CHAPTER 4

The Ears, Nose and Throat

Inflammation: When a physician looks at the ears, nose, and throat, she or he is often looking for signs of infection and/or inflammation which will help point to the right diagnosis. Inflammation is a complex set of chemical reactions and changes that tissues undergo in response to bacterial invasion or other diseases. Tissues undergo this response to injury as an early attempt to prevent further injury and as a means of beginning the healing process. The chemical reactions which occur act as signals which call different blood cells to the site of an injury. Some cells come to repair the damage while others come to fight the enemy (eg: a bacteria, virus, etc.).

There are many types of injuries which cause tissue inflammation including physical injuries (e.g. bruising and sprains, allergies and infections).

Infections occur when the tissues of the body are invaded by other living organisms which are not supposed to be living in that tissue. There are several types of organisms which can cause infections such as bacteria, viruses, parasites and fungi. When infection occurs in a tissue, there is almost always inflammation which accompanies it.

Doctors use four signs and symptoms to determine if inflammation may be present. The four hallmarks of inflammation are redness, pain, swelling and increased temperature. For example, if you were to fall and sprain your ankle, the body would respond to this injury with inflammation, and your ankle would become swollen, tender, red looking, and it would even feel hot to the touch.

When examining the ears, nose, and throat, it is important to determine if any of these structures are inflamed. If they are, this is usually a sign of infection but may be a sign of allergy or injury.

1. THE EARS:
   Let us review some of the basics of the ear. The ear consists of three parts: the outer ear, the middle ear and the inner ear. [Figure 4A]
   
   The outer ear: Only the outer ear is visible from the outside of the body. The outer ear is comprised of the unusually shaped pieces of cartilage (like soft bone) that appear on each side of the face and includes the tube that leads all the way to the eardrum. The eardrum is a thin membrane that functions much like a sail on a boat. When sound waves (which are much like shifting wind, but on a microscopic scale) enter the ear, they move the eardrum much in the same way that wind moves the sails of a sailboat. This movement is then transferred to bones in the middle ear which in turn move and thus transmit the sound deeper into the ear.
   
   The middle ear: The middle ear is a small, air-filled cavity directly behind the eardrum. At the back of this cavity is an area of spongy bone known as the mastoid. (The mastoid bone is located directly behind the ear, and it's the part of your skull on which the tips of your glasses rest.)
   
   The middle ear contains three small bones which connect the eardrum to the inner ear and transmit the sound from the outer ear through the middle ear and into the inner ear where special nerves are located to decipher sound. The middle ear is connected to the back of the throat by a small collapsible tube, known as the eustachian tube. This tube allows air into the middle ear so that the pressure inside the middle equals that of the atmospheric pressure outside. This tube is especially important when travelling at high altitudes or when diving deep below water. When pressures become unusually low or high, it is important that the middle ear pressure equalize with the outside pressure. Sometimes infection in the nose or throat spreads through this tube into the middle ear causing it to become infected.
   
   The inner ear: The inner ear is the organ of hearing and balance and contains specialized nerve endings which sense sounds and movement, thereby allowing us to hear and to keep our balance. These nerve endings go directly into the brain where the information, when sensed in the inner ear, can be interpreted.
   
   

   

   External examination:
   Careful examination of the outer ear can often alert the doctor to problems. Swollen lumps called lymph nodes (either in front of or behind the ear) are a clue to infection. These lymph nodes are special glands which are designed to accumulate the white blood cells which are fighting infection.
   
   Small bumps can form on the ear or in the canal because of blocked oil glands. These are called sebaceous cysts and are similar to acne. Small bumps are sometimes found which occasionally break open and shed small whitish crystals. These are often found in people with gout.
   
   Examining the ear canal and the eardrum:
   Doctors look into the ears of their patients using an otoscope. An otoscope is a special instrument designed to allow the physician to see the eardrum directly -- that is, if there is no ear wax in the way! The ear canal has special cells which secrete wax, and, as we all know, this wax can sometimes build up. This is usually of no significance unless the buildup is so great as to make hearing difficult or obstruct the doctor's view. In such cases, the wax can be dissolved and washed out.
   
