What is otorhinolaryngology?

Science and Profession

Otorhinolaryngology—whose practitioners are often referred to simply as otolaryngologists or ear, nose, and throat (ENT) doctors—is a medical specialty that requires a doctor of medicine degree followed by a hospital or medical center residency ranging from four to five years, depending on the institution in which it is served. Many physicians in this field develop subspecialties, for which additional training is required. Among the most common subspecialties are oncology of the head and neck, ear surgery, pediatric otolaryngology, and maxillofacial surgery.

The scope of the otorhinolaryngologist’s job is broad and overlaps several other medical specialties, notably general surgery, neurosurgery, plastic surgery, pediatrics, ophthalmology, and oncology. The otorhinolaryngologist treats all diseases and lesions that occur above the clavicle or collarbone except for those belonging to two categories: diseases and disorders of the eyes, which fall into the province of ophthalmology, and brain lesions, which are usually treated by neurosurgeons.

Otorhinolaryngology has existed as a specialty since the late nineteenth century. The need for it was great because ear, nose, and throat problems had, through the centuries, been among the most persistent killers of human beings. The areas affected have much to do with the ability to take in food and air. They also are directly connected with speech, smell, taste, hearing, and balance. Dysfunction of the ears, nose, or throat can profoundly affect a person’s well-being physically, emotionally, and socially.

Among the medical conditions and diseases that most frequently come under the purview of otorhinolaryngology are the following: cleft lip and palate deformities (which are often treated as well by plastic surgeons); thyroid tumors (which are also treated by oncological surgeons); skin cancers (which also fall within the practices of plastic surgeons and oncological surgeons); face lifts, the treatment of facial lacerations, and other reconstructive surgery (which plastic surgeons also handle); lumps on the salivary glands (which are sometimes treated by oncological surgeons); and jaw injuries, including fractures (which are treated by maxillofacial surgeons, many of them board-certified in otorhinolaryngology).

Some of the surgery once done by otorhinolaryngologists is now virtually unnecessary because of the development of antibiotics. For example, drugs can effectively combat the kinds of infections that used to result in mastoiditis (inflammation of the mastoid bone), which frequently required a mastoidectomy. The flexible fiber-optic endoscope permits doctors to look into areas that previously could be exposed only through surgery. Advances in research have revealed that nasal polyps, which had a high rate of recurrence and were removed on a continuous basis, can usually be treated effectively with antibiotics, making nasal polyp surgery unnecessary.

Until the mid-twentieth century, the most serious operation performed by otorhinolaryngologists was the laryngectomy (removal of the larynx, or voice box). By the end of the century, however, many practitioners in this specialty were routinely performing surgeries on tongue cancers and thyroid tumors because otorhinolaryngologists are often the ones who initially discover these conditions during head and neck examinations.

Because otorhinolaryngologists have long dealt with the grafting of bone and skin and the surgical management of skin flaps, much reconstructive and cosmetic surgery now falls into their specialty. Removal of tumors from the base of the skull, the interior ear canal, or the posterior cranial depression by means of modified craniotomies can be done by otorhinolaryngologists, who sometimes work in tandem with neurosurgeons in such cases.

Diagnostic and Treatment Techniques

The illnesses treated by otorhinolaryngologists have plagued the human race throughout history but could not be treated effectively until technology was developed that enabled physicians to look into the crowded crevices deep inside the body that were the source of many illnesses. In 1854, Manuel Garcia invented a concave mirror with a hole in its center through which doctors, attaching the implement to their heads, could peer as light from the mirror illuminated a patient’s ears, nose, and throat. Doctors discovered that, using the reflecting head mirror in combination with an angled mirror held as far back as possible in the throat, they could illuminate the laryngeal area and the pharynx as well as the area behind the nose, all previously unavailable for visual inspection. Eventually, rather than examining affected areas with the bare eye, physicians had available to them, imbedded in the eyepiece of a hollow instrument with a light at the end, a magnifying telescope through which they could examine remote cavities with considerable ease and in great detail.

Modern otorhinolaryngologists can also examine patients under mild local anesthetic with sophisticated endoscopes, flexible devices that can easily be inserted into the nose, mouth, or ear of the patient. Such procedures are usually carried out in the doctor’s office or in a hospital on an outpatient basis. These endoscopes, originally lighted with bulbs that heated up and burned out quickly, now carry light through light-bearing fiber-optic strands. In combination with small magnifying devices and cameras designed for this purpose, physicians can examine almost any area of the ears, nose, and throat and create color images, which can be invaluable in determining the presence of disease and in making an accurate diagnosis.

Modern technology has also made available to otorhinolaryngologists laser scalpels that permit extremely intricate surgery and accurate electronic audiometers. Audiometers eliminate the subjectivity of past tests of hearing acuity: In the nineteenth century, doctors either whispered into patients’ ears, increasing the volume until their whispers could be heard, or used tuning forks to determine how much their patients could hear.

Treatment of disorders and diseases of the ear, nose, and throat have changed rapidly with the introduction of increasingly sophisticated surgical equipment and with the development of new drugs to control many conditions that once could be managed only by surgery. Computers have also been a valuable tool in diagnosing many of the problems that fall within this specialty.

All the anatomical areas with which otorhinolaryngologists must deal are interconnected; therefore a disease that begins in the ears can affect the nose and the throat, and vice versa. The most common diseases of the ears include deafness and Ménière’s disease, an illness caused by an accumulation of fluid in the ear’s labyrinth that results in loss of balance. Both of these disorders are most common among people over fifty, although they can afflict people at any age. One out of every ten thousand babies born in the United States has some hearing deficit, and many—particularly those whose mothers contracted rubella (German measles) during pregnancy—are almost totally deaf.

