Broken nose | Nasal Bone Fracture aetiology and management

Definition: Fracture nasal bone (also known as Broken Nose) describes fracture of one of the bones of the nose and it is common due to many factors as described later.

Causes: Blow or accident.

Incidence: Common, due to nasal position and more common in males.

Pathology: 

Types depend on the direction & force of trauma:

Lateral trauma: fracture at the weakest point near suture line, resulting in lateral deviation.

Anteroposterior trauma: results in either:

• Comminution: multiple fractured bone fragments.
• Flaring of both nasal bones over the frontal process of maxilla.
• Telescoping of the nasal bone into the ethmoidal labyrinth, this may be associated with CSF rhinorrhea.

Symptoms of Fracture Nasal Bone

• History of trauma
• Pain
• Swelling & deformity
• Nasal obstruction
• Epistaxis

Signs:

• Inspection: Swelling – deformity, edema.
• Palpation: Tenderness -Crepitus.
• Anterior rhinoscopy: septal hematoma, blood clots, mucosal lacerations.

Investigations:

• X ray nasal bones lateral view: important medicolegally.

Treatment of Nasal Bone Fracture:

• First: control epistaxis.

(A) If patient is seen shortly (within few hours) after trauma; no marked edema:

- Reduction by Walsham & Asch forceps.

- Fixation by nasal pack & external nasal splint.

(B) If there is marked edema:

Wait for 5-7 days; give antibiotics, anti-inflammatory till edema subsides, then reduction and fixation.

(C) If patient is seen late (after two weeks): 

There is malunion: rhinoplasty is scheduled 3-6 months after the incident of trauma.

• Give prophylactic antibiotics in all cases.

Key points:

The most important issues about nasal bone fracture are the timing of repair and the management of complications especially septal hematoma being the most common associated complication which may be missed if not looked for especially in comatosed patients.

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Tinnitus definition, causes, investigations and treatment

Definition:Tinnitus is a subjective sensation of noise in the ear and / or the head, without an acoustic stimulation from outside.

Causes  and types of Tinnitus

a. Subjective: experienced by the patient only .It arises from pathological changes along the entire auditory pathway. According to the function and anatomy, the following three divisions can be made:

1. Conductive tinnitus: Outer and middle ear pathologies.
   
2. Sensorineural tinnitus: include all possible cochlear and neural (auditory nerve) pathology.
3. Central tinnitus:

• Primary central tinnitus,
• Secondary central is based on the fact that conductive and sensorineural tinnitus can only be perceived as such when the peripheral signal is processed in the brain,( phantom tinnitus) .

b. Objective: tinnitus is defined as sounds originating from the body and can be heared by the patient and examiner. It may be: 

1. Pulsatile tinnitus: is heartbeat synchronous, which is often caused by vascular abnormalities such as arteriovenous malformation, carotid stenosis, or dissections, venous sinus thrombosis, benign intracranial hypertension, and high jugular bulb or by increased blood flow (eg, in anaemia hypertension, thyrotoxicosis).
2. Non-pulsatile tinnitus: middle-ear myoclonus (tensor tympani) , palatal myoclonus, tempro-mandibular joint (TMJ) dysfunction, patulous Eustachian tube.

Investigations for diagnosis of Tinnitus:

General: personal & occupational history, blood pressure & blood picture, Auscultation of the neck

Special: Full ENT examination, audiometry & tympanometry, and CT & MRI of temporal bone

Doppler & angiography of carotids & vertebrobasilar arteries.

Treatment of Tinnitus:

1. Specific treatment of underlying pathology.

2. Management of comorbidities e.g anxiety, depression, insomnia, decreased sound tolerance (hyperacusis). Pharmacotherapy include: anti-depressants, anti-convulsant carbamazepine, benzodiazepines.

3. IV vasodilators & plasma expanders, steroids either systemic or intratympanic.

4. In addition to other treatments:

• Counselling and Psycho-education to help achieve habituation to the perception of the phantom sound.
• Sound therapy, using both environmental and custom sound generators to reduce the perception of the tinnitus sound. Tinnitus Retraining Therapy (TRT) is combination of counselling and sound therapy.
• Hearing aids for patients with tinnitus with hearing loss.

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Nystagmus definition, causes, diagnosis,types, investigations

Definition: Involuntary deviation of the eyes away from the direction of the gaze followed by return of the eyes to the central resting position.

Classification and types:

a. Physiologic (optokinetic): the rapid phase is towards the center.

b. Pathologic:

• Occular: rotatory or pendular.
• Vestibular: has a rapid phase and a slow phase.
• Central: vertical.

