D iseases of Ear, NosE aND ThroaT D iseases of Ear, NosE aND ThroaT head and Neck surgery Mohan Bansal ms phd fics facs Honorary Professor, Otorhinolaryngology Faculty of Medical Sciences Charotar University of Science and Technology (CHARUSAT) Changa, Anand, Gujarat, India Consultant, Ear, Nose, Throat, Head and Neck Surgeon Anand, Gujarat JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Panama City • London • Dhaka • Kathmandu Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: [email protected] Overseas Offices J.P. Medical Ltd Jaypee-Highlights Medical Publishers Inc 83, Victoria Street, London City of Knowledge, Bld. 237, Clayton SW1H 0HW (UK) Panama City, Panama Phone: +44-2031708910 Phone: +507-317-0496 Fax: +02-03-0086180 Fax: +507-301-0499 Email: [email protected] Email: [email protected] Jaypee Brothers Medical Publishers (P) Ltd Jaypee Brothers Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Shorakhute, Kathmandu Mohammadpur, Dhaka-1207 Nepal Bangladesh Phone: +00977-9841528578 Mobile: +08801912003485 Email: [email protected] Email: [email protected] Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2013, Jaypee Brothers Medical Publishers All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the publisher. Inquiries for bulk sales may be solicited at: [email protected] This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the author. Where appropriate, the readers should consult with a special- ist or contact the manufacturer of the drug or device. Diseases of Ear, Nose and Throat First Edition: 2013 ISBN 978-93-5025-943-6 Printed at dedicated to Almighty Lord, my parents, teachers, family, patients and students Shri Ramakrishna Paramhansa He indeed is blessed, in whom all the qualities of head and heart are fully developed and evenly balanced. He acquits himself admirably well in whatever position he may be placed. He is full of guileless faith and love for God, and yet his dealings with others leave nothing to be desired. When he is engaged in worldly affairs, he is a thorough man of business. In the assembly of the learned, he establishes his claims as a man of superior learning, and in debates, he shows wonderful powers of reasoning. To his parents, he is obedient and affec- tionate; to his relations and friends, he is loving and sweet; to his neighbors, he is kind and sympathetic and always ready to do goods; to his wife, he is the god of love. Such a man is indeed perfect. Holy Mother Sri Sarada Devi If you want peace, do not find fault with others. Rather see your own faults. Learn to make the world your own. No one is stranger, my child; the whole world is your own. Swami Vivekananda We are responsible for what we are, and whatever we wish ourselves to be, we have the power to make ourselves. If what we are now has been the result of our own past actions, it certainly follows that whatever we wish to be in future can be produced by our present actions. Man is man, so long as he is struggling to rise above nature, and this nature is both internal and external. Preface As long as I live, I learn. • Bhagwan Shri Ramakrishna Dev • Diseases of Ear, Nose and Throat, which represents otorhinolaryngology Head and Neck Surgery in all of its diversity, is created to fill the need of contemporary definitive book. The reader will find boxes, tables, flow charts, line diagrams and photographs, which serve to enhance learning. The book is comprehensive and of broader scope and is designed for students, residents and practitioners alike. It offers a balanced presentation of content and emphasizes the practical features of clinical diagnosis and patient management. The students