Tag Archives: E.N.T.



Tinnitus is not a disease rather an annoying symptom of myriad of conditions, caused by minor changes in the sensitive hearing system (Cochlea and auditory nerve).

Tinnitus (means ringing in Latin) is sound sensation in the ear or head, in the absence of any external source of sound.  Commonest types are hissing, roaring, swishing, rustling, buzzing, humming, or chirping.

(Photo by nathaniel)

Tinnitus varies in pitch and loudness and is more annoying in quiet surroundings, particularly at night.  It can be quite disturbing leading to sleep deprivation, depression & decreased work efficiency. Most important aspect of tinnitus is distress, irritation and distraction caused by the noise. Person often feels that such noise is a symptom of brain tumor or stroke. In most cases tinnitus is not harmful.

Patient with tinnitus should undergo thorough ENT and Audiological evaluation and if required neurological examination. ‘Nothing can be done and you have to live with it’ is to be avoided and patient should be investigated properly to find any treatable condition.

Treatment of the cause should take care of tinnitus but tinnitus may persist even after the disease causing tinnitus has been cured, When a lesion or disease process is not identifiable, then tinnitus management is more difficult.

In majority of cases our system adapts to noise over a period of time and is accepted as a part of normal environment. This process can be helped by proper reassurance and counseling. Relaxation, biofeedback and Yoga help to improve coping with the condition.

Hearing aids are helpful for tinnitus with hearing loss and tinnitus maskers are sometimes recommended. These are similar to hearing aids and generate continuous noise. Their use is based on the fact that the patient is more comfortable in a noisy environment than in a quiet surrounding.

Research shows encouraging result on the effectiveness of pharmacological therapy for tinnitus, such as carbamazepine, lidocaine, and intravenous barbiturates, but potentially serious side effects limit their use.

How hearing impairment is diagnosed in infant and young children?

Hearing loss can range from a mild impairment to profound loss. Conductive hearing loss is largely preventable and can be managed by medicine/surgery. Sensor neural hearing loss may need fitting with hearing aids.

Early identification of hearing loss in newborn and young children is of critical as he develops language and speech by hearing to his surroundings.

In general neonates and infants could be tested by BERA, children in the age group of 2 – 3 yrs could be screened using free – field audiometry, children above 4 yrs could be conditioned and then a audiometry can be performed to test hearing impairment.

Babies should be screened for hearing at birth especially high risk ones.

Child with mild hearing loss is generally labeled as inattentive or slow learner. Hearing should be tested as child grows at any time on slightest suspicion of hearing deficit by Parents, care givers, teachers and family doctors.

Screening for hearing has been done for many years but still does not detect hearing impairment as early as desirable. Mother’s instinct for her child is usually correct even at early age and should not be neglected.

The type of tests used to identify hearing loss depend on the age of the child, and include:

* Behavioural observation audiometry (BOA) – for babies less than seven months of age.

It consists of making noises, such as shaking a rattle close to ear, and then observing the baby’s response.

* Distraction method – it is formalized method of behavioral observation audiometry for children 7-19 months.

Infant sits on mother’s lap and one tester standing in front uses toys to raise attention. Other tester behind the child presents signals like shaking a rattle, or drum beat. First tester observes the child’s response. Response may be head turn, eye turn, frowning, sucking etc. After each response the signal intensity used to elicit a response is measured.

* Visual reinforcement orientation (VRA) – useful for children 7-30 months of age. The baby is taught to move their head towards sound by pairing it with an interesting visual stimulus, located in the direction of the speaker.  Their response to different sounds can then be measured. Test is done in sound proof room with speaker and headphone. The ears can be tested individually if the baby tolerates headphones.

* Performance audiometry test – older children are taught to respond to sounds by a performing a simple action or playing a game, such as dropping a marble when they hear the sound.

* Oto-acoustic emission – certain sounds generated by the inner ear can be recorded to check the function of the tiny hair cells in the cochlea.

* Auditory brainstem response testing – to check the electrical activity in the brain in response to a sound. Electrodes are placed on the head to measure the brain waves. It is most popular test for neonatal hearing assessment and for detection of hearing loss.

* Transtympanic Electrocochleography – to check the cochlea for signs of electrical activity in response to sound. It is better indicator of hearing threshold than any other auditory evoked response in children. An electrode is threaded through the eardrum to touch the cochlea and it requires general aneasthesia in children.

