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Diagnostic Audiology and Electrophysiologic Assessment of Hearing

Key Points The assessment and diagnosis of auditory function are integral clinical components of clinical decision making in otology. Diagnosis of hearing loss is often based on a battery of audiologic tests that help define the type and severity of the hearing loss. Acoustic immittance measures serve several purposes, including the identification and classification of peripheral and central auditory disorders; they may also be used as…

Geriatric Otology: Population Health and Clinical Implications

Key Points With an aging population, the number of older Americans is rapidly growing and becoming increasingly diverse. Demographics, such as race/ethnicity and socioeconomic position, and health-related factors have significant influence on the overall health of older adults, and otolaryngologists must consider these effects to provide comprehensive and patient-centered otologic care. Age-related hearing loss is highly prevalent and independently associated with negative outcomes across multiple domains…

Cortical Neuroplasticity in Hearing Loss

Key Points Neuroplastic changes in hearing loss and deafness are evident across the human lifespan. There are brief sensitive periods in early childhood during which the central auditory pathways are maximally plastic. Audiological intervention within these critical windows may allow for optimal development of the central auditory pathways, overcoming many deleterious effects of auditory deprivation. Cross-modal reorganization is a form of compensatory neuroplasticity, which occurs when…

Clinical Evaluation and Management of the Eustachian Tube

Key Points The eustachian tube contains a valve and serves three primary functions: (1) ventilating and equalizing pressure in the middle ear space, (2) draining secretions from the middle ear cavity by mucociliary clearance, and (3) protecting the middle ear from reflux of nasopharyngeal material, pathogens, and sounds. Obstructive eustachian tube dysfunction is caused most commonly by mucosal inflammatory disease from allergy, tobacco smoke exposure, and…

Anatomy and Physiology of the Eustachian Tube

Key Points The eustachian tube is involved in pressure equalization, mucociliary clearance, and middle ear protection. The principal dilator of the eustachian tube is the tensor veli palatini muscle. Anatomic changes in the tube with growth and development include increased length and diameter, increasing tubal angle, change in cellular composition of tubal cartilage, and increased efficiency of tubal opening. Since Eustachius first described the anatomy of…

Anatomy of the Vestibular System

Key Points The labyrinth develops from the otic placode, which invaginates to become the otic pit and then pinches off to form the otic cyst, or otic vesicle. The vertical canals are oriented at 45 degrees with regard to the sagittal plane, and the horizontal canal is tilted upward anteriorly about 30 degrees from the horizontal plane. Scarpa's ganglion has two parts, the superior ganglion and…

Physiology of the Auditory System

Key Points The external ear funnels acoustic signals into the ear and plays an important role in sound localization. The middle ear matches the impedance between the air-filled external environment and the fluid-filled inner ear. The inner ear has two mobile windows, the oval and round windows. A so-called third window associated with an abnormality of the inner ear (e.g., superior canal dehiscence or large vestibular…

Neuroanatomy of the Auditory System

Key Points The neuroanatomy of the central and peripheral auditory systems reflects their function: to extract specific information from the complex waveforms of speech, music, and environmental sounds. The cochlea is organized tonotopically, with low frequencies processed at the apex and high frequencies at the base. The tonotopic organization starting in the cochlea is reiterated throughout the central auditory system. The organ of Corti is the…

Anatomy of the Temporal Bone, External Ear, and Middle Ear

Key Points The temporal bone consists of four embryologically distinct components: these are squamous, mastoid, petrous, and tympanic . The temporal line is located approximately 5 mm inferior to the lowest level of the middle fossa floor. The mastoid antrum is located deep to the depressed cribriform area located posterior to the spine of Henle, known as the MacEwen triangle . The stylomastoid foramen is located at…

Management of Thyroid Eye Disease (Graves Ophthalmopathy)

Key Points Graves disease is an autoimmune disorder associated with hypermetabolism, enlargement of the thyroid gland, and exophthalmos. In Graves ophthalmopathy (GO), retrobulbar fibroblasts secrete glycosaminoglycans, causing engorgement of the extraocular muscles and orbital fat and increasing the volume of the orbital contents. Advanced GO can result in significant proptosis, optic neuropathy, and vision loss. Conservative measures for GO include medical therapy, administration of steroids, and…

