Guide to the ear, nose and throat specialist

It is the discipline of the senses: ear, nose and throat medicine (ENT) deals with all organs and structures of the head and neck, with the exception of the eyes and brain. ENT specialists are experts in the (early) detection, diagnosis, treatment and rehabilitation of diseases, malformations, injuries and functional disorders in these areas. Depending on the diagnosis, ENT specialists work both conservatively and surgically.

Abstract

• Ear, nose and throat medicine (ENT) is also known as otorhinolaryngology (ORL).
• ENT specialists deal with the prevention, (early) detection, diagnosis, treatment and rehabilitation of diseases, injuries, malformations, deformities and tumors of the ears, nose, paranasal sinuses, oral cavity, anterior and lateral skull base, pharynx, larynx and esophagus.
• ENT specialists are also responsible for functional disorders of the sensory organs, i.e. for hearing, smelling, tasting, swallowing, speaking, balance and the voice, including the associated nerves.
• ENT doctors treat illnesses such as colds, asthma or middle ear infections, but also dizziness , tinnitus and hearing loss.
• In addition, the diagnosis and treatment of tumors in the head and neck area is one of the central tasks of the specialty.
• Many ENT specialists have additional qualifications in allergology, sleep and aviation medicine or plastic surgery.
• An ENT specialist is the first port of call for hypersensitivity to sounds of normal volume (hyperacusis) and, of course, for hearing loss (hypacusis). They can identify the causes, carry out a hearing test and, in cooperation with an acoustician, fit hearing aids for adults and children.

Profile Otorhinolaryngology

The upper airways, nose and ears belong together anatomically: Anyone who has had a bad cold knows that a sore throat, runny nose and pressure on the ears often occur together. ENT doctors are specialists for all diseases in these areas.

Ear, nose and throat medicine (ENT) is also known as otorhinolaryngology (ORL). The anatomical structures include

• Pharynx with tonsils, upper esophagus, larynx, trachea
• Oral cavity with oral mucosa, tongue, palatine tonsils, lips, salivary glands, cheeks, tongue, base of tongue, floor of mouth
• Nose with nasal cavities, nasal conchae, nasopharynx, nasolacrimal ducts
• Inner and outer ear with the associated nerves, hearing centers and organ of balance
• Soft tissues of the facial skull and neck

Further training and tasks

After completing their medical studies and five years of further training, ENT doctors work in an advisory and preventative capacity; they diagnose acute and chronic illnesses, as well as malformations and malfunctions in the corresponding organ systems and body regions. In addition to conservative treatments, they also perform surgical procedures.

The diagnosis and treatment, follow-up treatment and rehabilitation of head and neck cancers are also central tasks of the specialty.

In 2020, there were 6,487 ENT doctors in Germany, a good two thirds of whom were in private practice or in a group practice.

Specializations

Like many doctors, an ENT specialist can also acquire additional qualifications. Classical further training courses are in the following areas:

• Allergology: Allergies often restrict the function of the airways.
• Sleep medicine: deals with the causes and diagnosis of sleep disorders and their effects on the body.
• Audiology: This deals with the question of where a problem with processing in the brain is located in the case of hearing loss.
• Plastic surgery: The field of cosmetic surgery with functional and aesthetic aspects is important, for example, when it comes to correcting protruding ears or anatomical malformations of the nose. Surgical procedures for the aftercare and rehabilitation of injuries following accidents also fall into this area.

ENT specialists also work on an interdisciplinary basis: in the case of multidisciplinary diseases, for example, they cooperate with oral and maxillofacial surgeons, neurologists, neurosurgeons, ophthalmologists, cancer specialists (oncologists) and psychosomatic specialists.

Frequent ENT diseases

Throat and laryngitis, inflammation of the tonsils

• Symptoms: Hoarseness, cough, sore throat, difficulty swallowing
• Diagnosis: (Purulent) inflammation of the throat, tonsils and/or larynx
• Causes: Mostly rhinoviruses
• Treatment: Inflammation in the throat and pharynx can almost always be cured with household remedies such as warm drinks (green tea with honey), suitable lozenges and gargling with chamomile infusions. In the case of frequently recurring inflammation of the tonsils, surgical removal may be considered

Inflammation of the paranasal sinuses (sinusitis)

• Symptoms: Inflammation of the mucous membranes in the sinuses. Severe mucus secretion may occur, but not necessarily. Protracted chronic sinusitis manifests itself in excruciating headaches in the nasal cavities and forehead area
• Causes: May be part of an upper respiratory tract disease in the course of which bacteria enter the sinuses
• Diagnosis: examination of the inside of the nose (rhinoscopy) and testing of air permeability
• Treatment: lukewarm salt water rinsing of the nose and sinuses, in severe cases accompanying treatment with antibiotics. In the case of sinusitis caused by allergies, anti-allergic medication and avoidance of allergens can help.

Chronic inflammation of the sinuses can be caused by pathological changes in the shape of the nose. Surgical correction is advisable.

