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The specialty of ear, nose and throat — head and neck (ENT — head and neck) surgery is very broad and complex. The common symptoms in the ear are otalgia, hearing loss, vertigo, tinnitus, aural fullness, discharge, hissing, facial weakness, bleeding and blockage.
When a patient presents with any of these symptoms (Table 2.1) it is important to characterise the symptoms in terms of site, severity, radiation, frequency, duration, exacerbating and relieving factors, associated features, the progression of symptoms and how it affects the patient’s activities of daily living. As stated, a systematic approach to examining the head should recognise the principles of ENT — head and neck and include this in the examination, along with the cranial nerves. When examining the nose assess for symmetry, nasal bones, upper lateral cartilages, lower lateral cartilages, the base and the lateral profile from the right and left sides. Inspect the internal nose by examining the septum and assessing for deviation, the appearance of the mucosa, the presence of blood, any perforation of the septum, pus, foreign bodies, polyps, mass lesions and also the appearance of turbinates and sinus drainage pathways.
When examining the throat, examine the mouth, the pharynx (which is subdivided into the nasopharynx, oropharynx and the hypopharynx), the tongue base and the larynx.
The mouth is examined in all four quadrants, assessing the teeth and salivary ducts while massaging the parotid, submandibular and sublingual glands in that order.
In the oropharynx, attention should be paid to the tonsils and posterior pharyngeal wall, assessing for any masses, ulcers or evidence of reflux suggesting submucosal gland hypertrophy. The hypopharynx and larynx are examined with a large mirror and head light as is the tongue base.
The nasopharynx is assessed and a tongue depressor is positioned, with a head light to shine on to the mirror to help visualise the post-nasal space. As in the abdomen, any part of the upper aerodigestive tract can be obstructed because of a mass, develop a fistula, have adhesions leading to a stenosis, have some form of perforation or can bleed. Palpation of the head and neck involves palpation of the lymph nodes and the thyroid gland. The other areas that need to be palpated are the parotid, the posterior occipital nodes and the post-auricular region. The lymph node groups drain specific areas of the head and neck, which in turn relates to the treatment of various head and neck cancers.
Table 2.2 outlines the process for performing a thyroid examination when thyroid disease is detected or suspected. A gait examination is often performed as part of the dizziness assessment and is covered in the neurologic examination. Flexible nasal endoscopy has also revolutionised the diagnosis of ENT — head and neck conditions. After the thorough history and complete physical examination have been performed, investigations are ordered. It is very important to know the regional anatomy and embryology of the structures of the ENT — head and neck. To examine an ear, systematically investigate the outer ear followed by the middle ear and then the inner ear (Fig 2.5).
For the outer ear look at the normal contour of the outer ear, the ear canal and the tympanic membrane. The sigmoid sinus runs from the superolateral aspect of the temporal bone coursing inferomedially to exit the skull via the jugular foramen. Otitis media with effusion (OME) presents with a conductive hearing loss and a dull ear drum. A chronic discharging ear for more than three months is termed chronic suppurative otitis media (CSOM). A cholesteatoma is a sac of keratinised squamous epithelium that has the potential to grow and erode the surrounding structures resulting in hearing loss, discharge and potential intracranial complications. A bacterial biofilm is a colony of bacteria that has formed a resistant matrix often on an inert surface. When evaluating hearing loss, the outer ear, middle ear, inner ear and central pathways need to be considered. A complete examination with tuning fork tests is required and an audiogram will guide the diagnosis (Figs 2.8a and b). Vestibular function testing may be of assistance in diagnosing the probable cause, as is imaging.
Defined loosely as noise generated somewhere in the head, tinnitus (Fig 2.10) is annoying to the patient and can be extremely disabling. When a patient presents with a facial weakness a systematic approach needs to be adopted, considering the components and course of the facial nerve together with the VITAMIN CID mnemonic. When approaching a presentation of facial nerve palsy, the function of the branches should be considered and addressed in order of importance.
