The specialty of otolaryngology - head and neck surgery requires from its doctors a breadth and depth of knowledge that continues to develop and expand. It was clear that there was no comparable clinical manual for otolaryngology – head and neck surgery.
Preface
Acknowledgments
Contributors
David Kriet, MD, FACS Associate Professor
Director of Head and Neck Surgery, Department of Facial Plastic Surgery, University of Virginia Charlottesville, Virginia 7.3.2. Pesek, MD Department of Surgery, University of Vermont School of Medicine/Fletcher Allen Health Care.
Plosky, MD
Schaitkin, MD Professor and Program Director Department of Otolaryngology University of Pittsburgh School of Medicine. Sykes, MD, FACS Professor of Otolaryngology Director of Facial Plastic Surgery University of California, Davis Medical Center Sacramento, California.
Board of Review
1 Perioperative Care and General Otolaryngology
Section Editor
Approach to the Otolaryngology–Head and Neck Surgery Patient Neck Surgery Patient
The generally accepted organization of history and physical examination for a new patient is outlined in Table 1.1. In the documentation for the patient visit, the note ends with an impression and a plan.
Preoperative Assessment
Does cardiac status prohibit the patient from achieving 5 METS (climbing stairs) without shortness of breath. NPO status Has the patient followed the ASA NPO guidelines. see also table 1.3) Alcohol/drug.
Airway Assessment and Management
The balloon cuff of the endotracheal tube should extend 1 to 2 cm from the vocal folds. Once the correct position of the endotracheal tube is confirmed, it should be placed in place.
Further Reading
Diagnostic Imaging of the Head and Neck
MRI is valuable in assessing intracranial extension of head and neck tumors. 99m Tc-sestamibi is a lipophilic cation that is taken up in the mitochondria of cells.
Anesthesia
- Principles of Anesthesia
- Regional Anesthesia Techniques
- Anesthesia Drugs
- Anesthetic Emergencies
The maxillary part of the trigeminal nerve innervates the middle of the face, from the lower part of the orbit to the mandible. Initially, 3 to 5 mL of local anesthetic is injected into the center of the SCM with a 27-gauge needle. It is not uncommon for the patient to describe mild paresthesia in the dermatome of the root, which is blocked.
After careful aspiration, 4 to 5 cc of local anesthetic (containing epinephrine) is injected at each of the three levels. It may be helpful to move the thyroid cartilage slightly to the side of the block.
Fluids and Electrolytes
Intraoperatively, there are four aspects of fluid management that must be considered: maintenance requirement, fluid deficit, third space loss, and blood loss. Replace OSW deficit: hourly maintenance rate ⫻ number of hours OSW Administer half of the deficit over the first hour intraoperatively and the remaining half over the next 2 hours. Replace each milliliter of blood loss with 3 mL of crystalloid, 1 mL of colloid solution, or 1 mL of packed red blood cells (PRBCs).
Hematology for the Otolaryngologist
If more than 4 units of group O, Rh-negative whole blood are administered, type-specific blood should not be given afterwards because the potentially high anti-A and anti-B titers can cause hemolysis of the donor blood. The reaction is the result of the action of recipient antibodies against donor antigens present on leukocytes and platelets; treatment includes stopping or slowing down the infusion and antipyretics. An urticarial reaction occurs in 1% of transfusions; This is thought to be due to sensitization of the patient to transplanted plasma proteins.
Patients with IgA deficiency may be at increased risk due to transfusion reaction of IgA with anti-IgA antibodies. Disseminated intravascular coagulation (DIC) is a hypercoagulable state caused by activation of the coagulation system leading to fibrin deposition in the microvasculature causing secondary fibrinolysis, leading to consumption of platelets and factors.
