Section Editor: Rakesh Prasad Shrivastav 1. Examination of the Ear, Nose and Throat 3 Rabindra B Pradhananga

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1 Contents Section 1: Ent Examination Section Editor: 1. Examination of the Ear, Nose and Throat 3 Section 2: The Ear Section Editor: Hari Bhattarai 2. Anatomy of the Ear and Facial Nerve 7 External Ear 7 Middle Ear Cleft 8 Inner Ear 11 Facial Nerve Physiology of Hearing and Equilibrium 17 Yogesh Neupane Physiology of Hearing 17 Physiology of Equilibrium Symptoms of Ear Diseases 22 Pabina Rayamajhi Earache (Otalgia) 22 Hearing Loss 23 Discharge 23 Vertigo 23 Tinnitus 24 Facial Nerve Paralysis 24 Itching/Irritation 24 Others 24 Symptoms Suggestive of Possible Complications Due to Otitis Media Clinical Examination of the Ear 25 Pabina Rayamajhi Auricle, External Auditory Canal (EAC) and Surrounding Area 25 Tympanic Membrane (TM) 26 Hearing Tests 27 Fistula Test 29 Eustachian Tube (ET) Function 29 Facial Nerve 30 Nystagmus 30 Tests for Vertigo Investigations for Ear Diseases 32 Inku Shrestha Basnet Audiological Investigations 32 Vestibular Investigations 35 Radiological Investigations Diseases of the External Ear 38 Diseases of the Auricle 38 Diseases of the External Auditory Canal (Eac) Infections of the Tympanic Membrane and Middle Ear Cleft 45 Infections of the Tympanic Membrane (Tm) 45 Infections of the Middle Ear Cleft Complications of Otitis Media 54 Routes of Spread 54 Extracranial Complications 54 Intracranial Complications 56

2 xviii An Illustrated Textbook: Ear, Nose and Throat and Head and Neck Surgery 10. The Mastoidectomy Operation 58 Canal Down Mastoidectomy 58 Canal Up Mastoidectomy Trauma to the Ear 62 Anupama Shah Rijal Physical Trauma 62 Barotrauma Otosclerosis 65 Definition 65 Types 65 Pathology 65 Characteristic Features of Otosclerosis 65 Clinical Features 65 Investigations 66 Treatment Neoplasms of the Middle Ear 67 Bikash Shrestha Malignant Tumors 67 Glomus Tumor 67 Langerhans Cell Histiocytosis 67 Osteoma Diseases of the Inner Ear 69 Hari Bhattarai Inflammatory Diseases 69 Trauma 70 Neoplasms 71 Autoimmune Diseases 72 Others Ototoxicity 77 Hari Bhattarai Clinical Features 77 Common Ototoxic Drugs 77 Treatment of Ototoxicity Vertigo 78 Definition 78 History 78 Causes of Vertigo 79 Examination 79 Investigations 79 Diagnosis of Common Causes of Vertigo 79 Treatment Hearing Aid, Cochlear Implant and Tinnitus Masker 81 Hari Bhattarai Hearing Aids 81 Ear Mould 81 Cochlear Implants 82 Tinnitus Maskers Facial Nerve Paralysis 84 Hari Bhattarai Bell s Palsy (Idiopathic Facial Nerve Paralysis) 84 SECTION 3: THE NOSE AND PARANASAL SINUSES Section Editor: 19. Anatomy of the Nose and Paranasal Sinuses 89 Meera Bista The Nose 89 The Paranasal Sinuses Physiology of the Nose and Paranasal Sinuses 96 The Nose 96 The Paranasal Sinuses 97