The septum is supplied by the facial artery, greater palatine artery, sphenopalatine artery, anterior ethmoid artery and the posterior ethmoid artery. The lateral nasal wall has its blood supply predominantly from the sphenopalatine artery, with contributions from the anterior and posterior ethmoid arteries. The nerve supply of the nose reflects its function: to smell, to warm and humidify the air that has been breathed in and to function as the airway.
IntroducaoA integridade bioquimica dos liquidos do ouvido interno e essencial para seu bom funcionamento.
When taking a history, the past history needs to be noted, including previous surgery to the respective parts of the ear, nose and throat, head and neck and any associated conditions. Assess the function of the nose by occluding the nasal airway on each side respectively and ask the patient to breathe in and out.
The mucosa and floor of the mouth are examined followed by the roof of the mouth, the uvula and finally the sulcus on either side of mandible, looking for any hidden lesions in the buccal or lingual sulcus. Other aspects to observe are evidence of post-nasal drip with secretions coming from the nasopharynx and evidence of any dryness of the mucosa.
Laryngeal assessment includes the epiglottis, vallecula, aryepiglottic fold, arytenoids, false cords, laryngeal ventricles, true cords, the subglottis and trachea. It is important to palpate one side of the head and neck at a time and systematically approach all the groups of lymph nodes (Fig 2.2). Lesions high in the nose should be treated with caution as there may be a communication with the CSF space. When assessing a lump in the neck consider the local anatomy of the skin, soft tissue, associated vessels, the lymph node drainage pathways, any potential nerves that may be in the area and bones.

This nerve courses through the temporal bone then enters the internal auditory canal in the antero-superior quadrant. The cochlear nerve occupies the antero-inferior quadrant of the internal auditory canal (IAC). Sound is conducted via the external canal, the tympanic membrane and the ossicular chain, then converted into electrical impulses by the cochlea.
This sensory apparatus is supplied by the vestibular component of the vestibulocochlear nerve. The internal carotid artery enters the floor of the petrous temporal bone via the carotid canal, passes below the cochlea and travels horizontally till it reaches the sphenoid and carotid siphon.
Water can be trapped behind the wax and become secondarily infected resulting in an early OE. Most cases of OME in children (about 90%) will resolve within three months, as there is often a preceding URTI. It results from chronic infection, with an associated biofilm formation or may be caused by a cholesteatoma.
There are many theories that relate to an imbalance in the flow of endolymph in the inner ear. MRI is used to assess the brain, brainstem and retrocochlear region, whereas CT is used to assess the middle ear anatomy.
It is known that if all the hearing mechanism was removed, tinnitus would still be reported by the patient because of a phenomenon known as brain plasticity — it creates the sound and amplifies it at the level of the patient’s awareness. One can explain tinnitus to patients as likening it to tuning in to external sounds such as an air conditioning fan or a car going past. Frontal — loss of this nerve results in an inability to raise the forehead, which is purely a cosmetic loss. The septum has a cartilaginous component and a bony component made up of the perpendicular plate of the ethmoid and the vomer. Posterior epistaxis is uncommon; it presents bilaterally and is often severe from the sphenopalatine artery.
Por suas multiplas atuacoes no organismo, as alteracoes hormonais que ocorrem durante o ciclo menstrual, gestacao e menopausa podem resultar em comprometimento da homeostase dos fluidos labirinticos, pois influem diretamente em processos enzimaticos e na atuacao de neurotransmissores29.
Addressing any problems relating to the head and neck with this in mind will allow you to systematically approach the patient’s problem. Common symptoms relating to the throat include pain, dysphagia (difficulty swallowing), dysphonia (abnormal voice production), reflux, referred pain, cough, haemoptysis, shortness of breath, snoring and drooling. A patient’s medication and adverse reactions to medication should be known, as well as their social history, including their smoking and alcohol consumption and environmental exposures such as noise, dust and any other potential allergens. Reflux can often be detected by visualising reddening of the posterior glottis and arytenoids.
