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  • Fiberoptic Video Oto Endoscopy

    Visualisation of the External ear, Ear drum, and Middle ear

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    Endoscopic view of Normal Nose and Nose with nasal polyp

    Normal ear drum

    Ear drum perforation

    Fluid & bubbles in middle ear
    seen through ear drum

    Chronic NonSuppurative Otitis Media (Otitis Media With Effusion)

    Conductive deafness due to Chronic Ear infection

    Secretory Otitis Media  (Otitis media with effusion)

    Mechanism of Eustachian tube obstruction


    Anatomy and Physiology of the Ear Click here

    Nature’s mechanism of ventilating the middle ear through the nose to maintain air on the inner side of the ear drum has disadvantages. All nasal diseases and Endoscopic view of fluid conditions can cause infective and obstructive symptoms affecting middle and bubbles behind ear drum ear function – e.g. common colds, viral and bacterial infections of the nose.                                .

    Obstruction at the nasal end of the tube can be caused by by enlarged adenoids, tumours, infected water during swimming, pressure changes during air travel and diving under water. Chronic nasal allergy accounts for a sizeable number of patients suffering from Eustachian tubal obstruction.

    When tubal obstruction remains for long, a vacuum forms. Fluid pours into the middle ear  (Secretory Otitis Media). The fluid is thin initially and later as days go by, it becomes thick like glue (gum), when the condition is called ‘glue ears’.

    How is the diagnosis made?

    The patient or relatives notice increasing difficulty in hearing. One’s own voice may sound loud in the affected ear. When fluid is present, head movements can cause a feeling of fluid moving in the ear.

    Clinical E.N.T. Examination show the ear drum on the affected side/sides to be moving poorly with some parts of the ear drum/drums drawn in. The nose and throat may show evidence of infection or allergy. Enlarged adenoids or other growth of the nasopharynx may be noted.

    Special tests

    Pure Tone Audiometry shows a conductive deafness. Acoustic Impedance Bridge studies confirm a Type B flat curve when fluid is present or a Type C Tympanogram for  negative pressure in the middle ear.

    Fiberoptic endo laryng pharyngeal nasopharyngoscopy for detailed visualization of the nasopharynx & nose.

    For assessing, nose, nasopharynx and paranasal sinus conditions, a C. T. Scan with (usually without injection of contrast dye material) of these areas may be necessary.

    What is the treatment?

    Treatment is aimed at establishing middle ear ventilation by treating the nasal end of the Eustachian tube.

    Any nasal infection or allergy has to be treated. The swelling of the lining of the eustachian tube has to be shrunk up by the use of nose drops. This allows to and fro air passage along the eustachian tube. Attempts are made to force air into the middle ear through the eustachian tube actively by the auto inflation exercise (Valsalva maneuver). explained elsewhere. Nasal steroid sprays on a long-term basis may be required in allergic conditions, swollen (edematous) mucous membrane lining and cases with nasal polyp formation.

    In a small percentage of patients if middle ear fluid is present, if the above measures do not give relief, surgical treatment is required – a small incision is made in the ear drum under local anaesthesia and the fluid sucked out. If the fluid is very thick, a small ventilation tube (grommet) is inserted through the incision and left in place. It normally takes 3 to 6 months to extrude spontaneously.

    Treatment of the nasopharyngeal condition like removal of enlarged adenoids in children or adequate treatment of nasopharyngeal growth is required. Clearance of nose and paranasal sinus disease by Functional Endoscopic Sinus Surgery (F.E.S.S.) may be required.

    Detection of allergies by an allergy test followed by proper treatment may be necessary.

    Fiberoptic Video Laryngo Pharyngoscopy

    Visualization of the throat and vocal cords

    Endoscopic view of Normal Larynx, Laryngo pharynx and Vocal folds


    During respiration


    During vocalisation

    Endoscopic view of Larynx in a patient with early vocal nodules


    During respiration


    During vocalisation

    Otosclerosis

    Otosclerosis – A common cause of middle ear deafness

    What is Otosclerosis?

    Otosclerosis is a disease of the hearing mechanism in the middle (and internal) ear in which the third bone of the chain of 3 bones in the middle ear gradually gets fixed due to new bone formation and decreasing the vibrations of sound entering the inner ear.  (see diagram). The cause of the disease is unknown. It usually manifests after the age of 15 years and is commoner in females. In 80 % of cases, the disease affects both ears to a greater or lesser extent.

