Maqbool''s Textbook of ENT 9th Edition [Ussama Maqbool]

Textbook of

Ear, Nose and
Throat Diseases



Textbook of

Ear, Nose and
Throat Diseases
Eleventh Edition

Mohammad Maqbool
MBBS DLO MS FICS

Ex-Professor and Head
Department of Otorhinolaryngology
Government Medical College
Srinagar, J & K
Suhail Maqbool
MBBS MS

Assistant Consultant
Department of ORL
King Fahad Medical City
KSA

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Textbook of Ear, Nose and Throat Diseases
© 2007, Mohammad Maqbool, Suhail Maqbool
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form
or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the
editors and the publisher.
This book has been published in good faith that the material provided by contributors is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error(s). In case
of any dispute, all legal matters to be settled under Delhi jurisdiction only.

First Edition : 1982
Fifth Edition : 1991
Ninth Edition : 2000

Second Edition : 1984
Sixth Edition : 1993
Tenth Edition : 2003

Eleventh Edition: 2007
ISBN 81-8448-081-4
Typeset at JPBMP typesetting unit
Printed at Gopsons Paper Ltd, Noida

Third Edition : 1986
Seventh Edition : 1996

Fourth Edition: 1988
Eighth Edition: 1998


This Edition dedicated to
the original Author—
a teacher to many,
a guide to many more and
to me all that and a loving father.



Foreword

Dear Reader,
The eleventh edition of the Textbook of Ear, Nose and Throat Diseases is an
excellent overview for medical students and the general practitioners. It
is a comprehensive review of many of the specific ENT problems which
trouble patients.
ENT problems form a large segment of general practitioner’s patient
evaluation and treatment. These doctors are the primary level of medical
care.
Many physician groups form the secondary level of ENT practice and
they are capable of proper evaluation and general surgical treatment of many disorders.
These secondary level specialists will also sometimes refer to yet more highly trained, tertiary
ENT sub-specialists who have become very skilled in a variety of relatively rare and challenging
issues.
Our hope and belief is that this compact volume, as it has throughout the history of its
publication and evolution, will continue to contribute to the knowledge of the wider medical

community, so that ENT-specific problems can be rapidly and accurately identified and these
patients either treated by their primary care providers, or appropriately referred.

Dr William F House
House Ear Institute
LA California
USA



Preface to the
Eleventh Edition
Through the grace of almighty God and the continuous appreciation of previous editions by
the vast number of medical fraternities from all over the country, the eleventh edition is in
the hands of the readers.
Efforts have been made to make this textbook more informative and update.
A new Chapter on Headache has been added. A few new topics such as Neck masses,
Tumours of Thyroid, Anthrax, etc. have also been incorporated. I am sure that the students
both undergraduate and postgraduate, interns and general practitioners, all will be benefitted.
Any constructive and healthy criticism to make this textbook more informative will be highly
appreciated.
I am highly thankful to my ex-students and colleagues Dr Rafiq Ahmad and Dr Qazi Imtiaz
for their deep interest in the script and additions in the book.
Thanks are due to Shri Jitendar P Vij, Chairman and Managing Director, Mr Tarun Duneja
(General Manager, Publishing) and Mr PS Ghuman (Senior Production Manager) of
M/s Jaypee Brothers Medical Publishers Pvt. Ltd., New Delhi for their kind cooperation.
Thanks are also due to Dr William F House for writing a foreword to this edition.
Mohammad Maqbool
Suhail Maqbool

Preface to the
First Edition
Though there are quite a few books on otorhinolaryngology now available in the country,
omission of some important topics or common conditions is noticed in most of these books. As
such, a student or a clinician feels handicapped and has to waste a lot of time in looking from
book to book for a particular topic or information. A humble effort has been made to prepare
a comprehensive Textbook of Ear, Nose and Throat Diseases which would provide all the necessary
details and conception to the reader. I hope and pray that all the readers of this textbook,
undergraduate and postgraduate students, academicians, and general practitioners will be
benefitted.
I owe personal thanks to my departmental colleagues particularly to Dr Ab. Majid,
Dr Ghulam Jeelani and Dr Rafiq Ahmad for their constant interest and contribution to the text.
I must particularly thank Shri Jitendar P Vij of M/s Jaypee Brothers Medical Publishers
Pvt. Ltd., New Delhi for his help and cooperation. I would feel grateful for any suggestions
and healthy criticism from readers.
Mohammad Maqbool