Inflammation of the middle ear (otitis media)

• Symptoms: Infections of the respiratory tract can affect the inner ear. A middle ear infection manifests itself as a stabbing earache and is often accompanied by a fever. As the eustachian tube is shorter in small children, they fall ill much more frequently than adults. Otitis media is not harmless: if it occurs frequently, it can damage hearing
• Causes: Acute otitis media is usually caused by the spread of viral or bacterial pathogens from the oropharynx
• Diagnosis: Examination of the external auditory canal up to the eardrum with a special microscope (otoscopy)
• Treatment: Antipyretic and anti-inflammatory medication and bed rest. Broad-spectrum antibiotics are prescribed for bacterial otitis media during the first six months of life due to the increasing resistance of germs in infants. In older children and adults, antibiotics are only used if healing is delayed or complications occur. In the case of persistent middle ear infection, high fever and impaired ventilation of the inner ear, a small incision in the eardrum can help, which heals without consequences. Many patients find additional heat treatment, e.g. with a red light lamp, beneficial, but it is not generally recommended

Ringing in the ears (tinnitus)

• Symptoms: Whistling, humming, rushing or pulsating sounds, which are perceived subjectively, often occur during the course of a cold. Whistling occurs when the internal ear pressure changes. However, the phenomenon is temporary. The noise causes great distress if it persists
• Causes: Mostly as a result of massive stress or heavy noise exposure, also after a sudden hearing loss. Other causes are also possible, including cardiovascular diseases, accidents, operations or misalignments of the cervical spine
• Diagnosis: The medical history clarifies the causes. Checking the blood flow in the carotid artery and in the ear can help to diagnose vascular tinnitus
• Treatment: The options include psychotherapy and the use of a noise generator (tinnitus masker, noiser). Noise machines muffle the annoying background noise by generating a uniform background noise consisting of tones of different pitches, the intensity of which can be individually adjusted. Noise machines can also be worn by patients with hearing aids. If a malformation or disease of the blood vessels or cervical spine causes “objective tinnitus”, a surgical procedure can correct this.

Balance disorders

• Symptoms: Sudden attacks of severe dizziness, which can also occur at rest and when lying down. Depending on the severity of the balance disorders, this can be associated with an increased risk of falls and accidents
• Causes: Rotational or positional vertigo is mainly caused by viral inflammation of the vestibular nerve (Nervus vestibularis) and the vestibular organ in the inner ear (vestibular apparatus). Above all, a disturbance of lymphatic activity (Menière’s disease) and the displacement of tiny calcite stones (otoliths) trigger vertigo attacks. However, thick plugs of earwax can also be the cause
• Diagnosis: Inspection of the inner ear. Balance tests in which patients perform movements with their eyes closed; also so-called vestibular tests; use of Frenzel glasses, which help to visualize how the pupil shifts when the patient is repositioned
• Treatment: Through physiotherapy and special exercises. So-called liberation maneuvers maneuver otoliths back into place and the dizziness disappears

Snoring and sleep apnea

• Symptoms:Snoring is a breathing disorder that is caused by a relaxation of the muscles of the soft palate in some people. The “flapping” of the soft palate produces the more or less pronounced snoring sound. Snoring is not fundamentally dangerous, but it can put a strain on the relationship. Interrupted breathing (sleep apnoea) causes an insufficient supply of oxygen to the blood and increases the risk of strokes. The resulting constant tiredness during the day increases the risk of accidents, among other things
• Diagnosis: The examination of the nasopharynx provides initial information on possible malformations. Especially if sleep apnea is suspected, a sleep protocol in a sleep laboratory is necessary. Heart rate and blood pressure, brain activity and the oxygen content in the blood are measured
• Treatment: While the removal of nasal polyps or surgical tightening of the soft palate can help with more harmless variants of snoring, apnoea patients require situational therapy. In addition, special ventilators are used to support breathing during sleep.

Diagnostics

Various tests can be used to make an accurate diagnosis. The hearing, balance, sense of smell and sense of taste are tested.

At the beginning of every treatment, the ENT doctor also starts with a detailed patient consultation, the

• Medical history: Provides an overview of the patient’ s state of health and the effects of possible chronic illnesses or long-term medication on the functionality of the throat, nose and ears. Also of interest are previous surgical interventions, particularly in the ENT area. The medical history also includes an “inventory” of the upper airways, nose and ears. The first thing to look at is the throat and pharynx, where inflammation, bleeding or mucus build-up can be detected. The nose and outer ear are also inspected. The lymph nodes in the neck area are checked for abnormalities by palpation of the neck and cheeks.