will like the simplicity, directness and clarity. Each chapter includes clear, compelling, and up-to-date discussions and expertly executed and generously sized art. The brevity, conciseness, readable format and easy acces- sibility of key information will facilitate efficient use in any practice setting. Each page is carefully laid out to place related text, figures, and tables near one another to minimize the need for page turning. To provide an overview, each chapter begins with the list of its content and ends with further Reading section. Each chapter has clinical Highlights section for the quick revision of the students. This section has been especially prepared for answering frequently asked McQs, short-answer questions and oral/viva questions. The Appendix contains Top 101 clinical Secrets and problem-oriented cases which will be of immense use and interest to the readers. I would like to acknowledge my parents, late Shri Ramchandra and Smt Kalawati Devi Bansal, for enabling me to survive comfortably during my seemingly endless years of education. My family has unswervingly endorsed the time required for this mission, so heartfelt love and thanks go to my wife, Sushma, as well as our children Tejal and Mohit and his wife Astha. My loyal assistant for the last 10 years, Tejal patel, has provided amounts of all-round care to cover for my time. I wish to thank my professor friends who spared their valuable time in reviewing the chapters. The process of learning is truly life-long. creating this text allows me to continue to become invigorated and inspired by otolaryngology. I hope that my quest to document significant and up-to-date information has been successful. My sincere hope is that readers, everywhere, will benefit from this book. I invite readers and educators to send their suggestions so that I can include them in the next edition. The structure, content, and production values of this book will be shaped by its relationship with educators and readers. Mohan Bansal ([email protected]) acKNoWLedGMeNts for this book Diseases of Ear, Nose and Throat, I have enjoyed the opportunity of collaborating with a group of dedicated and talented professionals. I would like to recognize and thank the members of the book team, who indeed worked hard, to bring this book to you. Shri Jitendar p Vij (chairman and Managing Director), Jaypee Brothers Medical publishers, illumi- nated the path for this book with his creative ideas and dedication. The insights and skills of Dr Richa Saxena (Editor-in-chief) helped in polishing this book to best meet the needs of students and faculty alike. Mr Ankit Vij (Managing Director), the young and dynamic leader, took personal interest and laid out each page of the book to achieve the best possible place- ment of text, figures, and other elements. The suggestions from Mr Saket Budhiraja (Director-Sales and Marketing) were very practical and meaningful. Mr Tarun Duneja (Director- publishing) demonstrated his untiring expertise during each step of the production process. I would like to thank Ms Sunita Katla (publishing Manager) for her efforts towards the finalisation of the book. I would also like to thank Mr KK Raman (production Manager), Ms Samina Khan (pA to Director-publishing), Mr Amit Rai (Editor), Mr Ashutosh Srivastava (Assistant Editor) and Mr Kapil Dev Sharma (DTp operator) for their work with efficiency. Ms Seema Dogra's (cover Designer) and Mr Sumit Kumar's (Graphic Designer) artistic ability, organizational skills, attention to detail and understanding of illustration preferences greatly enhance the visual appeal and style of figures. They are consummate