    The patient or relatives notice increasing difficulty in hearing, mainly in one ear. One’s own voice may sound loud and hence the patient tends to speak softly as compared with patients with a weakness of the hearing nerve (sensori neural hearing loss) who tend to speak loudly. In some patients the first complaint is an intermittent or  continuous spontaneous noise in the ear (tinnitus).

    For some reason, in females, every pregnancy increases the deafness.

    As the disease process advances, the otosclerosis can involve the opposite ear (in80% patients). When the inner ear is also affected by the process (cochlear Otosclerosis) a “mixed” deafness (conductive and sensori-neural) develops.

    Whites are the most affected race, with the prevalence in the Black and Asian populations being much lower. Females are twice as likely as males to be affected. Usually noticeable hearing loss begins at middle-age, but can start much sooner. The hearing loss often grows worse during pregnancy.

    The disease is inherited as an autosomal dominant fashion.

    Special tests for hearing

    Pure Tone Audiometry shows the exact levels of hearing and confirm a conductive deafness where hearing by bone conduction is better than hearing by air conduction. Acoustic Impedance Bridge studies confirm a fixation of the 3rd bone (Stapes) and also confirm normal middle ear pressure but diminished ear drum movement.

    What is the treatment?

    The main treatment is surgical. The ear drum is lifted up and the middle ear is entered. Under an operating microscope, the joint between the 2nd bone (Incus) and third bone (Stapes) is separated. The upper part of the Stapes bone (super structure) is removed. A very small microscopic hole of 0.6 to 0.8 mm diameter is made in footplate of the stapes bone (Stapedotomy). One end of a teflon piston is inserted through this hole, either directly or through a vein graft. The other end of the piston is hooked around the 2nd bone (Incus). The ear drum is then replaced back in the original position.

    Sound vibrations now travel from the ear drum via the  teflon piston.

    Hearing is restored to normal on the operating table in 97 to 98% of cases.

    A Hearing aid will also give satisfaction, as in any case of conductive deafness. However, it can  never give the satisfaction of normal natural hearing as a successful operation does.

    Otosclerosis is a slowly progressive disease. As years go by, deafness increases and the opposite ear too shows signs of involvement. In females, every pregnancy increases the deafness. Gradually, after the age of 45 or 50 years, when old age deafness sets in due to age related changes of the nerves of hearing, the hearing impairment becomes more pronounced and a definite handicap in communication.

    Treatment of otosclerosis relies on two primary options: hearing aids (more recently including bone-conduction hearing aids) and a surgery called a stapedectomy. Hearing aids are usually very effective early in the course of the disease, but eventually a stapedectomy may be required fordefinitive treatment. Early attempts at hearing restoration via the simple freeing the stapes from its sclerotic attachments to the oval window were met with temporary improvement in hearing, but the conductive hearing loss would almost always recur. A stapedectomy consists of removing a portion of the sclerotic stapes footplate and replacing it with an implant that is secured to the incus. This procedure restores continuity of ossicular movement and allows transmission of sound waves from the eardrum to the inner ear.

    A modern variant of this surgery called a stapedotomy, is performed by drilling a small hole in the stapes footplate with a micro-drill or a laser, and the insertion of a piston-like prothesis. The success rate of either a stapedotomy or a stapedectomy depends greatly on the skill and the familiarity with the procedure of the surgeon.

    Other less successful treatment includes fluoride administration, which theoretically becomes incorporated into bone and inhibits otosclerotic progression. This treatment cannot reverse conductive hearing loss, but may slow the progression of both the conductive and sensorineural components of the disease process. Recently, some success has been reported with bisphosphonate medications, which stimulate bone-deposition without stimulating bony destruction.

