E N T IN DAILY PRACTICE

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E N T IN DAILY PRACTICE.
Dr. Pranav Bhagwat,
M.D.(ayu.)
Reader, dept. Of Shalakya,
G.A.M.R.C.; Shiroda, Goa.
NOSE
contents
Nasasrava.
Nasanaha.
Kshavathu.
 Karnasrava,
Tinnitus.
Badhirya.
Dysphagia.
Nasasrava.
 duration - acute -pratishyaya,
vaatakaphaj jwara,
Jeerna- dushta pratishyaya,
nasasthigata pra.; kshawathu;
Type
• Watery- allergic- paroxysmal sneezes,
periodic nature, perennial or seasonal,
Irritation in nose (jantunaam iva sarpanam),
bluish nasal mucosa.
eosin. in discharge. Eosino in blood.
watery
• Pratishyaya- goes thru stages,
no paroxysms, no h/o exposure to
allergens.
Csf rhinorrhoea-
treatment
• Allergic- 1) nidan parivarjanam
2) avoid fan/ breeze.
3) cleaning of bed materials.
4) haridra khanda.
treatment
• Rasasindura, vacha, pimpali, vyoshadi vati,
sanjivani vati, bhallataka,
• Nasya- shodhana-kshavathuhara,
shamana-shadbindu,
Snehavirechanam.
treatment
•
•
•
•
Pratishyaya- vaatajaPachana-shodhana- chitraka haritaki.
Amla rasa, ardraka-guda,
Vyadhi pratyaneeka- panchalavana, vidari,
shatavari, tri.ki.,
• Dashamula taila,
• Basti,
• Vaso motor rhinitis = vataj pratishyaya.
Watery discharge
• Polyps- nasarsha.
1) Two types – ant.(allergic)
post.(sec to max. sinusitis)
2) kruchhrat shwasanam, peenasa, pratat
kshawa, sanunasika-vaditwam.
polyps
•
•
•
•
Pale, painless ,pearly white, polypoidal,
chitrakadi taila,
Treatment of cause.
Udavartahara yogas.
watery
• Nasasrava- more at night, pichchila,
continuous ,
• Kaphapradhana
• Teekshna shirovirechana.
Ghana srava
• Pratishyaya- pakwavastha
shirovirechanam, dhumapana,
vyoshadi vati,
tri ki. (If pitanubandha or pittaprakriti, sut
instead of tri ki.)
pratishyaya
•
•
•
•
Vaatapradhana tridosha.
Rasadhatu, mamsa, shukra.
Malasanchaya.
Jalagnidushti.
Ghana srava
• Nasasthigata pratishyaya
Frontal , ethmoidal or maxillary tenderness.
No facial swelling.
May be fever, headache, malaise.
Paranasal x ray.
treatment
• Nasya
• Dhumapana.
• Correct blowing of nose.
Foul smelling discharge
•
•
•
•
Old people- malignancy (blood stained)
Children – old neglected F B (blood stained)
Nasashosha .
Sinusitis 2” to dental infection.
Blood stained discharge
•
•
•
•
Malignancy.
Children.
Diphtheria.
Rhinosporidiosis.
Nasal obstruction
• Unilateral/ bil.
• Tempo/permanent.
• Intermittent or persistent.
Physiological
• Cyclic.
• Postural
• Reflex to cold.
pathological
• Choanal atresia- persistent unilateral nasal
discharge with blockage in an infant.
• If bilateral- cyclic asphyxia.
• Suckling difficult.
pathological
•
•
•
•
•
NasanahaKaphavrit udaan vayu.
r/o udavarta.
Snehapanam.
Tikshna nasya f.u. by balataila nasya.
DNS
•
•
•
•
Most cases are asymptomatic.
After puberty.
Opposite hypertrophic turbinates,
Rec. cold,rec. sinusitis,rec. middle ear inf.
adenoids
• Enlarged nasopharyngeal tonsil.
• Rec. cold, rec obstruction, immunity lowered.
• Lateral x ray of nasopharynx.
adenoids
•
•
•
•
Treatment – same lines of pratishyaya.
Nasya, dhumapana,
Balavardhana- suvarna.
pippali, kantakari, si.chu. Talisadi, rasasindura.
Gandamala kandana rasa. Yashada.
Hypertrophic turbinates
• Can be decongested. ( d d polyps)
• More at night.