Surgical Robotics in Otolaryngology

Key Points Surgical robots have evolved from being rudimentary scope holders to currently sophisticated and precise telerobotic systems, with “wristed” technology and true three-dimensional visualization. Adoption of robotic surgery has gained the most widespread adoption for upper aerodigestive tract early stage benign and malignant tumors and is approved by the Food and Drug Administration for these applications. New robotic systems are currently under development and clinical…

Management of Parathyroid Disorders

Key Points Most patients diagnosed with primary hyperparathyroidism are asymptomatic or are only mildly symptomatic, compared with the classic descriptions of patients with hyperparathyroidism. Calcium levels are regulated by the actions of parathyroid hormone (PTH), vitamin D, and calcitonin on the intestines, bone, and kidneys. Knowledge of parathyroid anatomy and embryology is key in finding diseased parathyroid glands in both their normal and abnormal locations. An…

Management of Thyroid Neoplasms

Key Points The incidence of thyroid cancer is increasing. Although some of this increase may be attributable to improved detection, other factors may also be affecting the biology and incidence of thyroid cancer. Women are three times more likely than men to develop differentiated thyroid cancers. Exposure to ionizing radiation remains the only well-established environmental risk factor for thyroid cancer. The molecular mechanism underlying thyroid carcinoma…

Disorders of the Thyroid Gland

Key Points Thyroxine (T 4 ) and triiodothyronine (T 3 ), produced by the thyroid gland, are iodinated derivatives of tyrosine. Most circulating thyroid hormones are bound to one of several plasma proteins, the most important of which is thyroxine-binding globulin, which accounts for nearly 75% of circulating hormone. Circulating T 3 accounts for most of the physiologic activity of thyroid hormone. The primary internal regulation…

Penetrating and Blunt Trauma to the Neck

Key Points Penetrating neck injury comprises 5% to 10% of all trauma cases. All penetrating neck wounds are potentially dangerous and require emergency treatment. Emergent surgical exploration is necessary for immediate life-threatening signs or symptoms, such as expanding hematoma, hematoma with hemodynamic instability, hemomediastinum, hemothorax, or hypovolemic shock. Classifying the neck zone involvement (zone I, II, or III), mechanism of injury, and velocity of the projectile…

Complications of Neck Surgery

Key Points Complications of neck surgery have evolved over time with the introduction of new procedures and philosophies in the management of patients with head and neck cancer. Neck complications can be categorized into four groups: wound, vascular, nerve, and chyle Knowledge of the pathophysiology of the various complications provides a framework to best avoid their development. Awareness, early recognition, and prompt and effective management of…

Radiation Therapy and Management of the Cervical Lymph Nodes and Malignant Skull Base Tumors

Key Points In the previously untreated neck, lymph node infiltration follows a predictable pattern. Except for nasopharyngeal carcinoma, selective irradiation can be applied for patients with an N0 to N1 neck. Three-dimensional (3D) delineation of the neck levels should be performed on thin-slice contrast-enhanced computed tomography sections following the consensus guidelines. A high (>90%) control rate of the node-negative neck is achieved with a prophylactic (a…

Lymphomas Presenting in the Head and Neck

Key Points Chemotherapy is the mainstay of treatment. Surgery does not play a role in the curative treatment of lymphoma. An adequate biopsy is critical to render an accurate diagnosis and classify lymphoma. An excisional or incisional biopsy is the preferred procedure for confirming a new diagnosis. Along with the patient's clinical history and differential diagnosis, specimens should be submitted to the pathologist in saline for…

Neoplasms of the Neck

Key Points Neck masses represent a diverse group of pathologic processes and require a broad differential diagnosis. Both benign and malignant lesions can present as a mass in the neck, which makes a careful approach to these lesions important. A complete history and physical examination as well as appropriate ancillary studies are important to arrive at the correct diagnosis. Appropriate use of fine-needle aspiration biopsy, immunohistochemistry…