ENT Voice & Speech Disorders

ENT
VOICE & SPEECH DISORDERS
HOARSENESS
DEFINITION- Roughness of voice resulting from variations of periodicity &/ intensity of
consecutive sound waves
ETIOLOGY- 1. Inflammation- A. Acute (acute viral laryngitis)
B. Chronic (chronic laryngitis)
2. Neoplasms- A. Benign (Papillomas)
B. Premalignant (Leukoplakia)
C. Malignant (Cancer, Sarcoma)
3. Non-Neoplastic lesions- Vocal nodules
4. Trauma- Laryngeal trauma, FB
5. Paralysis
6. Fixation of cords (arthritis)
7. Congenital (Laryngeal web, Laryngocele)
8. Systemic disorders
EVALUATION- 1. History (Mode of onset, Duration, Occupation, Habits, Associated complaints)
2. IDL
3. Examination of neck, chest, CVS & neurological systems
4. Lab Investigations & radiological examination
5. Direct laryngoscopy & micro-laryngoscopy
6. Bronchoscopy & esophagoscopy
DYSPHONIA PLICA VENTRICULARIS/ VENTRICULAR DYSPHONIA
Voice produced by false cords
FUNCTIONAL/HYSTERICAL APHONIA
PUBERPHONIA/MUTATIONAL FALSETTO VOICE
Persistence of childhood high pitched voice
PHONASTHENIA
DYSPHONIA
A. ADDUCTOR DYSPHONIA
ETIOLOGY- Parkinsonism
Myoclonus
Pseudobulbar palsy
Multiple sclerosis
Cerebellar disorders
Tardive dyskinesia
Amyotrophic sclerosis
CLINICAL FEATURES- Strained/ strangled voice
Phonation interrupted 》 voice breaks
DIAGNOSIS:- CT
MRI
Flexible fiber-optic laryngoscopy
TREATMENT- Botulinum toxin injection in thyroarytenoid on 1/both sides
Voice therapy
B. ABDUCTOR DYSPHONIA
CLINICAL FEATURES- Breathy voice/ breathy breaks in voice
Gradually progressive & aggravated during stress
TREATMENT- Injection of botulinum toxin in posterior cricoarytenoid
Thyroplasty type I/fat injection
Speech therapy
C. MIXED DYSPHONIA
HYPONASALITY/RHINOLALIA CLAUSA
Nasal polypi, adenoids, nasal allergy
HYPERNASALITY/RHINOLALIA APERTA
Velopharyngeal insufficiency, cleft palate, post-adenoidectomy
STUTTERING
CANCER LARYNX
EPIDEMIOLOGY
Males > Females
40-70 years
ETIOLOGY- Tobacco
Cigarette smoking (benzopyrene)
Alcohol
Previous radiation to neck for benign lesions/ laryngeal papilloma
Genetic factors
Occupational exposure to asbestos, mustard gas
SITES- 1. Supra-glottis- Suprahyoid epiglottis
Infrahyoid epiglottis
Aryepiglottic folds
Arytenoids
Ventricular bands
2. Glottis- true Vocal cords
3. Sub-glottis- upto cricoid cartilage lower border
HISTOPATHOLOGY
Types- SCC
Verrucous carcinoma
Spindle Cell Carcinoma
Malignant salivary glands tumor
Sarcomas
Grading- Grade I- well differentiated
Grade II- moderately differentiated
Grade III- poorly differentiated
TNM CLASSIFICATION & STAGING
Primary tumor (T)- T1s- Carcinoma in situ
T1- Tumor confined confirmed to region with normal mobility
T1a- Tumor confined to 1 site of the region
T1b- Tumor extending to 2 sites of the same anatomical region
T2- Tumor with extension to adjacent region without fixation
T3- Tumor confined to the larynx with one or both cord fixation or deep infiltration
T4- Tumor with direct extension beyond the larynx
