (e.g., small or absent auricle)
  • Abnormal craniofacial features may be present (e.g., hemifacial microsomia, cleft palate)
  • Hearing loss
    • Conductive hearing loss (most common)
    • Sensorineural hearing loss may be present (especially in congenital atresia because of the possibility of concomitant inner ear abnormalities)
• Diagnostics
  • Hearing test within the first days of life (e.g., otoacoustic emission measurements, brainstem auditory evoked potentials)
  • CT scan of the temporal bone
    • Children < 5 years of age
      • Surgery planning
      • Suspicion of cholesteatoma
    • Children ≥ 5 years of age: to assess the morphology of the ear and/or detect ear abnormalities (e.g., absence of ear ossicles)
• Management
  • Congenital atresia
    • Unilateral atresia
      • Close observation in school and regular hearing tests
      • Early treatment of middle ear infections (to preserve hearing in the unaffected ear)
      • Hearing aids can be used in patients with speech and/or language impairment.
    • Bilateral atresia
      • Early bone conduction hearing aids (within the first weeks of life)
      • Surgical intervention (e.g., canalplasty and tympanoplasty)
  • Acquired atresia: surgical repair
• Complications
  • Delayed speech and language development (especially with bilateral hearing loss)
  • Increased risk of cholesteatoma (in patients with stenotic ear canals)
  • Increased risk of acute otitis media

Children with congenital external auditory canal atresia may have other congenital anomalies; therefore, a thorough assessment is required.