3 Contents xix 21. Symptoms of the Nose and Paranasal Sinus Diseases 98 Meera Bista Pain 98 Nasal Obstruction 98 Nasal Discharge (Rhinorrhea) 99 Nasal Bleeding (Epistaxis) 99 Sneezing 99 Disorders of Smell 99 Nasal Deformity 100 Nasal Intonation of Voice (Rhinolalia) Clinical Examination of the Nose and Paranasal Sinuses 101 Sangeeta Shrestha Inspection and Palpation of the External Nose, Orbit and the Face 101 Palpation of the Paranasal Sinuses 101 Assessment of Nasal Patency 102 Inspection of the Nasal Vestibule 102 Anterior Rhinoscopy 102 Posterior Rhinoscopy 104 Endoscopic Examination of the Nasal Cavity and Nasopharynx Investigations for the Nose and Paranasal Sinus Diseases 107 Sangeeta Shrestha Radiology 107 Bacteriology 108 Tests for Allergy 108 Proof Puncture 109 Rhinomanometry 109 Test for Smell 109 Biopsy Diseases of the External Nose 110 Narmaya Thapa Infections of the External Nose and Nasal Vestibule 110 Neoplasms of the External Nose 111 Injuries to the External Nose 112 Congenital Anomalies of the External Nose 112 Others Noninfective Rhinitis: Allergic Rhinitis and Nonallergic Rhinitis 113 Yogesh Neupane Allergic Rhinitis 113 Nonallergic Rhinitis Rhinosinusitis 118 Acute Rhinitis or Common Cold or Coryza 118 Acute Sinusitis 118 Chronic Sinusitis 120 Drainage Procedures for Different Sinuses 121 Obliteration Procedures for Different Sinuses 122 Management of Associated Nasal Conditions 123 Fungal Rhinosinusitis 123 Other Types of Rhinosinusitis Complications of Rhinosinusitis 125 Yogesh Neupane Local Spread 125 Nasal Complications 126 Orbital Complications 127 Intracranial Complications 127 Pharyngeal, Laryngeal and Pulmonary Complications 128 Distant Complications Diseases of Nasal Septum 129 Yogesh Neupane Septal Trauma 129 Septal Hematoma/Abscess 129 Deviated Nasal Septum (DNS) 130 Septal Perforation 132 Septal Neoplasms 133

4 xx An Illustrated Textbook: Ear, Nose and Throat and Head and Neck Surgery 29. Nasal Polyps 134 Etiology 134 Types of Nasal Polyps 134 Differences between Antrochoanal and Ethmoidal Polyps 134 Differential Diagnosis 135 Investigations 136 Treatment Chronic Infections, Granulomas and Other Diseases of the Nasal Cavity 137 Chronic Infections 137 Granulomas 140 Other Diseases Neoplasms of the Nasal Cavity and Paranasal Sinuses 142 Narmaya Thapa Benign Neoplasms 142 Malignant Neoplasms Facial Trauma 146 Narmaya Thapa Fracture of the Nasal Bone 146 Fracture of the Orbit 147 Zygomaticomaxillary Complex Fracture (Tripod Fracture) 147 Fracture of the Middle 1/3rd of Face (Maxilla) 147 Fracture of the Mandible Epistaxis and its Management 150 Etiology 150 Site of Bleeding 150 Management Diagnosis and Management of Facial Pain, Headache and Neuralgia of the Face 154 Sangeeta Shrestha Local Causes of Pain 154 Pain of Vascular Origin 155 Neuralgias 155 Other Causes Functional Endoscopic Sinus Surgery and Other Endoscopic Procedures 157 Goals of Functional Endoscopic Sinus Surgery (Fess) 157 SECTION 4: THE ORAL CAVITY AND HEAD AND NECK Section Editor: 36. Embryology and Applied Anatomy of the Oral Cavity 161 Embryology 161 Applied Anatomy Physiology of the Oral Cavity: Perception of Taste Sensation, Formation and Functions of Saliva and Swallowing Mechanism 163 Perception of Taste Sensation 163 Swallowing Symptoms of Oral Cavity and Head and Neck Diseases 165 Oral Cavity 165 Head and Neck Clinical Examination of Oral Cavity and Head and Neck 168 Krishna Koirala Oral Cavity 168 Head and Neck Investigations for Oral Cavity and Head and Neck Diseases 171 Imaging 171 Thyroid Hormone Assay 172