Nodes (N)- N0- No evidence of regional lymph node involvement
N1- Movable homolateral regional nodes
N2- Involvement of movable contralateral or bilateral regional lymph nodes
N3- Fixed regional lymph nodes
Distant metastases (M)- M0- No evidence of distant metastases
M1- Evidence of distant metastases
Staging of carcinoma larynx- Stage I- T1, N0, M0
Stage II- T2,N0,M0
Stage III- T3,N0,M0 T1,T2,T3,N1,M0
Stage IV- T4,N0,N1,M0 AnyT,N2,N3,M0
AnyT, anyN, M1
CLINICAL FEATURES- Hoarseness
Throat pain
Dysphagia
Referred pain in the ear
Mass of LN in neck
Weight loss
Respiratory obstruction
Halitosis
SPREAD- 1. Local
2. Lymphatic
3. Hematogenous
DIAGNOSIS- 1. History
2. IDL
3. Flexible fiber-optic/Rigid/ Video Laryngoscopy
4. Neck examination
5. Radiography- X-ray Chest
Soft tissue neck lateral view
CT scan
MRI
6. Direct laryngoscopy
7. Micro-laryngoscopy
8. Supravital staining & biopsy
TREATMENT- 1. Radiotherapy
2. Surgical- Conservative laryngeal surgery
Total Laryngectomy
3. Combined therapy (Surgery +Pre/post-operative RT)
4. Endoscopic resection with CO2 laser
5. Organ preservation
GLOTTIC CARCINOMA
VOCAL REHABILITATION AFTER TOTAL LARYNGECTOMY
BENIGN TUMORS OF LARYNX
NON-NEOPLASTIC TUMORS
A. SOLID
1. VOCAL/SINGER'S/SCREAMER'S NODULES
Nodules appear symmetrically on free edge of Vocal cord at junction of anterior 1/3 & posterior
2/3(area of maximum vibration)
ETIOLOGY- Vocal trauma
Mostly affects teachers, actors, vendors/pop singers
PATHOLOGY- Edema & hemorrhage in submucosal space 》 Hyalinization & fibrosis
Overlying epithelium hyperplasia
Vocal fatigue
Pain in neck on Prolonged phonation
TREATMENT- Conservative
Voice rest
Speech therapy
Surgical excision with cold instruments/ laser
Re-education in voice production
2. VOCAL POLYP
3. REINKE EDEMA/ BILATERAL DIFFUSE POLYPOSIS
Also called Polypoid VC/Degeneration/Hypertrophy
Collection of Edema fluid in sub epithelial space of Reinke
Predisposing Factors- Vocal abuse
Smoking
Reflux disease
Pathology- BM thickening
Reinke space Edema
Thickening of walls of sub epithelial vessels
CLINICAL FEATURES- SYMPTOMS- Deepening of voice pitch
Voice gruffiness
Effortful speaking
Inability to raise voice pitch
Choking episodes
SIGNS- Vocal cords grey/yellowish with prominent superficial vessels
Diffuse symmetrical swelling of both Vocal cords
TREATMENT- Reassurance
Voice therapy
Smoking cessation
Treat the cause
Longitudinal incision in Vocal cords & gelatinous fluid removal
4. CONTACT ULCER/GRANULOMA
5. INTUBATION GRANULOMA
6. LEUKOPLAKIA/KERATOSIS
7. AMYLOID TUMORS
B. CYSTIC LESIONS
1. DUCTAL CYSTS
2. SACULAR CYST
3. LARYNGOCELE
NEOPLASTIC
A. SQUAMOUS PAPILLOMA
1. JUVENILE/RESPIRATORY PAPILLOMATOSIS
2. ADULT ONSET PAPILLOMA
B. CHONDROMA
C. HEMANGIOMA
D. GRANULAR CELL TUMORS
E. GLANDULAR TUMORS
F. RARE BENIGN LARYNGEAL TUMORS
LARYNGEAL PARALYSIS
NERVE SUPPLY OF LARYNX

MOTOR
Cricothyroid- SLN (External laryngeal nerve)
All other Muscles- RLN
SENSORY
