1 Sensoric disorders EAR 1. EXTERNAL EAR 1.1. INFLAMMANTIONS A. Circumscribed inflamations 1. Impetigo is caused by staphylococcal or streptococcal infection under the superficial layer of the skin. The disease is characterized by vesicles, which burst and dry up. The patient doesn´t have too much discomfort, and the disease is treated by locally applied antibiotics (for example Framykoin or Bactroban). 2. Folliculitis is the inflammation of hair follicles, usually caused by staphylococs. It looks like the yelowish infiltration of the skin with the hair in the middle. 3. Furunculus is usually localised in the external auditory meatus, in the entrance to the external auditory meatus and seldom on the auricle. The infection affects the hair follicle and the sebaceous gland. The infection is mostly caused by staphylococs or by pseudomonas pyocyanea. People working in the cement works, ironworks and sugar rafinery are more often affected by this disease as well as patients with diabetes. The infection cause the necrosis of the epithelium in the hair follicul and sebaceous gland, extends to surrounding tissues and cause severe local inflammatory reaction. If the inflammation is deep seated, it can lead to rising of the abscess, perichondritis and sometimes even the periostitis or osteomyelitis. The perforation of the drum, extension to the parotid gland and extension to processus mastoideus has been already described. The regional lymphadenitis is commonly found. B. Bacterial diffuse otitis externa 1. Erysipelas - streptococcal infection spreading in the superficial lymphatic vessels, localised often in the nasal cavity and the ear . The infection can get into the vessels through small injuries (scratching, pricking). There is also rising of the vesicles in severe cases (erysipelas vesiculosum or bulosum), besides the redness, which is in all cases. Symptoms : fever (39 - 40°C), generalisied illness, chills and shivering. Treatment : systemic antibiotics, local application of the liniments with topically active antibiotics. 2. Perichondritis of the auricle is often result of the injury, sometimes it can rise from the othematoma, furunculus or abscess. Ethiology : pyogenous cocs or pseudomonas pyocyanea. The inflammations are serous or purulent. The exsudation separate the perichondrium from cartilage and so damage nutrition, so in the end it can lead to the necrosis of cartilage. The inflammatory mass can burst outside through the skin and form, fistula. Through this fistula the necrotic cartilage is eliminated with pus (purulent matter). 1 2 C. Viral otitis externa - Herpes simplex - Herpes zoster D. Alergic inflamations They are caused by allergen, the substance to which is the skin sensitive. It can be chemical substance (colors, metals, cement, flour dust), drugs (penicillin, streptomycin, iodine), nutritions spread by the blood and causing the allergic inflammations in the region of the external meatus of auricle (eggs, fruit, meat, metabolic products), pus containing bacterial and mycotic toxins (in case of purulent otitis externa or otitis media). Eczema looks like deep-red inflammatory swelling (eczema erytematosum), sometimes with vesicles or papuls (eczema vesiculosum, eczema papulosum). Sometimes there are also crusts (eczema crustosum) or scales (eczema squamosum). Treatment include elimination of the allergen and local treatment (application of the liniments). 1.2. SPECIAL FORMS 1.2.1., 1.2.2. Bacterial otitis occurs in the circumscript [absces] and difuse form [phlegmona]. Differenties are in the appearence and in the course. Differenties of therapeutic approach [treatment of circumscripte and diffuse inflammation]. Danger - development of perichondritis with consequent deformation. External diffuse otitis as a frequent inflammation is caused by : ear wax, swimming pools. Very paninfull disease. Absces of external meatus: therapy - local (ointment, incision) - general (antibiotic therapy) 1.2.3. Herpes zoster oticus Dermatological – otoneurological disease. Damage of external ear and VIIIth cranial nerve. Therefore are the symptoms cochleovestibular. Therapy - corticoids - acyclovires Danger : permanent disturbance of VIIIth cranial nerve, oligoneuritis (VIIth cranial nerve!). 1.2.4. Myringitis bulosa Isolated para and post infections damage of ear drum. Therapy: predominantly local and symptomatic. Development of otitis! 