ear nose & throat

Clinical Handbook of Ear, Nose and Throat Disorders (Clinical Handbook Series)

Written primarily for medical students on otolaryngology rotation, and for residents and primary care physicians who are not specialists in this area, The Clinical Handbook of Ear, Nose, and Throat Disorders serves as a ready-reference clinical handbook of current diagnostic and therapeutic management of ear, nose, and throat disorders. The book takes a symptom-oriented approach that provides practical algorithms for diagnosis and management that make it an ideal quick reference. The appendixes

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Clinical Handbook of Ear, Nose and Throat Disorders

Ear, Nose and Throat Book: A Doctor’s Guide to Better Health

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Stuttering of stammering is a disorder of speech in which speech flow is disrupted with involuntary sound prolongation, repetitions of syllables or phrases. There are blocks and silent pauses due to which sounds are not produced. Speech impediments like stuttering cover a spectrum of severity of speech disorders.
The stuttering is not a physical disability but it is more of psychological nature. The stuttering has no effect on intelligence but has a great effect on the personality of the person. The people who have anxiety, stress or low self-esteem and nervousness may show more stuttering although there is no physical bearing of these on stuttering. The stuttering increases when the person is aware of the surrounding and there are many people around him. The stuttering may be more while speaking on telephone.
Characteristics of behavior in stuttering:
There are two types of behavior known as primary behavior and secondary behavior which are seen in the people suffering with stuttering.
· Primary behavior in stuttering displays such behaviors which are overt. The dis-fluency in speech in stuttering is may be profound and prolonged. The repetition, prolongation and blocks are commonly observed in the overt behavior. The person may prolong a word or sound or may repeat some syllable or word. The cessation of sound may also occur and the movement of tongue and lips may freeze.
· Secondary behaviors are the learned and acquired behaviors which include escape behaviors. They may stop eye contact and head jerks etc to hide their speech disorder. Some people mask their disability by using starter sounds like “um”, “ahh” or words like “you know” etc. secondary behavior also use avoidance strategies like avoiding words and situations that cause hesitation or increase the stuttering.
Types of Stuttering:
There are two subtypes of stuttering – developmental and acquired. The developmental stuttering occurs when the child begins to speak. There may be some structural and functional changes in the brain that cause stuttering. Mostly recovery happens and only about 1% childhood stuttering continues till adulthood.
The acquired stuttering may occur due to some neurological cause like head injury, stroke, tumor or drug abuse. Psychogenic stuttering occurs if the person has any traumatic experience like bereavement or breakup.
Treatment of stuttering:
The treatment of stuttering is more of behavior modification than medicines. One is the Fluency Shaping Therapy and the other is Stuttering modification therapy. Fluency shaping therapy encourages the people to speak more and speak fluent. In the second method, stuttering is not eliminated but is controlled. The techniques are used to make stuttering acceptable to the stutterer. Electronic fluency devices are also used but they are not very effective.
The person suffering from stuttering must take it without any anxiety and try to control it as much as possible through behavior modification.

Spasmodic dysphonia is a voice disorder that makes it difficult for the person to communicate with others. The disorder is mainly due to the movement of the larynx muscles. It is involuntary movement that causes spasm and the word may not come out as intended. This disorder is mainly found in the age group of 35-50 and affects women more than men. In this disorder, the voice breaks or has a strained and strangled quality. It seems someone has pressed the throat and therefore the voice is breaking.
Causes of spasmodic dysphonia:
There is no specific cause of spasmodic dysphonia. It was earlier thought as a psychogenic disorder but was later it was confirmed as a neurogenic disorder. The spasmodic dysphonia may occur simultaneously with blespharospasm, tremors etc. the chromosome 9 may be responsible for spasmodic dysphonia   which is inherited or run in the families. In some case physiological injuries can also cause spasmodic dysphonia. Any infection of upper respiratory tract, stress, larynx injury or extensive period of voice use can cause spasmodic dysphonia.
Types of the disorder:
There are mainly three types of spasmodic dysphonia namely, Adductor Spasmodic dysphonia, Abductor Spasmodic dysphonia and mixed dysphonia.
· Adductor spasmodic dysphonia- The involuntary movement of muscles or spasm causes vocal folds to close and stiffen.  Due to the spasms the vocal folds can’t vibrate and thus the voice is not produced. Words are difficult to start or get cut off in between making the speech choppy which sounds like stuttering. But the spasms are not found at the time of whispering, laughing, and speaking at a high pitch. Spasms are more if there is stress.
· Abductor spasmodic dysphonia: When the vocal folds are left open due to sudden spasm of the muscles. Thus the vocal folds can’t vibrate and produce sound. The air passes through the open vocal folds during the speech. The voice sound quiet, weak or whispery. The spasms don’t occur during singing or laughing.
· Mixed spasmodic dysphonia:  This type has both the features of adductor and abductor. The spasms can both open and close the vocal folds and as such the voice may not be produced.

