Editor's Note
The Mysteries of the Head and Neck
When I studied anatomy in medical school, the head and neck always seemed like a mysterious house. Obscure holes in the skull led to room-like fossae hidden from view. The petrous ridge of the temporal bone was a porch from which you could imagine viewing the cavernous expanse of the skull’s interior. The sinuses were secret hideaways. As you rotated the skull, every angle revealed a new detail that you couldn’t see before. The intact head and neck had a welter of muscles, nerves, and vessels that demanded meticulous dissection. And every encounter with our cadaver’s head and neck became a magical journey.
In clinical practice, the head and neck can also be a bit of a mystery. Internists look at the outside, feel for lumps and bumps, then peer into nose and ears with an otoscope and the mouth and throat with a light and tongue blade. Yet so much can lurk out of sight. Far beyond the reach of the otoscope lie the middle ear and inner ear, hidden sanctums that can disrupt hearing or balance. Bulky turbinates in the nose can shelter nefarious problems such as cancers and leaky capillaries. Vocal cords hover just below the reach of most oral/throat exams. Chasing ENT symptoms with routine office exams can be 10 percent observation and 90 percent inference.
That’s why we have otolaryngologists. Ear, nose, and throat docs still use the mirror and light, which for years were almost as iconic for physicians as the black bag and stethoscope. But they now have new tools that allow them to explore the mysterious realm that is their province. Fiberoptic scopes traverse those turbinates allowing perusal of the sinuses, the posterior pharynx, and the larynx. Surgical robots wielding cameras and cutting instruments delve into crevices and corners to carve out tumors. Otolaryngologists can even unroof the temporal bone overlying the inner ear to repair dehiscences of those obscure semicircular canals, a diagnosis only recently described. Amazing techniques to explore the maze that is the head and neck.
Over the years, ENT physicians have had to become schooled in other new diagnoses. When I started practice in 1977, obstructive sleep apnea didn’t exist. Now it has spawned hundreds of sleep labs across the country and has been fingered as a cause of hypertension and arrhythmias. When standard treatments fail, otolaryngologists have procedures such as uvulopharyngoplasty to offer. Oral cancer, previously thought to be a disease of smokers and alcoholics, has been tied to the human papillomavirus, requiring preventive screening as well as definitive resection.
Even tonsillectomy, the bread-and-butter ENT operation, isn’t the same. Gone are the days when the indications for tonsillectomy were either a sore throat and the presence of tonsils or the fact that your sister was having hers out and you wanted to be able to eat ice cream all day, too. Tonsillectomies for treating infections have become as rare as Viking victories, and now tonsils get removed to remedy obstructed breathing.
Otolaryngology has come a long way since our 1918 article described removing tonsils using instruments I had never heard of, and the nooks and crannies of that anatomical fun house have become a lot less mysterious.
Charles R. Meyer, M.D., can be reached at cmeyer1@fairview.org