2 3 1.2.5. Otitis externa maligna Expansive inflammatory disease – high mortality destruction of external meatus (osseous part, mandibule, skull basis). Diagnostic concribution of x ray examinations CT, NMR Therapy: - antibiotics - antimallarics Surgery – only additional tool 1.2.5.1. Otomycosis Very torpide disease by the changes of pH after middle ear surgery. Therapy: local antimycotics general antimycotics 1.2.5.2. Eczema As a result of maceration of the skin by swimmers as a result of bacterial flow from middle ear cavity – see 1.2.5.1. 1.2.6. Specific ear inflammations TBC occurs predominantly on the ear drum (multiple perforations) Specific changes on the bony chain (necrosis) Therapy: tuberculostatics and local (surgery) 1.3. TRAUMAS Injuries of the external ear -Trauma by mechanical violence -Chemical burns -Burns -Frostbite -Injury from radiation -Injury Traumas of the auricle-open injuries -closed Treatment: cleaning of the wound, surgical (suture), antibiotics, necrectomy. Amputation of auricle rarely. 1.3.1. Othematoma -closed blunt injury with dissection of the skin and perichondral layer from the cartilage and the formation of a subperichondrial hematoma. 3 4 Localisation-mostly fossa triangularis,sometimes the whole anterior part of the auricle. In the beginning fluctuation,later,if a hematoma is not treated,connective tissue organization,secondary deformity of the auricle(cauliflower ear). Treatment:a wide incision,removing of necrotic tissues, operation sec.Herrman, compression, antibiotic cover, important antisepsis 1.3.2. Injuries of meatus acusticus externus -from different objects, possibility of superinfection-furunculus -phlegmona -erysipel -iatrogenic injuries -rupture of the meatus acusticus externus in fractures of the petrose bone and the base of the skull -possibility of liquorrhea -syringitis or manipulation within the external auditory meatus must not be carried out Complications: -superinfection -meningitis Treatment: sterile tampon, antibiotics local and general 1.3.3. Frostbite-congelatio auriculae -more frequent than burn general predisposition-disorder of general and local circulation -exhaustion -disturbances of nutrition -intoxication Degrees of disturbance. Grade 1-congelatio erytematosa-cyanosis of the skin due to vascular spasm Grade 2-congelatio bullosa-ischemia with formation of vesicles Grade 3-congelatio escharotica-deep dressings,antibiotics,intravenous vasodilators,hot drinks 1.3.4. Perniosis at the places earlier frostbitten,where was damage of the vessels Treatment: local massage Burns-combuscio auriculae Grade 1-combuscio erytematosa Grade 2-combuscio bullosa Grade 3-combuscio escharotica Grade 4-carbonisatio Treatment:the same as burns of the skin 1.3.5. Damage from radiation -sunshine,X-ray,Radium,Solux Treatment:the same as burns 4 5 1.3.6. Chemical burns-corrosio -acids(coagulating necrosis) eyes(colliquating necrosis),yperit,lewisit Treatment:remove of toxic substance,neutralisation 1.4. WAX AND FOREIGN BODIES Wax is a yellowish-brown mass consisting of the secretion of the sebaceous and ceruminous glands, desquamated epithelium, hair and particles of dirt. Causes local:-narrowing of the external auditory meatus -wrong cleaning -inflammation of the external meatus -growth of hair general:-hypercholesterolemie -diabetes -nefritis, etc. Symtoms:deafness,tinnitus,vertigo,feeling of pressure in the ear Diagnosis:symtoms,otoscopy Treatment:otomicroscopic suction,irrigation with water at 37 degrees C contra-indication-perforation of the tympanic membrane and atrophy.Wax should be softened by 3% hydrogen peroxide for 1-2 dayr and then cleaning.The hearing should be tested after this procedure. Corpora aliena -anorganic - organic -mostly in childhood(marbles,beans,toys,beans,peas) -adults(toothpicks,cottonQ-tips,garlic,grain,straw,insects) Symtoms:feeling of pressure,pain in the ear,tinnitus,deafness,inflammation,vertigo Treatment:careful removal with hook(no forceps!),in small children using general anesthesia Complications:during removal-labyrintitis-meningitis-deafness 1.5. TUMORS 1.5.1. Benign tumors Benign tumors of the auricle are not very common. These include atheroma (it is in fact retention cyst of sebaceous gland). It is usually sphere-shaped, localised most often in the retroauriculary region. Other benign tumors are hemangioma, lymphangioma and fibroma. Cicatricial keloids are commonly described at the Africans after the treating of injuries on the auricle with cinders of the charcoal. In our conditions you can see most commonly the cicatricial keloids on the auricle after the itroducing of the earrings. Their colour is dark red and sometimes they can be as big as the pigeon egg. Meatal tumors include exostosis arising from the ossification centers in the anulus tympanicus. They can be solitary or multiple hemisphere-shaped tumors narrowing the external meatus. They can lead sometimes to the complete obturation of the external meatus. Their development is very slow. The incidence is higher at the swimmers. Treatment: surgical removing under the control of operation microscope. 