Sinus/rhinitis vascular supply-primarily the facial and opthalmic arteries

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Vascular supply-primarily the facial and opthalmic arteries
1. The external and internal carotid arteries supply the nose via their terminal branches.

2. The anterior and posterior ethmoidal arteries supply the region above the root of the

middle turbinate.

3. The sphenopalatine and labial arteries supply the remaining structures.

4. Venous drainage of the external nose is via the facial and ophthalmic veins to the

cavernous sinus [therefore, a superficial infection of the nasal lining may involve the

cavernous sinus].
Neurologic supply-primarily the opthalmic and maxillary nerves

The primary sensory supply is via the maxillary division of the trigeminal nerve.

The other sensory supply is via the facial nerve.

The pterygopalatine ganglion supplies the sympathetic and parasympathetic supply.

Secretory glands are under the command of the autonomic system.

The nasal vascular supply is constricted by the sympathetic system and dilated by the parasympathetic system.

Important anatomical notes

The ethmoid sinus walls are very thin and thus allow easy spread of infection and tumor to adjacent structures.

The sphenoid sinus is adjacent to the internal carotid artery, optic nerve and cavernous sinus.

The cavernous sinus contains the occulomotor, trochlear, abducens and the 1st and 2nd divisions of the trigeminal nerves. The pituitary fossa lies posteriorly.

General: possible signs and symptoms

facial pain

otological symptoms [otalgia, hearing loss, crackling, etc.]

disorders of smell

halitosis-bad breath




post-nasal drip fever
Facial pain-due to distribution of the trigeminal nerve via the ophthalmic and maxillary nerves-supplying the face, nose and paranasal sinuses
Otologic symptoms-due to disruption of the function of the Eustachian tube. Polyps, edema from allergies, tumors and post-nasal drip can physically block the tube
Halitosis-most often from poor dental hygiene and poor diet, but may be due to chronic sinusitis and post-nasal drip
There are several primary considerations involved when you include sinusitis/rhinitis in your diagnosis: timing, discharge, location, presence/absence of fever and the pain. The history, of course, is of primary importance in your work-up of the patient. It is vital that a proper examination is performed along with this. Please note that sinusitis may progress to several serious and, even deadly illnesses, so do not take these complaints lightly. Conservative management is useful in many cases but it should be monitored.
Work-up: history & physical examination: nasal illumination, palpation, visual inspection, observe eyes for bulging or displacement, sinus transillumination, radiography, laboratory
Transillumination of the sinuses-has been found to not be a reliable method for detecting fullness of the sinuses In a research study that compared general practitioners and specialists in the field of EENT. Radiography of the sinuses is more reliable if you question your examination results.
Nasal illumination-Inspect the nasal passages for polyps, drainage, color of mucosa, swelling, and foreign objects
Laboratory-performed by nasal swab-

most common organisms: strep. pneumo, hemophilus influenza, staph. aureus, beta strep.

eosinophilia-greater than 400-500 (cells/mm3) will support but not confirm a diagnosis of allergy
Hansel's Stain - used for leukocytes and eosinophils-Therefore, this stain will help you differentiate an infection from an allergy.
Skin tests- false negative results on skin tests are not infrequent. A negative response does not exclude allergy, and a positive response is not absolute proof that the specific allergen is causing the symptoms.
Location of Pain-you must know this!!!
ETHMOID-pain at bridge of nose
most frequent sinus involved

occurs especially in kids

also may have pain on eye movement
MAXILLARY-pain In teeth and cheeks
10% from dental infections

pain in several teeth, not just one

also after cold/flu

teeth painful on percussion

face may be puffy

Innervated by the infraorbital nerves

SPHENOID-occipital pain
may have dizziness

Innervated by the ophthalmic and maxillary nerves

supplied by the internal carotid artery

FRONTAL- pain on eye motion, supraorbital ache

also after cold/flu

severe in mid-day and then gets better

edema in eyelids

pain aggravated by postural changes

innervated by the supra-orbital nerve

Rhinitis-inflammatory state of the anterior nasal passages, the sinuses are spared.

Can be due to allergic, viral, hormonal or bacterial etiology. Simple allergic or viral

rhinitis may respond well to OTC nasal sprays and decongestants.

Sinusitis-inflammatory state of the sinuses can be due to allergic, viral, hormonal, tumor or bacterial etiology. The primary cause of this condition is BLOCKAGE of the sinuses preventing them from draining the discharge that is produced from any irritant. Nine out of ten people presenting with complaints of sinusitis actually have rhinitis. Sinusitis does not readily respond to nasal sprays and decongestants, despite the advertising.

Rhinorrhea- the watery discharge from the nasal passages one of the most common complaints

The nose produces 1-1.5 pints of mucous per day. Most of this mucous drains down the posterior nasopharynx where the cilia push it along. Smokers and city dwellers have more irritation and produce more mucous.
Anterior rhinorrheas-conditions of the anterior nose causing increased rhinorrhea. These Include excessive mucous production (infection, presence of a polyp, foreign object, etc.), ciliary abnormality (smoking), and nasal blockage.
Allergen- substance that elicits an allergic response-pollen from trees, grass and weeks, dust, mold, food and dander from animals

Allergic rhinitis- Includes hay fever, mold and dust allergies and other upper respiratory allergies. Symptoms include runny nose, sneezing and itchy, watery eyes.