The following examinations are common in an ENT practice:

• Nasal endoscopy (rhinoscopy): Depending on how detailed the examination is, the ENT specialist first looks into the nasalconcha with a funnel. A headlamp or other light source is used to determine the condition of the nasal mucous membranes. Depending on the area of the nose being examined, a distinction is made between anterior, middle and posterior rhinoscopy. A special nasal endoscope is used for middle rhinoscopy, for example. The flexible cable with an integrated camera provides images of the nasal cavity, the exits of the sinuses and the posterior nasal passages and is used to diagnose polyps, tissue changes and tumors. With a mirror in the throat and pharynx and good illumination, the posterior nasal area can also be examined.
• Nasal function test: clarifies the air patency of the nose and the function of the nasal mucous membranes.
• Ear microscopy: A special microscope allows insights into the external auditory canal up to behind the eardrum. Ear microscopy is not the same as otoscopy (ear examination). Rather, ear microscopy has replaced examination with an otoscope.
• Laryngoscopy (laryngoscopy ): An endoscope equipped with a magnifying glass and a flash of light detects functional disorders of the vocal folds by measuring their vibrations. Stroboscopy can also be used during laryngoscopy to examine the vibration behavior of the two vocal cords in the larynx.

If the examination methods do not provide clear findings, an ultrasound or X-ray examination is usually carried out.

Treatment procedure

Modern treatment methods are common for this specialty, as ENT doctors want to maintain the full ability of all senses to communicate. Various medications are available for diseases, as well as surgical methods such as minimally invasive, i.e. endoscopic surgery, laser surgery, microsurgery and other new technical aids. Examples are

• Operations to improve hearing
• Implants for the reconstruction of a perforated eardrum
• Function-preserving tumor therapies
• Surgery of the paranasal sinuses
• Plastic surgery, for example for accidental injuries to the facial skull, pathological changes to the shape of the nose and ears or cancer of the salivary glands, face and neck

Operations are generally performed on an inpatient basis.

The hearing test

Hearing loss (hypacusis) can have various causes: Noise, age, heredity, illness, earwax, medication, alcohol, smoking, water or blockage due to earwax in the ear. If hearing loss is suspected without a remediable cause due to blockage, the ENT specialist will carry out a hearing test. Sounds at different pitches are played through headphones and the patient confirms that they can hear the sound by pressing a button. The results are recorded in a diagram and may help with programming the chips of hearing aids.

Infants and small children who are not yet able to speak are diagnosed using a tuning fork that is struck and held against the skull bone.

Similar to hearing loss and tinnitus, overstimulation of the auditory system with strong sensitivity to noise (hyperacusis) has various causes. Organically, this mainly includes inner ear hearing loss. On a psychological level, hyperacusis is usually an expression of overload, depression or anxiety disorders.

When and for whom?

Hearing loss or complete deafness are not visible diseases. Accordingly, hearing loss is often only recognized late. As deafness can be congenital, infants and young children are also examined for diseases or malfunctions of the ears during early childhood check-ups.

Later hearing loss can be caused by illness, for example as a result of scarlet fever, or it can develop gradually with age. If conversation, especially in groups, becomes increasingly difficult or children do not start speaking, a hearing test can provide clarity.

A hearing test is also part of the diagnosis for hyperacusis.

Hearing aids – small and almost invisible

Otorhinolaryngology is characterized by particular innovative strength, for example, it was the first medical discipline to replace a sensory organ: the sense of hearing.

But even if there is already a significant hearing loss and conversations in a group, watching TV, going to the movies or a concert are gradually becoming impossible: In high-tech times like these, those affected still shy away from going to the ear, nose and throat specialist. Nowadays, hearing aids are tiny and almost invisible. Modern hearing aids restore almost natural hearing. There are three basic models:

• In the ear: Small hearing aids inserted into the external auditory canal are the classics.
• Behind the ear: The behind-the-ear devices are significantly smaller than years ago and are more comfortable to wear.
• “Open” fitting: Hearing aids behind the ear, from which a thin, almost invisible tube leads into the ear without completely closing the external auditory canal, makes these devices comfortable.

If a hearing aid is to be used as a hearing aid in the event of permanent hearing loss, the ENT doctor works together with an acoustician or pediatric acoustician (for children).

Hearing aids are no longer adjusted by the wearer. The volume control used in the past is no longer necessary, as a chip in the hearing aid is programmed by the acoustician according to the results of the hearing test. This ensures a natural hearing experience from the very first time the hearing aid is worn .

Increasingly intelligent hearing systems adjust to the type of noise source and allow background noise to be filtered or masked out almost naturally.

Cochlear implant (CI)

When hearing aids are of little or no help, cochlear implants (CI) offer new access to the world of hearing – and therefore the chance of a new life. This is because CIs stimulate the auditory nerve directly.

Every CI system consists of two components:

• an outer part consisting of a sound processor with a transmitting coil that is worn behind the ear,
• an inner part, the actual implant, also known as the receiver coil.

The receiver coil is implanted under the skin above the outer ear and anchored in the bone. From there, fine wires run through a small tube into the cochlea, where they can control the placed electrode arrays individually and in a targeted manner. The resulting electrical impulse is transmitted directly to the auditory nerve as an acoustic signal and converted into an electrical signal. The frequency is encoded in this way. The patient perceives the signal as speech, noise or music and can hear.

Such an operation normallytakes between 45 and 60 minutes. If the above conditions are met, it does not necessarily matter how old the patient is.

Questions & Answers

Sources

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