Eagle Syndrome

Eagle syndrome (ES) is a disease characterized by cervicofacial
pain caused by elongation of the styloid process,
which occurs due to extensive ossification of the stylohyoid
ligament . ES is noted to occur in
some patients with a previous history of tonsillectomy.
The disease has an incidence of 4% in the general
population, with a female predominance. The typical ES
patient is female between 30 and 50 years of age with an
elongated styloid process and cervicofacial pain.
ES can be asymptomatic, while some patients present
with cervicofacial pain in the distribution of the
carotid artery, neuralgia of the pharynx, dysphagia, and
alteration in taste. Other patients present with chronic
headaches with pain in the ophthalmic and the occipital
regions when they turn their heads. This pain is classically
seen due to bilateral internal carotid artery
compression.
The key diagnostic presentations of ES according
to otolaryngologists include a patient with throat pain
radiating to the ear post tonsillectomy and a patient
with a throbbing pain through either the external or the
internal carotid artery distribution.
Symptoms are believed to be caused by compression
of the external carotid artery, internal jugular vein,
or cranial nerves  by the deviated, calcifi
ed stylohyoid ligament, or by a fi brous tissue scar
post tonsillectomy.

Epistaxis 2010

Epistaxis
(epí stázo – Hemorragia nasal). [griego, antiguo]

La epistaxis, conocida también como sangrado nasal, es una entidad común que suele presentarse por diversas causas. Estas pueden ser traumáticas, metabólicas, farmacológicas, tumorales, anatómicas, vasculares, hematológicas, por desordenes psiquiátricos.

El primer paso que debe seguirse en estos casos, es el de tener la experiencia necesaria para saber que es lo que se debe realizar cuando un paciente presenta un cuadro de estas características. Solo se consigue con la investigación y el análisis de la información obtenida.
Recuerdo anatómico.

Las fosas nasales son dos cavidades anfractuosas que contienen estructuras irregulares en su interior, estas cumplen diversas funciones, como calentar, humedecer, filtrar, el aire inspirado; además, de la función capital en la olfacción, que en adultos tiene o cumple una función social, sexual y alimentaria.
La irrigación de las fosas nasales tiene como componentes principales a la carótida externa y la interna. Esta es dada mediante las ramas de la facial, coronarias superiores, arteria del subtabique, palatina mayor, esfenopalatina, maxilar interna, para la carotida externa. En la carótida interna, la irrigación se produce a través de las aterías etmoidales anterior y posterior, ramas de la oftálmica, rama única de la carótida interna.

Ambos sistemas confluyen en dos plexos, uno anterior y otro posterior.

El plexo anterior, famoso, conocido como Plexo de Kiesselbach o de Little, es donde confluyen las ramas de las etmoidales anterior y posterior, arteria del subtabique, ramas de la esfenopalatina.

El plexo posterior, menos conocido o Plexo de Woodruff sinónimo de la esfenopalatina, se localiza en el agujero esfenopalatino localizado aproximadamente 1cm por debajo y anterior al borde posterior del cornete inferior; la rica distribución y anastomosis que se presenta en esta zona puede llegar a comprometer la vida, por la dificultad que se presenta para cohibir este tipo de sangrado.
Clasificación:
Las Epistaxis se pueden clasificar en tres tipos, según el área de sangrado:

1. Epistaxis Anterior. (EA) La más frecuente. Corresponde al Plexo anterior o de Kiesselbach, que comprende aproximadamente el 96 a 98% de los casos. El tratamiento generalmente suele ser la cauterización o el taponamiento.
2. Epistaxis Superior: (ES) La segunda en frecuencia e importancia, después de la anterior. Generalmente proviene de las arterias etmoidales anterior o posterior. Menos frecuente, importante por ser difícil de localizar e identificar en el personal inexperto, por la falta de conocimiento de la región anatómica. Puede llegar a comprometer el estado general por la persistencia del sangrado. Este tipo de sangrado, muy poco descrito, suele ser el más frecuente en pacientes con traumatismo nasal y fractura con sangrado secundario masivo.
3. Epistaxis Posterior: (EP) La menos frecuente, cuando se presenta puede llegar a comprometer la vida del paciente, por la magnitud del sangrado, y por la dificultad que representa el acceso a la zona para localizar el vaso sangrante.

Tratamiento:

Epistaxis Anterior: Es la zona más apta para realizar la cauterización, ya sea química o eléctrica. En ancianos suele ser recomendable el taponamiento, dependiendo de la intensidad de la aterosclerosis subyacente, que puede impedir una buena respuesta a los procedimientos hemostáticos.

Epistaxis Superior: En un sangrado masivo, antes de pensar en una epistaxis posterior, siempre debe sospechar una epistaxis superior. Ante la imposibilidad de identificar el vaso sangrante, debe realizarse un taponamiento superior, es decir hacia la zona del cornete superior, o encima del cornete medio, ya que es la zona de emergencia de las arterias etmoidales. En muchas ocasiones se realiza el taponamiento posterior y persiste el sangrado porque no se ha identificado el origen superior de la epistaxis.

Epistaxis Posterior: Solo si se ha descartado el origen superior de la epistaxis, se realiza el taponamiento posterior que deberá estar orientado generalmente hacia el origen de la arteria esfenopalatina y sus ramas, por detrás y debajo de la cola del cornete inferior. Según la técnica, si el taponamiento es con gasa, puede introducirse los dedos índice y medio hacia la coana afectada, presionando hacia el área anatómica descrita, para posteriormente proceder a la fijación. Otros autores recomiendan la insuflación de agua destilada en un balon de sonda Foley, que deberá realizarse pensando siempre la orientación hacia el área anatómica del Plexo de Woodruff.