Histamine- chemical produces by the body and released during allergic reactions. When released, it causes the dilation of blood vessels and contraction of muscles. Permeate nasal tissue and cause capillaries to swell and ooze. Fluid from capillaries passes through tissue into nasal cavity. A runny nose results.
Antihistamine-chemical treatment that actually thickens the discharge by decreasing its water content; so it gets thicker and decreases the drainage. They may be taken Initially but then the patient should get off them or they will stop the drainage and make the problem worse.
Immunotherapy- typically administered in allergy shots. Injections of Increasing doses of an allergen to which the patient is sensitive. The pt. gradually becomes less sensitive.
Mast cells- large cells In connective tissue which release histamines during the allergic response, below epithelial cells become swollen with histamines and release histamines and other inflammatory chemicals
Pollen- microscopic round or oval grains that fertilize flowers. Particles from wind ­pollinated plants are lighter and smaller and tend to be more allergenic than those from bee-pollinated plants.
Hay fever- type of allergic rhinitis, seasonal-ragweed most common cause. Season runs until October, and ends at first frost, warm humid air and lack of breeze traps the airborne allergens in the area-uncontrolled, allergies can lead to upper-respiratory infections and serious bouts of asthma-IF symptoms continue past first frost, then possibly sensitive to mold spores
Vasoconstrictor Treatment used to constrict vessels in nasal passages to decrease the

amount of fluid passing from them to the mucosa to decrease inflammation. Long term use can lead to "Rebound Phenomenon

Rebound Phenomenon-nasal passage swelling due to long term use of vasoconstrictors.

Normal utilization is 4-7 days to shrink mucosa and allow drainage, over 4-7 days can lead to

this phenomenon, leading to blockage. This phenomenon is called Rhinitis Medicamentosa.
Rhinitis Medicamentosa-constant reactive vasodilation of the nasal mucosa due to an

acquired sensitivity of the nasal ling to prolonged use of topical drops and sprays. Many OTC drugs due fall into the category. Topical steroids may be needed to wean the patient off or will have severe blockage.

Polyps-sessile or pedunculated overgrowths of mucosa due to recurrent episodes of mucosal edema, frequently seen in long-standing allergic rhinitis. Typically found bilaterally with the cardinal symptom of progressive nasal obstruction. Most frequently they are found protruding from the middle meatus as smooth, gray, pale, spherical masses of mucosa, that are mobile and insensitive to a probe (which distinguishes them from swollen turbinates) and do not bleed. They frequently recur after removal.

Note: polyp-When found in children, consider performing a chloride sweat test to rule out cystic fibrosis and if found in an adult, consider the possibility of a neoplasm.

Halitosis-bad breath

Discharge from the nose
Blood – (epistaxis) Typically a trivial occurrence due to nose picking or trauma leading to bleeding from Kiesselbach's plexus, a vascular network in the anterior nasal septum. It can also be due to anemias, Infections and hypertension. The vessels in the posterior nose belong to the external carotid artery system. Therefore, if the site of bleeding cannot be seen, consult one of your texts or send for concurrent management.
Clear - allergic, hormonal, polyps, adenoids, HTN, foreign object, neoplasm, asthma, CSF [CSF will dry soft and not crusty as normal mucous does]
white to yellow - viral, possibly associated with low-grade fever (less than 101 degrees)
yellow to green-bacterial, possibly associated with a fever, may be atrophic sinusitis or foreign object or polyp degeneration, may be fungal infection, especially in immunocompromised patients (diabetics) may appear at the end of a cold-smear would show lots of leukocytes
clear with red streaks-CSF (on a white cloth, a halo will develop)
brown - smokers
SINUSITIS: inflammation of the sinuses

Primary Cause: anything that obstructs the nose

Pain: location of pain typically tells the site of the sinus involved

Treatments: objective is to open sinuses, keep nose open to let air in

1. antihistamines actually thicken the discharge and decrease the drainage, they can be

used initially but should be discontinued ASAP

2. moist heat or diathermy if it is not bacterial

3. vasoconstrictors- spray once, wait five minutes and spray again, then the patient is to

breath through a wet, steamy towel or use a steam apparatus to increase the fluid in the mucous and increase drainage. Use a vasoconstrictor for 4-7 days to shrink the mucous and allow drainage. If used over 4-7 days, the patient may have Rebound Phenomenon

4. hang head over edge of bed to promote drainage with affected sinus up for 5

minutes, 3 times a day, for 3-4 weeks.

5. saline spray-may be used to thin mucus and lead to drainage

6. vitamin therapy

7. antibiotics-if bacterial infection

first the basic things you should already know...
Allergic Sinusitis- the pt. may not have nasal obstruction or nasal discharge. If there is discharge. it will be clear. You may find copious amounts of this discharge draining down the posterior pharynx. Watch for timing and look for allergens. The patient will have pain and full feeling In the involved sinus. The patient will not demonstrate fever or body pains but may have itchy, watery, red eyes and/or coughing/sneezing. The sinus pain may become severe and debilitating. If the head pain gets severe enough, a tension headache may overlay the original pattern and make your diagnostic efforts more complicated. Nasal smear should be performed with Wrights or Hansel's stain for eosinophils. A count of more than 10% confirms the diagnosis of allergy.

Allergic rhinitis-nasal discomfort and clear discharge (rhinorrhea) without a fever or body pain. It may be accompanied by itchy, red eyes &/or coughing, sneezing, etc. It is important to track the cause of the discharge, watching for timing and possible allergens.

Chronic sinusitis-a complication of any acute sinusitis. The pain will be worse on arising in the morning as there is less drainage while lying down. The pain will be less pronounced during the day because movement promotes drainage. The tenderness over the sinus will be minor and the patient will have a normal temperature.
Acute Bacterial Sinusitis-typically there is a hx of an URI. The pt. will have pain in the area of the involved sinus and possibly redness and tenderness over it and fever. The mucosa will be swollen and angry red with inflamed turbinates. Copious purulent discharge will be noted that when checked on nasal smear will show neutrophils. An x-ray will show clouding of the sinus(es) involved or even a fluid line. always culture (typically gram+ strep. pneumococcus Infection). These Infections are very resistant to antibiotics and may require several prescriptions. Can have severe complications.


The location of the primary Infection will typically dictate what the complication will be. The following is a list of the primary sinus that was Infected and what is (are) the most likely complication(s).
Ethmoid sinus > orbital cellulitis, periorbital abscess

Frontal sinus > meningitis, osteomyelitis, brain abscess

Sphenoid sinus > meningitis

Maxillary sinus---->

ANY sinus > cavernous sinus thrombosis
Periorbital abscess-pus extends through the lateral wall of the sinus to form an abscess between the ethmoid plate and the fascia lining the orbit.
S&S: some increase in fever, pain on movement of the eye, edema between the inner canthus and the bridge of the nose, tenderness of the edematous region, the pus may push the eye slightly down and laterally. No chemosis (swelling of the conjunctiva) is present.