Above Vocal cords- Internal laryngeal nerve (SLN)
Below Vocal cords- RLN
RLN- Right RLN from Vagus at subclavian artery level 》 hook around 》 Ascend
between trachea & esophagus
Left RLN from vagus in mediastinum at aortic arch level 》 Loop around 》 Ascend
into neck in tracheoesophageal groove
SLN- From inferior ganglion of vagus 》 Descend behind ICA 》 At level of hyoid
greater cornu divide into external & internal branch
Internal branch also Sensory supply of hypopharynx
LARYNGEAL PARALYSIS
CLASSIFICATION
I. 1. Unilateral
2. Bilateral
II. 1. RLN
2. SLN
3. Combined/complete
CAUSES
1. Supranuclear
2. Nuclear- a. Vascular
b. Neoplastic
c. Motor neurone disease
d. Polio
e. Syringobulbia
3. High vagal lesions
4. Low vagal/RLN
5. Systemic
6. Idiopathic
RLN PARALYSIS
CAUSES
Right- Neck trauma
Thyroid surgery
Benign/malignant thyroid disease
Cervical lymphadenopathy
Carcinoma cervical esophagus
Idiopathic
Left- I. Neck- Accidental trauma
Thyroid disease
Thyroid surgery
II. Mediastinum- Bronchogenic cancer
Carcinoma thoracic esophagus
Aortic aneurysm
Both- Thyroid surgery
Carcinoma thyroid
Cancer cervical esophagus
A. UNILATERAL
Ipsilateral paralysis of all intrinsic muscles except cricothyroid
Vocal cords assume median/paramedian position & not move laterally on deep inspiration
Theories- 1. Semon law
2. Wagner & Grossman hypothesis
CLINICAL FEATURES- Asymptomatic
Gradual improvement in voice
Hoarseness
TREATMENT- 1. No treatment with gel-foam /fat injection
2. Thyroplasty type I (Medialization Thyroplasty)
3. Thyroplasty type I with arytenoid adduction
4. Teflon injection
B. BILATERAL/ BILATERAL ADDUCTOR PARALYSIS
ETIOLOGY- Neuritis
Surgical trauma
Position of Vocal cords- Median/paramedian
CLINICAL FEATURES- Good voice
Inadequate airway
Dyspnea & stridor worse on exertion/attack of acute laryngitis
TREATMENT- Tracheostomy
Widening airway without permanent tracheostomy (Endoscopic/External cervical approach)-
Transverse cordotomy/Kashima operation
Partial arytenoidectomy
Reinnervation procedures
Thyroplasty type II
SLN PARALYSIS
A. UNILATERAL
Rare
Cricothyroid paralysis & ipsilateral anaesthesia above Vocal cords
ETIOLOGY- Thyroid surgery
Thyroid tumors
Neuritis
Diphtheria
CLINICAL FEATURES- Weak voice with inability to raise pitch
Decreased ability to sing
Askew position of glottis
Shortening of cords with loss of tension
Flapping of paralyzed cords
B. BILATERAL
ETIOLOGY- Surgical/Accidental trauma
Neuritis
Neoplasms
CLINICAL FEATURES- Food & pharyngeal secretions inhalation 》 cough & choking
fits
Weak husky voice
TREATMENT- Tracheostomy with Cuffed tube
Esophageal feeding tube
Epiglottopexy
COMBINED/COMPLETE PARALYSIS
ETIOLOGY- I. Intracranial- Posterior fossa tumors
Basal meningitis
II. Skull base- Fractures
Nasopharyngeal cancer
Glomus tumor
III. Neck- Penetrating injury
Parapharyngeal tumors
Metastatic nodes
Lymphoma
A. UNILATERAL
Paralysis of all muscles on 1 side except Interarytenoid
ETIOLOGY- Thyroid surgery