Detection and diagnosis of Nystagmus

a. Direct observation by looking into the eyes.

b. Observation using Frenzel glasses to abolish the optic fixation.

c. Electronystagmography and videonystagmography.

A. Positional testing and search for any nystagmus (central or peripheral) in:

i. Static head and body position tests (supine - head right- head left - body right - body left).

ii. Dynamic (positioning tests) for diagnosis of BPPV:

• Dix-Hallpike test
• Roll test.

B. Sound stimuli, the Valsalva maneuver, and tragal compression to test Tullio phenomenon

C. The Vestibulo-Ocular Reflex testing (VOR)

• Horizontal Head impulse test (hHIT)
•  Dynamic visual acuity test (DVA)

D. Clinical oculography test: Saccades, smooth pursuit and optokinetic testing (rotating drum test).

Vestibular investigations to diagnose Nystagmus

1. Video-nystagmography (VNG): A video of the eye that could be recorded

Caloric test:

• The caloric test is performed with the subject reclining, head inclined 30 degree up from horizontal so as to make the lateral canal horizontal.
• Bi-thermal caloric test stimulates the left or right ear with warm and cool air or water causing a fluid density change in the lateral canal.
• Water is introduced into the ear canal on one side, either 7 deg centigrade above or below assumed body temperature.
• The flow rate is such that the ear rapidly equilibrates with the water. The water is stopped after 30 seconds, and nystagmus is observed, while the subject is distracted.
• Eye movements are usually recorded, and by comparing the response of the left and right ear to warm and cool stimuli one can determine if there is a unilateral or bilateral weakness.

Positional testing

and search for any nystagmus and determine whether central or peripheral, as in clinical testing.

Occulographic tests:

• Saccades testing: re-fixation on new targets
• Smooth Pursuit: tacking slow objects with foveal vision
• Optokinetic test: sensing objects with peripheral vision

Determining the presence or absence of spontaneous or Gaze evoked nystagmus

2. Computerized dynamic Posturography (CDP):

• Postural sway has been used as an indicator of balance function.
• It can be recorded by force platform Posturography that measures forces needed to maintain the balance and support the body weight while standing on the platform.

3. Rotatory chair testing:

• The rotational chair has primarily been used for analyzing horizontal canal vestibulo-ocular reflex (VOR). 
• Angular acceleration stimulus to test VOR. Both sides are stimulated simultaneously. 
• It is the Gold-standard test for Bilateral vestibular loss  
• Useful to validate caloric paresis.

Other investigations:

Audiologic: PTA, Speech audiometry, Tympanometry, ABR, and OAE.

Laboratory: CBC including Hb %., blood lipid profile, Blood glucose level, Thyroid function tests, and Syphilis serology.

Radiological: -CT scan Bain, brainstem and cerebellum -MRI Bain, brainstem and cerebellum.

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Vertigo causes, ddx, Clinical approach of diagnosis and treatment

Definition: Vertigo is a sensation of being off balance, whn you feel like you are spinning or as if the world is spinning around you.

Causes of vertigo:

A-Physiologic: 

• Height vertigo 
• Motion Sickness

B-Pathologic:

• Peripheral: Labyrinthine and vestibular nerve disorders.
• Central: Vestibular disorders involving vestibular nuclei and their connections in the brainstem and cerebellar .

I. Peripheral

1-Benign paroxysmal positional vertigo (BPPV):

• Very common.
• May occur after head trauma, infection or spontaneous.
• Recurrent attacks of severe vertigo provoked by change in head position, no deafness.
• Due to presence of stray otoconia in the SSC.
• A Dix-Hallpike manoever is diagnostic…..transient vertigo and nystagmus.
• Treated by Epley manoever.
• In resistant cases singular nerve section (the nerve supplying post. SCC).

2-Meniere’s disease

3-Secondary endolymphatic hydrops e.g. due to Otosclerosis

4-Infections 

• Viral Herpes Zoster, Vestibular neuritis
• Bacterial: (labyrinthitis)

5-Autoimmune inner ear disorder

6-Vascular Infarction

7-Traumatic Temporal bone fracture

• Labyrinthine concussion 
• Perilymphatic fistula (PLF)

8-Tumor:

-Acoustic neuroma (vestibular schwanoma) - Meningioma

9-Iatrogenic:

• Post-ear surgery 
• Trans tympanic gentamycin ttt.

II. Peripheral and/or central

• 1) Basilar migraine.
• 2) Benign paroxysmal vertigo of childhood.
• 3) Vestibular paroxysmia (Neuro-vascular cross-compression; disabling positional vertigo): pressure-induced dysfunction of the eighth nerve by direct pulsatile compression by arteries or rarely veins in the cerebellar pontine angle.
• 4) Vertebro-basilar ischemia 
• 5) AICA ischemia.