professionals whose efforts I truly appreciate. Tejal patel, my assistant, shepherded the manuscript and electronic files. Sushma coordinated the development of many supplements that support this text. Dr Rimpal chauhan, chandani, priti, falguni, Rina, Rashmi, Tejal, Bimal and Hansika, my students, have collaborated on the illustrations for this book. The pG seminars, Journal club meetings and case discussion at pSMc, Karamsad, Anand, Gujarat, are very enriching. So I am thankful to prof Ravi Tiwari, prof Girish Mishra, prof Yojana Sharma, Dr Hiren Soni, Dr Siddharth Shah, Dr Nimesh patel and pG students for their valuable and meaningful discussions. I feel immense pleasure to express my heartfelt emotions to my phD guide prof Vikas Sinha (prof, ENT, and Dean, Mp Shah Medical college, Jamnagar) and prof Nitin Nagarkar (Govt Medical college, chandigarh) and facul- ties of BJMc, Ahmedabad, prof R Vishwakarma, prof Bela J prajapati, Dr Neena H Bhalodiya, Dr BK Kedia, Dr Kalpesh patel, and Dr Divang Gupta, Dr Shaun and Dr Shashank for their kind cooperation and friendly help. Under the GSE program of Rotary foundation, I visited some of the best medical centers in the USA including the Mayo Hospital with my friend prof Ranjan Aiyar. I appreciate his whole-hearted support. I am happy to express my thanks to my friend prof Mohan Jagade with whom I received the Garnett passé and Rodney William Memorial foundation, International Educational Scholarship for attending the 16th World congress of oRL, Head and Neck Surgery, in Australia. I would like to express my feelings of gratitude to my MS (ENT) teachers of Rajasthan especially Late prof p chatterji, prof NK Soni, prof Jp Gupta, prof AS Bapna, prof AK Gupta, prof AK Singhal, prof Ajit Singhji, and prof prakash Mishra. I wish to especially thank several of my academic colleagues for their helpful contribution to this book. I am grateful to the dedicated educators who have contributed to the quality material that accompanies this text: prof Swati Shah, prof Amit Goyal, Dr AS Solanki, Dr Ritesh prajapati, Dr Jayesh patel, Dr Jaydeep Doshi and Dr Suhail Amin patigaroo. ReVieweRS The chapters were emailed to the following otolaryngology professors. Majority of them generously provided their time and expertise and reviewed the chapters. I am extremely grateful to them. Their insightful suggestions for improvement helped me maintain book’s accuracy and clarity. Their names are acknowledged in the following list: • Arun Agarwal, Maulana Azad Medical college, New Delhi • Anirban Biswas, Kolkata, West Bengal • Navneet Agarwal, SNMc, Jodhpur, Rajasthan • Renuka Bradoo, LTM Medical college and General Hospital, • Sp Aggarwal, cSMMU, Lucknow, Uttar pradesh Mumbai, Maharashtra • Hemant Ahluwalia, Medical college, Agra, Uttar pradesh • Shelly chadha, Maulana Azad Medical college, New Delhi • Ranjan Aiyar, Govt Medical college, Vadodara, Gujarat • Suvamoy chakraborty, Sikkim Manipal Institute of Medical • TS Anand, Lady Hardinge Medical college, New Delhi Sciences, Gangtok, Sikkim • Brajendra Baser, SAIMS, Indore, Madhya pradesh • Bhagwat chaudhary, Rajiv Gandhi Medical college, Thane, • Sangita Bhandary, Bp Koirala Institute of Health Sciences, Maharashtra Ghopa – Dharan, Nepal • Viral A chhaya, Mp Shah Medical college, Jamnagar, Gujarat • Satheesh Kumar Bhandary, KS Hegde Medical Academy, • Aniece choudhary, SMGS Hospital and Govt Medical college, Deralkatte, Mangalore, Karnataka Jammu (J&K) • HS Bhuie, RNT Medical college, Udaipur, Rajasthan • Jaymin contractor, Govt Medical college, Surat, Gujarat • Jyoti Dabholkar, Seth GSMc & KEM Hospital, Mumbai, • Jc passey, Maulana Azad