Chemosensory disorders relate to the disorders of smell, taste or odor. These chemosenses are complicated processes which when distorted or damaged can cause different types of problems. There may be complete loss of senses or the senses may get reduced. The complete loss of smell sense is called Anosmia and the reduced sense is known as Hyposmia.  In the same manner, the complete loss of taste is known as Ageusia whereas reduced taste sense is called Hypgeusia.
In some of the chemosensory disorders the person may misread the odor or taste. Something that is pleasant to eat may taste bad or a pleasant smell may be detected as four odors. The smell disorders may turn out to be serious as they are the alert signals for the body for any danger. If a person has smell orders, then he may not be able to detect the foul odor of gas, fire etc and some accident might occur. If the taste buds don’t work properly, then the person may consume some toxic or rotten food and fall sick.
Some medical conditions or disease have been associated with the chemo-sensory disorders. People suffering with conditions like obesity, hypertension, malnutrition, diabetes and Parkinson’s disease have been seen having chemo-sensory disorders.
There are many causes of the taste and smell disorders. For some patients the disorder may be congenital but mostly these are acquired.
· Some illness of the throat or nose.
· If there is any injury to the olfactory nerves, may be due to head injury.
· The dental problems may also lead to different types chemo-sensory disorders.
· Certain medicines and chemicals can also dull the taste and smell senses.
The diagnosis of the chemo-sensory disorders:
There are many ways by which the chemo-sensory disorders can be detected. These may include:
· Complete physical examination and medical history of the person.
· The reorganization capacity of the patient for the lowest concentration of the chemical.
· Specific tests like scratch and sniff diagnostic tests can be used.
Once it is established that the person has some taste and smell disorder then it is necessary to get it properly treated.  The age and extent of the disorder will determine the treatment that is to be administered. The treatment may include:
· Change of the medicines that have contributed to the chemosensory disorder. The ongoing medication may also be stopped to treat the disorder.
· The chemosensory disorder of taste or smell might be due to some underlying medical problems. These problems have to be treated and cured so that the chemo-sensory disorders are treated.
· Sometimes surgery might be required to remove the obstruction that is responsible for causing the disorder.
The chemosensory disorders are not life threatening disorders but they may hamper the normal functioning of life.

Aphasia is a term used for the disorder of language. The most common form of aphasia is dysphasia where the speech is impaired although there is no loss of speech. In some cases, the person suffering from aphasia is able to write but not speak or vice versa.
· In other cases, though unusual, many patients can sing extremely well and clearly but can’t speak.
· Aphasia many a times occur with Dysarthria or Apraxia, which too are speech disorders.
The causes of aphasia:
The aphasia may occur due to lesion in the brain mainly to the areas which are associated with language. One of the common areas for lesion is Broca’s area. The lesions are inevitably found in the left hemisphere of the brain where the language is produced and comprehend.  The causes of aphasia are many and varied but the major causes include brain injury and stroke. Brain tumor, Parkinson’s disease and Alzheimer’s disease are also responsible for causing aphasia. If there is any hemorrhagic cause in the brain, then also aphasia can occur.
The symptoms of aphasia:
The symptoms of aphasia are many. In the patients of this disorder, one or more symptoms may occur. Some of the symptoms are-
· inability to understand and comprehend language, write or read
· not able to pronounce even when there is no weakness or paralysis of the muscles
· speaking spontaneously becomes hard
· can’t form words or name objects
· use and creation of neologisms which are meaningless to others
· Paraphasia, Dysprosody and Agrammatism are common
· Leaves the sentences incomplete

Ageusia is a disorder of the chemosensory organ of taste. In this disorder the patient is not able to get any taste. The tongue loses the function of taste and can’t feel any taste. Most of the people suffering with ageusia may also have loss of smell as taste and smell go hand in hand. The tongue can only feel the texture and therefore the person feels the taste of the flavor only after both sense organs i.e. nose and tongue function properly.
In ageusia, the patient doesn’t feel any taste whether it is sour, sweet, bitter, salty etc.  The ageusia is a very rare condition, the common condition that is seen is the hypogeusia where the patient has a limited loss of tate sense. They can feel the taste but in reduced intensity. The other form is dysgeusia where the distortion of taste takes place. Sometimes, even alteration of taste may occur where the patient may mistake salty taste with sourness as he cannot differentiate among the taste. In the elderly people hypogeusia is common and in many cases the elderly people are not able to feel the bitter taste.
How is ageusia diagonised?
There are many physical examinations that are conducted to find if the patient is suffering with ageusia or not. Even the cause is determined so that proper treatment can be given. There are some specific  tests that are conducted to determine the stage of ageusia. Patients are given concentration of chemicals to compare so that the doctors can understand the level up to which the patient can differentiate.
There are many causes of ageusia but most of the time, the following causes are attributed to the disorder:
· Damage of the nervous system:  If there is any injury or damage to the nerves of the tongue, it can cause ageusia. If the lingual or the glossopharyngeal nerve is damaged then the patient may sufer from this disorder. Some neurological disorders may