5 Contents xxi Endoscopy (Sialendoscopy) 172 Tests to Assess Taste Sensation 172 Pathological Tests Inflammatory Diseases of the Oral Cavity, Diseases of the Tongue and Immune Disorders of the Oral Cavity 174 Inflammatory Diseases of the Oral Cavity 174 Diseases of the Tongue 175 Immune Disorders of the Oral Cavity Neoplasms, Tumor-like Lesions and Premalignant Conditions of the Oral Cavity 177 Benign 177 Tumour-like Lesions 177 Premalignant Conditions 177 Malignant Neoplasms 178 Other Malignant Neoplasm Oral Manifestations of Systemic Diseases 181 Hematological Disorders 181 Endocrine Disorders 181 Acquired Immune Defici ency Syndrome (AIDS) 181 Others Infections of the Salivary Glands and Sialolithiasis 182 Toran KC Infections of the Salivary Glands 182 Sialolithiasis Neoplasms of the Salivary Glands 185 Toran KC Benign Neoplasms 185 Neoplasms of Variable Malignancy 185 Malignant Neoplasms Neoplasms of the Thyroid Gland 187 Thyroid Gland 187 Benign Neoplasms 187 Malignant Neoplasms Other Diseases of the Thyroid Gland including Endocrine Disorders 190 Infections/Inflammation of the Thyroid Gland 190 Acute Infections/Inflammation 190 Chronic Infections/Inflammations 190 Nontoxic Goiter 191 Endocrine Disorders Applied Anatomy and Diseases of Deep Neck Spaces of the Neck 193 Urmila Gurung Layers of Deep Cervical Fascia 193 Classification of Deep Neck Spaces 193 Retropharyngeal Space 194 The Carotid Space 195 Parapharyngeal Space 195 Peritonsillar Space 196 Submandibular Space 196 Parotid Space 197 Masticator Space Swellings of the Neck 198 Heempali Dutta Lateral Neck Swellings 198 Mid-line Neck Swellings 200

6 xxii An Illustrated Textbook: Ear, Nose and Throat and Head and Neck Surgery SECTION 5: THE PHARYNX AND LARYNX Section Editor: 50. Anatomy of the Pharynx 203 Anatomy of the Pharynx Anatomy of the Larynx Physiology of the Pharynx and Larynx 210 Toran KC Physiology of the Pharynx 210 Physiology of the Larynx Symptoms of Pharyngeal and Laryngeal Diseases 212 Inku Shrestha Basnet Pharynx 212 Larynx Clinical Examination of the Pharynx and Larynx 215 Bikash Shrestha Pharynx 215 Larynx Investigations for Pharyngeal and Laryngeal Diseases including Endoscopy 219 Imaging 219 Histopathological Investigations 220 Flexible and Rigid Endoscopy 220 Tests for Esophageal Diseases Diseases of the Tonsils 222 Kunjan Acharya Acute Tonsillitis 222 Ulcers of the Tonsil 222 Tonsillar Cysts and Tonsollith 222 Unilateral Tonsillar Enlargement Neoplasms of the Nasopharynx and Skull Base including Basic Principles of Skull Base Surgery 224 Squamous Cell Carcinoma (Scc) 224 Angiofibroma 225 Basics of Skull Base Surgery Infections and Non-neoplastic Diseases of the Pharynx including Snoring and Sleep Apnea in Adults 227 Infections of the Pharynx 227 Non-infective Diseases of the Pharynx 228 Pharyngeal Manifestations of Systemic Diseases 229 Snoring and Sleep Apnea Neoplasms of the Pharynx 232 Urmila Gurung Neoplasms of the Nasopharynx 232 Neoplasms of the Oropharynx 232 Neoplasms of the Hypopharynx Infections and Non-neoplastic Diseases of the Larynx 235 Infections of the Larynx 235 Non-neoplastic Lesions of the Larynx Neoplasms of the Larynx 239 Urmila Gurung Benign Neoplasms of the Larynx 239 Malignant Neoplasms of the Larynx Neurological Lesions of the Pharynx and Larynx 243 Heempali Dutta Etiology 243 Investigations 243 Intracranial Causes 243 Extracranial Causes 244