Medical college, New Delhi x Maharashtra • chandrakant patil, JNMc, Wardha, Maharashtra • Sudip Kumar Das, Institute of postgraduate Medical Education • Abdul Rasheed patigaroo, Era Medical college, Lucknow, and Research Medical college, Kolkata, West Bengal Uttar pradesh • Vishal Dave, GS Medical college, Ahmedabad, Gujarat • SK pippal, Bundelkhand Medical college, Sagar, Madhya pradesh • Surendra Gawarle, Govt Medical college, Nagpur, Maharashtra • VK poorey, SS Medical college and GM Hospital, Rewa, • Ajay George, Suman Deep Medical college, Vadodara, Gujarat Madhya pradesh • Swapan Kumar Ghosh, IpGME & R, Kolkata, West Bengal • Bela prajapati, BJ Medical college, Ahmedabad, Gujarat • cS Gohil, Sharadaben Hospital, Ahmedabad, Gujarat • Kishore chandra prasad, Kasturba Medical college, Manipal, • Amit Goyal, NEIGRIHMS, Mawdiangdiang, Shillong, Meghalaya Karnataka • Arun Goyal, University college of Medical Sciences and GTB • prabhati purkayastha, Silchar Medical college, Silchar, Assam Hospital, Delhi • Madhavi Raibagkar, Shardaben Hospital, Ahmedabad, Gujarat • Vp Goyal, JLN Medical college, Ajmer, Rajasthan • Anoop Raj, Maulana Azad Medical college, New Delhi • Ashok Gupta, Geetanjali Medical college & Hospital, Udaipur, • Dwarkanath D Reddy, IJo & HNS, Hyderabad • Vishnu Vardhan M Reddy, osmania Medical college, Govt ENT Rajasthan Hospital, Hyderabad • Ashok Gupta, postgraduate Institute of Medical Education • Up Santosh, JJM Medical college, Davangere, Karnataka and Research, chandigarh • Rohit Saxena, Santosh Medical college, Ghaziabad, Uttar • Nilima Gupta, University college of Medical Sciences and GTB pradesh Hospital, Delhi at • Sc Gupta (col), command Hospital(cc), Lucknow, Uttar pradesh • Saurav Sarkar, calcutta Medical college, Kolkata, West Bengal o • Hardik Shah, Shola Medical college, Ahmedabad, Gujarat hr • Vipan Gupta, Gian Sagar Medical college, patiala, punjab • UB Shah, VS Medical college, Ahmedabad, Gujarat T • Achal Gulati, Maulana Azad Medical college, New Delhi • Dinesh Kumar Sharma, GMc & RH, patiala, punjab d • KK Handa, AIIMS, New Delhi • Karan Sharma, Medical college, Amritsar, punjab n • Hathiram Bachi, TN Medical college and BYL Nair Hospital, a • Ravinder Sharma, Subharti Medical college, Meerut, Uttar e Mumbai, Maharashtra pradesh s • Abhay Havle, Krishna Institute of Medical Sciences, Karad, o • Yojana Sharma, pS Medical college, Anand, Gujarat N Maharashtra • Bikash L Shrestha, Kathmandu University School of Medical ar, • Sf Hashmi, Jawaharlal Nehru Medical college, AMU, Aligarh, Sciences, Dhulikhel, Nepal E Uttar pradesh • Brian Shunyu, NEIGRIHMS, Shillong, Meghalaya of • c Jacinth, Govt Stanley Medical college and Hospital, chennai, • Amrik Singh, Guru Ramdas Medical college, Amritsar, punjab s Tamil Nadu • Dalbir Singh, Govt. Medical college, patiala, punjab se • Mohan V Jagade, Grant Medical college & Sir JJ Group of • Ishwar Singh, Bp Koirala Institute of Health Sciences, Dharan, a Hospitals, Byculla, Mumbai, Maharashtra Nepal e s • Sushil Jha, Sir ST Medical college, Bhavnagar, Gujarat • Mangal Singh, MLN Medical college, Allahabad, Uttar i D • M panduranga Kamath, KMc Hospital, Mangalore, Karnataka pradesh • Atul Kansara, LG Hospital, Ahmedabad, Gujarat • Vikas Sinha, Mp Shah Medical college, Jamnagar, Gujarat • Ashish Katarkar, cU Shah Medical college, Surendranagar, • Gangadhara KS Somayaji, Yenpoya Medical college, Gujarat Mangalore, Karnataka • Sandeep Kaushik, GSVM Medical college, Kanpur, Uttar pradesh • Hiren Soni, Gotri Medical college, Vadodara, Gujarat • Vinod Khandar, Medical college, Surendranagar, Gujarat • NK Soni, Rama Medical college, Ghaziabad, Uttar