Orbital cellulitis-A periorbital abscess may extend to produce a diffuse cellulitis of the orbital tissue. Invasion may be heralded by a chill, high fever and dull pain in the eye. There is still pain on ocular motion. The eyelids (especially the upper lid) are edematous, especially at the inner canthus. Chemosis (swelling of the conjunctiva around the cornea) develops, which begins at the medial canthus. Ultimately the eye will become fixed. The patient appears very ill and requires immediate surgery.

Meningitis-The Infection travels through the perforations of the bones along veins between the periosteum. The patient will have daily spiking fever, stiff neck. Immediate intervention is required.
Brain abscess-The infection uses the same route as for meningitis, along the veins, to penetrate the dura and arachnoid layers. The patient will demonstrate weight loss and anorexia, vomiting and nausea, headache and a low-grade afternoon fever.

Frontal osteomyelitis-redness and swelling of the frontal bone, exquisitely tender! Can look like acute bacterial infection, just hurts MORE!

Cavernous sinus thrombosis-The patient is VERY ILL! This is the most feared complication of nasal Infections, the mortality rate is over 50%. The Infection spreads from the nose through the angular vein to the cavernous sinus, where septic thrombosis occurs. The patient will complain of deep pain in the eyes, headaches, rigors. The patient is prostrated and may rapidly become comatose. Early on, selective occular palsy involving one of the nerves in the cavernous sinus, either the occulomotor (3) or the trochlear (4) or the abducens (6). As this progresses, exophthalmos can develop. Later, both eyes will become Involved with them being immobilized and demonstrate proptosis and chemosis. (This can also be a complication of infected facial wounds, a retrograde infection via the facial veins) High-dose antibiotics may help.

NOTE: Selective ocular palsy occurs early in cavernous sinus thrombosis, whereas orbital abscess produces complete immobilization of the globe gradually, without preliminary disorder of a single nerve.

Clear sinus discharge
Clear sinus discharge can occur with allergies, atrophy, foreign object, hormonal dysfunction and tumors.
1.Vasomotor rhinitis

-mucosa appears hypertrophic

-profuse, watery discharge

-decreased airway-unilateral or bilateral

-swollen turbinates, esp Inferior

-deep pink to dusky red mucosa due to vasodilation

-hypertrophic changes (mulberries) seen on Inf turbinates seen on post. rhinoscopy

-neurovascular-type reaction

-predisposing factor-STRESS, psychological, endocrine, genetic, allergy

-20-40 yr old esp females

-stimulation of parasympathetics or depression of sympathetics leading to vasodilation and subsequent increase in secretion, associated with sneezing

-assoc with hormonal changes-puberty, pregnancy, menses, etc.

2. nasal polyp

often associated with vasomotor rhinitis and allergic rhinitis breathing difficulty, Increase discharge, may need x-ray and post exam see earlier information in Definitions Section

3. CSF rhinorrhea

-CSF leakage due to trauma to subarachnoid space

- intermittent- when the head in forward position

- fluid dries softly

  • has a lot of glucose-use a dipstick

  • must be treated in ER

4. atrophic rhinitis-characterized by copious amounts of dry crusted material with dry crusted nasal membranes and atrophy of the membranes and turbinates. The patient is also anosmia [loss of sense of smell] so the patient cannot tell that the breath is fetid [rotten] due to the lack of mucus. Treatment with syringing the nose 3-4 TID with a syringe or water-pick, steam inhalations, glucose in glycerine drops. May be associated with syphilis or tuberculosis.

5. systemic [HTN, thyroid], drugs [cocaine], trauma
6. allergic rhinitis

-seasonal, mucosa is edematous and bluish color

-primary symptoms are nasal obstruction from engorged and swollen Inferior turbinates profuse, thin, mucoid drainage from the ant and post nose, lacrimation, puffiness and discoloration around the eyes, glossy and swollen mucosa (pale and boggy), sneezing can be year round, if so then S&S are less severe

allergen causes vasodilation leading to increased capillary permeability leading to edema leading to persistent edema leading to prolapse of tissue leading to polypoid development leading to polyp formation leading to Increase secretion of seromucinous glands

DD: check hx carefully, family, onset, HTN, thyroid disease, cocaine, URI effusions and perforation of the tympanic membrane

10-20% of the population suffer to some degree form nasal manifestations of an antigen­/antibody type 1 hypersensitivity reaction
The symptom complex, nasal obstruction due to mucosal vasodilatation and edema, rhinorrhea, paroxysms of sneezing due to mucosal stimulation, is produced by allergen binding on to immunoglobulin E (IGE), which In turn is bound to mast cells. This binding causes degranulation of mast cells and the release of mediator substances such as histamine, leukotrienes and SRSA. Many patients will also have a history of asthma, eczema, allergic dermatitis, drug allergies, aspirin sensitivity.
Allergy myths- allergies are psychosomatic moving to Arizona will help, shorthaired pets do not cause allergies, allergies are all sniffles and scratches, but no one ever dies from them you can catch poison ivy by just standing near the plant

Types of Allergies

1. seasonal allergic rhinitis

-primarily caused by tree pollens such as olive, elm and oak and grass pollens such as bermuda

-symptoms-watery, runny nose and/or eyes, sneezing, itching in nose, throat, roof of mouth or deep in ears

-Condition is aggravated by low humidity, dust, wind and pollution.

2. perennial allergic rhinitis

-caused by house dust, dust mites, mold spores, pet dander, saliva and urine, feather pillows, pollens, foods and aggravated by pollution

-symptoms-same as seasonal but constant and less dependent on season.

-note-wheat, eggs, milk and nuts may also be culprits

3. occupational allergic rhinitis

-caused by fumes from cleansers, solvents and industrial chemicals and molds, pollens and dust as they collect on furniture or in air ducts

-symptoms-sneezing, watery eyes, runny nose, headaches, and dry scratchy throat only while in work environment.