7 Contents xxiii 63. Laryngotracheal Injuries 247 Heempali Dutta Acute Laryngeal Trauma 247 Chronic Laryngeal Stenosis Voice Disorders including Phonosurgery 249 Toran KC Voice Disorders 249 Phonosurgery Stridor and Management of Obstructed Airway 252 Stridor 252 Management of Obstructed Airway 252 SECTION 6: AERODIGESTIVE TRACT Section Editor: Chop Lal Bhusal 66. Anatomy and Physiology of Esophagus and Tracheobronchial Tree 261 Chop Lal Bhusal The Esophagus 261 The Tracheobronchial Tree Foreign Bodies in the Aerodigestive Tract including Bronchoscopy and Esophagoscopy Procedures 264 Chop Lal Bhusal Foreign Bodies in the Airway 264 Foreign Bodies in the Digestive Tract Dysphagia 269 Acute Dysphagia 269 Chronic Dysphagia 270 SECTION 7: PEDIATRIC ENT Section Editor: Rajendra PS Guragain 69. Congenital Diseases of the Ear, Nose and Throat 275 Anupama Shah Rijal Congenital Diseases of the Ear 275 Congenital Anomalies of the External Auditory Canal (Eac) 276 Congenital Anomalies of the Inner Ear 276 Congenital Diseases of the Nose 276 Congenital Diseases of Oral Cavity and Head and Neck 277 Congenital Diseases of the Pharynx 279 Congenital Diseases of the Hypopharynx 279 Congenital Diseases of the Larynx 279 Congenital Diseases of the Trachea and Esophagus Acute Otitis Media 282 Rajendra PS Guragain 71. Otitis Media with Effusion 284 Rajendra PS Guragain 72. Diseases of the Adenoids including Snoring and Obstructive Sleep Apnea 287 Anupama Shah Rijal Diseases of the Adenoids 287 Adenoidectomy 288 Snoring and Obstuctive Sleep Apnea in Children Infections of the Tonsils 291 Rishi Bhatta Surgical Anatomy of the Palatine Tonsil 291 Infections of the Tonsils 291 Complications of Acute Tonsillitis Pediatric Upper Airway Problems 297 Rajendra PS Guragain Upper Airway Problems 297

8 xxiv An Illustrated Textbook: Ear, Nose and Throat and Head and Neck Surgery 75. Pediatric Neck Swellings 300 Rishi Bhatta Inflammatory Conditions 300 Congenital Conditions 300 Neoplasia 300 Others The Deaf Child 302 Rajendra PS Guragain SECTION 8: related topics Section Editor: Narmaya Thapa 77. Emergencies in ENT and Head and Neck 307 Anil Kumar Jha Ear 307 Nose and Paranasal Sinuses 308 Oral Cavity, Pharynx, Larynx and Head and Neck Imaging in ENT and Head and Neck Diseases 309 Ultrasonogram (USG) 309 Computed Tomography (CT) 309 Magnetic Resonance Imaging (MRI) 309 Radioisotopes and Radiotracers (Nuclear Medicine) Radiotherapy in ENT and Head and Neck Cancers 311 Pabina Rayamajhi Curative Radiotherapy 311 Adjuvant Radiotherapy 311 Types of Radiotherapy 311 Units of Radiation Measurement 312 Sources of Radiation 312 Conventional Fract ionation of Radiotherapy 312 Side Effects of Radiotherapy Chemotherapy in ENT and Head and Neck Cancers 313 Pabina Rayamajhi Types of Chemotherapy Laser in ENT and Head and Neck Surgery 316 Principle of Laser Action 316 Types of Lasers 316 Advantage of Lasers over Conventional Surgery Common Instruments Used in ENT and Head and Neck Surgery 318 Krishna Koirala Ear Instruments 318 Nasal Instruments 320 Throat Instruments Common X-rays in ENT and Head and Neck 325 Narmaya Thapa Ear 325 Nose and Paranasal Sinuses 326 Head and Neck 328 Index 331

Preface... Contributors... 1 Embryology... 3

Preface... Contributors... 1 Embryology... 3 Contents Preface... Contributors... vii xvii I. Pediatrics 1 Embryology... 3 Pearls... 3 Branchial Arch Derivatives... 3 Branchial Arch Anomalies: Cysts, Sinus, Fistulae... 4 Otologic Development... 4