• Probing reveals soft nature and deep bones.(
d d DNS).
Atrophic rhinitis
• Progressive atrophy of mucous membrane.
White mucosa, sup. Turbinate.
• Ozaena, merciful
anosmia,
treatment
• Yashti ghrita nasya
• Balataila pana.
Lateral wall of nose
Ear.
Ear diseases
• Karnasrava,
• Badhirya.
• Tinnitus.
karnasrava
• HETU : if the pt had• Shiro abhighata i.e. trauma causes raktasrava
• Jalanimajjana i.e. swimming causes Jalavat srava or
puyasrava.
• Prapaka of vidradhi i.e. rupture of furuncle causes
puyasrava
AGE
• If the pt is a child-A.S.O.M. IS COMMON As The
Eustachian tube is shorter, wider more horizontal
and opens at a lower level
• 15-20yrs-Keratosis obturans
• Middle age-Glomus jugulare
Past history
• H/O water entering into ear for e.g. swimming,
head bath, damp climate or rainy season then- ---Acute otitis ext; otomycosis, A.S.O.M.
• Trauma to ear e.g. traumatic perforation of
eardrum, traumatic ulcer-Aural polyp, scratching,
slapping, cleaning, head injury, foreign body or
valsalva procedure done forcefully can cause --A.O.E. otomycosis or A.S.O.M.
• H/O Recurrent URTI---- A.S.O.M.
• H/O Influenza---- Viral O.E.
• H/O Recurrent sinusitis & bronchiectasis----Keratosis obturans
• H/O Diabetes----- A.O.E.
• Recurrent furuncles----- A.O.E., unhealed
furuncle or Aural polyp
• H/O recurrent diseases of Mid. Ear----- C.S.O.M.
A.S.O.M. or Acute mastoiditis
• Prolonged use of antibiotics----- Otomycosis
• Presence of skin infections----- Otomycosis
• Sudden or insidious onset with unilat. Deafness &
pulsatile tinnitus----- Glomus jugulare
• Operative history- e.g. H/O Adenoidectomy or post
nasal packing then---- A.S.O.M.
character
• The ear discharge may be profuse or scanty,
continuous or intermittent.
• Serous: may be due to eczematous otitis
externa
• Mucoid or mucopurulent: containing mucin is
produced by the mucous of the middle ear in
patients with perforated ear drum
•Purulent: may come from the lesions of ext. ear,
middle ear or an abcess of the parotid gland or
temporomandibular jnt
Foul smelling: often due to cholesteatoma
Sanguineous: due to polyp, granulations, trauma or
tumor
Watery: C.S.F. otorrhoea
Brownish/Blackish: Otomycosis
Asso. with severe pain & deafness: Keratosis obturans
Blood stained: Viral otitis ext., Glomus jugulare
Bleeding from ear: Traumatic perforation of ear drum,
Aural polyp
•
•
•
•
•
Bleeding on touch: Cancerous growths
Intermittent or pulsatile: C.S.O.M.(Benign)
Continuous: C.S.O.M.(Dangerous)
Copious: C.S.O.M.(Benign)
Scanty: C.S.O.M.(Dangerous)
Associated symptoms
• PAIN- A.O.E., trauma & Wax- pain is the
presenting symptom
• Severe pain- Keratosis obturans, Viral O.E., A.S.O.M.
• Boring type of pain in mastoid area-A. Mastoiditis.
•
•
•
•
•
DEAFNESS
Conductive deafness- Viral O.E.
Unilateral deafness- Glomus jugulare
Also in A.O.E., Keratosis obturans, C.S.O.M. & Aural
polyp
ITCHING
A.O.E., Wax & Aural polyp
Prominent in Otomycosis
•
•
•
•
•
TINNITUS
A.O.E., Wax, C.S.O.M.
Pulsatile tinnitus- Glomus jugulare
GIDDINESS
C.S.O.M., Wax
FEVER & MALAISE
A.S.O.M. & are aggravated in acute mastoiditis
BLEEDING
C.S.O.M.
SIGNS
• SWELLING- Gen. in A.O.E.-local. In A.O.E.,
C.S.O.M., Keratosis Obturans
• TENDERNESS-C.S.O.M., K. Obturans & on
mastoid antrum in acute mastoiditis
• COTTON LIKE/WET NEWSPAPER LIKE MASSOtomycosis
•
•
•
•
HAEMORRHAGIC VESICLES- Viral O.E.
