develop.
FOREIGN BODIES IN THE ESOPHAGUS
These are usually unintentionally swallowed objects of various types. Children,
usually those younger than 3 years, swallow coins, toys, etc., whereas adults
swallow bones, glass splinters, fish bones, parts of false teeth, nails,
needles, large fruit stones, or even cutlery (e.g., prisoners).
Symptoms. They include considerable dysphagia (difficulty in swallowing),
sialorrhea, odynophagia (pain on swallowing), localized to the neck or
retrosternal area and rarely the epigastrium, and attacks of coughing.
Lifethreatening symptoms include severe pain in the back between the shoulder
blades and behind the sternum and indicate early mediastinitis.
Pathogenesis. Foreign bodies usually stick in the upper sphincter, the
esophageal orifice, and rarely at the second or third sphincters. Retained or
impacted foreign bodies cause necrosis of the esophageal wall leading, depending
on the site, to mediastinitis, pleuritis, or peritonitis with the formation of
paraesophageal abscess and, on occasion, surgical emphysema.
Diagnosis. It is made on the history. Initially, the pain on swallowing is
localized to a certain area and the neck and the cervical spine are held rigid.
There may be swelling of the neck or surgical emphysema, or crepitation on
palpation of the neck and the supraclavicular fossae. Lateral radiographs of the
neck, the thorax, and the chest are taken to determine the position of
radiopaque foreign bodies. Air shadows in the esophagus above a foreign body are
also shown as is mediastinal emphysema in perforation. Contrast radiographs are
used for a radiolucent foreign body. Esophagoscopy is carried out both to
establish the diagnosis and for treatment.
Treatment. Esophagoscopy is done as early as possible with a rigid or flexible
esophagoscope under general endotracheal anesthesia to allow removal of the
foreign body.
Course and complications. There may be no sequelae if the foreign body is
removed rapidly without complications. If it is retained for a long period,
pressure necrosis occurs leading to mediastinitis whose symptoms are rapidly
increasing pain behind the sternum or between the shoulder blades. A lateral
radiograph shows a prevertebral air shadow, and a gastrografin swallow shows the
site of perforation. Many small foreign bodies that impact initially pass on
into the stomach and have a 95% chance of being passed spontaneously. The stool
should be checked for up to 8 days or even longer to ensure that the foreign
body has been passed.
FOREIGN BODIES IN THE LARYNX
Symptoms. The initial symptoms are attacks of coughing, stabbing pains in the
larynx, and dysphagia which occur during eating. Dyspnea may occur especially
because of the tendency of the infant's mucosa to produce edema. Large,
especially vegetable foreign bodies may cause asphyxia due to their swelling
properties.
Pathogenesis. Laryngeal foreign bodies are rarer than tracheal or bronchial
foreign bodies. Sharp-edged, pointed, or large foreign bodies may remain
impacted within the larynx. The danger of foreign body aspiration is
particularly great in sudden fright, laughing, or absence of the sensory
innervation of the larynx.
Diagnosis. It is made by indirect laryngoscopy. Laryngotracheobronchoscopy
should also be carried out in all suspect cases. Edema may overlie an impacted
foreign body. Only radiopaque, especially metallic foreign bodies can be
recognized easily by radiography.
Treatment. The foreign body is removed carefully using the rigid endoscope,
taking care to preserve the mucosa. A tracheotomy may be necessary before the
removal of large impacted foreign bodies in the larynx with associated edema.
A laryngeal foreign body may occasionally be coughed out, but it is more often
aspirated into the tracheobronchial tree.
Course. The mucosa tends to produce reactive edema, particularly in children.
Steroids are then indicated and precautions taken for emergency tracheotomy
should severe dyspnea develop.
FOREIGN BODIES IN THE TRACHEA OR BRONCHI
Foreign bodies in the trachea or bronchi usually occur in children, with about
80% occurring between the 1st and 3rd year of life. Typical foreign bodies
include peanuts, nails, needles, buttons, coins, balls, peas, and bits of
eggshell.
Symptoms. The main symptoms are episodes of coughing, intermittent or continuous
dyspnea, cyanosis, pain, and intermittent hoarseness. Total occlusion of the
airway causes sudden death. There may also be apparently symptomfree intervals
of days to weeks.
Site. It depends on the size and shape of the foreign body. The most common site
is the right main bronchus because of its straighter angle of origin from the
trachea. If the foreign body is retained for a longer period the following occur
depending on the type of foreign body and duration: accumulation of secretions:
tracheitis or bronchitis with edema, swelling, and granulations; bleeding and
bloodstained secretions; inspiratory and expiratory valvular stenoses: partial
obstruction of the lower airway or emphysema; atelectasis or overinflation of
the poststenotic part of the lung.