Stop the transfusion
Check for error in patient or donor identification
Send donor unit and newly obtained blood sample to blood bank for re- cross match
Treat hypotension with fluids and pressors as needed
If transfusion is required, use type O-negative PRBC and type AB FFP
Monitor for signs of DIC clinically or with laboratory tests
Send patient blood sample for direct antiglobulin (Coombs) test, free Hb, haptoglobin; send urine for Hb
- Common Postoperative Problems
- General Otolaryngology .1 Obstructive Sleep Apnea .1 Obstructive Sleep Apnea
- Odontogenic Disorders
- Benign Oral Pathology
- Temporomandibular Joint Disorders
INR is a way to standardize PT values: it is the ratio of the patient's PT to the control PT value. If the ECG is positive, transfer of the patient to the ICU and a consultation with cardiology is mandatory. Alternatively, thorascopic ligation or percutaneous lymphangiography-guided embolization of the thoracic duct may be useful.
Hypocalcemia can be seen in the head and neck after thyroid or parathyroid surgery. Lesions are asymptomatic and generally solitary, although they may be multiple in immunocompromised patients.
Myogenous temporomandibular disease: muscular hyperactivity and dysfunction due to dental malocclusion. Psychological factors often are
The joint should be palpated, inferior to the zygomatic arch 1 to 2 cm anterior to the tragus, in both open and closed positions.
Articular temporomandibular disease: joint dysfunction related either to (a) displacement of the meniscus disk, or (b) diseases causing degen-
- Geriatric Otolaryngology
- Lasers in Otolaryngology
- Robotic-Assisted Head and Neck Surgery
- Complementary and Alternative ENT Medicine
It has been said that "there is nothing like an operation or an injury to bring a patient to chronological age." The elderly patient with potentially limited reserve, impaired organ function, and/or polypharmacy requires special attention, especially when considering surgical intervention. Adjacent thermal effects may alter the effects of laser treatment, beneficially (eg, by stimulating neocollagen production in heated tissue) or not. Fluence is the measurement of laser energy per unit area (usually reported as joules per square centimeter).
It is important to keep the smoke evacuator within 2 cm of the source of the laser plume. The use of robotic-assisted surgery in transnasal and otological procedures is currently limited by the size of the instruments.
2 Otology
Embryology and Anatomy of the Ear
At the level of the notch of Rivinus and above, the middle fibrous layer is less well organized and is known as the pars flaccida. It is included in the TM from the lateral process to the tip of the manubrium (umbo). The tensor tendon runs from the cochleariform process of the middle ear to the medial surface of the neck and the manubrium of the malleus.
The stapedius tendon runs from the pyramidal eminence to the posterior surface of the capitulum or the posterior crus. The cochlear aqueduct runs from the basal turn of the cochlea to the subarachnoid space.
Otologic Emergencies .1 Sudden Hearing Loss.1 Sudden Hearing Loss
- Ear and Temporal Bone Trauma
- Acute Facial Paresis and Paralysis
- Ear Foreign Bodies
High-resolution CT scan of the temporal bone is the most useful imaging study for temporal bone trauma. Electrophysiological testing of the facial nerve in the setting of traumatic paralysis may be useful in terms of predicting recovery and guiding treatment decisions. If there is complete facial nerve palsy, it may require surgical exploration, depending on the nature of the injury.
Inflammation leads to physical compression as the facial nerve enters the fundus of the temporal bone and forms the labyrinthine segment. A high-resolution CT scan of the temporal bone is the most useful imaging study if there is concern for a middle or inner ear injury.
Otitis Media
- Acute Otitis Media
- Chronic Otitis Media
Unilateral otitis media in adults (more commonly chronic serous effusion) may occur secondary to a nasopharyngeal neoplasm, causing obstruction of the opening of the Eustachian tube. The appearance of TM will change as the disease process follows its usual course. Most commonly, the bacteria that cause AOM will gain access to the middle ear cleft via the Eustachian tube.
This condition must be distinguished from persistent serous effusion of the middle ear, sometimes referred to as chronic otitis media with effusion, but which is better named. In addition to COM, painless otorrhea with a TM perforation may result from TM or middle ear carcinoma and may arise from ears with a history of COM.
Atticotomy: during tympanoplasty, but without performing a mas- toidectomy, removing the posterior bony annulus and scutum can im-
The infection and drainage can be eradicated, the TM can be repaired, hearing can be improved, and in the case of cholesteatoma, the disease can be removed and the ear made safe. It is better to dry the ear before the surgical procedure, but sometimes this is not possible. In cases of intraoperative drainage, continue culture-directed antibiotics in the preoperative and postoperative periods.