RISING SUN SIGN- Glomus jugulare
BROWNISH/BLACKISH MASS IN EAR- Wax
PERFORATED EARDRUM- A.S.O.M., C.S.O.M.(attic/
marginal) & irregular in traumatic type
• PEDUNCULATED MASS IN EXT. AUDI. CANALpolyp.
• PROBING- Profuse bleeding on probing IN
Glomus jugulare & malignancy.
Treatment
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•
•
•
•
Karnadhavana. – trifala, panchavalkala.
Karnadhupana- guggulu, ghita,
Purana- kshara taila, jatyaditaila.
Vrana ropaka chikitsa.
Kushtha chikitsa
1)
2)
3)
4)
5)
Karnashuula
Karnasraava
Puutikarna
Krumikarna
Karnapaaka
1)
2)
3)
4)
5)
6)
Karnapratinaaha
Karnavidradhi
Karnashotha
Karnaarbuda
Utpaata
vidaarikaa
Tinnitus
PERCEPTION OF SOUND WITHIN THE HUMAN
EAR IN ABSENCE OF CORRESPONDING
EXTERNAL SOUND
USUALLY DESCRIBED AS
"A RINGING NOISE”
BUT IN SOME PATIENTS IT TAKES THE FORM OF




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
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A HIGH PITCHED WHINING
BUZZING
HISSING
SCREAMING,
HUMMING
WHISTLING SOUND
TICKING
Diagnostic approach
• OTOLOGIC PROBLEMS, ESP HEARING LOSS, - MOST COMMON
CAUSES OF SUBJECTIVE TINNITUS.
• UNILATERAL HEARING LOSS PLUS TINNITUS -SUSPICION FOR
ACOUSTIC NEUROMA.
• SUBJECTIVE TINNITUS - NEUROLOGIC, METABOLIC, OR
PSYCHOGENIC DISORDERS.
• OBJECTIVE TINNITUS - VASCULAR ABNORMALITIES OF THE
CAROTID ARTERY OR JUGULAR VENOUS SYSTEMS.
• INITIAL EVALUATION OF TINNITUS SHOULD INCLUDE A
THOROUGH HISTORY, HEAD AND NECK EXAMINATION, AND
AUDIOMETRIC TESTING TO IDENTIFY AN UNDERLYING ETIOLOGY.
DIAGNOSTIC APPROACH TO TINNITUS
Treatment.
SNEHAPAN
ABHYANGA
PASCHAT VIRECHAN (ERANDATAILADI)
VAATHARA SWEDA- NADISWEDA OR PINDASWEDA
BHOJAN PASCHAT GHRITAPAN
PASCHAT DUGDHAPAN
BASTIKARMA
MURDHABASTI (BALATAILA)
Rule out PANDU / ADHIMANTHA/ SHIROROGA (VAATAJA)/grahani.
Badhirya.
• Deaf mutism- a very important condition.
• No defect in speech mechanism.
• Early noting of disease by parents , very imp.
• If the deafness occurs till the age of 5 years,
whatever speech is acquired may be lost or
distorted.
• Causes- preeclampsia, HT, DM, german measles,
G.A. during pegnancy, Rh incompatibility, prolonged
labour, ototoxic drugs,pematurity, kernicterus.
Treatment.
• Hearing aid- ASAP.
• Speech therapy,
• Prevention is important.
Badhirya.
• The plight of a blind or a lame can easily be
visualized by everybody and they evoke
sympathy, but no one sympathises with deaf
cos his handicap is not noticeable.
• Tuning fork test to evaluate whether conductive or
sensori-neural.
• Audiogram to confirm.
• Suspect deafness if the person misses telephone
ring or call from adjoining room, or difficult to
distinguish 20 and 30.
• Or requests to repeat the sentence.
Causes.
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•
•
•
•
•
•
SNHLOtotoxic drugs.
Senility
Loud noise.(40 hrs per wk of 90 dB.)
Head injury.
DM, HT, CVA, smoking , alcohol.
Hypothroidism,
conductive
• Wax. Fungus,
• Middle ear conditions, otosclerosis.
Treatment.
• Sensory neural- viguna vaata.(vaatavyadhi Induvati,
vasant kusumakara, Bilvataila, mahalaxmivilasa,
vacha, aswagandha, rasasindura.