Contents

SECTION ONE: EAR
1. Development of the Ear

3

2. Anatomy of the Ear

7

3. Physiology of the Ear

23

4. History Taking with Symptomatology of Ear Diseases

29

5. Examination of the Ear

32

6. Congenital Diseases of the External and Middle Ear

48

7. Diseases of the External Ear

51

8. Diseases of the Eustachian Tube

57

9. Acute Suppurative Otitis Media and Acute Mastoiditis

58

10. Chronic Suppurative Otitis Media

64

11. Complications of Chronic Suppurative Otitis Media

71

12. Nonsuppurative Otitis Media and Otitic Barotrauma

77

13. Adhesive Otitis Media

80

14. Mastoid and Middle Ear Surgery

82

15. Otosclerosis

88

16. Tumours of the Ear

94

17. Otological Aspects of Facial Paralysis

101

18. Ménière’s Disease and Other Common Disorders of the Inner Ear

106

19. Ototoxicity

111

20. Tinnitus

113

21. Deafness

115


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Textbook of Ear, Nose and Throat Diseases

22. Hearing Aids and Cochlear Implant

124

23. Principles of Audiometry

132

SECTION TWO: NOSE
24. Development and Anatomy of the Nose and Paranasal Sinuses

147

25. Physiology of the Nose and Paranasal Sinuses

155

26. Common Symptoms of Nasal and Paranasal Sinus Diseases

158

27. Examination of the Nose, Paranasal Sinuses and Nasopharynx

162

28. Congenital Diseases of the Nose

168

29. Diseases of the External Nose

171

30. Bony Injuries of the Face

175

31. Foreign Bodies in the Nose

178

32. Epistaxis

180

33. Diseases of the Nasal Septum

183

34. Acute Rhinitis

190

35. Chronic Rhinitis

192

36. Nasal Allergy, Vasomotor Rhinitis and Nasal Polyposis

201

37. Sinusitis

208

38. Tumours of the Nose and Paranasal Sinuses

226

39. Headache

236

40. Facial Neuralgia (Pain in the Face)

238

SECTION THREE: THROAT
41. Oral Cavity and Pharynx

243

42. Common Symptoms of Oropharyngeal Diseases
and the Method of Examination

249

43. Common Diseases of the Buccal Cavity

252

44. Cysts and Fistulae of the Neck

260

45. Salivary Glands

274

46. Pharyngitis

279

47. Tonsillitis

283

48. Adenoids

291


Contents

xv

49. Pharyngeal Abscess

294

50. Tumours of the Pharynx

296

51. Miscellaneous Conditions of the Throat

303

52. Larynx and Tracheobronchial Tree

307

53. Physiology of the Larynx

314

54. Common Symptoms of Laryngeal Diseases

316

55. Examination of the Larynx

318

56. Stridor

324

57. Acute Laryngitis

330

58. Chronic Laryngitis

332

59. Laryngeal Trauma

337

60. Laryngocele

339

61. Oedema of the Larynx

340

62. Foreign Body in the Larynx and Tracheobronchial Tree

344

63. Laryngeal Paralysis

346

64. Tracheostomy

351

65. Disorders of Voice

356

66. Tumours of the Larynx

358

67. Block Dissection of the Neck

372

68. Thyroid

375

69. Bronchoscopy

380

70. Oesophagus

383

71. Common Oesophageal Diseases in ENT Practice

385

72. Oesophagoscopy

393

73. Laser Surgery in ENT

395

74. Principles of Radiotherapy

397

75. Syndromes in Otorhinolaryngology

401

76. Common ENT Instruments

421

Index

427



Introduction
PRELIMINARY CONSIDERATIONS IN
EXAMINATION
History Taking
Before proceeding to the examination of a
patient, a detailed and proper history taking
is a must. The relevant points to be noted may
vary from one organ to another, hence are
described at the beginning of each section.
The examination room should be reasonably large and noise free.
Most of the ear, nose and throat areas lend
themselves to direct visualisation and palpation but a beam of light is needed for proper
visualisation of the inside of the cavities.