III. Central

• 6) Vestibular epilepsy
• 7) Paroxysmal ataxia/dysarthria (MS)
• 8) Familial episodic ataxia
• 9) Paroxysmal ocular tilt reaction

N.B. Some central and peripheral vestibular disorders are associated with auditory dysfunction

 Clinical approach of diagnosis and treatment of Vertigo

a. History taking

This allows differentiation of the patient’s complaint into:

• Dizziness and light-headedness: a sensation of spatial disorientation.
• Vertigo: abnormal sense of rotation either of the patient or the surrounding or it is a hallucination of movement.
• Disequilibrium: off-balance, imbalance or giddiness, walking on uneven surfaces.
• Oscillopsia: difficulty walking, riding, or reading, unable to focus on objects with movement (apparent motion of the visual scene).

Important points about history

1. Make sure that the patient is actually describing vertigo (sense of rotation).
2. Timing of vertigo; occurs in attacks or persistent.
3. It should be determined whether vertigo is provoked by certain positions, as in benign positional vertigo.
4. Associated symptoms of nausea, vomiting and diarrhea indicating the severity of vertigo.
5. Loss of consciousness should raise the possibility of epilepsy.
6. Symptoms of ear disease: deafness, tinnitus, earache, and discharge.
7. Neurological symptoms: Headache, weakness, parasthesia, diplopia, ataxia and in coordination, may suggest a central cause.

b. Bedside Examination of a Dizzy Patient (clinical testing):

1. General examination: pulse B.P. for atherosclerosis, pallor for anemia.

2. Full neurological examination: including coordination, motor power, superficial and deep sensations, reflexes of UL and LL.

3. Cranial nerves examination

4. Vestibular examination:

• Head Posture and Ocular Alignment.
• Neurological examination: including cranial nerve testing, coordination, motor power, superficial and deep sensations, reflexes of UL and LL.
• Balance:

Romberg test: the patient is asked to stand with the feet close together with the eyes open, and then to close the eyes. The test result is positive when the patient is stable with the eyes open but loses balance with the eyes closed.

Gait assessment (eg. Ataxic?)

Stepping test (Fukuda)

Causes of Dizziness and light-headedness (Differential diagnosis):

1-Pre-syncopal dizziness (cardiac and non-cardiac):

• a. Orthostatic hypotension 
• b. Cardiac arrhythmias.

2-Psychosomatic dizziness: 

• a. Panic attacks 
• b. Hyperventilation syndrome.

3-Metabolic hypoglycemia.

4-Alcohol and drug intoxication.

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Otorrhoea (Aural/ ear discharge) definition, causes, ddx, types

Definition: Otorrhoea describes any discharge which comes out from the ear (from clear to purulent) through a prforation in the tympanic membrane or through a ventilation tube (surgically placed).

Types and causes of Otorrhoea

A-Watery: Cerebrospinal otorrhoea, due to:

• Trauma either fracture base of the skull or after stapedectomy. 
• Tumours.

B-Serous: 

• Bullous myringitis. 
• Allergic dermatitis of the external canal.

C-Mucopurulent:

• Acute suppurative otitis media. 
• Tubo-tympanic type of C.S.O.M.

D-Purulent:

• Cholesteatoma. 
• Furunculosis and otitis externa. 
• Malignant tumors.

E- Bloody:

1-Trauma: 

• Foreign body or lacerations of the E.A.C.
• Fracture base of the skull.
• Traumatic rupture of the T.M.

2-Bullous myringitis.

3-Tumors: 

• Glomus. 
• Malignant.

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Otalgia (Earache)| causes and differential diagnosis of ear pain

Otalgia is a medical term that is used to describe ear pain or earache, and it is one of th main syptoms of ear diseases and disorders and there are many causes of otalgia.

1-Local causes

• Auricle: Hematoma, laceration, perichondritis, and carcinoma.
• EAC: Forign body, otitis extrna (all types), and carcinoma.
• Tympanic membrane: Bullous myringitis, rupture, and barotrauma.
• Middle ear: trauma, acute OM, complicated CSOM, and carcinoma.
  

2-Referred Otalgia

To determine the cause of earache when the ear appears normal, the areas supplied by 5th, 7th, 9th, and 10th cranial nerves, and the 2nd and 3rd cervical nerves should be examined.

A. Oral cavity: (along the 5th nerve).

1. Dental carries, dental infections, un-erupted or impacted wisdom tooth.
2. Glossitis, stomatitis (particularly herpetic).
3. Malignant tumours of the tongue, and oral cavity.
4. Calculi of the parotid (wharton’s) duct.
5. Temporomandibular joint arthritis or dislocation.