* Impedance audiometry or Tympanometry – a probe which snugly fits into the ear and air is pumped into the ear canal. Neonates and young infants may be examined so long as the probe tone is 660 Hz and not 220 Hz. Stapedius reflex are used to assess middle ear disfunction. Impedance audiometry is not an alternative to behavioral audiometry.t

** Hearing test for older children are same as for adult

Risk factors for development of fuid in middle ear

Certain factors predispose a child for development of fluid in the middle ear like:-

  • Allergy
  • Enrolment in day care
  • Exposure to second hand smoke
  • Bottle feeding
  • Use of pacifier
  • Lower socioeconomic group because of overcrowding and poor hygiene
  • Certain syndromes like downs, hunter and hurler’s syndrome, some kids with skull base or nasopharyngeal abnormalities like cleft palate and immunosuppressive disorders, such as HIV are more likely to develop OME.
  • Parents who smoke or pregnant woman who drink alcohol put their babies at risk.

Management of fluid in middle ear or ‘glue ear’

fluid in middle earPopularly known as ‘glue ear’,  Otitis media with Effusion or fluid in the middle ear is the commonest cause of hearing difficulty and most frequent reason for visits to Otorhinolaryngology (ENT) clinic in children. More common during the age when child is developing speech and language skills by hearing to his surroundings,  because it is not painful, it may present as speech and language delay or defects.

Underlying mechanism in collection of fluid in the middle ear may be either Blockage of Eustachian tube or Increased production of mucus in middle ear:

Children have shorter and more horizontal tubes and immune system are not well developed, that is the reason which explains more common ear infection in a child. If Eustachian tube gets blocked because of some reason middle ear air replacement fails and potential vacuum forms, this vacuum draws fluid inside the middle ear.

This could be basis of effusion in Baro-trauma, adenoids, viral infections (as evidenced by association of OME with influenza), second hand smoke, allergy, immunological factors, birth defects(such as cleft palate), cystic fibrosis, or cilia abnormality (as in Kartageners syndrome).

In some cases Eustachian tube is patent; here other factors like increased mucus production in the middle ear as is seen in upper respiratory infection or allergy, may play a role.

Benign and malignant tumor should always be ruled out in adult having otitis media with effusion in one ear.

Treatment: –

Medical treatment:

There is high rate of spontaneous resolution; most episodes are short lived and 75% of cases resolve in 3 months so normally a ‘wait and watch’ policy is advised.

According to ‘American Academy of Otorhinology-Head and Neck Surgery’ (AAO-HNS): –

  • Child is kept under observation with regular follow ups for first three months.
  • If condition lasts longer than 3 months, a hearing test is conducted and child re-evaluated. If hearing is within normal range (below 20 decibels) child is prescribed with antibiotics and kept on periodic check-ups for 4-6 months.

Management is aimed to encourage natural process; useful measures are control of environment factors, management of allergy, nasal decongestant drops, and  Valsalva’s maneuver (Forced expiration with both the mouth and nose closed à Increased air pressure in nasopharynx à opening of the Eustachian tube).

Surgical treatment:

Child is considered for surgical treatment if OME lasts for more than 4-6 months, or there is hearing loss more than 20 decibels or child is at risk of developmental delays because of recurrent problem.

Mainstay of treatment is myringotomy (a small incision is made in ear drum and fluid is suctioned out) and placement of ventilation tubes (Grommets).

Procedure takes less than 30 minutes, ear tube falls out after few months and incision heals spontaneously. Ear tube relieves pain and restores hearing.

There are chances of relapses in 20%-50% children and tube placement may have to be repeated.

Sometimes removal of adenoids is to be done along with tubal placement.

Management of risk factors: –

  • Well balanced healthy diet with fresh fruits and vegetables rich in antioxidants and lacto bacillus.
  • Avoidance of bottle feeding and pacifiers
  • Restricting exposure to day care
  • Wash hands and toys frequently
  • Avoidance of passive smoking
  • Management of associated nasal conditions
  • Avoidance and management of allergy
  • Pneumococcal and flu vaccine

Studies have evaluated that antibiotics and other medicines have short term effect and no long term cure. Putting ventilation tubes is effective but some newer studies have questioned the role in view of spontaneous resolution and frequent need for repeat tubal placement.

Several studies are being conducted but there are still so many unanswered questions and still need for proper research.

entindia by Dr Rajesh Kalra

I am always inspired by Dr Rajesh Kalra’s blog – ‘http://www.entindia.net/‘ , a sincere and nice effort helpful to E.N.T fraternity and to all.

I regularly follow his blog to know recent activity or conference going on in the field of oto-laryngology, in fact I found his blog long back while searching for ‘workshops in Mumbai’.

Anatomy of human ear

Click here to see Anatomy of ear and hearing, animation on medindia.net

Ear is divided into three parts-

  • Outer ear (pinna and external auditory canal)
  • Middle ear (ear drum, ear ossicles)
  • Inner ear (cochlea,semicircular canals and vestibule)

normal ear anatomy

Outer ear protects ear drum and sends sound to the middle ear and protect ear drum. Outer 1/3rd of canal contains ceruminous glands which secret wax .