   When the otoscope is correctly positioned in the ear, the doctor can see the translucent eardrum and can also see some of the small bones in the middle ear.
   
   A normal eardrum is almost round, pinkish-gray in color and reflects the light which is coming in from the otoscope. This is called the light reflex. The shape of the eardrum is somewhat like a round tent. This tenting of the eardrum is caused by the malleus (one of the bones of the middle ear) which indents it.
   
   In addition to looking at the ear, the physician can also observe the movement of the eardrum by pumping small amounts of air into the ear canal. Most otoscopes are designed to accept the attachment of a rubber tube with a bulb at the end (this attachment looks somewhat like an antique perfume bottle attachment). With the rubber tube and bulb attached, the physician can place the otoscope in the ear and blow air onto the eardrum. This is called pneumatic otoscopy. The normal ear drum will move in and out as the pressure increases and decreases. This is a sign that the middle ear is filled with air as it should be.
   
   Some diseases diagnosed by examining the ear:
   When the outer ear and ear canal become infected, they exhibit the typical signs and symptoms of inflammation and become red, warm, swollen and tender. This diagnosis can be easily made because it is painful to pull on the cartilage of the outer ear and the ear canal looks red and swollen. Doctors call infection of the outer ear otitis externa. A common example of this would be the infection which people call swimmer's ear.
   
   When the middle ear becomes infected it too becomes inflamed, but since the physician cannot see directly into it (the eardrum obscures this view), other signs and symptoms must be relied upon. In middle ear infection, the eardrum becomes red, and the normal light reflected off the eardrum makes it appear dull and less transparent. Small blood vessels in the eardrum appear which are barely visible. Also, fluid or pus may collect behind the eardrum and this can sometimes be seen with the otoscope. If fluid cannot be seen and the doctor still suspects infection, she or he may choose to do pneumatic otoscopy to see if the eardrum moves freely. Fluid behind the eardrum causes it to move slowly, or not at all. Sometimes fluid or pus will collect under such pressure that it causes the eardrum to burst. The doctor may see pus (yellow colored fluid) in the outer ear canal. When the middle ear is infected, otitis media is diagnosed, and antibiotic therapy is usually required because the infection is often caused by bacteria. The patient may even have an earache and fever which are additional signs of infection.
   
   The mastoid bone and its small air chambers sometimes become infected also, and this is called mastoiditis. Here the bone behind the ear is tender, and there may be redness and swelling.
   
   Occasionally there may be fluid behind the eardrum which is not pus. Such a fluid is called an effusion and can be due to a viral infection or to the trauma caused by changing pressures. Antibiotics are not utilized since viruses do not respond to antibiotic treatment. Fever and pain can always be treated, but the viral infection must be left to run its course.
   
   Rarely, the outer ear can become painful and have blisters in the canal and on the eardrum. This infection is caused by a virus as well. There is frequently an earache associated with this condition and the fluid which drains may even have blood in it.
   
   Tests for hearing:
   The standard physical examination does not usually include tests for hearing since patients often report if there is a hearing problem. Tests of hearing are more important in children who are less able to explain that they are not able to hear well. A child who has had a serious ear infection can have some hearing loss for several months after the infection has ended, and testing is sometimes warranted. Children should have one formal hearing test before entering school, and they should be tested immediately if their speech is delayed. Poor hearing is often a cause of delayed speech development in children.
   
   Two types of hearing loss:
   There are two different types of hearing loss and each has different causes. The first is hearing loss due to problems with conducting sound through the outer and middle ear and into the inner ear where the specialized nerve endings are located. Causes include: wax in the ear, hardening of the bones of the middle ear, fluid in the middle ear, and a hole in the eardrum. This type of hearing loss is called conductive loss and is the most common type in people below the age of 40. The second type of hearing loss occurs when the sensory cells (which are designed to collect the sound) and nerves are not transmitting sound effectively to the brain, or when the brain has difficulty receiving them. Causes include: aging deafness, drug-induced nerve damage to the nerves of hearing, and excessive exposure to loud noise. This type of hearing loss is called sensorineural loss and is most common in adults over the age of 40.
   