-Commuters exposed to pollens and smog on the way to work may mistakenly attribute symptoms to the workplace.


August and September-WEEDS, chiefly ragweed and lamb's quarter

Mostly in winter, but all year-molds, as in damp basement and air-borne

March through May, tree pollens are heaviest now

June on to first frost-grasses

pollen counts are highest from 1 AM to 9 AM

pollen counts are lowest in the late afternoon and evening

-Mast cell stabilizers- block the release of histamines and other chemicals by mast cells

-antihistamines-prevent histamine from acting on nasal tissue

-decongestant sprays-shrink blood vessels to reduce swelling caused by histamines

-oral decongestants-shrink blood vessels in the nose, reducing swelling

-corticosteroids- shut off nasal inflammation
Other tx
desensitization-injections working on the principle of producing IgG antibody that prevents antigen binding to IgE. The treatment is only of value if specific allergens can be identified, and it is essential to commence the series of injections well in advance of exposure.

allergies and asthma Asthma and allergy foundation 692-2422

pollen and mold counts St. Louis County Health Dept. 854-6825


Cerumen is produced by seromucinous glands. These secretions combine with desquamated cells and debris to form wax. Most people are obsessive about it. Tell them to relax. Production of cerumen appears to be partly controlled by circulating catecholamines. An over production of wax is often found in patients with essential fatty acid deficiency and can also indicate atherosclerosis (perform a SMAC)

Appearance of cerumen: Cerumen is shiny and when it builds up it looks lumpy. These are constants. The color of cerumen is not constant.

white, shiny = water logged

pale yellow, shiny = new cerumen

golden, shiny = been around awhile

amber, shiny = been around awhile longer

blood-colored, shiny = been around even longer

scab-colored, shiny = boy, it's been there so long, we should name it

brown, shiny = it's been around so long, it should get a job

black, shiny = it's been around so long, it should get a medal
Differentiating a tumor, blood, fungus, or other discharge from the ear from cerumen­


Removal of ear wax [cerumen]

Using a syringe filled with tap water at body temperature, the pinna is pulled to straighten the EAM, the syringe is tilted to the superior wall of the EAM [never at the tympanic membrane], and examine the canal after. Be sure to drape the patient and place a bowl under the ear to catch the fluid. This should not be done if there is a possibility of a perforated tympanic membrane or if the debris is likely to swell. A curette or spoon may sometimes be used if you can control the patient and are sure not to touch the highly sensory innervated walls of the EAM as it may cause the patient to cough and have severe pain Further, the tissue is very fragile and you can cause severe tearing if you scrape the walls. Never use a curette if the object or wax is very dry. If it is very dry, then when you try to remove it, it will be like pulling off a scab and tear the EAM. Very dry cerumen should be hydrated for several days [7-10] with Sweet Oil [special virgin olive oil], a solution of one part alcohol and two parts water or an over the counter product. Patience is necessary.
A build up of cerumen is frequently due to dust, hair spray and other environmental debris. More frequently it is due to cotton swabs being pushed into the canal causing a bit of cerumen to be pushed in and creating a dam effect.
TINNITUS-use a 512 cps tuning fork
Definition: noises in the ear, real or imagined.

[Most common in patients who have been exposed to long-term, high level intensity noise. The TMJ, eustachian tube and carotid artery can produce sounds which are usually innocent and can be heard by the examiner also (objective tinnitus). ototoxicity, neurologic or mechanical etiologies can also be at fault.]

Rule of thumb:

high pitched tinnitus-typically due to neurologic etiology, includes chemical toxicity.

-sensorineural hearing loss can also be described as a rushing, hissing or buzzing by the patient
low pitched tinnitus-typically due to mechanical etiology, includes middle and outer ear problems.

Why do you need to understand this condition? 35 million people are afflicted with tinnitus annually

Systemic causes and their pictures: typically high pitched
1. Costen's Syndrome: typically in menopausal females

the patient may present with ear discomfort and Slight deafness with tinnitus

the tinnitus is due to abnormal stresses of the TMJ

a general picture will present with dryness of the eyes and mouth, sialoadenitis, recurrent attacks of arthritis

2. Diabetes neuritis-unilateral sensorineural deafness with tinnitus of course, other systemic signs will be seen

don't forget to check the PDR for the influence of any medication

3. Syphilis-unilateral sensorineural deafness with tinnitus vertigo is present

other systemic signs and symptoms will also be present

4. cerebral tumor-intermittent tinnitus associated with aura and seizure
5. persistent noise exposure-ringing or cricket sounds

If the patient has had short4erm exposure to noise, the sound may be temporary.

It would be wise to have the patient's hearing screened by an audiologist to monitor for sensorineural hearing loss

  1. acoustic neuroma-constant tinnitus. begins faint and gets louder as the tumor grows, vertigo accompanies this condition. The vertigo comes on gradually, as does the tinnitus, so the patient may be able to compensate fairly well, so you may see some ataxia.

Acoustic Neuroma-a benign, expansile lesion located anywhere along the 8th cranial nerve from the cochlea to the brainstem.

The patient can have other signs and symptoms depending on the location and the size of the tumor. If the patient has loss of the corneal reflex, then the growth of the tumor is compromising the 5th cranial nerve.
If the patient is experiencing facial Palsy, then the growth of the tumor is compromising the 7th cranial nerve. Though this is a benign tumor, death may occur, if the tumor gets large enough, it can significantly increase intracranial pressure.
7. Hypertension constant tinnitus

may be due to hypoxia from the typically associated atherosclerosis
8. Anemias constant tinnitus due to hypoxia
9. Presbycusis-YOU MUST KNOW THIS DEFINITION -tinnitus due to aging. It is typically associated with sensorineural hearing loss and therefore; typically high pitched.

An interesting point-Due to the gradual onset, the patient may be unaware of the noise until a heavy cold produces a temporary conductive hearing loss, which highlights the tinnitus. With aging, there is degeneration of the hair cells of the Organ of Corti and the cochlear nerve fibers.