    Sequence of a Stapedectomy operation

     

    Equipment

    Equipment

    An Endoscope is an optical instrument with bundles of optical fibers that transmit light from a source outside the body so that one end can enter passages and cavities inside the body for visualization of these structures in utmost detail. The advantage is that the intensity of light at the source is transmitted almost with no loss of intensity to the end of the cable into the interior of the organ. This allows detailed visualization and also video photo recording at the tip at absolutely close quarters. The heat of the light source is not conducted and therefore the light source is referred to as a cold light fountain. Certain instruments also carry extra tubes for suction and tubes to guide instruments for biopsy of pathologies deep in. Also it replaces rigid tube endoscopes of the past.. Flexible cables can see around bends and corners. Flexible endoscopes are also used when required.

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    Endoscopes for visualization of the Ear, Nose & Throat passages

    image0061Endoscope with cold light switched on.

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    Light source – cold light “fountain” supplying illumination
    through light fibers from source to the end of the cable

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    Recordings are stored in discs for study later, comparisons
    over a period of time, second opinions etc.

    Barotrauma

    Mechanism of middle ear pressure changes during air travel

     

     

     

     

     

    Need for Second opinion in E.N.T

    The Complexity of Radiology & Imaging Today

    Today, radiology and imaging includes a large number of modalities and covers virtually all organs in the body. It is virtually impossible for any one individual to keep abreast of all developments and to be as good in all of them.

    We, at Jankharia Imaging, have subspeciality training in specific organ systems and modalities and each one of us is an expert in our area of expertise

    Today, radiology and imaging includes a large number of modalities and covers virtually all organs in the body. It is virtually impossible for any one individual to keep abreast of all developments and to be as good in all of them.


    There are many situations in which, after you have had a radiology examination performed (e.g., x-ray, mammogram, bone densitometry, CT scan or MRI), you may feel the need for another opinion. The reasons may include one or more of those listed below:

    • When assurance is need about the report’s conclusions from another expert radiologist
    • When a subspeciality opinion is required as against that of a generalist
    • When the case is complex, and a diagnosis has not yet been reached

    Radiology Opinions

    Using our expertise, we will read your examinations, sent to us on CT, films or via the Internet, as the case may be and will get back to you within two working days at the most. We are happy to receive examinations from

    · Patients

    · Referring Doctors

    · Radiologists

    Drop attacks and frequent falls

    A drop attack is a sudden fall, with or without unconsciousness, due either to collapse of muscle tone or abnormal muscle contraction in the legs. Many neurological diseases, cardiac diseases, ear diseases, muscle dysfunction conditions like myoclonic syndromes and startle responses can cause drop attacks. In about 30% of drop attacks the cause is unknown.

    Weakness of muscles of the legs

    Weakness of the hip and knee extensor muscles (important for maintaining an erect posture)
    Some causes include muscular dystrophy, neurogenic atrophy, polymyositis, myasthenia gravis and spinal cord ischemic attacks. Duchenne’s muscular dystrophy is the most common cause of muscle dystrophy.

    Isolated quadriceps weakness – secondary to diseases like polymyositis, inclusion body myositis and neurogenic atrophy, and the legs may suddenly give way without warning to cause falls

    Intermittent spinal ischemia can produce sudden attacks of transient paraparesis or falls, and causes include syphilitic arteritis, arteriosclerosis of the distal aorta, adhesive arcachnoiditis, spinal compression due to spinal stenosis or disc herniation; the attacks are often precipitated by exercise and relieved by rest

    Neurodegenerative diseases

    Patients with Parkinson’s disease often fall due to defective postural reflexes, sudden freezing, and uncoordinated turning; their stooped flexed posture predisposes them to falling forward because their centre of gravity is displaced forward when standing or walking.
    Other neurodegenerative diseases associated with frequent falls include progressive supranuclear palsy, corticobasal degeneration, Huntington’s chorea, multiple system atrophy and Alzheimer’s disease

    Transient ischemic attacks
    A patient with vertebro-basilar artery ischemia can present with a sudden loss of tone in their legs, causing their knees to buckle. The patient falls powerlessly without protective arm movements; There may be no precipitating head or neck movements or loss of consciousness, The patient can get up and walk immediately or within one minute. Usually other symptoms of brainstem ischemia are present (vertigo, diplopia, blurred vision, sensory changes, motor weakness, which suggest the diagnosis.