Deep palpation of the jugular chain is important because these glands are deep to sternocleidomastoid. There are many hidden areas in ENT — head and neck examination and the nasoendoscope has permitted access to the internal nose, sinus outflow tracts, post-nasal space, larynx, hypopharynx, tongue base and sometimes the proximal oesophagus (Fig 2.4). Think about the pathway for development of the thyroid, parathyroids, branchial cleft cysts, ear cysts and their appendages. When assessing the middle ear also assess for tympanic membrane mobility using what is called pneumatic otoscopy.
It then passes forwards in what is called the labyrinthine segment and passes above the cochlea, contributing to the geniculate ganglion that has branches to the petrosal nerves.
The superior division of the vestibular nerve occupies the postero-superior quadrant of the IAC and the inferior division of the vestibular nerve occupies the postero-inferior quadrant.
The superior petrosal sinus courses along the postero-superior aspect of the temporal bone from the cavernous sinus to the transverse sinus. The tympanic membrane may spontaneously rupture, resulting in a discharging ear and immediate pain relief.
The ongoing therapy involves physiotherapy and occupational therapy to make sure it is safe for a patient to return home.
Essas alteracoes podem ser assintomaticas ou clinicamente referidas como vertigens, instabilidade, zumbidos, plenitude auricular, hipoacusia ou algiacusia18.O ciclo menstrualDurante o ciclo menstrual, observamos flutuacao do limiar auditivo tonal, notadamente nas frequencias agudas3,12. As in any aspect of clinical medicine, the initial diagnosis is made by taking a thorough history prior to a complete physical examination that is supplemented by special investigations. The family history should be known and it is also wise to find out about any family tendencies regarding bleeding disorders and deafness. Any lesion should be palpated after asking the patient to stick their tongue to one side between their teeth to protect the examiner from any reflex bite.
Check any perforation of the tympanic membrane by assessing its size, the site, associated discharge and the condition of the middle ear mucosa. It then turns back and runs between the lateral semicircular canal superiorly and the oval window that is attached to the stapes, inferiorly.
The cochlear nerve conducts sound and the vestibular nerve conducts the sensation of balance. If you don’t concentrate on it then you don’t hear it and so with tinnitus it will stop bothering you. Treatment involves padding the eye closed and lubricating drops during the day and night with ophthalmological referral. Essas diferencas parecem ser mais acentuadas em mulheres portadoras de tensao pre-menstrual (TPM)2.
After passing these two structures it courses down in the stylomastoid canal giving off two branches: first, the nerve to the stapedius and then the chorda tympani that relays taste sensation from the anterior two-thirds of the tongue.
The labyrinthine artery, which is a branch of the basilar artery or anterior inferior cerebellar artery, supplies the petrous temporal bone entering via the internal auditory canal. In children, the Eustachian tube is shorter and more horizontal, therefore, more prone to blocking. In longstanding effusions, a middle ear ventilation tube (grommet) is inserted to resolve the effusion. Prior to performing a Dix-Hallpike manoeuvre the stethoscope should be used to listen for any carotid bruits because the Dix-Hallpike manoeuvre may precipitate a TIA. Durante o ciclo menstrual, alem do limiar tonal, ocorre flutuacao dos limiares do reflexo estapediano25 (Figura 1).Sao descritos casos de mulheres que apresentam severo aumento de limiares auditivos na segunda fase do ciclo menstrual, notadamente nas frequencias agudas.
The stethoscope is also used to listen for pulsatile tinnitus and is placed on the mastoid tip.

The Dix-Hallpike manoeuvre is diagnostic of benign paroxysmal positional vertigo (BPPV) and is performed on an examination couch. It gives off its auricular branch and then separates into a superior and inferior division. Apenas um caso descrito foi acompanhado durante longo tempo, evoluindo sem melhora com uso de contraceptivos orais, assintomatica durante a gestacao e aleitamento, e com piora apos a volta dos ciclos1. While sitting up, the patient turns their head quickly to one side while keeping the eyes wide open and focusing on a spot in the distance in the line of their eye sockets. The superior division has temporal, zygomatic and buccal branches and the inferior division has the marginal mandibular and the cervical branches. Tal paciente obteve beneficios com o uso de bloqueadores diretos de hipofise, com eliminacao do ciclo hormonal, porem nao pode continuar o tratamento em razao de seus efeitos adversos.Quando realizado na fase estrogenica ou lutea, o exame vestibular tambem mostra variacao15,26.