Mastoid abscess

. A red,
acutely tender swelling filling the
postauricular sulcus (arrow), and pushing
the pinna conspicuously forwards
and outwards, is characteristic of a mastoid
abscess.
In the past, mastoidectomy was
needed for an acute mastoid abscess
complicating acute otitis media. This
was extremely common in the preantibiotic
era, and required exenteration of
the mastoid air cells (cortical mastoidectomy).
The operation is now
rarely performed in countries where
antibiotics are available.

Cholesteatoma

Cholesteatoma. The debris,
when removed, exposes a white mass of
epithelium characteristic of a
cholesteatoma. Cholesteatoma
is not a neoplasm; it is simply squamous
epithelium in the middle ear.
If ignored, it increases in size,
becomes infected, and is associated
with a scanty, fetid otorrhea. It may
erode bone, leading to serious complications.
Extension to involve the dura
with intracranial infection may occur,
and the facial nerve and labyrinth too
may be eroded. The extent of the
cholesteatoma determines the danger:
A small attic pocket of epithelium is relatively
harmless, and can be removed
with suction, but an extensive mass of
epithelium is dangerous and needs
exploration and removal via a mastoidectomy
approach.
A chronic discharging ear is not
painful, and persistent pain and
headache, or severe vertigo, strongly
suggest an intracranial complication or
labyrinth.

Ear Osteomas

Osteomas. White, bony, hard swellings in the deep meatus are a common
finding during routine examination. They usually remain small and symptom
free, and tend to be symmetrical in both ears.
Swimmers are susceptible to these lesions, which are sometimes called “swimmer’s
osteomas.” There is experimental evidence to show that irrigation of the
bony meatus with cold water produces a periostitis that leads to osteoma formation.
Histologically, these bony lesions are hyperostosis, rather than a bony tumor,
so that the term “osteoma,” although established, is not strictly correct.

Bullous otitis externa (bullous myringitis)

Bullous otitis externa (bullous
myringitis). This unusual otitis
externa frequently follows influenza or
an upper respiratory tract infection. A
complaint of earache followed by bleeding,
then followed by relief of pain is
diagnostic of this condition.
Examination shows hemorrhagic
blebs on the drum and meatus, similar
to the vesicular eruption of herpes. If
there is pyrexia with a conductive hearing
loss, the otitis externa is associated
with an otitis media, and systemic
antibiotics are necessary. In the absence
of pyrexia and hearing loss, this condition
settles spontaneously without
treatment.

Malignant otitis externa

“Malignant” otitis externa is
a rare and serious form of otitis externa
to which elderly diabetics are particularly
susceptible. Granulation tissue is
found in the meatus infected with
Pseudomonas and anaerobic organisms.
This granulation tissue tends to erode
deeply, involving the middle and inner
ear, the bone of the skull base with
extension to the brain, and also the
great vessels of the neck. If uncontrolled,
the condition may be fatal.
Intense antibiotic therapy sometimes
associated with surgical drainage
of the affected areas is necessary. It is
not a “malignant” condition in the histological
sense, for the biopsies of granulation
tissue show inflammatory
changes only. “Necrotizing” otitis externa
may be more accurate, but “malignant”
indicates the serious clinical
nature.

Exploding Head Syndrome

“Exploding head” syndrome is a condition that causes
the sufferer to occasionally experience a tremendously
loud noise as if originating from within his or her own
head. The “exploding head” symptoms usually occur
during sleep or drowsiness. Individuals with these
symptoms explain it as explosions in the head. This
syndrome can also cause the sufferer to feel an extreme
rush of adrenaline kick going through his or her head,
sometimes multiple times.
The “exploding head” syndrome and the abnormal
perceptions that some people with tinnitus may experience
is unpleasant and even described as a terrifying
sensation of flashing lights, the sound of an explosion,
gunshot, door slamming, roar, waves crashing against
rocks, loud voices, a ringing noise, or the sound of an
electrical short circuit. In some cases, an instant flash
of what is perceived as video “static” is reported.
The “exploding head” syndrome may have similarities
with audiogenic seizures, which has been studied in
animals where it was found that the inferior colliculus
was involved.
The exploding head phenomenon may be a failure
to prepare the nervous system for sleep. It may be an
exaggeration of the events that normally occur in the
transition between being awake and being at sleep.

Misophonia

The condition misophonia was proposed
in 2003  to convey many of the same sentiments
as phonophobia but removing the phobic
connotation as an automatic accompaniment. This is
potentially useful as in some health economies it is not
lawful to treat a phobic condition unless one is a
licensed psychologist or psychiatrist. In 2004, Jastreboff
and Hazell describe misophonia as “a negative
reaction to sound results from an enhanced limbic and
autonomic response, without abnormal enhancement
of the auditory system.” They suggest that phonophobia
is a subsection of misophonia where fear is the
chief component. The word “misophonia” has yet to
enter widespread usage and is not a recognized term in
many healthcare databases such as Medline.

Phonophobia

Phonophobia, literally meaning fear of sound, is a
widely used term in neurology, particularly in association
with migraine. Woodhouse and Drummond
reported that at least 50% of migraine attacks are
accompanied by increased sensitivity to sound, and
uncomfortable loudness levels are reduced during
attacks. From an audiological point of view, however,
phonophobia implies reaction to certain sounds that
have specific emotional associations for that person.