Pathogenesis. The cause is usually aspiration. Rare causes include broncholiths,
i.e., calcification of retained sputum, rupture of tuberculous lymphadenopathy
into the trachea, and ascarides.
Diagnosis. The history shows that the symptoms are of sudden onset often
coinciding with eating. Percussion shows a dampened or hyperresonant note.
Auscultation reveals a hissing stenotic noise at the level of the foreign body
and rhonchi. If the bronchus is occluded, there is cessation of respiratory
sounds and delayed movement of one half of the thorax on respiration.
Radiography includes chest views, tomograms, and bronchography. Bronchoscopy is
the most important therapeutic procedure.
Differential diagnosis. It includes diphtheria, pseudocroup, laryngeal spasm,
whooping cough, bronchial asthma, intraluminal tumors, pulmonary tuberculosis,
pneumonia and laryngeal stenosis. Marked up and down movements of the larynx are
absent in tracheal stenoses.
Treatment. Endoscopy is performed and the foreign body is extracted.
EPISTAXIS
Epistaxis is common and can occur at any age. It has a maximal incidence in
childhood when respiratory tract infections are commonest. It is unusual between
the ages of 20 and 60, and becomes more common and more serious in the elderly.
Aetiology. The main cause of epistaxis is trauma. This can be major trauma which
causes a fracture of the nasal bones, or minor trauma as in picking the nose, or
micro-trauma due to crusting and local infection within the nose.
Eighty per cent of epistaxis comes from Little's area, which is on the nasal
septum just behind the mucocutaneous junction. As the mucous blanket is wafted
posteriorly by the cilia, this area of the nose is the one most likely to be
left uncovered by mucus, and it is also the area into which cold unhumidified
air impinges on inspiration, causing crusting and irritation of the sensitive
stratified ciliated columnar epithelium.
Epistaxis is common and frequently a minor self-limiting complaint. It can
however be serious and life-threatening in the elderly. It may be the
manifestation of systemic disease such as a blood clotting disorder like
haemophilia, leukaemia, familial telangiectasis or purpura, or of cardiovascular
disease such as hypertension or atherosclerosis, and epistaxis can be difficult
to control in patients on anticoagulant therapy. It may also signify serious
local disease such as tumours of the nose and sinuses, or an angiofibroma of the
nasopharynx.
Diagnosis. When the nose is actively bleeding there is no doubt about the
diagnosis. If no bleeding is present, some cotton wool moistened in 0,1%
adrenaline should be placed in the nose for 10 minutes, in order to shrink the
mucosa and to moisten and remove the crusts, so that inspection becomes easier
and the dilated blood vessels are more obvious.
Treatment. First-aid treatment consists of sitting the patient with his head
forward and mouth open and compressing the ala of the bleeding nostril against
the septum for 5 minutes. This brings direct pressure onto Little’s area, and
allows clotting to occur.
The definitive treatment consists either of cauterizing or of packing the nose.
The nose must first be anaesthetized with 3% dicaine for 10 minutes. Once the
nose has been adequately anaesthetized, the mucosa will have shrunk, and a good
view should be obtained; the nose is less likely to be actively bleeding, and a
search can be made for the dilated vessel causing the epistaxis.
With the exception of young children, the treatment of choice is cautery. The
limitations of cautery are that the source of bleeding must be visible, that it
can be easily reached by the cauterizing agent and that there should be no
active bleeding. A small bead of chromic acid fused to a wool carrier is the
most useful substance for cautery, and excess acid should be carefully removed
thereafter with cotton wool on a probe. Alternative chemicals which can be used
are trichloracetic acid and silver nitrate. While electric cautery is
theoretically safer than chemical cautery, it is more difficult to use.
Packing of the nose should be reserved for patients in whom cautery is
contra-indicated, either due to active bleeding or to inability to see or reach
the bleeding point. The bleeding nostril may be packed, either with a pneumatic
bag or by ribbon gauze which is impregnated with an antiseptic or antibiotic.
The pneumatic bags are unsuitable for use on outpatients, but have the advantage
that, they are less traumatic to insert and remove. When a gauze pack is used,
about 1 metre of 25-mm wide ribbon gauze should be inserted into an adult
nostril. It should be placed in double layers, right to the back of the nose,
and built up from the floor to the roof. The pack should remain in the nose for
48 hours, so that a firm clot will have formed, which will not be broken down by
the fibrinolytic enzymes produced by the normal bacteria of the upper
respiratory tract. On occasion it will be found that an adequate pack cannot be
inserted because of a deviation of the nasal septum, or a large spur on the
floor of the nose, and in this situation a preliminary submucous resection
operation may be required.