pradesh • Swagata Khanna, Guwahati Medical college, Guwahati, Assam • Jagdish Kumar Sunkum, Mamata Medical college, • pS Kohli, Adesh Institute of Medical Sciences and Research, Khammam, Andhra pradesh Bathinda, punjab • JR Talsania, Smt NHL Municipal Medical college, Ahmedabad, • Dharmendra Kumar, SN Medical college, Agra, Uttar pradesh Gujarat • Abhineet Lall, Seth GS Medical college, Mumbai, Maharashtra • Hc Taneja, University college of Medical Sciences & GTB • S Laxmi, Kempegowda Institute of Medical Sciences, Hospital, Delhi Bengaluru, Karnataka • MK Taneja, IJo, Ghaziabad, Uttar pradesh • Manish Mehta, pDU Medical college, Rajkot, Gujarat • Alok Thakar, AIIMS, New Delhi • Girish Mishra, pS Medical college, Karamsad, Anand, Gujarat • Sudhakar Vaidya, RDGMc, Ujjain, Madhya pradesh • prakash Mishra, SMS Medical college, Jaipur, Rajasthan • phaniendra Kumar Valluri, Guntur, Andhra pradesh • Sanjeev Mohanty, SRMc & RI, porur, chennai, Tamil Nadu • Ashish Varghese, christian Medical college, Ludhiana, punjab • Saurabh Varshney, Himalayan Institute of Medical Sciences, • Manish Munjal, DMcH Dayanand Medical college, Ludhiana, Jolly Grant, Doiwala, Dehradun, Uttarakhand punjab • Rupa Vedantam, christian Medical college & Hospital, Vellore, • A Muraleedharan, Govt Stanley Medical college and Hospital, Tamil Nadu chennai, Tamil Nadu • Vp Venkatachalam, Vardhman Mahavir Medical college & • pSN Murthy, IJo & HNS, Vijaywada, Dr pinnamaneni Siddharta Safdarjung Hospital, New Delhi Institute of Medical Sciences, Hyderabad, Andhra pradesh • Rajesh Vishwakarma, BJ Medical college, Ahmedabad, Gujarat • Nitin Nagarkar, Govt Medical college, chandigarh • K V Vishwas, Rajarajeshwari Medical college and Hospital, • V Natesh, Bp Koirala Institute of Health Sciences, Dharan, Nepal Bengaluru, Karnataka • Nupur Nerulkar, Sion Hospital, Mumbai, Maharashtra • B Viswanatha, Banglore Medical college, Bengaluru, Karnataka • Rafiq Ahmad pampori, Govt Medical college, Srinagar, J&K • Raman Wadhera, pGIMS, Rohtak, Haryana • Naresh K panda, pGIMER, chandigarh • Basavaraj Walikar, Al Ameen Medical college, Bijapur, Karnataka • Vishala pandya, Baroda Medical college, Vadodara, Gujarat • Bhushan Wani, Jawaharlal Nehru Medical college, Wardha & • Rupa parikh, Medical college, Municipal corporation, Surat, Tata Memorial Hospital, Mumbai, Maharashtra Gujarat • Rc Yadav, Medical college, Kota, Rajasthan coNteNts Section 1 : Basic Sciences 1. Anatomy and Physiology of ear 1 Temporal Bone 2  Anatomy of External Ear 2 Auricle 2; External Auditory Canal 4; Tympanic Membrane 5; Middle Ear Anatomy 6; Parts of Middle Ear (Tympanum) 6; Boundaries of Middle Ear 7; Ossicles 8; Intratympanic Muscles 9; Intratympanic Nerves 9; Middle Ear Mucosa 9; Compartments and Folds of Middle Ear 9; Mastoid Antrum 11; Types of Mastoid 11; Korner’s Septum 11; Blood Supply 13; Lymphatic Drainage of Ear 13  Anatomy of Internal Ear 13 Bony Labyrinth 13; Membranous Labyrinth 15; Inner Ear Fluids 16; Organ of Corti 16; Vestibular Receptors 16; Blood Supply of Labyrinth 19; Internal Auditory Canal 19  Development of Ear 19  central connections (Neural pathways) 20 Auditory Neural Pathways 20; Central Vestibular Connections 21; Physiology of Hearing 22; Conduction of Sound 22; Transduction of Mechanical Energy to Electrical Impulses 23; Medial Geniculate Body and Temporal Lobe Auditory Cortex 25  physiology of Vestibular System 25 Semicircular Canals Functions 25; Utricle and Saccule Functions 26  Maintenance of Body Equilibrium 26 2. Anatomy and Physiology of Nose and Paranasal Sinuses 29  Anatomy of Nose 30 External Nose 30; Internal Nose 30; Anatomy of