Examination is negative.
The patient will play the TV loudly, complain that people mumble.
Masking is helpful with most to cover the tinnitus if it disturbs sleep.
Hearing screening is definitely in order.

10.Bell's Palsy-tinnitus with pain around the ear, eyelid fasciculation and facial twitch most common cause of facial paralysis and is a diagnosis of exclusion. The nerve will swell within the bony canal causing a conduction block [neuropraxia]. Discomfort or pain around the mastoid may precede the palsy. Loss of hearing, taste and hyperacusis may be present. When the palsy is incomplete, 90% of patients have a satisfactory recovery within 6 weeks of onset.

[Note: The facial nerve is a motor nerve which has a complex course from the brain stem through the temporal bone and the parotid gland, before innervating the muscles of the face that result in expression. There are also sensory fibers that run along this nerve for taste from the anterior 2/3 of the tongue and secromotor fibers for the lacrimal, submandibular and sublingual glands. The site of the lesion of the nerve will determine the picture the patient will present. For instance, in supranuclear lesions, the forehead is often spared due to bilateral innervation; infranuclear lesion produce lower motor neuron paralysis with both the upper and lower facial muscles involved.
Facial palsy can be due to trauma to the facial nerve, herpes zoster oticus, cholesteatoma, parotid tumor, acoustic neuroma, or facial nerve tumor.]
To differentiate stroke (supranuclear) from Bell's Palsy (infranuclear) check the frontalis muscle. Always examine all the cranial nerves.
11. ototoxicitv- The active metabolic processes of the inner ear are very susceptible to drugs. Those that affect the renal system will frequently affect the ear, ie. aminoglycosides and cytotoxic agents, salicylates and quinine. Typically will be a constant high pitched tinnitus.
Local causes of tinnitus

1. torus tubaris dysfunction-a blowing or swishing sound is reported by the patient

2. foreign body in the middle ear-a phlebolith can break free and begin moving in the middle ear. Auscultate the ear while the patient is moving the head.
3. Meniere's Disease or Multiple Sclerosis-unilateral tinnitus with hearing loss, also vertigo

5. Carotid stenosis, arteriovenous aneurysm, nasopharynx carcinoma-These will produce a low/pulsing swish that is synchronous with the heartbeat
6. any air conduction hearing loss (ie. otitis media, otitis externa with moderate to severe swelling, any eustachian tube dysfunction)- low Ditched tinnitus on the side of involvement, may he intermittent, may be constant. dependent on cause

ie. otitis externa tinnitus accompanied with itching around the ear

ie. foreign body or impacted cerumen~constant, low pitched

ie. perforated tympanic membrane~constant, low pitched, until healing occurs

ie. serous otitis media-may have intermittent low pitched tinnitus if the eustachian tube drains occasionally

NOTE: a conductive hearing loss may lead the patient to have tinnitus that is associated with chewing.

7. myofascitis-typically, trigger points of the masticatory muscles, especially the upper posterior deep masseter muscle will refer motor unit activity to the stapedius muscle causing movements of the ossides leading to motion of the oval window leading to activity in the cochlea resulting in the stimulation of the nerve fibers, There is not a hearing deficit with this condition.

Causes-cutting thread with teeth, chewing ice, incessant gum chewing, pipe stem holding with teeth, cracking nuts, mouth breathing, emotional tension [the muscles of mastication are the first muscles to contract in reaction to tension (fight or flight response)], occlusal disharmony.


Definition: earache. Diagnosis is made by examination of the pinna, ear canal and tympanic membrane. If the ear is normal, the pain may be referred by one of several cranial nerves supplying the external and middle ear or via myofascitis.
Note: Pain can be referred to the ear via

C2 and C3 [cervical spondylosis]

FYI: C2 via the lesser occipital nerve and C2 &~ via the greater auricular nerve

5th cranial nerve [teeth. parotid. TMJ. Tongue, nose and sinuses]

FYI: especially the auriculo-temporal branch of the trigeminal

7th cranial nerve [sensory branch]

9th cranial nerve [oropharynx]

10th cranial nerve [larynx. hypopharynx and esophagus

1. Otitis externa-Infection or inflammation of the EAM

The patient may have mild to severe pain.

Symptoms are aggravated with movement of the tragus.

Fever is not uncommon.

If swelling is significant, there may be a conductive hearing loss and possible low pitched tinnitus

S&S: mild itching, swelling, pale to red epithelium, otorrhea is possible, lymphadenopathy is possible

anterior to the tragus
Note: if the condition is due to frequent water exposure. the condition is called Swimmer's Ear. The cerumen, which protects the EAM [external auditory meatus], is washed away frequently allowing drying of the epithelium with resultant irritation and possible opportunistic infection by streptococci, staphylococci, pseudomonas and fungi. Therefore, it is important to monitor these cases.

If your patient has Swimmer's Ear-

-ear plugs should be used to allow the cerumen to build up and protect the ear.

-If water does get in the ear, it should be removed, a hairdryer or 1:2 solution of alcohol, and

water can be used to remove the water

-Cortisone creams or triple antibiotics may be used

-can irrigate with a solution at 38 degrees Centigrade (body temperature) with 1 part 70 % peroxide, 2 parts water, 1 part 5% vinegar 3 times per day

2. furunculosis the infection of a hair follicle in the EAM usually a staph infection

S&S: severe throbbing pain with a red, tender eminence with or without a pustule

3. malignant otitis externa-an aggressive form of otitis externa

This pathology commonly occurs in immunocompromised patients.

It is a spreading osteomyelitis and can lead to intracranial infection

S&S: severe pain that extends beyond the ear

4. myringitis bullosa-a localized form of otitis externa where blisters form on the tympanic membrane and deep in the external auditory meatus

It is presumed to be a viral infection and treatment is symptomatic

5. foreign bodies in the EAM-do not flush dried objects The EAM is innervated by:

6. perforations of the tympanic membrane - The patient will initially have pain when the rupture occurs and then the pain stops. There will be a conductive hearing loss and the patient will state that it sounds as if they are speaking in a cloud. Tinnitus [low frequency] is possible. A large perforation will typically heal in six weeks.