It should be possible to control 98% of epistaxis either by cautery or packing.
Failure can be due to two separate problems. The first is that adequate packing
does not control the bleeding, because the responsible vessel is situated too
far posteriorly for adequate pressure to be brought against it, and the second
is that bleeding restarts as soon as the pack is removed. The former is managed
by the insertion of a postnasal pack. This may be made from a rolled gauze swab
inserted into the nasopharynx through the mouth, and kept in place by two tapes,
which are passed through the nostril. It is difficult to insert without a
general anaesthetic and rather uncomfortable when in place. The nostril is then
packed with ribbon gauze as far posteriorly as the balloon of the catheter. As
the postnasal pack lies against the mouth of the Eustachian tube, prophylactic
antibiotics should be used to reduce the chance of development of otitis media.
In the second problem group, those in whom the bleeding restarts when the pack
is removed, one of the feeding blood vessels should be tied, or embolisation. If
the bleeding is coming from the level of the middle turbinate or above, the
anterior ethmoidal artery should be clipped as it exits from the orbit. If the
bleeding is coming from below the level of the middle turbinate, the maxillary
artery and its branches should be clipped within the pterygopalatine fossa.
In addition to stopping the bleeding, the general care of the patient is also
important. Those who have lost a lot of blood will require admission to
hospital, with treatment for shock, and fluid or blood replacement. A search
should also be made for any underlying systemic disease which may also require
treatment.
There are two groups of patients in whom the above general principles of
treatment do not apply. The first is young children, in whom the epistaxis is
often slight, often bilateral and virtually always from Little's area. Cautery
is not recommended in such children, because the resulting crust is
uncomfortable and picked off early, leading to further bleeding. The simple
local application of oil solution of Vit. A for a few weeks to lessen crust
formation is usually sufficient to stop further trouble.
The second group is those with clotting factor deficiencies. These patients
should not have their noses packed, because the dynamic fibrinogenic and
fibrinolytic cycles involved in clotting when a pack is applied can rapidly
exhaust the already small supplies of clotting factor, necessitating replacement
therapy, with its attendant problems. These patients should have the bleeding
point very accurately and carefully cauterized when the resulting eschar seals
the vessel. Packing should therefore be reserved for an acute haemorrhagic
crisis, when multiple vessels are bleeding, and replacement of deficient
clotting factors will be required in any case.
Part 11
NON-SUPPURATIVE DISEASES OF THE EAR
ACUTE CATARRHAL OTITIS MEDIA
This may occur in both adults and children, and it is commonly encountered after
an upper respiratory tract infection, especially of the influenzal type. The
aetiological factor responsible is thought to be Eustachian tube obstruction due
to adenoids which have enlarged with infection, or to simple oedema of the
Eustachian tubal mucosa from the same cause. Clinically it presents with
deafness and “popping” in the affected ear. There is no pain. The nasal and
pharyngeal symptoms are those of an upper respiratory tract infection. In
children there may be no complains because, on the whole, they do not notice a
mild degree of deafness, but the observant mother may discover that the child is
either not hearing what is being said, or is giving incorrect answers to
questions.
On examination there is usually nasal obstruction with a mucopurulent nasal
discharge. The pharynx may or may not be congested. The affected tympanic
membrane is retracted, sometimes acutely, but its colour is normal or slightly
pink with a few dilated surface vessels. There is no pyrexia or malaise. Hearing
tests or audiometry will show the deafness to be conductive in type and
slight-to-moderate severity.
Treatment. It is expectant because the condition normally resolves as the upper
respiratory tract symptoms disappear. Nasal decongestants, combined with an oral
decongestant syrup, may prove most helpful. The Eustachian tube may be inflated
once the acute nasal symptoms have subsided. This may be done by auto-inflation
by Valsalva’s method, Politzerization or Eustachian tubal catheterization, in
that order, until the tube opens and the hearing returns. In Valsalva’s
auto-inflation the nostrils are pinched to close them and the patient is asked
to make a forced expiration with his mouth shut. If this succeeds air enters the
middle-ear cavity with a cracking noise. Politzerization is carried out with a
Politzer bag, about the size of a large orange, connected to an olivary nozzle.