    Epilepsy
    Drop attacks can be due to sudden muscle contractions associated with generalized convulsive epilepsy, or a sudden loss of postural tone due to atonic epilepsy or epileptic negative myoclonus.
    Atonic epileptic attacks in children can occur when standing or sitting or lying, and there is no aura or state of confusion; sudden drop attacks can cause the patient to collapse with triple flexion of the legs and no involvement of the arms. The patient can usually get up immediately after an attack.

    Various myoclonic syndromes
    Mycoclonus is a sudden brief, shock-like muscle movement caused by a brief muscle contraction (positive myoclonus) or inhibition of a muscle contraction (negative myoclonus)
    It can mimic idiopathic drop attacks, and the patient can fall suddenly with buckling of the legs

    Startle reactions
    Pathological startle reactions (hypereflexia) are characterized by an exaggerated motor response to unexpected auditory stimuli, and less frequently to visual or somasthetic stimuli.
    They consist of both brief myoclonic jerks and longer tonic spasms
    Hypereflexia may have a variety of causes eg. idiopathic, hereditary, or secondary to acquired brainstem diseases – post-anoxic encephalopathy, viral or paraneoplastic brainstem encephalitis, multiple sclerosis, sarcoidosis or brainstem strokes. Myoclonic jerks occur frequently during the day, but also at night when the patient is asleep, and mainly affect the legs
    Sterotyped tonic spasms consist of facial grimacing, flexion of the neck and trunk, flexion or extension of the hips and knees, and characteristic abduction of the shoulders with flexion of the elbows. The patient falls forwards rigidly like a log, but sometimes falls backwards; protective reflexes are impossible and injuries common; consciousness is maintained during the fall and recovery is fast

    Cataplexy and paroxysmal choreoathetosis
    Cataplexy can cause sudden falls without LOC, but the patient cannot speak during the fall
    Characteristic precipitating factors include laughter or a sudden emotional stimulus. Minor symptoms of cataplexy may consist of a brief drop of the jaw and sagging of the head, but severe attacks can cause loss of tone in all the antigravity muscles and the patient falls powerlessly and loosely and remains immobile for many seconds (longer than in hypereflexia)

    Paroxysmal choreoathetosis – attacks are usually precipitated by sudden leg movements during standing or running or social embarrassment => the patient may suddenly lose control due to tonic spasms or an involuntary choreoathetotic muscle movement and fall like a log

    Posterior cranial fossa pathology
    Mass lesions around the foramen magnum can cause drop attacks
    Odontoid process fractures
    Arnold-Chiari type I malformations
    Drop attacks can be precipitated by neck movements, coughing or sneezing, or vertical head compression;
    the drop attack patient presents with a stiff neck, spastic paraplegia and limb paresthesias
    Posterior fossa arachnoid cysts, midline metastatic cerebellar tumors, vermis hemangioblastomas, and obstructive hydrocephalus due to third ventricle cysts

    Meniere’s drop attacks (Tumarkin’s otolithic crisis)
    Seen in the early or late stages of Meniere’s disease when there is a sudden change in endolymphatic pressure which causes end-organ stimulation with a reflex-like vestibulospinal loss of postural tone. The patient suddenly loses control of balance and falls and he sometimes with a distinct feeling of being pushed or thrown to the ground. The patient does not lose consciousness.
    (* a patient with Wallenberg’s syndrome, due to a lateral medullary stroke, may have a similar transient sensation of being pulled or pushed to the side, and the patient suddenly falls to the side without realizing that it is his active shift of the centre of gravity – lateropulsion – that causes the momentary imbalance)

    Idiopathic drop attacks (no specific cause found)
    A fall without warning, not associated with loss of consciousness, not apparently due to any malfunction of the legs, not induced by changes of posture or movement of the head, and not accompanied by vertigo or other cephalic sensation, and not associated with myoclonic jerks
    It usually appears between the ages 40 – 60 years. Patients only fall when standing or walking, and they usually buckle at the knees and fall forwards.
    The attacks occur very suddenly and the patient cannot remember if he lost consciousness, or not; the patient can get up immediately unless accidental injury occurs (minor upper limb fractures and/or dislocations are common in the elderly)
    Serial attacks are rare, and spontaneous remission is common (25 – 80%)

    Scope of ENT speciality

    Superior canal dehiscence syndrome (SCDS)

    Superior canal dehiscence syndrome (SCDS)