7. acute otitis media - overall view

Otitis media is a result of blockage of the eustachian tube allowing build up of the normally produced serous fluid in the middle ear chamber or the proliferation of viruses or bacterial in the middle ear.

It occurs most often in infants UD to 4 years old due to the horizontal orientation of the eustachian tube.

Pain will occur when pressure in the middle ear develops and will resolve upon spontaneous rupture of the drum.
first, a rule of thumb. Once a child has had a middle ear infection, serous or purulent, the child will have more bouts of this.
Second, prevent this in your patients. An infant should not be fed with a bottle lying down or given a bottle while in its crib. The milk will pool and block the torus tubaris leading to eustachian tube dysfunction.

Third, if your young patient has allergies or recurrent bouts of otitis media, discuss the utilization of decongestants with the concurrent care provider or home therapy to open the eustachian tube. If the child is old enough, regular gargling several times per day to dear the mucus from the torus tubaris may be of great assistance in preventing otitis media or even resolving it.

note: blue posterior to the tympanic membrane = blood

white = pus, purulent otitis media

bubbles with fluid line = fluid, serous otitis media

Antibiotics are frequently prescribed, even for the serous type. It is thought that this is leading us to super infections.

Antihistamines in some studies have proven to be effective.
A pharyngeal sweep, from superior to inferior, can prove to be effective by pulling the fascia surrounding the torus tubaris open and removing mucus from the t. tubaris. This must be done repeatedly if the patient is having significant post-nasal drainage.
[Pharyngeal sweep-slide your gloved finger along the gums or molars toward the back of the throat, move your finger slightly medially to pass around the pharyngeal fold and the tonsil, move your finger superiorly to just above the hard palate and sweep firmly inferiorly to the oral pharynx. This can have a high success rate with just one treatment. Be sure to warn the patient/parent that the patient may gag. Be forewarned, you may get bitten. With very small children, you may wish to do this only when other treatments have been unsuccessful. If you can, you may wish to sweep/massage the posterior pharyngeal area with your finger to massage the lymph chain.]
Cervical spine adjustments may be helpful by increasing blood flow to the area to dear the infection and the by-products of infection from the area, by decreasing the inflammatory chemical concentrations and increasing the lymphatic flow.
NOTE: There are multiple complications of the purulent middle ear infection. Extracranial complications of otitis media

1. mastoiditis- still the most common complication and mostly in children severe pain, usually localized over the mastoid process

Early signs of mastoiditis include a sagging or swollen posterior EAM wall and edema over the mastoid and zygomatic areas. Eventually the pinna will be pushed anterior and inferior by a subperiosteal abscess.
2. facial paralysis-if the facial nerve in the middle ear is not covered by bone in your patient, there may be enough pressure developed to cause a neuropraxia

3. labyrinthitis-A giddiness and loss of balance with nausea and vomiting, and sensorineural hearing loss following a bout of otitis media. The patient will lie in bed with the affected ear up to decrease the 5 sensations.

Intracranial complications of otitis media

1. Intracranial suppuration-a significant mortality rate,

2. Meningitis-headache, fever; later-stiff neck, irritability, confusion

3. Cerebellar abscess-nystagmus, past pointing and ataxia with headache

4. Temporal lobe abscess-headache, rigors, fever and vomiting (cerebritis) then after several weeks present with paralysis or visual field changes or "fits"

5. Thrombosis of lateral venous sinus-due to the infection passing through the mastoid. A clot will develop until the lumen is occluded. S&S: rigors and high fever

Hearing Loss

Sensorineural hearing loss-loss of sound perception due to any disorder from the oval or round window to the brain due to trauma, infection, congenital, etc. causes

Conduction hearing loss-loss of sound perception due to the blockage of the sound waves reaching the receptor organ. Due to blockage, infection, trauma or congenital malformation.

Tuning fork tests­

Best performed with a 512 cps tuning fork, a 256 cps tuning fork is acceptable.
Rinne Test Normal AC > BC positive

Abnormal AC < BC negative

Weber Test lateralized sound to one ear

The sound will be heard in the good ear with a sensorineural loss-

The sound will be heard in the bad ear with a conduction loss-

TRAUMA to the head
Mandibular fractures-typical site it the condylar neck

--the patient will have severe trismus

Malar fractures typically due to a blow to the cheek

---the fracture will produce a depression that may be obscured by swelling

---palpation may reveal a step over the infraorbital ridge, if the infraorbital nerve has been insulted, then the cheek may display sensory loss
Maxillary fractures-Le Fort I, II and III

---severe hemorrhage and fatal airway obstruction can complicate these fractures

---palpation reveals bony irregularities
Orbital blow-out fractures-a blow that pushes the eye into the orbit

---the orbital floor is fractured

---limited eye movement
Nasal fractures-most are lateral

---a lateral fracture may have to wait 7 days for correction due to swelling

---an anterior fracture may have to wait10 days for correction

It is important to note that a fracture anywhere in the skull may cause one or both eves to blacken.



Vestibular apparatus-

hair cells >neurons->vestihular [Scarpi's] ganglion~>cerebellum

[fastigial nucleus]

[flocculonodular lobe]

[nuclei of cranial nerves III, IV and VII

[spinal cord-primarily the vestibulospinal tract]

the eyes reflex [as in nystagmus] along the medial longitudinal fasciculus

Proprioceptive input

upper cervical is actually more responsive due to the more direct neural communication

Cl -C2 lateral cervical nerve - nerves are monsynaptic and have direct connections to the spinal cord

stimulation of muscles innervated by these nerves can cause nystagmus [splenius capitus]

C2 dorsal root ganglia-takes sensory information from the joints and muscles

-has direct connection with the spinal cord and brainstem nuclei [medullary nuclei-inc. vestibular nuc, cuneatus]

stimulation of traumatized cervical muscles can cause nystagmus
It is assumed that you realize that trauma to the head and neck can cause significant neurologic, vascular and soft tissue problems. Further information on this will not be pursued in this course. It is your responsibility to seek out this information.