The nozzle is inserted into the nostril of the affected side to close it and the
other side of the nose is pinched shut. The patient is given a sip of water and
is told to swallow it. At the moment at which he does so, just as the larynx is
seen to begin to rise, the Politzer bag is sharply compressed expelling air
through the closed nasal cavity. Once again a successful inflation is
accompanied by a cracking noise. Should both these measures fail a Eustachian
catheter is passed, tip down, along the floor of the nose until it reaches the
posterior nasopharyngeal wall. With the catheter steadied at the anterior naris
the tip is rotated through a right angle medially and the catheter gently
withdrawn until the tip is held up against the posterior end of the nasal
septum. Once again the catheter is steadied and rotated through 180° with the
beak passing downwards and laterally to lie in the nasopharyngeal end of the
Eustachian tube. A Politzer bag is attached and air is blown through the
catheter, while the surgeon listens through an otoscope, the other end of which
is placed in the patient’s external meatus. Air may be heard to bubble or
crackle through the Eustachian tube, or, if it is patent, a blowing sound will
be heard. Decongestive drugs, such as Hydrocortizone, are introduced into
Eustachian tube through the catheter. As a rule, one of these measures will
result in restoration of hearing. If the condition recurs regularly in children
it may be necessary to advise adenoidectomy.
CHRONIC CATARRHAL OTITIS MEDIA
Chronic tubal obstruction has many causes, originating either at the tympanic or
the pharyngeal end of the tube, which produces hyperplastic thickening,
adhesions or strictures, but in a number of cases no abnormality is present in
these areas or it has previously been eliminated. In such cases repeated
infections, often accompanied by otitis media, have caused thickening of the
tubal lining and consequent obstruction. Rarely congenital stenosis or other
anatomical abnormality gives rise to obstruction.
Chronic salpingitis produces conductive deafness described as a blocked or
stuffy feeling in the ear with a variable amount of discomfort. The patient
cannot clear the ear by auto-inflation (Valsava’s manoeuvre) although
catheterization may inflate the ear with improvement in hearing which is not
maintained for more than a few hours.
On examination the characteristic feature is retraction of the drumhead in whole
or in part. Retraction of the membrane tensa is seen when the handle of the
malleus appears shortened and lies in a more horizontal position, the lateral
process of the malleus is prominent and the cone of light is absent. Partial or
localised retraction may involve any segment of the drumhead but often produces
an appearance in which the membrane is draped over the incudostapedial joint or
appears to adhere to and outline the promontory of the middle ear. On
catheterization of the tube the sounds heard on auscultation differ from the
soft blowing murmur heard with a normally patent tube.
Treatment. In the majority of patients treatment of this condition provides only
temporary relief. Periodical catheterization and inflation is usually practised
despite its short-term benefit. At the pharyngeal end of the tube any factors
predisposing to infection should be treated. The insertion of a grommet may
required in cases with recurrent middle-ear exudate, and the prescription of a
hearing aid is necessary in those patients whose deafness persists.
SECRETORY OTITIS MEDIA
This condition is a common one in modern pediatric otological practice and the
interesting point about it is that although it was first described over a
century ago, it is only since about 1940 that it has reached major proportions.
Whether this is because it is recognized more often now and perhaps over-treated
or whether there is in fact a true increase it is difficult to say.
Being a common condition it has many pseudonyms and these include
non-suppurative otitis media, seromucinous otitis media, exudative otitis media
or often simply “glue ear”.
When biopsies are taken of the middle-ear mucosa in children with this disease,
the predominant finding is that of hyperplasia of the mucus-secreting cells of
the ciliated cuboidal epithelium and cytologically the fluid contains
polymorphonuclear leucocytes, macrophages and cell debris. The fluid is always
sterile on culture and biochemically the major constituents are glycoproteins
and nucleoproteins with the glycoproteins predominating in the more viscous
secretions. immunoglobulin-producing plasma cells have also been identified in
the middle ear but the significance of these is uncertain.
Aetiology. When the cause of a condition is unknown there are always a variety
of theories put forward by those with special interests in medicine, and
secretory otitis media is no exception. Allergy, virus infections, Eustachian
tube malfunction, Eustachian tube obstruction (adenoids) have all been suggested
by various authorities, and in most of these there is evidence to show that they
do not give the whole answer. Many viral studies have been carried out and there
is almost no evidence to support this theory. Allergy has been blamed,
particularly in North America, but in the absence of a significantly raised
eosinophil count in the secretions this seems unlikely. Perhaps nasal allergy
with resultant Eustachian tube malfunction is a possibility, and certainly in
cleft palate children with deficient tensor and levator palati muscle action the
condition is more commonly seen. The problem of differentiating between
Eustachian tube malfunction and Eustachian tube obstruction due to enlarged
adenoids is one that remains difficult to investigate scientifically.