5 6 1.5.2. Precancerous and Malignant tumors Precancerous lesions – we can find on the auricle most commonly cornu cutaneum and senil keratosis: a) cornu cutaneum is a sharply limited warty growth of the epidermis without any cartilage invasion. The colour is not different from the colour of the surrounding skin. b) senile keratosis is a round yelowish-brown smooth mass covered with crusts. There is not any cartilage invasion as well. The treatment of both of them is surgical (excision). Malignant tumors – they include basal cell carcinoma, squamous cell carcinoma and malignant melanoma. a) basal cell carcinoma manifests like a vaulty infiltration, often ulcerated, causing destruction of cartilage and tissuses under the skin. Exulcerated basal cell carcinoma is called ulcus rodens. b) for squamous cell carcinoma is typical growth with infiltration of the surrounding tissues, exulceration of tumor and the destruction of tissues infiltrated by tumor. About 20% of patients have regional lymph node metastases. About 50% of the squamous cell carcinoma of the external ear is localised in external meatus. c) melanoma is characterized by verrucous rapid growth and the darkbrown colour. The tumor give rise to early metastases. All the malignant tumors of the auricle are supposed to be treated by partial or total resection of the auricle, sometimes with resection of the surrounding tissues. It is necessary to carry out the revision or the resection en bloc of the affected cervical lymph nodes. Especially in case of malignant melanoma the treatment has to be very radical. Surgical treatment should be combined with radiotherapy. 1.6. CONGENITAL ANOMALIES Embryogenesis, clasification … 5 min 1.6.1. Reconstructive operations indication chart, correction of the auricle in case of bat ear, multiple stage operations – local shifts, implantation of costal cartilage. … 10 min. 6 7 2. THE MIDDLE AND INTERNAL EAR 2.1. DISORDERS OF VENTILATION OF THE MIDDLE EAR The middle ear cavity and pneumatic system are aerated by the Eustachian tube. The tube serves to equalize the pressure and drainage between the middle ear and nasopharyngx. The tube is closed, opened is actively by contraction of the tensor palati and levator palati muscles/yawning and swalowing/. Disorders of ventilation and drainage are acute or chronic.Otoscopy shows a retracted tympanic membrane,or occurs transudate in the middle ear.There is e feeling of pressure and fullnes in the ear, pain, crascling noise on swalowing,yawning and sneezing. Conductive hearing loss, Weber s test localizes the tone in the diseased ear,tympanometry type C or B. Pathogenesis tube dysfunction due to following factors: chronic inflammation, allergy,hypertrophied adenoids,tumor of the nasopharyngx.Treatment and prognosis . removing adenoids,treatment allergy and inflammations,progress to chronicity lead to adhesive process. 2.1.1. Acute tubal occluson (serotympanum) Pathogeneseis:complication of the inflammation of the nasopharynx, nose and PNC,oedema with closure of the Eustachian tube with bad ventilation and underpressure in the middle ear cavity,heperaemia e vacuo,transsudation(hydrops e vacuo) Symtoms-feeling of the pressure in the ear,deafness,pain,crackling nose on swallowing Diagnosis-otoscopy:retracted tympanic membrane,injection of the handle of the malleus and of the vessels of the tympanic membrane,an exudate or bubbles of air in the middle ear -audiometry-light or middle conduction deafness Differential diagnosis-to exclude acute otitis media Treatment:degongescant nose drops,vasoconstrictors,antihistamines,therapy of sinusitis,hypertrophied adenoids are removed later if necessary,insufflation of air Course and prognosis:the symtoms usually resolve rapidly,but occasionally the disease progresses to a chronic seromucinous otitis media 2.1.2. Cronic seromucinous otitis media Pathogenesis: underpressure in the middle ear. Tubal incompetence, obstructive processes of the nasopharynx, disorders of tubal kinetics, incompetence of the muscles in cleft palate, barotrauma, infections. The primary cause can be adenoids, sinusitis, allergy or tumour. Symtoms: feeling of pressure and fullness in the ear, often accompanying an infection of the upper airway and considerable