Vestibular System (see table 22C in class file)
Equilibrium-maintained by three sources: eyes, proprioception and vestibular apparatus in inner ear

-for instance, a person with congenital atresia of the labyrinth system will be able to accommodate due to vision, but in the dark or swimming, the person will be disoriented

-vestibular impulses caused by motion of the head help the eyes fixate on an object

-it is thought that loss of proprioception or vision causes more significant balance and equilibrium problems, if both vestibular systems were congenitally absent or ablated, the patient would have problems in the dark or on a soft surface.

Vestibular System-the righting mechanism, a function of the vestibular division of the VIIIth cranial nerve, the acoustovestibular nerve. The vestibular system is part of the extrapyramidal tract as it does not involve the cerebral motor cortex and it is reflexive.
The vestibular System called the labyrinth is comprised of the three interconnected structures of different function, which can be divided into two Systems.

1. for linear acceleration-the utricle and the saccule [two fluid-filled sacs]

  1. the utricle-position of the head relative to gravity b. the saccule-same-but for high velocities

2. for rotation of the head-the three semicircular canals [fluid-filled and perpendicular to each other]. They have hair cells [receptor cells] that wave in the fluid currents of the endolymph that moves when the head moves.
The semicircular canals begin and end at the utricle. At the origin of each canal is an enlarged area or dilation called the ampulla [containing the end organ of balance, the crista] The receptors, linings and endolymph are the same throughout the system except for their organization, giving them different functions. In the ampulla is the crista, lying Perpendicular to the orientation line of the semicircular canals. On top of the crista, are hair cells with a gelatinous cap that forms a valve-like structure that is sensitive to the smallest motion of the endolymph. They stay behind or lag when movement is initiated by the head; so you get a lag in the sensory input from this system which conflicts with the proprioceptive and visual input you are getting at the same time.
The receptors in the saccule and the utricle respond to the pull of gravity and to the inertial movement caused by linear acceleration and deceleration.
The ampullae receptors in the semicircular ducts respond to the rotation of the head in any plane.
The hair cells in the vestibule contact dendrites of neurons in the vestibular ganglion. Most of the axons of these neurons end in the vestibular nuclei, but a few go directly to the cerebellum.
Neurons in the vestibular nuclei have axons that end in the vestibulocerebellum [fastigial nucleus and flocculonodular lobe], the nuclei of cranial nerves Ill, IV and VI; and the spinal cord. There also is a pathway to the thalamus and cerebral cortex.

Reflex movements of the eyes in response to stimulation of the kinetic labyrinth require the integrity of a reflex arc that includes fibers in the medial longitudinal fasciculus.

You can test the vestibular apparatus with rotation, caloric or galvanic stimulation.
Vestibular nystagmus occurs when the semicircular canal system is overstimulated. It is seen as the slow phase of the nystagmus and the brain causes the fast [snap back] portion of the nystagmus, as seen with rapid spinning.
With caloric testing, warm or cold water is placed in the EAM, the temperature being transmitted through the bone to die semicircular canals. Since the horizontal semicircular canal is closest to the water, it is most affected, therefore, you will see most of the effect in the horizontal plane. The ampulla lies medially and anterior [superior when supine] to the semicircular canal.

Placing the patient supine with 30 degrees of head flexion [bringing the horizontal semicircular canal to a vertical position], the cool water irrigating the EAM will cool the endolymph, especially of the horizontal canal. The endolymph gets denser and its fluid level falls decreasing the stimulation to the crista in the ampulla, causing the eyes to rotate toward the cool water irrigated ear. This is due to the sensation that you have rotated your head in the opposite direction. You will see a slow motion of the eyes toward that ear [vestibular phase] and a fast motion away brain phase]. If the ear is irrigated with warm water, making the endolymph less dense and stimulating the crista in the eyes will move away from that ear, endolymph and an imbalance between the two ears giving a sensation that yon have turned your head in the opposite direction. In short, the eyes move opposite the side of stimulation which is the Opposite of head movement.

COWS - cold opposite, warm toward as the nystagmus is named for the fast phase Neurology of this system - an afferent reflex input to the motor system

Stimulation of the labyrinth [vestibular system] leads to

stimulation of the vestibular ganglion (Scarpi's] in the internal auditory canal
1. going to the vestibular nuclei ~ the medulla and pons
the medial and superior vestibular nuclei project via the ascending medial longitudinal fasciculus to the oculomotor nuclei of the 3, 4, and 6th cranial nerves vestibuloocular reflex
(note the medial vestibular nuclei also sends descending projections via the medial vestibulospinal tracts in the medial longitudinal fasciculus to cervical musculature]
2. some fibers go directly to the cerebellum in the area of the fastigial nuclei flocculonodular lobe, inferior vermis. This area also receives direct fibers of the vestibular nerve. The vestibulocerebellum also has efferent fibers that terminate with the vestibular nuclei.

The role of the cerebellum in maintaining equilibrium is exerted mainly through pathways from the vestibular nuclei to the spinal cord via the vestibulospinal tract. The fibers originate in the lateral vestibular nucleus descend in the medulla into the ventral funiculus of the spinal cord, terminating in the medial part of the ventral horn mostly in the lumbar and cervical regions. Therefore, the vestibulospinal tract is important in the regulation of the tone of muscles in posture for balance. Stimulation of the vestibular nucleus on that side will stimulate the extensors in that limb and inhibit the flexors, causing the foot to press into the ground.

The symptoms of nausea and vomiting are from excessive or prolonged stimulation of the vestibular system with efferent fibers from the vestibular nuclei with collateral branches ending in visceral centers and parasympathetic nuclei in the brain stem.

VERTIGO-the illusion of movement
The cause of vertigo may be peripheral [otological] or central (brainstem]

The peripheral system of the ear receives input from the ear, eye, joint proprioceptors, and cerebellum

Examination :Cranial nerves, otoscopic, tuning fork, ophthalmoscopic, Romberg's Test, gait, vitals
Otoscopic exam may reveal-middle ear disease

Romberg's Test may reveal that the patient sways when the eyes are closed which deprives the patient of this sensory input. This is positive with loss of joint proprioception or peripheral vestibular disturbance. Blood pressure-may reveal postural hypotension

Positional Test-From an erect position on a couch, the patient lies down with the head turned to one side. The onset of vertigo is noted. Have any feeling of vertigo or signs of nystagmus settle prior to having the patient sit up. Have the patient sit up and repeat with the head turned to the opposite side. This test differentiates vertigo of the peripheral apparatus vs. a central cause.