Next, the patient lies back with their head dependent over the head of the examination bench. Na fase lutea, podemos encontrar maior incidencia de nistagmo de posicao, ausencia de inibicao do nistagmo pos calorico com a fixacao ocular e preponderancia direcional. The examiner inspects for nystagmus, which indicates an overstimulated semicircular canal system. As alteracoes descritas sao frequentemente associadas ao edema de SNC15 (usual nessa fase) secundario a atuacao hormonal.
It is a positive result when nystagmus is elicited on the side to which the head is turned. Quadros de hidropsia labirintica muitas vezes sao observados nessas pacientes, as quais referem instabilidade, intolerancia ao ruido e sensacao de "cabeca oca"2. No campo da pesquisa clinica, o estudo do TTS (temporary threshold shift) revela que, durante a fase lutea, a mulher tem recuperacao auditiva pos ruido muito mais rapida11,27, quando comparada a fase estrogenica ou ao sexo masculino. Todas essas variacoes sao atribuidas ao alto indice hormonal que ocorre nessa epoca.E interessante notar que a afinidade dos receptores perifericos de insulina varia conforme a fase do ciclo hormonal4,13. Durante a segunda fase do ciclo menstrual ha "resistencia" periferica a insulina, por queda da afinidade aos receptores insulinicos.
Essa situacao tem como consequencia a hiperinsulinemia e o aumento da glicemia que poderiam levar a disturbios metabolicos no ouvido interno.Os sintomas decorrentes da TPM sao facilmente trataveis com dieta hipossodica e diuretico leve, durante a segunda fase do ciclo. Muitas vezes, podemos retirar a medicacao e a dieta apos 4 a 6 meses de ausencia dos sintomas. Quando o quadro e de hidropsia, em relacao a surdez, a melhora ocorre apenas nos casos onde nao ha lesao de percepcao2.Contraceptivos OraisCom o uso de contraceptivos orais, o reflexo estapediano nao varia como no ciclo menstrual e apresenta em niveis normais, embora ocorra diminuicao do limiar auditivo. Isso caracteriza aumento do campo auditivo, considerado um sinal de comprometimento do tronco cerebral30.
Observamos melhores limiares auditivos sob a acao dessas drogas, quando comparados a fase estrogenica e ao sexo masculino.
Em contrapartida, sao descritos casos de surdez subita sob o uso de estrogeno e progesterona, isolados ou associados19,21,31.
Sabe-se, ainda, que o uso prolongado dos anticoncepcionais pode levar a compromentimento auditivo em frequencias agudas, de carater neurossensorial27.Os casos descritos de surdez subita atribuida ao estrogeno, progesterona ou sua associacao apresentaram invariavelmente boa evolucao quando retirada a droga e realizado tratamento apropriado da fase aguda.
A arteria auditiva interna divide-se em dois ramos: vestibular anterior e coclear comum, que por sua vez da origem aos ramos coclear e vestibulo-coclear. A obstrucao vascular acarreta comprometimento do territorio por ela irrigado, que pode abranger coclea, vestibulo ou ambos (Figura 2).Nos ultimos anos, os contraceptivos orais tem cada vez menos estrogeno e progesterona, sendo chamados de contraceptivos de baixas doses ("low dose"). A utilizacao de hormonios em dosagens menores reduziu sensivelmente a ocorrencia de surdez subita. Atualmente, observamos quadros de instabilidade e algiacusia com o uso dessas formulacoes, parecendo que os sintomas estao relacionados a dose de progesterona. O estrogeno parece diminuir o intervalo entre as latencias interpicos7, enquanto que a progesterona, apresenta atuacao no tronco cerebral, comprometendo a conducao no complexo olivar superior, alterando a morfologia da onda8. As alteracoes sao encontradas quando o exame e sensibilizado atraves do aumento de "clicks"30. A explicacao para tal ocorrencia parece ser que as alteracoes clinicas, tais como zumbidos, precedem a lesao anatomica e exprimem maior "irritabilidade" das vias auditivas centrais7,30.Fase GestacionalDurante o ciclo gravidico, notamos variacao significativa da resposta vestibular.