Middle ear is an air filled cavity separated from external ear by ear drum and connects to nasopharynx by Eustachian tube. Middle ear contain three small movable bones (ossicles) malleus, incus and stapes which converts sound waves into mechanical vibrations.

Inner ear contains cochlea (for hearing ) and semicircular canals & vestibule (for balance ).

Criteria for hearing screening of new born babies

First three years of life are critical for a child to develop speech and language skill. For effective language and communication skill development child need to hear normally. If any hearing impairment is there it should be managed at the earliest.

With modern technologies like Brain-stem evoked response audiometry it is possible to identify hearing-loss within days of birth.

There are certain criteria which needs to pay attention and newborn should be subjected to hearing evaluation:–

1. Parental concern about hearing levels or speech delay in their child

2. Family history of hearing loss

3. History of in-utero (cytomegalovirus, rubella or syphilis) or post natal infections (meningitis)

4. Low birth weight babies

5. Hyper Bilirubinemia

6. Cranio facial deformities or certain syndromes

7. Head injury

8. Recurrent or Persistent otitis media with effusion

9. Exposure to ototoxic drugs

Tests of Hearing

Tests of hearing:-

  • Finger friction test
  • Watch test
  • Speech test; whisper and conversational speech
  • Tuning fork tests
  • Pure-tone audiometry
  • Impedance audiometry / tympanometry
  • Brain-stem evoked response audiometry

Finger friction test, watch test, clinical speech test and tuning fork tests are often used for hearing screening or bed side testing.

Tuning-forks test :

256, 512 and 1024 Hz frequency, vibrating tuning forks are placed in front of ear (to test air conduction), behind the ear and over the forehead (to test bone conduction; here sound is directly transmitted to the cochlea) to get an idea of hearing, and degree & type of hearing impairment if any.

The tuning fork should be struck against elbow or knee, and not against a table or desk to avoid undesirable harmonics.

Result of tuning fork test:

Rinne test described as being positive (normal/conductive deafess) or negative (sensorineural deafness),

Weber test described as being central (normal) or lateralized to one ear (same side conductive loss or other side sensorineural loss; interpreted along with Rinne test)

Schwabach’s test where patients bone conduction is compared with that of examiner’s..

Pure-tone Audiometry:-

Audiometer is an electronic device which produces pure-tones.

Person has to put on headphones and then listen for some different tones from low pitch to high pitch. Person has to push a button or raise hand when he hears each tone.

Hearing is measured at different frequencies from (250 Hz to 8,000 Hz). Results in decibels are charted in the form of graph called audiogram.

This procedure is called Pure-tone Audiometry.

It is a subjective test of hearing and cooperation and understanding of patient is of utmost importance.

Audiometry is required: –

1. To know degree and type of hearing loss.

2. To keep record and for medico-legal purposes.

3. Before prescribing a hearing-aid.

Reading Audiogram:

pure-tone-audiogramFigure 1: An audiogram of an ear with normal hearing

Result interpretation; Reading Audiogram-

Normal hearing: less than 15-25 decibels

Minimal loss: 16 to 25 decibel loss

Mild loss: 26-40 decibel loss

Moderate loss: 41-55 decibel loss

Moderately severe Loss – 56 to 70 decibel loss
Severe loss: 71 to 90 decibel loss
Profound: 91 decibel loss and above
To know the type of hearing loss bone conduction is tested, If hearing is better by bone conduction a conductive loss is present.

Speech audiometry:

Patient’s ability to hear and understand speech is measured.

Certain number of words presented via head phones or free field loud speakers, and person asked to repeat the words.

Speech reception threshold is minimum intensity at which a person is able to repeat at least 50% of words correctly. Here a set of two syllable words with equal stress on each syllable (spondee words) are used.

Speech discrimination score is percentage of words heard correctly when phonetically balanced words at 30 to 40 decibel above the person’s hearing threshold are presented.

A score of 90 – 100% is considered excellent, 80 – 89% is good, 70 – 79% is fair, 60 – 69% is poor, <50% is considered very poor.

Tympanometry or Impedance audiometry –

Objective test of hearing; particularly useful to test hearing in infant and child, to know patency of Eustachian tube, and to know condition of middle ear like presence of fluid or fixation (as in otosclerosis) or dislocation of ossicles.

Ossicles are 3 small bones present in middle ear namely malleus, incus and stapes.

Equipment consists of a probe which snugly fits into external ear canal.

Tymanometry is the dynamic measurement of middle ear pressure through measuring mobility of the tympanic membrane. The resultant changes in air pressure variation are plotted on a graph called tympanogram.

Acoustic reflex testing consists of response contraction of subjecting the ear to a loud sound a rough method of evaluating hearing.

