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 • • • • • 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 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. • • • • • • • 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. • • • • • • 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) • • • • • • • • 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.