thieme: color atlas of ent diagnosis

Thieme-VerlagFrau Kurz

Sommer-DruckFeuchtwangen

Bull:CA of ENT Diagnosis

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56 2 The Ear

from: Bull et al., Color Atlas of ENT Diagnosis (ISBN 9783131293954)© 2010 Thieme Verlag

Fig.2.17 Keloid formation may be unpre-dictable: a normal ear punctum from anearring puncture is adjacent to a large ear-ring keloid.

Fig.2.18 “High” ear piercing shows theunpredictable nature of keloids. (No keloidat lobule earring site.)

Fig.2.19 An infected granuloma at thesite of earring insertion.

Fig.2.20 Nickel sensitivity limits the use ofcertain earrings and has caused eczema onthe lobule (arrow).




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The Pinna 57


a

b

c

Fig.2.22 Trauma. Traumatic “cutting-out”when the earring is pulled by a baby or adultin ill-humor. Infection at the time thesleepers are inserted is another hazard(see Fig.2.19). Surgical repair requires aZ-plasty, for simple excision and suturingmay cause “notching” of the lobule.

◀ Fig.2.21a–c “High” ear piercing (Fig.2.20,arrow) complicated by infection (frequentlypseudomonas) may lead to abscess formula-tion. The puncture with high ear piercing(unlike the lobule) punctures cartilage andmay lead to the additional problem of carti-lage infection—perichondritis. Abscess inci-sion with drainage, splinting, and antibiotictherapy (e.g., ciprofloxacin) is needed. Per-manent deformity of the pinna may result,requiring a difficult plastic surgical repair(a). This involves taking a rib graft and mod-eling this to reconstruct the absent helix,antihelix, and scaphoid fossa of the pinna(b; c, post-op.).




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84 2 The Ear


Fig.2.71 Serious complica-tions may arise from spread ofinfection from chronic suppu-rative otitis media (CSOM)with or without cholestea-toma, but are uncommon.Labyrinthitis, facial nerve dam-age, and intracranial infectionmay all occur. The figureshows posterior fossa brain ab-scesses (lower arrows) (a ven-triculoperitoneal shunt is inplace; upper arrow).

Fig.2.72 Aural granulation. In the sameway that epithelium may migrate througha perforation into the middle ear, mucousmembrane may extrude outwards to themeatus. Middle-ear mucous membrane ex-truding through a perforation (arrow) be-comes infected and presents with a dis-charging ear. An aural granulation is seen inthe deep meatus. Granulation may alsoform on the drum of the margin of the per-foration, and rarely granulation tissue formson an intact drum in otitis externa (granularmyringitis) (see Fig.2.49).




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The Tympanic Membrane and Middle Ear 85


Fig.2.73 Aural polyp. If the growth of gran-ulation tissue is exuberant, a pedunculatedpolyp develops, which may present at theorifice of the meatus (arrow). Granulationsand polyps commonly arise from the tym-panic annulus posteriorly, but the originat-ing site may also be the mucous membraneof the promontory, eustachian tube orifice,and antrum and aditus. Careful and thor-ough removal of polyps and granulation tis-sue to their site of origin is necessary. If thepolyp is associated with cholesteatoma, re-moval by mastoid approach is required.

Fig.2.74 Mastoid abscess. A red, acutelytender swelling filling the postauricular sul-cus (arrow), and pushing the pinna conspic-uously forwards and outwards, is character-istic of a mastoid abscess.

In the past, mastoidectomy was neededfor an acute mastoid abscess complicatingacute otitis media. This was extremely com-mon in the preantibiotic era, and requiredexenteration of the mastoid air cells (corti-cal mastoidectomy). The operation is nowrarely performed in countries where antibi-otics are available.




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110 3 The Nose


Fig.3.9 Nasal papilloma. Benign lesions onthe nose such as a mole or papilloma arecommon. If large, however, the obvious siteon the nose necessitates excision and bi-opsy.

a b

c d

Fig.3.10 Nasal papilloma excision. Excision is not straightforward. An elliptical excisionwith closure will produce an obvious nasal asymmetry, and more elaborate techniques arerequired to ensure a satisfactory result, e.g., an island sliding flap (a–c).




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Cysts 111


a b

Fig.3.11a,b Rhinophyma, in which the skin becomes thickened and vascular, may producegross nasal deformity in which the skin epithelium becomes thickened and vascular. “Shav-ing” of the excess skin (without skin grafting) is the surgical treatment. Irregular areas of epi-thelium (arrow) should be sent for histology since basal or squamous cell carcinoma mayoccur within a rhinophyma.




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138 3 The Nose


a

b c

Fig.3.44a–c External rhinoplasty. A transverse incision across the columella (a, with a“notch” to give a minimally perceptible scar) enables the skin of the nose to be elevatedsuperiorly with exposure of all the underlying structures (b).

This rhinoplasty approach is used for many nasal deformities. It also enables lesions onthe dorsum of the nose to be excised without an obvious overlying scar. The lesion beingremoved here is a nasal sinus (c).

a b

Fig.3.45a, b Mentoplasty. The improvement with rhinoplasty in this case has been accen-tuated by mentoplasty (see Fig.3.46).




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Rhinoplasty 139


Fig.3.46 A silastic implant has beeninserted adjacent to the mandible. A reced-ing chin is not to be overlooked in a patientseeking rhinoplasty, for it accentuates thenasal deformity, and mentoplasty gives asubtle but striking improvement in appear-ance.

This implant may be introduced eitherby an external submental incision or on in-traoral incision via the mucosa of the buccalsulcus.

a b

Fig.3.47a–c Marked mandibular underde-velopment (a) in which a mandibular ad-vancement to restore dental occlusion aswell as the esthetics was combined with arhinoplasty (b). The radiograph (c) showsthe sliding advancement and wiring of themandibular bone.

c




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190 4 The Pharynx and Larynx


Fig.4.10 A large torus palatinus may take on a curious, irregular appearance suspicious ofa carcinoma. Similar bony swellings occur on the lingual surface of the lower alveolus oppo-site the premolars (torus mandibularis).

Fig.4.11 Torus mandibularis. A white bony hard lesion arising from the inner aspect of themandible may present as a swelling in the floor of the mouth (arrow). This is considerablyless common than the torus palatinus.




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The Oropharynx, Mouth, and Lips 191


Fig.4.12 A bilateral torus mandibularis (arrows).

Fig.4.13 Ectopic pleomorphic adenoma. A palatal swelling which is not bony and hardmay be a fissural cyst if mid-line, but if placed to one side (as it is here), it is almost certainlya tumor of one of the minor salivary glands. Biopsy is necessary. It is frequently a pleomor-phic adenoma, but may be an adenoid cystic carcinoma or other malignant salivary tumor.A tumor extension from the maxillary antrum must also be excluded.

thieme: color atlas of ent diagnosis

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