    Superior canal dehiscence syndrome (SCDS) is a rare condition of the inner ear, first described in 1998 by Dr.Lloyd Minor of Johns Hopkins University, Baltimore, USA, leading to hearing and balance disorders in those affected. The symptoms are caused by a thinning or complete absence of the part of the temporal bone overlying the superior semi circular canal. This may result from slow erosion of the bone or physical trauma to the skull and there is evidence that the defect or susceptibility is congenital.
    Symptoms

    Autophony – Patients with SCDS-related autophony report hearing their own voice as a disturbingly loud and distorted sound deep inside the head as if relayed through “a cracked loudspeaker.” Additionally they may hear the creaking and cracking of joints, the sound of their footsteps when walking or running, their heartbeat and the sound of chewing and other digestive noises. A distinctive feature of this condition almost exclusively associated with SCDS is hearing the sound of the eyeballs moving in their sockets (e.g. when reading in a quiet room) “like sandpaper on wood”.
    Tullio phenomenon, another of the more identifiable symptoms leading to a positive SCD diagnosis is sound-induced loss of balance. Patients showing this symptom may experience vertigo, a feeling of motion sickness or even actual nausea, triggered by normal everyday sounds. Although this is often associated with loud noises, volume is not necessarily a factor. Patients describe a wide range of sounds that affect balance: a telephone ringing; a knock at the door; music; the sound of children playing and even the patient’s own voice are typical examples of sounds that can cause a loss of balance when this condition is present, although there are countless others. For such persons, a visit to the concert hall or to a noisy playground may seem like being at the epicenter of an earthquake. A change of pressure within the middle ear (for example when flying or nose-blowing) may equally set off a bout of disequilibrium or nystagmus.
    Low-frequency conductive hearing loss is present in many patients with SCDS and is explained by the dehiscence acting as a “third window.” Vibrations entering the ear canal and middle ear are then abnormally diverted through the superior semi circular canal and up into the intracranial space instead of being registered as sound in the hearing center, the cochlea. This hearing loss being greater in the lower frequencies and may initially be mistaken for otosclerosis.

    Pulsatile tinnitus is yet another of the typical symptoms of SCDS and is caused by the gap in the dehiscent bone allowing the normal pulse-related pressure changes within the cranial cavity to enter the inner ear abnormally. This pressure change thus becomes audible and an existing tinnitus will be perceived as containing a pulse-synchronized “wave” or “blip” which patients describe as a “swooshing” sound.
    Brain fog and fatigue are both common SCDS symptoms and are caused by the brain having to spend an unusual amount of its energy on the simple act of keeping the body in a state of equilibrium when it is constantly receiving confusing signals from the dysfunctional semicircular canal.
    Headache and migraine are also often mentioned by patients showing other symptoms of SCDS. A direct causal link has yet to be proven.
    Causes
    In approximately 2.5% of the general population the bones of the head develop to only 60-70% of their normal thickness in the months following birth. In SCDS the section of temporal bone separating the superior semicircular canal from thecranial cavity, normally 0.8 mm thick, shows a thickness of only 0.5 mm, making it more fragile and susceptible to damage through physical head trauma or from slow erosion.

    Diagnosis
    The presence of dehiscence can be detected by a high definition (0.6 mm or less) coronal CT Scan of the temporal bone, currently the most reliable way to distinguish between superior canal dehiscence syndrome (SCDS) and other conditions of the inner ear involving similar symptoms such as Meniere’s disease and Perilymph fistula. Other diagnostic tools include the VMPtest, CENG (Computerized ElectroNystagmography) or VNG, electrocochleography (ECOG) and the rotational chair test. An accurate diagnosis is of great significance as unnecessary exploratory middle ear surgery may thus be avoided. Several of the symptoms typical to SCDS (e.g. vertigo and Tullio) may also be present singly or as part of Ménière’s disease, sometimes causing the one illness to be confused with the other. There are reported cases of patients being affected by both Ménière’s disease and SCDS concurrently.

    Treatment
    Once diagnosed, the gap in the temporal bone can be repaired by surgical resurfacing of the affected bone or plugging of the superior semicircular canal. These techniques are performed by accessing the site of the dehiscence either via a middle fossa craniotomy or via a canal drilled through the transmastoid bone behind the affected ear.