No inicio da gestacao, observamos "sensibilizacao" da audicao, com melhora dos limiares tonais e diminuicao do limiar de excitabilidade labirintica a PRPD, semelhante ao que ocorre no uso prolongado de contraceptivos orais.
As alteracoes vestibulares normalizam-se ao longo do periodo gestacional, o que nos leva a supor que ha habituacao labirintica, enquanto os limiares tonais continuam estaveis6,10.E descrito na gestante o aumento do campo auditivo, caracterizado pelo melhor limiar auditivo e valor normal do reflexo estapediano9. Tal achado caracteriza comprome-timento do tronco cerebral, provavelmente secundario ao edema caracteristico desta fase. O efeito parece ser se-cundario a atuacao da progesterona sobre o tronco cere-bral que, conforme descrito experimentalmente, comprome-te a conducao auditiva no complexo olivar superior.A melhora do limiar auditivo parece estar relacionada com a evolucao da especie, que selecionou as femeas que tinham capacidade de estar mais atentas ao meio ambiente.
Ouvindo melhor durante a gestacao e fugiam dos seus predadores antes dos outros animais, compensando, assim, seu aumento de peso14.ClimaterioE comum observarmos mulheres com instabilidade, zumbidos eventuais e flutuacao durante o climaterio e menopausa. Tais sintomas parecem estar relacionados a insuficiencia estrogenica que ocorre nessa fase.
Alguns ginecologistas, ao usarem cinarizina com a finalidade de reduzir a sensacao de calor propria do periodo, promovem a diminuicao da sintomatologia.
O beneficio da reposicao estrogenica nessa fase e clinicamente verificado17,20.Existe em literatura a descricao de um caso de surdez subita atribuido ao uso de etinilestradiol para reposicao hormonal. Como nos demais casos de surdez secundaria ao uso de estrogenos, houve boa evolucao apos tratamento adequado32.HistofisioPatologiaLaugel et al descreveram experimen-talmente a variacao do fluxo sanguineo da coclea decorrente da acao dos hormonios ovarianos23,24.
Segundo os autores, o estrogeno e progesterona afetam a resposta do organismo a mediadores quimicos vasopressores, como a nicotina e fenilefrina.
As alteracoes histologicas sao semelhantes as descritas sob o uso de outros ototoxicos, que agridem preferencialmente as celulas basais da estria vascular, que se apresentam vacuolizadas a microscopia de luz.
No estudo eletrofisiologico, a analise dos potenciais auditivos demonstra a atuacao hormonal no tronco cerebral, com comprometimento das latencias e amplitudes das ondas.Embora existam evidencias clinicas e experimentais da acao dos hormonios ovarianos sobre a funcao labirintica, os sintomas nao guardam relacao imediata com os valores sorologicos absolutos de estrogeno e progesterona, mesmo que so ocorram quando estes estejam elevados5. E nossa opiniao, que alem de altos niveis individuais, deve existir alguma proporcao entre os dois hormonios para que esses sintomas aparecam1,5.
Novamente, ressaltamos a possibilidade de a sintomato-logia ser devida a alteracoes metabolicas resultantes da acao dos hormonios.
Sabemos que existe influencia no metabolismo de triglicerides e variacao da afinidade dos receptores da insulina, levando a hiperinsulinemia na presenca de estrogeno e progesterona, condicoes altamente favoraveis ao aparecimento de sintomatologia cocleo-vestibular.Bibliografia 1.

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