B. Nose: (Along the 5th nerve).

•  Sinusitis.
•  Barotrauma of sinuses.
•  Tumors of the nose and para nasal sinuses.

C. Pharynx: (Along the 9th nerve).

• Tonsillitis, Quinsy, pharyngitis and retropharyngeal abscess.
• Malignant tumours especially of the tonsils, hypopharynx and nasopharynx.
• Postadenoidectomy and post tonsillectomy.

D. Larynx: (Along the 10th nerve).

• Non specific laryngitis. - Epiglottitis.
• T.B. Laryngitis. - Perichondritis.
• Malignant laryngeal tumors.

E. Oesophagus: (Along the 10th nerve)

• Forign Body. 
•  Oesophagitis. 
• Malignant tumors.

F. Cervical: (along the 2nd and 3rd cervical nerves).

• Spondylosis. 
• Osteoarthritis of cervical spine.

G. Miscellaneous:

• Great vessel aneurysm. 
• Acute thyroiditis.
• Migraine. 
• Angina pectoris. 
• Long styloid process.

3-Neuralgias

• Trigeminal neuralgia (5th nerve).
• Glossopharyngeal neuralgia (9th nerve).

 4-Psychogenic: 

This is diagnosed by exclusion of all other etiologies.

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Cochlear Implants| def., components, Prerequisites and factors affecting

Definition: A cochlear implant is an electronic device that can provide useful hearing and improved communication abilities for persons who have severe to profound sensorineural hearing loss and who cannot benefit from hearing aids.

Components of Cochlear Implants

A cochlear implant has an external and internal component:

1. External component: It consists of an external speech processor and a transmitter.

2. Internal component: It is surgically implanted and comprises the receiver/stimulator package with an electrode array.

How it works?

Sound is picked up by the microphone in the speech processor. The speech processor analyses and codes sounds into electrical pulses.

The electrical impulses are sent from the processor to the transmitting coil which in turn sends the signal to the surgically implanted receiver/stimulator via radiofrequency.

The receiver/stimulator decodes the signal and transmits it to the electrode array inside the cochlea to stimulate the spiral ganglion cells. The auditory nerve is thus stimulated and sends these electrical pulses to the brain which are finally interpreted as sound.

Prerequisites of cochlear implantation:

1. Bilateral severe to profound SNHL. 

2. Little or no benefit from hearing aids.

3. No medical contraindication for surgery. 

4. Realistic expectation.

5. Good family and social support toward habilitation.

6. Adequate cognitive function to be able to use the device.

Candidates with such hearing impairment may be defined as prelingual or postlingual depending on whether they were deafened before or after the acquisition of speech.

In children who have hearing impairment at birth or early in childhood, early intervention with hearing aids or a cochlear implant is vital for auditory stimulus. Auditory deprivation, i.e. lack of auditory stimulus in the early developmental period causes degeneration in the central auditory pathways. This will limit the benefit in terms of speech and language acquisition following cochlear implantation.

Factors that predict a successful clinical outcome are:

1. Previous auditory experience (postlingual patients or prior use of hearing aids).

2. Younger age at implantation (especially for prelingual children).

3. Shorter duration of deafness.

4. Neural plasticity within the auditory system.

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Hearing aid| definition, use, components and types

Definition: Sound amplification system, that increase the level of surrounding sounds to make them audible to hearing aid users.

Goals and uses of hearing aids

1. Amplify normal speech.
2. Hear warning signals.
3. Help in education & language development.

Components:

1-Microphone: pick up sounds and transfer to electric energy.

2-Amplifier: amplify the electric energy.
3-Receiver: converts electric energy to sounds.

4-Power supply.

5-Controls: gain and tone control.

Types of Hearing aids

• Air conduction: Open fit, behind the ear (BTE),in the canal hearing aid (CIC),or receiver in the ear.
• Bone conduction hearing aid

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Tests of hearing, Audiological assessment, types and result interpretation

Clinical speech testing.

The patient is asked to repeat whispered words at different intensities (other ear is masked by Barany’s box).

Tuning fork tests

Audiological assessment (Audiometery)

This is the measurement of hearing by the use of a special apparatus (audiometer) for studying the degree of hearing at different intensities and different frequencies. The resultant data are recorded as an audiogram.

Value:

•  To detect the hearing threshold of the patient.
•  Detect the type of hearing loss (conductive, sensorineural, or mixed).
•  Detect the degree of hearing loss (mild, moderate, severe, or profound).
•  Selection of a hearing aid if needed.