decrease in hearing, noises in the ear on yawning, swallowing, sneezing. No pain. Diagnosis: otoscopy-retracted tympanic membrane, discoloration of the tympanic membrane , fluid level or air bubbles audiometry-conductive deafness for the entire frequency range of 40 to 50 dB B impedance curve X-ray-in Schueller´s view shows opacity of the cell system without bone changes Differential diagnosis: hemotympanum, otitis media chronic with perforation, with cholesteatoma 7 8 Treatment: removing of primary cause-therapy of sinusitis, adenoidectomy or readenoidectomy, antiallergic treatment, mucolytics, antibiotics, alpha-chymotrypsin, hyaluronidase, corticosteroids surgical-paracentesis and drainage of the middle ear Course and prognosis: in proportion of patients is progressive chronic course leading to adhesive processes and tympanosclerosis 2.2. MIDDLE AND MASTOIDAL EAR INFLAMATIONS As a one of most frequent diseases in ENT (see 2.1.1. and 2.1.2.). Prevalency in childern – in adults less frequent but course could be secions (conductive hearing loss – permanent) 2.2.1. Otitis media acuta 2.2.2. Mastoiditis As a complication of acute or subacute otitis – palpation ab planum mastoideum and otoscopic finding as a most decisive indicators (i.e. depression of posterior – superior part of external bony meatus) Danger of further intracranial complications (sinus signoideus, facial nerve, invasion into cranial cavity and labyrinth). Surgery: exenteration of diseased and necrotised mastoidal cells. 2.2.3. Otitis media chronica Predisposing factor – mostly in infants repeated acute otitis – not properly treated. Intratympanic fibrosis, epitympanal adenoids, retractory pocket, atelectatic. 2.2.3.1. Otitis media chronica simplex As relative simple form of chronic inflammation with good prognosis. 2.2.3.2. Otitis media chronica cholesteatosa Conditions for a development of cholesteatoma – penetration of epidemius through tympanic membrane (i.e. its upper part). Agressive properties of cholesteatoma toward ossicular chain. Towards ossicus parts of middle ear cavity. Possibility of penetration to – posterior scull base cavity pyramidal apel. Diagnosis – local findings (CT, NMR) 8 9 2.2.3.3. Otitis media chronica cum ostitide mostly as a consequence of 2.2.3.2. Surgery 2.3. CONGENITAL CHOLESTEATOMA 2.4. TYMPANOSCLEROSIS as a consequence of not well treated middle ear information in childern. Reconstructive surgery 2.5. OTOGENIC INFECTIVE COMPLICATION 2.5.1. Labyrinthitis 1. circumscribed labyrinthitis 2. serous diffuse labyrinthitis 3. purulent diffuse labyrinthitis 1. Circumscribed labyrinthitis is an inflammation of circumscribed part of the labyrinth, most often the lateral edge of the horizontal membranous semicircular canal. It is caused most often by cholesteatoma. There is a penetration of toxins and bacterial invasion through fistula into the horizontal semicircular canal. The patient has feeling of dizziness, nystagmus, especially during any manipulation in the middle ear. The fistula test is positive . Circumscribed labyrinthitis is an indication for surgical intervention. The fistula is cleaned from the cholesteatoma and granulomatous matters and covered with fascia. 2. Serous labyrinthitis starts after the penetration of mitigated infection from the middle ear. Most often is involved bacterial infection. There is not too much leukocytes inside the labyrinth. Dizziness, nystagmus and loss of hearing are present. The surgical intervention is needed. Paracentesis in case of acute otitis media, sometimes antrotomy, combined with systemic antibiotics. 3. Purulent labyrinthitis usually folow up the acute mastoiditis or chronic otitis with cholesteatoma. There is very strong infiltration of labyrinth by leukocytes and destruction of membranous labyrinth. The disease can continue into cranial cavity and cause purulent meningitis. Purulent labyrinthitis is characterized by heavy dizziness and spontaneous nystagmus (the nystagmus beats toward the labyrinth without inflamation). There is also very fast and irreversibil deafness in a few hours. The surgical treatment is necessary- mastoidectomy or tympanomastoidectomy combined with systemic antibiotics. Labyrinthectomy is not carried out now so much as before, because of higher efficiency of the antibiotic therapy. 