Early sign Epstein Barr virus

Seen early in the course of EBV infections,

transient bilateral upper eyelid edema is rare and is

known as the Hogland sign.

Café au lait macule

Tan to light-brown macules with uniform pigmentation
that present in early childhood. They are benign, vary in size, and
grow in proportion to the growth of the child. Identifying this type of
lesion warrants full-body examination for additional spots. Patients with
six or more may have type 1 neurofibromatosis. Other diseases that have
been associated with cafe au lait macules indude McCune-Albright syndrome,
Fanconi anemia and tuberous sclerosis.

Phonation

Phonation, the production of vocal sounds, is a function of the larynx. Sounds are then modulated as they pass through the nasopharynx and mouth, which act as resonators. Articulation consists of contractions of the pharynx, palate, tongue, and lips, which alter the vocal sounds. Hoarseness and dysphonia  refer to altered phonation, whereas dysarthria consists of defective articulation. Vowels are of laryngeal origin, whereas most consonants  are formed during articulation. The consonants m b, and p are labial, I and t are lingual, and nk and ng are guttural (pharynx and soft palate). Test phrases or rapid repetition of lingual, labial, and guttural consonants can bring out the particular abnormality (eg, Ia-la-la, me-me-me, k-k-k).

Rhinorrhea

 Inflammatory
-Allergic rhinitis will have dear mucoid rhinorrhea, which can be watery
and thin. or also somewhat sticky and tenacious, but always dear. It is
associated with nasal congestion, sneezing, itchy nose and eyes, and
epiphora. Other symptoms of generalized allergy are generalized pruritis,
itchy ears, and dark circles under the eyes. On nasal examination,
typical findings include edematous mucosa throughout the nasal cavities
bilaterally; pale, bluish, hypertrophic turbinates; dear, thin, mu134
Differential Diagnosis in Otolaryngology
coid nasal drainage; and hyperreactive mucosa associated with sneezing
during endoscopy.
 Infectious

- Viral rhinitis and sinusitis usually cause clear, thin, mucoid nasal rhinorrhea.
Bacterial rhinitis and rhinosinusitis usually cause thick, purulent
rhinorrhea
 Autonomic
- Vasomotor rhinitis is associated with clear, mucoid rhinorrhea in the
absence of inhalant allergies. Rhinorrhea can be exacerbated by exercise,
cold temperatures, or eating.

Beta-2 transferrin

Beta-2 transferrin is a protein found in CSF and the aqueous and vitreous
humor of the eye. Nasal fluid is collected and sent for laboratory examination.
Electrophoresis is performed to separate proteins and detect beta-2
transferrin. When present, CSF leak is confirmed; however, a negative
test result does not exclude the diagnosis of CSF leak.

Tips

The mucous blanket
o The nasal cavity produces 1 to 2 L of mucus per day.
o Mucus is highly acidic (pH- 6.0) and contains:
-Water
-1-2%salts
- 2-3% glycoproteins
-Immunoglobulins
o Mter secretion, mucus forms a bilayer consisting of a thicker, more viscous
gel layer on the surface. This overlies the more serous sol layer.
o Mucus is swept from posterior to cmterior by cilia toward the nasal
vestibule.

Nasal Polyps (NP)

Eosinophilic inflammation is an important feature in

the pathogenesis of chronic rhinosinositis (CRS) with
nasal polyps with NP. The eosinophilic accumulation
in the polyp stroma is basically caused by increased
transendothelial migration and increased survival time
in the tissue, where an increased concentration of interleukine
5 (IL-5) plays a major role. The
increased amount of IL-5 is predominantly released
from T-lymphocytes, independently of atopy, and the
highest concentration has been found in polyps from
patients with non-allergic asthma and acetylsalicylic
acid (ASA) intolerance. These are the sub-groups of
patients also known to exhibit the greatest accumulation
of eosinophils.
In the ASA intolerant patients, a lowered prostaglandin
E2 (PGE2) production has been observed. PGE2
has a significant anti-inflammatory
activity, including
inhibition of eosinophils. A possible intrinsic defect in
PGE2 production might, therefore, be responsible for a
further increase
of eosinophilic accumulation in ASA
intolerant patients.

PRESBYCUSIS

Presbycusis is defined as progressive sensorineural hearing
loss associated with aging.

This large cross-sectional study
demonstrates that the majority of sensorineural hearing
loss occurs in the elderly.

Longitudinal studies of hearing
loss accounting for age, sex, and noise exposure history
demonstrate that 97% of subjects experienced a decrease
in hearing over time.

Patients younger than 55 years
lost hearing at an average rate of 3 dB per decade, and
patients 55 years and older lost hearing at a rate of 9 dB
per decade.

By correlating pure tone audiometry and temporal bone
histologic findings in patients with presbycusis, four types
of presbycusis can be defined:

sensory (hair cell loss)

neural (spiral ganglion cell loss)

metabolic or strial (loss of the stria
vascularis)

mechanical (change in the mechanical stiffness
of the cochlear duct with aging).

Noise Trauma

When hair cells die, a permanent hearing loss
results because mammalian cochlear hair cells do not
regenerate.

With extremely loud noise trauma, such as
from a blast injury, there is widespread fracture of the tight
junctions between cells in the organ of Corti, as well as
damage to Reissner’s membrane, the basilar membrane,
and the pillar cells. This can lead to mixing of endolymph
and perilymph, resulting in a severe sensorineural hearing
loss.

TIP – COCHLEAR PHYSIOLOGY

The cochlea acts as both a passive
filter and an active filter. The passive filtering properties create
a tonotopic distribution of the frequency spectrum along
the length of the cochlea, based on the inverse relationship
between the mass and the stiffness of the basilar membrane.
The basilar membrane is narrow and stiff at the base of the
cochlea, which corresponds to high-frequency tuning. At the
apex of the cochlea, the basilar membrane is wider and
less stiff, which corresponds to low-frequency tuning. Thus,
each point along the basilar membrane has a characteristic
frequency to which it is tuned.

When a patient with a suspected cochlear sensorineural
hearing loss is first identified, the work-up should try to
identify the si te of the lesion in the cochlea. The major
sites that can be affected are the stria vascularis, the hair
cells (both inner and outer), the afferent nerve fibers (spiral
ganglion cells), and the otic capsule. The area in the
cochlea most often affected is the outer hair cell because it
is the first cell to be damaged by noise trauma, ototoxic
substances, and the effects of aging.

Noise-induced damage in the inner ear is first identified
in outer hair cells. The attachments of outer hair cell stereocilia
to the tectorial membrane can be broken even by
quite mild noise.