Hands should be free for any manipulation. This is achieved, if a beam of light is
reflected by a head mirror or head light.
Usually the head mirror is used. The head
light serves the same purpose in the operation theatre.
Head Mirror
This consists of a concave mirror on a headband with a double box joint. The head mirror
should be light as it is worn for long periods
of time and may cause headache. The purpose

of the double box joint is to enable the mirror
to be as close to the examiner’s eye as
possible. The centre of the mirror has a hole
about 2 cm in diameter.
The focal length of the head mirror is
generally 8 to 9 inches (25 cm). It is the distance
at which the light reflected by the mirror is
sharply focussed and looks brightest. It is also
the distance where most people can see and
read clearly.
The head mirror is worn in such a way that
the mirror is placed just in front of the right
eye (in right handed persons). The examiner
looks through the hole in the mirror and thus
binocular vision is retained.
Light Source
The light is provided from an ordinary lamp
fixed in a metallic container with a big convex
lens and fitted on a movable arm which
slides on a rod with a firm base (bull’s eye
lamp) or a revolving light source provided

with ENT treatment unit (Fig. I.1). This light
source is kept behind and at the level of the
patient’s left ear. Light from this source is
reflected by the head mirror worn by the
examiner.


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Textbook of Ear, Nose and Throat Diseases

Fig. I.1: ENT treatment unit

Fig. I.2: Mother holding child for examination

Fig. I.3: Position of the patient for ENT examination

Fig. I.4: Common instruments used in
ENT outdoor examination

Position of the Patient
The patient should remain comfortably
seated. Young children usually do not permit
the examination in this position and need
assistance. The assistant sits in front of the
examiner and holds the child in his/her lap
(Fig. I.2). The legs of the child are held inbetween the thighs of the assistant. One hand
of the assistant holds the child’s hands across
his chest while the other hand stabilises the
child’s head.

Position of the Examiner
The examiner sits in front of the patient on a
stool or revolving chair (Fig. I.3). The legs of

the examiner should be on the right side of
the patient’s legs.
Examination Equipment
The following are the instruments routinely
used for ENT examination (Fig. I.4).
1. Tongue depressor
2. Nasal specula
3. Ear specula
4. Holm’s sprayer
5. Laryngeal mirrors
6. Postnasal mirrors
7. Seigle’s speculum
8. Eustachian catheter


Introduction
Contents
9. Ear forceps
10. Nasal forceps
11. Tuning forks
12. Probes
13. Ear syringe
14. Auroscope.
Besides, a sterilizer, Cheatle’s forceps,
spirit lamp and few small labelled bottles
containing the commonly used solutions,

paints and ointments are also needed.

xix

Suction Apparatus
A suction apparatus with suction tubes and
catheters of various sizes is very helpful for
cleaning the discharges to allow proper
examination. It is also used for removing wax
from the ears of the patients who have wax
along with CSOM, where water should not
be syringed in.



 Development of the Ear
 Anatomy of the Ear
 Physiology of the Ear
 History Taking with Symptomatology of Ear Diseases
 Examination of the Ear
 Congenital Diseases of the External and Middle Ear
 Diseases of the External Ear
 Diseases of the Eustachian Tube
 Acute Suppurative Otitis Media and Acute Mastoiditis
 Chronic Suppurative Otitis Media
 Complications of Chronic Suppurative Otitis Media
 Nonsuppurative Otitis Media and Otitic Barotrauma
 Adhesive Otitis Media
 Mastoid and Middle Ear Surgery
 Otosclerosis

 Tumours of the Ear
 Otological Aspects of Facial Paralysis
 Ménière's Disease and Other Common Disorders of the Inner Ear
 Ototoxicity
 Tinnitus
 Deafness
 Hearing Aids and Cochlear Implant
 Principles of Audiometry


1

Development of the Ear

The knowledge of the development of the ear
is important for the diagnosis and therapy of
the various diseases of the ear. It is also necessary to know the various anatomical variations
that the surgeon may encounter on the table.
The two functional parts of the auditory
mechanism have different origins. The sound
conducting mechanism takes its origin from
the branchial apparatus of the embryo, while
the sound perceiving neurosensory apparatus of the inner ear develops from the
ectodermal otocyst.
Development of the External
and Middle Ear
The structures of the outer and middle ear
develop from the branchial apparatus (Figs 1.1
and 1.2). During the sixth week of intrauterine
life, six tubercles appear on the first and

second branchial arches around the first branchial groove. These tubercles fuse together to
form the future pinna.
The first branchial groove deepens to
become the primitive external auditory
meatus, while the corresponding evagination
from the pharynx, the first pharyngeal pouch,
grows outwards. By the end of the second
foetal month, a solid core of epithelial cells