Types:

A- Pure tone audiometry: (PTA)

1- It is the measurement of the patient’s hearing threshold by using pure tones of a single frequency.

2- The test is done once with the ear phone to determine AC curve and once with a B.C. vibrator over the mastoid to determine B.C. curve. The hearing threshold is obtained at 8 frequencies (250, 500, 2000, 4000, 6000, 8000 HZ).

3- The hearing threshold is the minimum intensity of sound that the person can hear. Normally it varies from 0-20 dB at all frequencies.

4- The resultant two curves (A.C. curve and B.C. curve) are plotted on a graph (audiogram) and this will show the type of hearing loss.

Results:

1- Conductive hearing loss: elevated A.C. threshold, while B.C. threshold is normal (i.e. Air/bone gap).

2- Sensorineural hearing loss: Both A.C. and B.C. threshold are elevated .

3- Mixed hearing loss: Both A.C. and B.C. thresholds are elevated but with an air / bone gap (e.g. A.C. threshold is elevated more.

To determine the degree of hearing loss:

The average of A.C. threshold at 500, 1000, and 2000 HZ is obtained then the degree of hearing loss is obtained as follows:

1.  Normal: 0 – 20 dB.
2. Mild hearing loss: 20- 40 dB.
3. Moderate hearing loss: 40 – 60 dB.
4. Severe hearing loss: 60 – 80 dB.
5. Profound hearing loss: more than 80 dB.

B- Speech audiometery

This is the hearing assessment using spoken words presented to the patient through earphones, and he is asked to repeat those words. It provides an idea about the ability to communicate:

Speech tests include:

1. Speech reception threshold (SRT)

It is the level (in dB) at which the patient can correctly repeat 50% of the presented speech material. It should match with the hearing threshold level obtained by PTA.

2. Speech discrimination

It is the percentage of the correctly repeated speech material by the patient to that presented to him. Scores of 90- 100% are normal. In SNHL it is poor than expected.

Values of speech audiometery:

-Confirms results of PTA. -Selection of a hearing aid.

-Detects malingerers. - Differentiates between cochlear and retrocochlear .

C- Impedence audiometry

(1) Tympanometry

This is the measurement of middle ear pressure, through measuring the mobility (compliance) of the T.M. :

1. Type A tympanogram: (normal)

2. Type As tympanogram: The pressure is normal but the compliance is reduced in cases of ossicular fixation as in otosclerosis.

3. Type A  tympanogram: (Hypermobile or flail)

The pressure is normal, but the compliance is increased above 1.75 mm H2O & it may exceed the limits of the machine. This occurs in ossicular disruption or dislocation.

4. Type B Tympanogram: (Flat curve) This occurs in secretory otitis media.

5. Type C Tympanogram: Normal compliance with negative pressure. This occurs in ET dysfunction.

N.B: Oscillating tympanogram occurs with glomus tumours.

(2) Acoustic reflex

Usually stapedius muscle contracts 70 – 90 dB above hearing threshold level.

D- Evoked response audiometery

This is recording of the action potentials anywhere in the auditory pathway from the cochlea up to the auditory cortex. They include:

1-Electocochleography. Diagnostic in Meniere’s disease.

2-Auditory brain stem response audiometry (ABR).

It records the electrical activity in the auditory pathway (from wave I to V.)

-Objective detection of hearing threshold level.

-Differentiates between cochlear and retrocochlear, a delay in latency of 0.4 m.sec. between the wave number V of both sides is suggestive of a retrochlear pathology (e.g. Acoustic neuroma).

3-Cortical evoked response.

E- Otoacoustic emission (OAES)

These are low intensity waves produced in the cochlear and recorded in the EAC. They are classified into:

1. Spontaneous OAES: recorded in the E.A.C. without provoking stimulus

2. Evoked OAES: recorded in response to a provoking stimulus (tones or clicks).

They are very sensitive to any cochlear abnormality and can detect and cochlear affection very early. It is used in hearing threshold detection especially in infants and children.

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Psychogenic deafness and Sudden Sensory Neural Hearing Loss

 Psychogenic deafness

- Sudden deafness or unexplained fluctuation, related to emotional stress.

- Marked disparity between PTA & speech audiometry.

- Improve by psychotherapy.

Sudden SNHL:

It is an important entity, where the patient has sudden, unilateral or bilateral, partial or complete SNHL, it is either viral or vascular in origin, treated by systemic steroids, it is crucial to start treatment early to save the hearing, intratymoanic steroid injection is done if systemic steroids are contraindicated, vaso dilators and hyperbaric oxygen are also tried in an attempt to prevent permanent disabling SNHL.

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