Tympanometry usually demonstrates increased middle-ear negative pressures in
children with secretory otitis media, but equally one can have high middle-ear
negative pressures without the accumulation of secretions and secretory otitis
media without negative middle-ear pressures. The significance of the adenoids
and, in particular, the aggregation of lymphoid tissue around the orifices of
the Eustachian tubes is still to be finally established, and more work in this
difficult field is going on.
In summary, therefore, the aetiology of secretory otitis media remains
ill-defined and perhaps when it is known prevention will become standard
practice.
Symptoms. The condition can occur at any age from infancy to adulthood but the
peak ages of occurrence are between 4 and 7 years. It is because this coincides
almost exactly with the age of maximum adenoid size that the adenoids have so
often been incriminated as aetiological factors. Secretory otitis media usually
presents as an insidious painless deafness, sometimes in association with a
coryzal infection or an acute otitis media, but more frequently it is not
associated with any obvious precipitating cause. It may be unilateral but is
more commonly bilateral. Some children with the problem seem to be prone to
recurrent short-lived attacks of acute otitis media which settle with
antibiotics, although the secretions never quite disappear from the middle ear.
The conductive deafness of about 30-40 dB is often noticed by observant parents,
doctors or school teachers, but in large families or big school classes it can
often go unrecognized and hence the child’s education may suffer. Children will
rarely complain of deafness of this degree and, as otalgia is not a common
complaint in children with secretory otitis media, the diagnosis may easily be
missed. The parent or teacher often finds difficulty in distinguishing between
deafness and inattention, and unless treatment is instigated the condition will
persist.
There is also a define group of children who have fluctuating hearing problems
and in these there is often a sump of middle-ear secretions which remain between
attacks but which increase intermittently in association with coryzal
infections.
All children on entering school ideally have a sweep pure-tone audiogram carried
out or they should be screened by tympanometry. The recognition of secretory
otitis media may often not be achieved until this is done.
Diagnosis. The child will rarely complain of deafness or of feeling unwell. If
the condition is suspected then the diagnosis can only be confirmed by a full
ear, nose and throat examination including otoscopy and tuning-fork tests.
Pure-tone audiometry, including bone-conduction levels and also impedance
audiometric assessment, should be carried out if the facilities are available.
The appearance of the eardrum itself may be of great help, but even in
experienced hands it may be difficult to be certain of the diagnosis on
otoscopic grounds alone. A diagnostic fluid level in the middle ear is rarely
seen in children, and the most common clinical sign is a change in the lucency
of the tympanic membrane with dilated blood vessels parallel to or radiating
from the handle of the malleus. The colour of the membrane varies from yellow to
red, while a blue tinge denotes the presence of blood in the middle-ear
secretion. The membrane itself is often retracted, but may bulge, either
generally or inferiorly. The fact that as many as thirteen “classical”
appearances of the tympanic membrane have been described in secretory otitis
media gives some indication of the difficulty of otoscopic diagnosis.
Tuning-fork tests children over 4 years of age are usually fairly reliable, and
one can generally tell by the expression on the child’s face, or the loudness of
his reply, if bone conduction is better heard than air conduction. Pure-tone
audiometry commonly shows a fairly flat 30-40 dB conductive loss, and
tympanometry will give an almost completely flat response with reduced
compliance and often negative middle-ear pressure changes.
Treatment. It is difficult to be dogmatic about treatment in this condition
because the aetiology is obscure and because in some children the condition
undoubtedly exhibits periods of exacerbation and spontaneous remission.
Medical treatment is to be considered along two separate lines. One theory is to
decongest the Eustachian tube and so allow spontaneous drainage of the
secretions. This may be accomplished by the use of local nasal decongestant
drops in conjunction with an oral decongestant syrup. Alternatively mucolytic
agents to prevent the secretions from becoming too viscid are supported by some
physicians. Evidence in flavour of these lines of treatment is difficult to
assess.
Surgical treatment is by myringotomy with or without adenoidectomy and with or
without the insertion of a grommet tube to give longer aeration of the middle
ear.
OTOSCLEROSIS
In normal conditions the membranous labyrinth is surrounded by two distinct
layers of bone. The inner of these two, the labyrinth capsule proper, is
composed of dense bone directly derived from the cartilaginous capsule of the
otic vesicle in the embryo. For good hearing it is necessary that the nerve
structures of the inner ear should be immediately surrounded by this layer of
dense non-vascular bone. Enclosing this cartilaginous bone, but distinct from
it, there is the ordinary lamellar bone derived from the mucoperiosteum of the
middle ear and from the osteogenic layer of the dura mater. These two layers are
partially separated from one another in the embryo, and also in infants, by a
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