9 10 2.5.2. Otogenic brain abscess Otogenic brain abscess is caused by penetration of infection into the cranial cavity. In the initial stage the increased intracranial pressure and vomiting are present. In the latent stage diffuse headeache is present. As for manifest stage, the symptoms depends on localisation of abscess. It can be for example amnestic aphasia, in case of localisation of abscess in the left hemisphere. The diagnosis should be confirmed by CT scan. The cooperation with neurosurgeon is needed during the treatment of brain abscess. The primary focus is removed by mastoidectomy or radical mastoidectomy by an otologist before a neurosurgical procedure to remove the abscess. 2.5.3. Otogenic sinus thrombosis Thrombophlebitis of sigmoid sinus starts after the extending of the inflammation to the region of sigmoid sinus. There is usually periphlebitis and a perisinus abscess before. Sepsis, a spiking temperature chart and chills are usually present. The throbosis sometimes extends to internal jugular vein. In such a case we can palpate rigid painfull cord on the neck. We can find infection metastases to the lungs, kidneys and liver. In some more serious cases the primary focus can give rise to an endocarditis. Surgical treatment is combined with systemic antibiotics. The involved sinus is exposed and after the intersection of sinus, the thrombus is removed. After that the ligature of the jugular vein is made. 2.5.4. Pachymeningitis externa It´s present like a complication of acute otitis media. The inflammation is spreading toward the dura matter of the middle or posterior cranial fossa. Dura starts to cover with granulomatous mass and fibrin and granulomatous mass starts to produce pus. Collection of pus in that space can form the extradural abscess. Perisinus abscess can rise if the collection of pus is in the tissues surrounding sigmoid sinus. Dull pulsating pain in the retroauricular region, irradiating to the top (parietal region) is usually present. The surgical treatment (opening and drainage of abscess) is combined with systemic antibiotics. 2.6. DISEASES OF THE CAPSULA OF LABYRINTH chochlear or stapedial form of otosclerosis,CT findings,audiometry findings 2.6.1. Otosclerosis stapedial form,audiometry findings,prosthetic solution,indicate system to surgical treatment,types of operations,audiometry results,stapedotomy 10 11 2.7. MIDDLE AND INNER EAR INJURIES Causes: traffic accidents, violence, shot injuries Frequency - 3% of all injuries, in 45% connected with the fracture of the skull base Symptomatology - bleeding, liquorrhea-nasal, ear, epipharyngeal function of the facial nerve, heamotympanon, earrum perforation, step-shaped fracture of the external auditory canal (otoscopy findings), event. presence of the brain tissue in the ext. Auditory canal, hearing losts - conductive, sensorineural-its quantification, vertigo, dizziness, nystagmus 2.7.1. Temporal Bone Fractures Types - longitudinal, transversal, oblique - involvement of the middle and inner ear according to the types Symptomatology and differential diagnosis in between the types Mechanism of injury Diagnostics - imaging methods, local findings - otoscopic, neurologic audiometry, vestibular investigation, neurology, special tests Schirmer test, Gustometry, tympanometry, EMG Treatment - conservative, surgical - indications and its priority Course, prognosis, complications - early and late 2.7.2. Labyrinthine Commotion Definition - normal morphology including imaging methods, function disoders of the inner ear after the injury Symptomatology: tinnitus, sensorineural hearing lost, vertigo Pathogenesis: violence, resp. its effects on the labyrinthine membrane Diagnostics: morphologic and function findings Differential diagnosis: acutrauma, psychopathology according to the injury Treatment, course, prognosis. 2.7.3. Direct (injuries of the Middle and Inner Ear) Symptomatology: otoscopic, audiologic ev. vestibular findings and its differences in middle and inner ear traumas Pathogenesis: sharp particles in the external auditory canal-in childern cleaning of the ear, professional injuries (hot metallic particles) Diagnostic: otoscopic findings, imaging methods, audiovestibular findings Treatment: conservative, surgical (types of the operations) Course and prognosis 11 12 2.7.4. Barotrauma Causes: pressure changes (pressure chambers, aircrafts, diving) Mechanism of injury - pressure - bleeding - transudation on the Middle ear event. membr. foramen rotundum. Treatment: conservative and surgical 2.7.5. Acoustic Trauma 2.7.5.1. Acute Difference between explosion (pressure wave more than 1,5 ms) and gunshot (pressure wave cca 1,5 ms) Pathogenesis: mechanical component (pressure wave), metabolic component (changes in microcirculation) Diagnostics: otoscopic findings (explosion, gunshot) audiovestibular findings Symptomatology: tinnitus, hypacusis, vertigo, pain (localisation and type) Treatment, course and prognosis 2.7.5.2. Chronic Symptomatology: pressure, hypacusis, tinnitus, fatigue Pathogenesis: adaptation, metabolic changes leading to degeneration of the inner and external hairy cells Diagnostics: otoscopic finding, intermitent or permanent hypacusis audiovestibular findings (shape of the curve) Differential diagnosis: other types of hypacusis (hereditary, toxic, plurimetabolic lesions) Treatment, course and prognosis. Literature: Škeřík, Hybášek, Rems: Náhlé a neodkladné stavy v ORL, Avicenum 1985 Becker, Neumann, Pfaltz: Ear, nose and throat diseases Thieme 1994 12 13 2.8. TUMOURS OF THE MIDDLE AND INNER EAR,N.VESTIBULOCOCHLEARIS 2.8.1. Benign tumours of the middle ear The most frequent tumour hier is glomus tumour(chemodectomas,nonchromaffin paraganglioma).It is a benign tumour,but in advanced stages it can cause intracranial extension,death of the patient.More often in women. 2.8.2. Malignant tumours of the middle ear They are rare,the most frequent of them is a squamous cell carcinoma.Mostly in women,age of patients is 50-60 years. Prognosis is poor. 2.8.3. Tumours of the inner ear They are rare too,the most frequent is acoustic neuroma(schwannoma). Symtoms:unilateral progressive deafness,tinnitus,paresis facial nerve. Lesion is diagnosed by neurovestibular investigation(mainly BERA),CT,MRI. Treatment:neurosurgery or otologic surgery Literature:viz česká verze 2.9. CONGENITAL ANOMALY embryogenesis,CT findings 2.9.1. Combine anomalies of the middle and inner ear,prosthetic solutions,surgical methods,indicate system to surgical treatment,results of treatment 2.10. COCHLEOVESTIBULAR DISORDERS 2.10.1. Toxic Damage 2.10.1.1.Aminoglycoside Antibiotics The toxic concentrations in the inner ear retained for a longer period lead to irrevesible damage to outer hair cels at higher conzentratitins,the inner hair cells, later the stria vascularis and the ganglion cells. Streptomycin is mainly vestibulotoxic, Dihydrostreptomycin is ototoxic. Neomycin and Kanamycin strongly ototoxic, Gentamycin is oto and vestibulotoxic. The development damage depends on the dose, and its half-life,renal function and condition of the stria vascularis and the resorptive cells in the inner ear. Diagnosis depends on audiogram, vestibular tests and abnormal renal function.Treatment includes immediate cessation of the aminoglycosides, intravenous infussion vasoaktive drugs, cortisone and nootropics. Prognosis is poor. 13 14 2.10.1.2. Ototoxic Occupational Damage Exogenous ototoxins are in many industrial products. Tinnitus and hearing loss are progressive, vertigo is associated with nausea. Carbon monoxide causes a peripheral cochlear and central vestibular failure. Other substances cause degeneration of neurons, central nuclei and pathways, on the first place of sensory cells. Arsenic compounds, Mercury salts, Lead salts, Organic phosphate, Sulphur, Tetrachlorcarbon compounds, Benzol, Nitrobenzol and Aniline caused toxic Damage to the hearing and balance apparatus. 2.10.2. Inflammatory Lesions of the Hearing and Balance Apparatus 2.10.2.1. Herpes Zoster Oticus The disorder is due to a viral infection and may occur at any age. Symptoms: fever,erythema and vesicles on the auricle and external meatus, regional lymhadenitis, otitis, peripheral facial paralysis in 60 to 90 ˇ%, neuralgic pain, retrocochlear hearing loss and vertigo. Diagnosis: otoscopy, audiometry, neurootology tests, viral serology. Differential diagnosis: myringitis bullosa, idiopathic facial paralysis. Treatment : antiviral agent, B vitamins. Prognosis poor for function. 2.10.2.2. Other Viral Infections Influenza, measles, adenovirus, chicken pox, coxackie, mumps often causes symptoms corresponding neuritis statoacustica. Infections with mumps virus is the most frequent cause of unilateral deafness in young children. The vestibular part of the labyrinthis almost never attacked by mumps. The viruses has particular affinity for the cochlea and spiral ganglion. Prognosis is poor, irrevisible damage frequent. 2.10.2.3. Serous Labyrinthitis This condition is a toxic or virally determined serous inflammations of the peri and endolymphatic spaces with destruction cochlear and vestibullar sensory cells. Loss of function is irreversible with total and reversible in cases with partial destruction sensory cells. Symptoms: dizzines and deafness. Prognosis: Different clinical forms and courses of labyrinthitis are possible. 