Paranasal Sinuses 37  physiology of Nose 39 Respiration 39; Air-Conditioning of Inspired Air 40; Protection of Airway 40; Vocal Resonance 41; Nasal Reflexes 41; Olfaction 41  physiology of paranasal Sinuses 41 Functions 41; Ventilation of Sinuses 42 3. Anatomy and Physiology of Oral Cavity, Pharynx and esophagus 43  oral cavity 44  Salivary Glands 46  pharynx 49 Waldeyer’s Ring 51  Nasopharynx 51 Adenoids 52  oropharynx 52 Palatine (Faucial) Tonsils 53  Laryngopharynx 56  Esophagus 56  physiology of Swallowing 58  Embryology 58 4. Anatomy and Physiology of Larynx and Tracheobronchial Tree 61  Anatomy of Larynx 61 Cartilages 61; Joints 62; Membranes and Ligaments 62; Cavity of the Larynx 63; Mucous Membrane of the Larynx 64; Lymphatic Drainage 64; Spaces of the Larynx 64; Functional Divisions of Vocal Folds 65; Phase xii Difference 65; Muscles of Larynx 65; Nerve Supply of Larynx 66; Development 67  functions of Larynx 68 Protection of Lower Airways 68; Phonation and Speech 68; Respiration 68; Fixation of Chest 68  Anatomy of Tracheobronchial Tree 68 Trachea and Bronchi 68; Tracheal Cartilages 68; Mucosa 69; Bronchopulmonary Segments 69 5. Anatomy of Neck 72 Surface Anatomy 72; Triangles of Neck 73; Cervical Fascia 74; Lymph Nodes of Head and Neck 75; Neck Dissection 78; Thyroid Gland 78; Parathyroid Glands 79; Development 79 6. Bacteria and Antibiotics 80  Bacteria 81 Staphylococci 81; Streptococci 83; Corynebacterium Diphtheriae 83; Neisseria Species 84; Morexella Catarrhalis 84; Haemophilus Influenzae 84; Bordetella Pertussis 84; Pseudomonas Aeruginosa 84; Enterobacteriaceae 84; Anaerobes 84; Microaerophilic Bacteria 84; Mycobacteria 84; Mycoplasma Pneumoniae 85; Chlamydiae 85; Spirochaetes 85  Antibiotics 85 at Inhibitors of Bacterial Cell Wall Synthesis (Beta-Lactam Antibiotics) 86; Inhibitors of Nucleic Acid Synthesis 88; o r Inhibitors of Bacterial Protein Synthesis (Ribosomal) 88; Antitubercular Drugs 89; Nonspecific Antiseptics 90 h T 7. Fungi and Viruses 92 d n  fungi 93 a e  Antifungal Therapy 93 s o  Viruses 94 N  Antivirals 95 r, a Pandemic Influenza A H1N1 (Swine Flu) 96 E f 8. Human immunodeficiency Virus infection 101 o s HIV/AIDS 101; Cervical Adenopathy 104; Neoplasms 104; Nose and Sinuses 105; Nasopharynx 105; Ear 105; e s Oral Cavity 105; Occupational Exposure 106 a e s 9. History and examination 107 i D Otorhinolaryngology 107; History Taking 108; Physical Examination 108; General Set-Up 109; Swellings and Ulcers 109; Examination of Cranial Nerves 115; Headache 115; Facial Pain 120; Temporomandibular (Craniomandibular) Disorders 121 Section 2 : ear 10. Otologic Symptoms and examination 125  Ear Symptoms 125  Ear Examination 125  otalgia (Earache) 128  otorrhea 130 Assessment 131  Ear polyp 132  Tinnitus 132  Hyperacusis 135 11. Hearing evaluation 137 Audiology and Acoustics 138; Types of Hearing Loss 139; Need of Hearing Evaluation 139; Methods of Hearing Evaluation 139; Tuning Fork Tests 140; Pure Tone Audiometry 142; Speech Audiometry 143; Impedance Audiometry 144; Electrocochleography 145; Brainstem Evoked Response Audiometry 146; Otoacoustic Emissions 146; Auditory Steady State Response (ASSR) 147 12. Conductive Hearing Loss and Otosclerosis 149 Classification of Hearing Loss 149; Conductive Hearing Loss 149; Otosclerosis 150; Stapedectomy 153 13. Sensorineural Hearing Loss 156 Sensorineural Hearing Loss 157; Labyrinthitis 158; Syphilis 158; Cisplatin 160; Aminoglycoside Antibiotics 160; Noise Trauma 160; Sudden Sensorineural Hearing Loss 161; Presbycusis 162; Genetic Sensorineural Hearing Loss 163; Non-Organic Hearing Loss 163; Degree of Hearing Loss 164; The Only Hearing Ear 165