Otologists (physicians who treat diseases and disorders of the ear) have made considerable headway in treating some forms of deafness, particularly conductive deafness, which results from a narrowing of the ear canal to the point of closure. Shortly before 1920, it was discovered that considerable hearing can be restored through fenestration—that is, through making a small surgical opening in the eardrum through which sound can pass. The complications associated with this procedure have been largely overcome with stapedectomy (the removal of all or part of the stapes, one of the bones of the middle ear) and the insertion of a prosthetic device, which is made of wire or Teflon and used in combination with a gelatin sponge or the patient’s own veins, connective tissue, and fat. Although fenestration is highly successful in cases in which deafness is conductive, it does not alleviate deafness whose cause is sensorineural, so-called nerve deafness, which is often treated palliatively with hearing aids. These devices are constantly improving, however, as they are decreasing in size and increasing in effectiveness.

Tumors of the inner ear can now be successfully removed through a translabyrinthine approach. The ear canal is entered with tiny, well-illuminated laser instruments to which magnifying devices are attached. Such surgery is often performed by otologists, although many undertake it collaboratively with a neurologist. Pituitary tumors, once the responsibility almost solely of neurosurgeons who performed craniotomies to reach the diseased area of the brain, are often treated by otorhinolaryngologists, who approach the tumor through the nose. Thus the tumor can be removed without the need for debilitating surgery.

From the earliest beginnings of otorhinolaryngology, the larynx has been among the parts of the anatomy most often treated by its practitioners. The laryngectomy, with its radical side effect of rendering the patient unable to speak, was once the treatment of choice for malignant laryngeal tumors. Such tumors can now be treated successfully with radiation, obviating the need for more drastic treatment. Teflon injections have been used to treat patients whose vocal cords have been compromised by surgery or by radiation. Because the larynx is in the area of the thyroid glands, otorhinolaryngologists also possess expert knowledge of thyroid disorders and may perform a thyroidectomy (removal of the thyroid), a procedure that is now emphasized in their residencies.

Two of the most frequent surgical procedures of the field in the mid-twentieth century were the removal of the tonsils (tonsillectomy) and of the adenoids, the masses of lymphoid tissue in the lining at the back of the tongue that produce white blood cells, which fight disease. Tonsils and adenoids were once removed routinely if children suffered from frequent colds. Now this surgery is discouraged because it has been discovered that the tonsils and adenoids help children develop a resistance to infection. When these tissues become inflamed, they can be treated conservatively and successfully through medication.

Otorhinolaryngologists regularly work in concert with physicians in other specialties, particularly neurosurgery. An internist treating a patient who suffers from loss of balance usually refers that patient to an otologist, who orders diagnostic tests to check for fluid in the inner ear, which would suggest Ménière’s disease. If such tests fail to reveal a buildup of fluid in the inner ear, the otologist usually refers the patient to a neurologist or neurosurgeon to check for other causes, including a tumor or a disorder in the central nervous system.

Otologists sometimes perform plastic surgery on ears that are abnormally protrusive. This reduction is a form of cosmetic surgery. By the end of the twentieth century in the United States, it was common for otorhinolaryngologists to perform most cosmetic and reconstructive surgeries related to these areas of the body. Consequently, residencies in this specialty offer considerable training in plastic surgery, especially in the procedures that otorhinolaryngologists have come to perform routinely in connection with thyroid, nasal, and other surgeries. They are often the physicians of choice in cases of cleft lip and cleft palate, the treatment of which normally falls largely within the province of reconstructive surgery. Because much cosmetic and reconstructive surgery involves the face, maxillofacial surgeons are often otorhinolaryngologists.

The common cold, although usually treated by an internist or family doctor if it is referred to a physician at all, sometimes involves complications such as bronchitis, pneumonia, or ancillary infections of the ears and sinuses. In such cases, an otorhinolaryngologist may be consulted for treatment. Dealing with the common cold is merely a waiting game: colds generally go away after a week or ten days. Colds afflict the average adult about four times a year and the average child twice that often (because young children have not yet built up the immunity that prevents infection).

Perspective and Prospects

Many of the illnesses that fall within the purview of otorhinolaryngology became more threatening and more frequent when the Industrial Revolution of the eighteenth century caused the relocation of large numbers of people from rural to urban settings. Cities grew as factories opened. Living conditions were often deplorable and, at best, overcrowded. Added to this situation was the pollution of the air by the waste products expelled by smokestack industries. Wherever pollution is prevalent, diseases of the upper respiratory tract are endemic.

The eighteenth century spawned conditions that compromised the environment and severely affected humans, but until physicians had a way of examining the body’s more remote crevices, the diagnosis and treatment of ear, nose, and throat problems were difficult. Such treatments as bleeding frequently killed rather than cured patients. Surgery was a treatment of last resort because the major anesthetic was whiskey. Patients sometimes died of shock from the unbearable pain that they suffered during surgical procedures.

Once physicians had reliable means of seeing into the body by using such equipment as reflective mirrors, endoscopes, x-rays, tomography, and ultrasonography, they could treat many illnesses nonsurgically. It is hoped that in the future even less invasive surgery will be done in all fields of medicine, including otorhinolaryngology.

Even when surgery is indicated, in the field of otorhinolaryngology it can often be performed without an incision by entering the body through the ear canal, nose, or throat. Advanced technology has produced surgical instruments that, in combination with computer imaging, work precisely and with less trauma. In cases where incisions are necessary, the opening is often so small that it is almost undetectable a year after the procedure.

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