2.10.3. Menières Disease This disease is caused by a disturbance of the quantitative relation between the volume of the peri and endolymph. This cause is hydrops. Symptoms consists of attacks classic triad : rotatory vertigo, deafness and tinnitus, usually unilateral. Typical attack begins acutely, the hearing often returns to norma, tinnitus disappears.In the disease free intervals is a patient without cochleovestibular failure, in the early phases of the disease. In the later stages is persistent tinnitus, hearing loss, fullnes in the ear and frequent attacks of rotatory vertigo with vomitus. Treatment during an attack consists of bed rest, antivertiginous and antiemetic drugs. In the symptom free interval psychotropic and vasoaktive therapy. Betahistin is very usefull. 14 15 In cases with poor hearing and marked tinnitus the treatment of choice is surgical technique /neurectomy,endolymphatic sac drainage etc./ 2.10.4. Vestibular neuronitis The disease /Acute vestibular paralysis/ may be caused by a disturbance of the microcirculation due to an infection direct inflammatory damage to the vestibular organ, the peripheral neurons or the higher primary centers. Symptoms: rotatory dizziness, nausea, vomiting perissting for days and weeks. Hearing is normal. Treatment is mainly symptomatic. Course and prognosis depend supon site, cause and age. 2.10.5. Sudden Deafness Initially symptoms are feeling of pressure in the ear followed by tinnitus and severe hearing loss beginning within minutes. This disease is a medical emergency. Pathogenesis is largely unexplained, probable the cause is a disorder of mikrocirculation or autoimmune or viral disease. Audiogram shows usually unilateral sensorineural hearing loss. Differential diagnosis must exclude acoustic neuroma, tubal occlusion, cerumen, herpes zoster oticus etc. Treatment must be instituted within 24 hours by infused vasoactive drugs, corticoids or low molecular weight Dextran. Spontaneus remission often occurs. 2.10.6. Symptomatic Cochleovestibular Disorders This term covers a group of symptoms of different origin /circulatory,traumatic,inflammatory and degenerative/. THE CERVICAL SYNDROME. Includes brief attacks of dizziness dictated by the position and changes in position of the head.The cause is a lesion of the joints of the cervical spine and of the muscles of the neck. SYNDROME OF BENIGN PAROXYSMAL POSITIONAL NYSTAGMUS is a peripheral lesion.Deposition of inorganic substances in the cupula of posterior semicircular canal increases the sensitivity of the sensory end organ to linear as well as centrifugal acceleration. In this situation the normal physiologic stimuli inducing a positional nystagmus and vertigo. VERTEBROBASILAR INSUFFICIENCY causes central vestibular symptoms, irregular provoked nystagmus, patology in optokinetic tests, drop attacks. The blood flows in the wrong vertebral artery due to stenosis could be a cause. The result is transient, reversible ischemia in the brainstem. MULTIPLE SCLEROSIS is demyelinating disorders of the central nervous system with spastic paralysis, dysdiadochokinesis, dissociated nystagmus, retrobulbar neuritis, irregular positional nystagmus, abnormal caloric responses and optocinetic reflexes, vestibulospinal reflexes and ataxia. 2.10.7. Presbyacusis This is a degenerative process in the inner ear and CNS. Include hearing loss on boths sides, for the high tones initially and later for the middle frequencies. Loud sounds cause discomfort due to positive recruitment. The hearing for speech is affected.Ahearing aid, lip reading course are prescribed for treatment. 15 16 2.10.8. Central Deafness The main symptom is the delayed development of speech in childrens age, due to the absence of acoustic ability. Adults suffer from absence of acoustic ability to differentiate disturbances of perception articulation. Directional hearing is lost.Causes may be cerebral and skull trauma, encephalitis, pre, peri and postnatal damage to the CNS. Diagnosis can be made after observation over a period time, EEG, CT, ERA audiometry and psychotechnical investigation. Long term treatment includes acoustic exercises, articulation training and hearing aid. Rhytmic music therapy and lip reading are usefull too. 2.11. BASIS OF REHABILITATION OF DEAFNESS 2.11.1. The Cochlear Implant Bilateral complete deafness is in selected cases children as well as adults indicated for a cochlear implant. Implant consists of a directional microphone, which picks up speechsounds and transmits them to a speech processor. This device encodes speech information, which is transmitted through the intact skin by radio waves to a receiver stimulator implanted in the mastoid