   There are two simple tests to help distinguish these two types of hearing loss: Rinne's Test and Weber's Test. Each is conducted with the use of a tuning fork which can be struck, causing it to vibrate at a certain frequency.
   
   Weber Test: The doctor strikes the tuning fork and places the base of it in the middle of the patient's head at the top, asking in which ear the sound is the loudest. Normally, the sound is equal in both ears. If the noise is heard louder in one ear, this is abnormal. If an ear has sensorineural loss, the sound will seem softer in that ear. [Figure 4B]
   
   
   Rinne Test: The doctor strikes the tuning fork and places its base against the mastoid bone of the patient's ear (behind the ear). The patient is told to inform the doctor when sound is no longer heard. This is the time when bone conduction of sound stops. At this point, the doctor moves the vibrating ends of the tuning fork to within 1-2 inches of the patient's ear and asks if the sound can be heard again. The answer should be yes, since air conduction is normally better (louder and longer) than bone conduction. If a patient has conduction hearing loss, the sound will be heard louder and longer while the tuning fork is against the bone than when the sound is only traveling through air. This is a negative Rinne test and it is abnormal. A positive Rinne test (normal) is when the sound is heard longer through the air.
   
   The hearing of babies can be crudely tested by making a sound near the baby's ear (such as snapping the fingers) and seeing if her or his eyes blink. This is called the acoustic blink reflex.
   
   Other tests:
   Audiometry: When hearing loss is strongly suspected or documented by Rinne's and Weber's tests, more sophisticated tests of hearing can be done. Patients can be tested at different frequencies and volumes with audiometric equipment to determine exactly the amount of loss.

2. THE NOSE:
   Upper respiratory infections are among the most common human ailments. They often start in the nose and throat, but frequently affect the ears and lungs. Most upper respiratory infections are caused by viruses, however, some are due to bacteria.
   
   A complete physical examination should include a careful examination of the nose, especially in someone with symptoms of an upper respiratory infection -- such as cough, sore throat, "runny nose", and fever. The physician can look into the nose with a special attachment which fits onto the otoscope and can see the mucous membranes in the nose. The doctor should see a moist, pinkish surface. Sometimes the membrane is more red than normal and has a lot of clear fluid coming out of it. This points to viral infection. Sometimes the membrane is more red than normal and has a lot of yellowish or brownish fluid coming out of it. This points to bacterial infection. The membrane can appear pale or whitish in color and be covered with a clear fluid, and this usually indicates that the symptoms are due to an allergy instead of infection. In addition to color changes, several other observations help to make a diagnosis. Polyps are outgrowths of the membrane which occur often in people with allergies such as "hay fever". Bleeding spots indicate areas which have been inflamed for so long that the irritation has caused a break in the membrane. Examining the nose can help the doctor to see objects that children may have placed in their noses. Areas that are pre-cancerous can often be removed before they become dangerous.

3. SINUSES:
   After examining the nose, the doctor may choose to tap on the head over the sinuses to see if they are infected. Recall that infected tissue is tender. So if one taps over the maxillary sinus (over the cheek bone) or over the frontal sinuses (over the eyebrow), this may cause sharp pain which indicates that the patient may have a sinus infection. The doctor may shine a light into the sinuses through the skin and see if the light passes through. An infected and clogged up sinus will usually not allow light to pass through it. You can try this on your own by getting in a dark room and pressing a small flashlight onto your cheek (just below your eye). You should be able to see the light shining through and glowing inside your mouth!

4. NECK PALPATION:
   A physician may also examine a patient's neck for additional clues to make a diagnosis. Again, this examination usually begins with inspection. An enlarged area of the neck may indicate a thyroid disorder (in which case the mass may be called a goiter). The doctor then begins systematically palpating the neck to identify any abnormalities. Many times lymph nodes will be felt which may indicate infection. Palpable lymph nodes, however, may also be present in healthy individuals.