Causes (See table 21B in class file)

  1. Meniere’s Disease – an endolymphatic imbalance that occurs in periodic clusters affects young and middle aged adults, cause unknown, tinnitus with sensorineural hearing loss will begin as fluctuating and become constant and herald the onset of vertigo.

2. Acoustic neuroma-benign expansile tumor of the eighth cranial nerve anywhere from the brainstem to the ear

The tinnitus will begin as faint and get louder.

Vertigo-You may see more Ataxia than vertigo because the slow growing lesion allows the patient to accommodate.
3 proprioceptive vertigo-commonly seen in whiplash injuries, discogenic spondylosis, cervical disc injuries and myofascitis

Proprioceptors orient the head to the body whereas the vestibular apparatus orients the body to space

3a. myofascial proprioceptive vertigo typically the clavicular division of the SCM*

The patient will have the illusion of disagreeable motion that occurs with a sudden turning of the head or other motions.

The patient may fall when bending forward, stooping or be ataxic.

The patient may simply feel like falling backwards when looking up and visa versa.

These attacks can last just a few seconds [or last for hours]

Nausea is common

Other symptoms include: carsickness, frontal headaches, dizziness, turning in bed, holding the phone with the shoulder.

Activated by painting, sleeping on two pillows, sports, scoliosis, emphysema, neckties.

Another myofascial proprioceptive vertigo is EAGLE Syndrome

The styloid process is elongated by calcification of the stylohyoid ligament

There are trigger points in the posterior belly of the digastric and medial pterygoid muscles

Note: There are typically concurrent trigger points in the SCM

S&S: dizziness, visual blurring with decreased vision on the same side.

Pain and dizziness on extreme rotation of the head

This may give suspiciously positive signs like a + George’s Test.

but there is no nystagmus and does give pain.

3b. spondylosis

3c. cervical muscle strain and joint sprain

4. Hypoglycemia-mostly the complaints are of a lightheadedness nature.

The complaints will typically be in the morning or 3A hours post-prandial.

A serum glucose test should be performed while the patient is symptomatic.

If the results are positive, Then, you order a glucose tolerance test.

5. Vestibular neuronitis-A viral infection of the vestibular nerve

There is often a history of an upper respiratory infection 2-3 weeks prior to the onset of symptoms

There is a sudden onset of dizziness and sometimes nausea.

The patient may complain of feeling the earth move.

The episodes may be short and mild or long and severe

The viral infection typically clears in 3 weeks to 3 months.

6. (demyelinating disease- nystagmus, sensorineural hearing loss, dizziness, etc. what you see here is a global pattern that involves several systems.

7. Benign postural hypotension - take the blood pressure sitting, standing and recumbent

8. middle ear disease - unsteadiness on the feet, true vertigo
9. Benign paroxysmal positional vertigo-An episodic vertigo, usually dramatically described as occurring on turning the head, particularly in bed. It can follow an upper respiratory tract infection or head injury, but there may be no preceding illness. The vertigo lasts several seconds and fatigues with repetitive stimulation such as repeated positional testing. These typically resolve spontaneously.
10. aging -loss of balance due to failing eyesight and hearing. Cervical spondylosis and vertebrobasilar ischemia and atherosclerosis or the cerebral arteries. There may also be postural hypotension and cardiac arrhythmias. A medication may also be at fault, ie. antihypertensives.
11. Migraine -only unsteadiness and imbalance, not a true vertigo
12. Transient ischemic attacks- sense of imbalance associated with other neurologic signs that last 24 hours

Vertigo-Testing - Always perform complete HEENT Exam
1. OBSERVATION-while going to room gait-unsteadiness or leaning mood-anxiety, moodiness, confusion


while testing, observe facial movements-could be indicative of acoustic neuroma, stroke checking peripheral vision, vision loss, blurring-tumor, trauma, MVA
3. EAR ­otitis externa, otitis media, cholesteoma

cervical lymph nodes, trigger points


posterior to mastoid if tinnitus timed with pulse~arterivenous aneurysm

cervical vessels-bruit

positional, antihypertensives


DTR [increased with UMNL], Dermatomes [checking for numbness], Myotomes

Nylen-Barany or Barany or Halipike or Dix-Hallpike Test for dx of BPPV

pt. seated then lie the pt. down with head in extension 30-45 degrees and 30-45 degrees rotation
a. BPPV-vertigo and nystagmus appear after 3-4 seconds and will decrease and stop after 10-60 seconds

slow phase of nystagmus goes down toward the downward ear

[R ear down = eyes R]

1. peripheral cause - decrease with repetition

2. central cause-no decrease in vertigo or nausea
b. Have patient stand on one foot with eyes closed, and then other foot-if can do then EN [uemura]

c. Have pt. hop on one foot-difficulty hopping if cerebellar dysfunction on the same side as the foot being hopped on

d. Tandem Romberg-have the patient read a sign over the shoulder while walking the other direction
e. Sharpened Romberg-have the patient stand with arms across chest with eyes closed and head rotated as if reading over the shoulder [Tandem Romberg position]

normal-can maintain position > 30 seconds purpose-vestibular systems screen

f. stepping test-marching in place 50 x at same speed as in walking watch for turning of head, position of arms/body or sway ABN = > 30 body rotation or 1 meter of body movement from starting place. The key here is nystagmus.

Sore throats-patients describe a sore throat ranging from dryness to pain.
Important !!!When do you need to culture a sore throat­

1. if there is a history of exposure to strep

2. if there is a fever over 101 degrees

3. if there is tonsillar or pharyngeal exudate

4. if there is tender, cervical lymphadenopathy

5. if the condition is not resolving

6. if the condition is worsening

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