bone. A multi electrode array implanted into basal turn of cochlea simulates normal sound encoding by electrical stimulation of the remaining auditory nerve fibers in the inner ear. 2.11.2. Hearing Aids This devices are indicated if deafness cannot be relivied or improved by other means such as surgery. A hearing aid comprises microphone, an amplifier and headphone drive by a battery. The sound is conducted into the patient ear by tube and earpiece. A bone conduction aid can be supplied in cases of chronic ear inflammation or congenital anomalies etc. This functional prosthesis must be prescribed by specialist after pure tone audiometry and speech audiometry. The choice of hearing aid: pocket apparatus, behind the ear and in the ear device is determined by electroacoustic properties. These include amplification, frequency characteritics, maximal output sound predsdure peak, automatic gain control or peak clipping. This properties must correspond to the type of deafness and its site, middle or inner ear, recruitment, the patient hearing dynamics and the shape of discrimination curve in speech audiometry. 16 17 SMELL 1. OLFACTORY FUNCTION OF THE NOSE The sense of smell and taste are stimulated by substances in liquids of the nose and mouth and the sense of smell can stimulate or depress appetite. Smell receptors responds to gaseous substances in inhaled air.Human olfactory organ of the nose is relatively small-it is regio olfactoria in the ceiling of the nose and part of the septum.It contains the bipolary nerve cells,which are to be regarded as the sensory cells.They continue as fila olfactoria through lamina cribriformis and run to the primary of the olfactory center of the olfactory bulb. It is said,that there are about 30,000 different olfactory substances in the atmosphere,of these,humans can perceive about l0,000 and are able to distinguish among 200. 1.1. INVESTIGATION OF SMELL-OLFACTOMETRY We can devide tests to the qualitative and quantitative methods 1.1.1. Qualitative tests -Patient smells different substances and is asked to say which substance is it We can distinguish 3 groups of substances: a/substances which stimulate the olfactory nerve exclusively/vanilla/ b/substances that also stimulate the trigeminal nerve/acetic acid/ c/substances that also stimulate the sense of taste subserved by the glossopharyngeal nerve 1.1.2. Quantitative tests Zwardemaker test,Elsberg test(they are not practise routinly) ERO(evoked response olfactometry) 2. OLFACTORY DISORDERS 2.1. CAUSES: 2.1.1. Intranasal a/ mechanical obstruction of the airway b/ lesions of the olfactory receptors 2.1.2. Intranasal a/ trauma b/ infection c/ tumour d/ vascular e/ systemic diseases f/ congenital olfactory disorders g/ hormonal olfactory disorders h/ psychotic olfactory disorders 17 18 2.2. TYPES OF OLFACTORY DISORDERS ANOSMIA-is complete loss of the ability to smell HYPOSMIA-reduced ability to smell PAROSMIA-the subjective impression does not correspond to the substance offered CACOSMIA-all smells appear to be offensive 18 19 TASTE ANATOMY AND PHYSIOLOGY OF THE SENSORY ORGAN FOR TASTE 1. Gustometry-investigation of taste Stimulus for sense of taste are substances in saliva or food,which are penetrating into the taste buds-They are lying in the vallate papillae,foliate papillae and fungiform papillae on the tongue and also on the hard pallate,the anterior faucial pillar,the tonsil,the posterior pharyngeal wall and the buccal mucosa.The sensory nerve supply is provided peripherally by two nerves in the particular:the anterior half of the tongue is supplied by ipsilateral chorda tympani(by n.VII) and accompanying the lingual nerve from the Vth cranial nerve.The vagus nerve has sensory contributions to the epiglottis,the laryngeal additus and the upper part of the oesophagus. The basic taste sensations are sweet,salty,sour and bitter.All other tastes are mixed sensations. 1.1. INVESTIGATION OF TASTE-GUSTOMETRY We are testing 4 basic taste perceptiones(glucose,sodium chloride,citric acid,quinine). 1.1.1. Electrogustometry -electric current may also be used to stimulate the taste receptors(instead of the test solutions) 1.1.2. Objective gustometry 2. DISTURBANCES OF TASTE 2.1. CAUSES: a/ congenital b/ local lesions c/ exogenous chemical toxins d/ toxicity e/ peripheral nerve lesions f/ central taste disorders g/ endocrine disorders h/ others 2.2. CLASSIFICATION OF THE DISORDERS OF TASTE HYPOGEUSIA-reduced sensitivity HYPEREGEUSIA-increased sensitivity AGEUSIA-absence of the sense of taste PARAGEUSIA-faulty taste CACOGEUSIA-unpleasant taste 19 20 20