Miscellaneous ear, nose, and throat disorders

This article covers various ear, nose, and throat conditions, including external auditory canal atresia, ear barotrauma, deviated nasal septum, nasal septal ulcers and perforation, nasal turbinate hypertrophy, and patulous eustachian tube.

• 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:^[1][2]

• 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 ^[6]
  • 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:^[7][8]

• 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:^[9][10][11]

• Definition: an absent or stenotic external auditory canal
• Epidemiology: ♂ > ♀ (2.5:1) ^[12]
• Etiology ^[13]
  • Congenital (most common) ^[14]
    • 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.