Interpretation of tympanogram:-

types of tympangrams

Fig-2: Different types of tympanograms (pic taken from   http://ivertigo.net/graphics/v14.gif)

The shape of the tympanogram suggests how the eardrum is functioning.

1. Normal eardrum movement is shows a well-formed peak, where height of the peak indicates the amount of eardrum compliance, (type A).

2. A flat line indicates little or no eardrum movement. This type of  tympanogram (type B)is commonly seen when fluid is present behind the eardrum or when there is a hole or perforation in the eardrum .

3. A peak to the left of the normal pressure range (type c) means adequate eardrum movement with negative middle ear pressure, seen in persistent cold or initial phase of fluid accumulation or recovery phase of fluid accumulation.

Reduced mobility with normal middle ear pressure (type As) is seen in otosclerosis.

Normal middle ear pressure with hyper-mobility (type Ad) is seen in disruption of ossicular chain.

Brain stem evoked response audiometry (BERA): –

Auditory brain stem response (ABR) audiometry, Brainstem auditory evoked response audiometry (BAER)

It is a test of neurological activity of auditory nerve and brain stem in response to auditory stimuli.

Electrodes are placed on scalp and ear lobe and patient is asked to relax and remain still .

Clinical uses of BERA

1. It is an effective screening tool for evaluating cases of deafness due to retro cochlear pathology i.e. (Acoustic schwannoma).

2. Used in screening newborns for deafness

3. Used for intra-operative monitoring of central and peripheral nervous system

4. Monitoring patients in intensive care units

5. Diagnosing suspected demyelinated disorders (multiple sclerosis)

E.N.T. clinic set up; Instruments and common terms

E.N.T. Specialist (oto-rhino-laryngologist):-

A doctor who specializes in diagnosing and managing diseases (by medicines or surgery) of Ear-Nose and throat.

Evaluation of the ear, nose and throat requires good source of light. Most important is, no doubt, skilled hands and experienced eyes.

Some instruments and common terms used in E.N.T. practice:

Head-mirror and bulls lamp: –

bulls-lamp Bulls lamp placed above and behind the patient’s shoulder has got a bulb and Plano-convex lens to send focused light to head mirror.

head mirror and ent-specialist1 Head mirror (I like to describe it as “naag-mani”), has special concave lens to reflect light from bull’s lamp. The examiner sees through the hole in the center of the mirror for binocular vision.


Some professionals use Head-light in place of bull’s lamp and head mirror.

Endoscopy unit:

endoscopelight source, camera and nasal endoscope are being used in a modern

ENT set-up for video demonstration of otherwise hidden- from patient’s-cavities.

Tongue depressor: –


To depress tongue and examine oral cavity.

Nasal speculum: –

thudichum nasal_speculumHelp in viewing inside of nose, procedure to inspect nasal cavity is called anterior rhinoscopy.

Laryngeal mirrors: –

il-mirror Used to examine larynx and laryngo-pharynx. Doctor will hold your tongue and will see reflection of larynx in the mirror that is why it is called indirect laryngoscopy.

Video-laryngoscopy is routinely used now a days using telescope.

Postnasal mirror: -used to examine nasopharynx and posterior part of nasal cavity, a procedure called posterior rhinoscopy.

Ear-speculum: –

ear_specula Inserted into ear to see inside of ear canal and ear drum.



It is battery operated device with magnifying glass, gives magnified view of ear drum.

ear-exam1Otoscope is most essential tool in the hands of otolaryngologist; I often use it to inspect ear, nose and throat of infant, child or bed-ridden patients or places (like rural-camps) where an equipped E.N.T. set-up is not present.

Siegel’s speculum: – It helps to test mobility of ear drum, a very essential part of ear examination.

Jobson-Horne’s probe:

jobson-horn-and-probe1 I call it “chhoti jadu ki chhadi” (tiny magic-stick). On the one end of the probe cotton can be applied and used to clean ears of any discharge. Other end has got ring like structure to remove wax, dried secretion and foreign body.


hartmann-forceps161noyes-forceps141 (Tilley’s or Hartman’s) for packing or grasping.

Eustachian catheter: – To see the patency of Eustachian tube.

Suction-apparatus: – To suck out discharge or blood from ear or nose for detailed examination.

Ear microscope (operating microscope): –

ent-microscope To examine the ear drum more precisely under magnification, a procedure called Examination under microscope (EUM).

It gives the doctor the freedom to use suction and other Instruments in the ear.

Microscopy is used to clean discharge, to inspect ear drum, middle ear or any pathology before surgery, and to remove impacted wax or foreign bodies from ear.

Tunning Forks:

tunning-forkTo roughly assess degree and type of hearing impairment.

Pure tone audiometer and impedance meter:-

To test degree and type of hearing-loss.


pure tone audiometer

Pure tone audiometer and Tympanometer