• Conductive- vaat-kapha.(pratishyaya.)-sarivadi,
laxmivilasa, removal of cause.
THROAT
Dysphagia.
for some people, difficulty in swallowing
makes every meal a challenge.
•
•
•
•
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•
Symptoms of Dysphagia
eating slowly
trying to swallow a single mouthful of food several times
difficulty coordinating sucking and swallowing
gagging during feeding
drooling
a feeling that food or liquids are sticking in the throat or esophagus, or
that there is a lump in these areas
• discomfort in the throat or chest
• congestion in the chest after eating or drinking
• coughing or choking when eating or drinking (or very soon afterwards)
•
•
•
•
•
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•
•
wet or raspy sounding voice during or after eating
tiredness or shortness of breath while eating or drinking
frequent respiratory infections
color change during feeding, such as becoming blue or pale
spitting up or vomiting frequently
food or liquids coming out of the nose during or after a feeding
frequent sneezing after eating
weight loss
causes
• Inside lumen
• Inside wall
• Outside the tube.
DIFFERENTIAL DIAGNOSIS
(I)
(A)
(1)
Oesophageal –
In The Lumen :
Foreign bodies – cause acute dysphagia. If the foreign body is
small, it may not cause dysphagia.
(2)
Large bolus – may produce dysphagia.
(B) In The Wall :
(1)
CONGENITAL –
Tracheo oesophageal fistula: the symptoms of dysphagia appear
right from birth.
Depending upon the type of lesion, there are respiratory &
alimentary symptoms.
(2) TRAUMA –
(i) Corrosive poisoning – may necrose the mucosa
with or without the necrosis of the submucosa. It
causes painful dysphagia.
Strong alkalis may lead to perforation of the
oesophagus.
(ii) If there is stricture formation later, there is
chronic dysphagia particularly for solids.
(3) INFLAMMATION –
(i) Corrosive poisoning causes acute oesophagitis.
(ii) Hiatus hernia may produce chronic dysphagia due to
the reflux of the gastric secretion in the lower end of the
oesophagus.
(4) NEOPLASMS –
(i) Benign neoplasms are very rare.
(ii) Any elderly patient having dysphagia for more than
two weeks should be investigated thoroughly to rule out
malignancy.
• NEUROLOGICAL –
• (i) Paralytic conditions are more likely to affect the
pharynx rather than the
•
oesophagus.
•
The gag reflex is absent, & other neurological
findings may be present.
• (ii) Spasm of cricopharynx & oesophagus.
• (iii) Tetanus
• (iv) Myasthenia gravis.
Paterson Brown Kelly Syndrome
• Lady near menopause,
• Anaemia, kolionychia,
• chronic dysphagia.angular stomatitis, glossitis,
Achalasia cardia
Failure of relaxation of the lower oesophageal sphincter for the
passage of food.
There is marked dilatation, elongation, tortuosity of the lower third
of the oesophagus.
•
Dysphagia is progressive, more to liquids than solids & there is
epigastric discomfort.
•
Regurgitation of undigested food may occur. Later, pulmonary
complicatins due to aspiration may occur,
Ca Oesophagus
• Progressive, solids then liquids,
• Elderly, smoking, alcohol, gutkha,
• Indirect laryngoscopy, esophagoscopy.
DIAGNOSIS
1) Indirect laryngoscopy may show pooling of saliva in the
pyriform fossa. Vocal cord palsy may be present.
2) Barium swallow shows irregular filling difect with rat-tail
appearance & no proximal dilatation.
3) C.T. scan will also outline the lesion.
4) Oesophagoscopy & biopsy confirms the diagnosis.
C:\WINDOWS\hinhem.scr
Ulcerating squamous cell carcinoma of lower end of
oesophagus.
Ca Oesophagus.
TREATMENT
1) Upper third carcinoma: radiotherapy is the treatment of choice.
2) Middle third carcinoma: radiotherapy or surgery may be
advised. Surgical excision is followed by colonic transplant or
gastric anastomosis.
3) Lower third carcinoma: radiotherapy can be given except for
adenocarcinoma which is radio resistant. Surgical excision
followed by oesophago-gastrostomy is the treatment of choice.
PROGNOSIS :
Is poor. Most cases present late & are inoperable.
Gastrostomy has to be done in late cases with acute
dysphagia.
• THANK YOU.
• -DR. PRANAV BHAGWAT.
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