5. THE MOUTH AND THROAT:
   So why does my doctor say, "open your mouth and say 'Ah'?" This is to get a better look at the back of the throat. When we say "Ah," our tongue is pressed into the bottom of the mouth, and the doctor can see better. If the patient doesn't open wide enough or the tongue is not on the bottom of the mouth, the doctor may place a tongue depressor in the mouth and press the tongue down.
   
   It is important to examine the mouth because abnormalities can be helpful in diagnosing diseases in their early stages. In examining the mouth, the doctor usually looks in with a light and then can feel areas of abnormality with his or her fingers. The tongue, teeth, gums, roof and floor of the mouth should be inspected first, and then later the physician can look at the tonsils and throat. A sore in the mouth could be as simple as a canker sore, but it could also be a cold sore from herpes infection or the chancre sore of early syphilis. Small areas of red or whitish discoloration could point to early cancer, and it is especially important to look for them in patients who use any tobacco products. Sometimes the inside of the mouth can become coated with white spots, and this may indicate infection with a fwlgus called Candida. Most people know this infection as thrush, and it is commonly seen in infants.
   
   The tonsils and throat are usually examined to look for infection. Since the tonsil is just a specialized lymph node, it frequently swells and becomes tender when infection is present. When the tonsils are infected they look like bright red olives, speckled with yellow pus spots. When a doctor sees these, it is likely that one of two infections is present: "strep throat" or mononucleosis. Both of these infections can be serious and need medical treatment.
   
   Finally, the back of the throat is examined. It, too, is a mucous membrane and shows the same signs of infection as other membranes which we have discussed. When inflamed, it becomes tender, red, and swollen. These signs, in combination with fever, usually indicate infection of the throat.
   
   Appearance of the throat in different infections:
   Viral infection -- redness, prominent bumps on the back of the throat which are swelling of lymph tissue.
   
   Mononucleosis (Epstein Bar Virus) -- red dots on the roof of the mouth, enlarged lymph nodes around the ears, and in the neck.
   
   Strep throat -- Swollen tonsils, yellow patches on the tonsils, swollen and tender lymph nodes in the neck.
   
   Diphtheria (now very rare due to immunization) -- dull red color of the throat with a thick gray layer of fluid.
   
   Most infection is caused by viruses, but since those caused by bacteria can be serious if left untreated, most doctors will choose to culture the throat when infection is diagnosed. A culture is made by swabbing the throat with a cotton tip and transferring the bacteria onto a special jelly plate which is put in an incubator and allowed to grow. Laboratory technologists are able to determine exactly which bacteria is causing the infection and let the doctor know which antibiotic will best treat the infection. Throat cultures are expensive and time-consuming, so some doctors choose to do a quick test in the office. This way, immediate treatment can begin without waiting for the bacteria to grow. This quick test involves placing a swab into the back of the throat to obtain some fluid. This fluid is then mixed with chemical reagents. The type of chemical reaction observed indicates the presence of certain kinds of bacteria.

6. OTHER TESTS:
   Patients with complaints such as hoarseness or difficulty swallowing need more extensive evaluations of their mouths and throats, and these cannot be performed with the usual equipment. There are special instruments which enable the doctor to see down into the throat and into the back of the nose, but these are reserved for special cases and are not included in the routine physical examination.

7. THE IMPORTANCE OF TREATING STREP THROAT:
   Each year, many people are treated for strep throat, a fairly common aliment. People with strep throat usually have a sore throat and fever. The usual treatment is 10 days of Penicillin. Most patients don't know why their doctor want them to take medicine for 10 days when they usually feel better after three or four days. The reason has nothing to do with the sore throat or how the patient feels, but relates to the fact that if strep throat is not treated completely, it can lead to rheumatic fever, which can destroy the valves of the heart. The most common reason (worldwide) for trouble with heart valves is rheumatic fever from a sore throat, which was caused by strep, and was not treated with a full 10 days of Penicillin! So if your doctor diagnoses strep throat, be sure to take the full 10 days of treatment, even if your throat feels better long before 10 days.

Chapter 5