Fig. 1.1: Visceral arches, clefts and
pharyngeal pouches

grows inwards from the primitive funnelshaped meatus towards the epithelium of the
pharyngeal pouch. By the seventh month of
embryonic life, the cells of the solid core of
epithelium split in its deepest portion to form
the outer surface of the tympanic membrane
and then extend outwards to join the lumen
of the primitive meatus. Thus, congenital
atresia of the meatus may occur with a
normally formed tympanic membrane and
ossicles, or with their malformation depending upon the age at which development gets
arrested.
The first pharyngeal pouch becomes the
eustachian tube, middle ear cavity and inner lining
of the tympanic membrane. The cartilages of the


4

Textbook of Ear, Nose and Throat Diseases

Fig. 1.2: Development of the pinna: A. Primordial elevations on the first and second arches. B and C. Progress
of embryonic fusion of the hillocks. D. Fully developed configuration of the auricle

first and second branchial arches proceed to
form the ossicles.
The malleus and incus basically develop
from the Meckel’s cartilage of the first branchial
arch. From the second branchial arch develop
the stapes, lenticular process of the incus and the
handle of malleus.
The foot plate of the stapes is formed by the
fusion of the primitive ring-shaped cartilage
of the stapes with the wall of the cartilaginous
otic capsule. The ossicles are fully formed at
birth.
As the ossicles differentiate and ossify, the
mesenchymal connective tissue becomes
looser and allows the space to form the middle
ear cavity. The air cells of the temporal bone
develop as out-pouchings from the tympanum, antrum and eustachian tube. The extent
and pattern of pneumatisation vary greatly
between individuals. Failure of pneumatisation or its arrest is believed to be the result
of middle ear infection during infancy. The
mastoid process is absent at birth and begins to
develop during the second year of life by the
downward extension of the squamous and
petrous portions of the temporal bone. This is

of importance in infants where the facial nerve
is likely to be injured during mastoidectomy
through the postaural route. In order to avoid
injury to the facial nerve, the usual postaural
incision is made more horizontally.
Points of Clinical Importance
1. Hearing impairment due to congenital
malformation usually affects either only
the sound conducting system or only the
sensorineural apparatus because of their
entirely different embryonic origin, but
occasionally both can be affected.
2. The particular malformation present in
each case depends upon the time in embryonic life, at which the normal development was arrested, as well as upon the
portion of the branchial apparatus affected.
3. Failure of fusion of the auricle tubercles
leads to the development of an epitheliallined pit called preauricular sinus.
4. Failure of canalisation of the solid core of
epithelial cells of the primitive canal leads
to atresia of the meatus.


Development of the Ear
5. At birth, only the cartilaginous part of the
external auditory canal is present and the
bony part starts developing from the
tympanic ring which is incompletely
formed at that time.
The best indication of the degree of middle
ear malformation in cases of congenital atresia

is the condition of the auricle. As the auricle
is well formed by the third month of foetal
life, a microtia indicates arrest of development of the branchial system earlier in
embryonic life with the possibility of absent
tympanic membrane and ossicles.
Development of the Inner Ear
At about the third week of intrauterine life a
plate-like thickening of the ectoderm called
otic placode develops on either side of the head
near the hindbrain. The otic placode invaginates in a few days to form the otic pit. By the
fourth week of embryonic life, the mouth of
the pit gets narrowed and fused to form the
otocyst that differentiates as follows (Fig. 1.3):
i. At four and a half weeks the oval-shaped
otocyst elongates and divides into two
portions—endolymphatic duct and sac
portion, and the utriculosaccular portion.
ii. By the seventh week arch-like outpouchings of the utricle form the semicircular canals. Between the seventh and
eighth weeks, a localised thickening of
the epithelium occurs in the saccule,
utricle and semicircular canals to form
the sensory end organs.
Evagination of the saccule forms the
cochlea, which elongates and begins to coil by
the eleventh week. A constriction between the
utricle and saccule occurs and forms the
utricular and saccular ducts, which join to form

Fig. 1.3: Development of the inner ear

the endolymphatic duct.
The mesenchyme surrounding the otocyst
begins to condense at the sixth week and
becomes the precartilage at the seventh week
of embryonic life. By the eighth week the
precartilage surrounding the otic labyrinth
changes to an outer zone of true cartilage to
form the otic capsule. The inner zone loosens
to form the perilymphatic space.
The perilymphatic space has three prolongations into surrounding osseous otic
capsule, viz. the perilymphatic duct, the fossula
ante fenestram, and the fossula post fenestram.
Development of the Bony Labyrinth
In the otic capsule, the cartilage attains maximum growth and maturity before ossification
begins. The endochondral bone initially
formed from the cartilage is never removed
and is replaced by periosteal haversian system
as occurs in all other bones of the body, but

5