Tympanoplasty without mastoidectomy: eradication of disease confined to the middle ear, whether TM transplantation is required or not. Otorrhea can be controlled, TM corrected, middle ear cholesteatoma removed, and hearing improved or stabilized.
Tympanomastoidectomy with an intact canal wall: opening the mastoid in conjunction with debriding and reconstructing the middle ear can
Atticotomy: During tympanoplasty, but without performing a mastoidectomy, removal of the posterior bony annulus and scutum may have implications. With appropriate thinning of the posterior meatus and tegmen, the epitympanum can often be completely exposed. Removal of the malleus head is often necessary if the disease extends medially or into the supratubal recess.
A second-look operation is often planned in cases of cholesteatoma, to assess for recurrent disease and/or perform ossicular reconstruction.
Tympanomastoidectomy with canal wall down: this technique is em- ployed in managing COM with extensive cholesteatoma, and rarely in
- Complications of Acute and Chronic Otitis Media
- Cholesteatoma
Acute otitis media is one of the most common diagnoses in patients presenting to a doctor. Facial paralysis results from inflammation of salient segments of the facial nerve, secondary to infection. Children with AOM are suspected to have a congenital dehiscence of the tympanic segment of the facial nerve.
Signs of a congenital cholesteatoma include conductive hearing loss and a white pearl in the anterior superior quadrant of the middle ear behind an intact TM. There may also be visible erosion of the back wall of the external ear canal.
Scutal erosion 2. Ossicular erosion
However, it is useful to routinely image all cholesteatomas to inspect the extent of the disease and local anatomy. The cholesteatoma appears as a homogeneous soft tissue density that is often difficult to distinguish from soft tissue edema or fluid. Therefore, it is essential to use the physical examination and the CT together, and not rely solely on a CT to diagnose cholesteatoma.
Ossicular erosion
Status of antrum and other air cells 3. Lateral semicanal fistula
Status of the facial nerve Other Tests
Epithelial Rest: there is a localized epithelial rest that has been identified in the fetal temporal bones at the lateral wall of the Eustachian tube i.
Epithelial rest: there is a localized epithelial rest that has been identified in fetal temporal bones at the lateral wall of the eustachian tube in the
Acquired inclusion: the speculation is that a microinjury and retrac- tion occurs to the pediatric TM allowing small foci of epithelial tissue
Epithelial migration (secondary acquired): migration of canal and TM epithelium through a TM perforation. This occurs most commonly with
Implantation (secondary acquired): similar to migration except that epithelium is actively implanted into the middle ear secondary to either
Metaplasia (historical theory): chronic OM is believed to trigger meta- plastic change of middle ear mucosa from cuboidal to keratinizing
Tympanoplasty alone or with atticotomy: indicated for small cholesteatomas mainly of the middle ear without any evidence of mastoid involvement.
Tympanoplasty alone or with atticotomy: indicated for small cholestea- tomas primarily of the middle ear with no evidence of mastoid involve-
Tympanomastoidectomy with canal wall up (CWU): indicated for cholesteatomas that extend through the antrum into the mastoid air
Tympanomastoidectomy with canal wall down (CWD): indicated for large cholesteatomas, cholesteatomas with significant preoperative
- Otitis Externa
- Uncomplicated Otitis Externa
- Malignant Otitis Externa
- Audiology
- Basic Audiologic Assessments
- Pediatric Audiologic Assessments
- Objective/Electrophysiologic Audiologic AssessmentsAssessments
- Hearing Loss
- Conductive Hearing Loss
- Sensorineural Hearing Loss
- Hearing Aids
This indicates immobility of the eardrum, which may be due to fluid in the middle ear or tympanic atelectasis. Hearing loss is one of the most common medical problems and is often undiagnosed and undertreated. Hearing loss is caused by the dysfunction of the sensory (cochlea) or neural components of the auditory system.
Hearing loss may be present at birth due to congenital defects in either the structure or physiology of the inner ear. Fractures of the temporal bone involving the ear capsule usually lead to pronounced hearing loss.