CLINICAL FEATURES- Vocal cords in cadaveric position
Glottic incompetence
Hoarseness & liquid aspiration
Ineffective cough
TREATMENT- Speech therapy
Procedures to medialize cords- Injection of teflon paste lateral to paralyzed cord
Thyroplasty type I
B. BILATERAL
Both cords in cadaveric position
Total anaesthesia
CLINICAL FEATURES- Aphonia
Aspiration
Inability to cough
Bronchopneumonia
TREATMENT- Tracheostomy
Gastrostomy
Epiglottopexy
Vocal cord plication
Total laryngectomy
Diversion procedures
CONGENITAL VOCAL CORDS PARALYSIS
PHONOSURGERY
1. Benign/ malignant lesions excision by micro laryngeal surgery/ Laser
2. Injection with teflon paste/ gel-foam
3. Thyroplasty- a. Type I- Vocal cords medial displacement
b. Type II- Vocal cords lateral displacement
c. Type III- Shorten/relax Vocal cords [Mutational Falsetto]
d. Type IV- lengthen/tighten Vocal cords
4. Laryngeal reinnervation procedures
CONGENITAL LESIONS OF LARYNX & STRIDOR
CONGENITAL LESIONS OF LARYNX

1. LARYNGOMALACIA/ CONGENITAL LARYNGEAL STRIDOR
2. CONGENITAL VOCAL CORDS PARALYSIS
3. CONGENITAL SUBGLOTTIC STENOSIS
4. LARYNGEAL WEB
5. SUBGLOTTIC HEMANGIOMA
6. LARYNGO- ESOPHAGEAL CLEFT
7. LARYNGOCELE
8. LARYNGEAL CYST
STRIDOR
DEFINITION- Noisy respiration produced by turbulent airflow through narrowed air passages
TYPES- 1. Inspiratory (obstructive lesions of supra-glottis/pharynx)
2. Expiratory (lesions of thoracic trachea, primary & secondary bronchi)
3. Biphasic (lesions of glottis, sub-glottis & cervical trachea)
ETIOLOGY- I. A. Congenital- Laryngomalacia
Laryngeal web
Subglottic stenosis
Haemangioma
Vocal cords paralysis
Tongue & jaw abnormalities
B. Acquired- 1. Afebrile- Papillomatosis
Injury
FB
Laryngeal Edema
Adeno-tonsillar hypertrophy
2. Febrile- Epiglottitis
Acute laryngitis
Laryngotracheitis
Diphtheria
Retropharyngeal abscess
Infectious mononucleosis
Peritonsillar abscess
II. 1. Nose- Choanal atresia
2. Tongue- Macroglossia
3. Mandible- Micrognathia
4. Pharynx- Adeno-tonsillar hypertrophy
5. Larynx- a. Congenital
b. Inflammatory
c. Neoplastic
d. Traumatic
e. Neurogenic
f. Miscellaneous
6. Trachea & bronchi- a. Congenital
b. Inflammatory
c. Neoplastic
d. Traumatic
7. Lesions outside respiratory tract- a. Congenital
b. Inflammatory
c. Traumatic
d. Tumors
ASSESSMENT OF PATIENT- History of Patient- Congenital or acquired
Duration of stridor
History of foreign body, cough and choking
History of sore throat and fever
History of trauma and swelling in the neck
Clinical Examination
Inspection of neck and chest for evidence of respiratory distress
Examination of nose, nasopharynx, throat, chest, respiratory and cardiovascular system
DIAGNOSIS- IDL
Flexible fiber-optic Laryngoscopy
X-ray soft tissue neck lateral view, chest PA view
Contrast enhanced CT scan
Angiography
Esophagogram
Micro-laryngoscopy & bronchoscopy under GA
TREATMENT- Hospital admission is must
Look after the patient's airway
Oxygenation and humidification
Antibiotics with or without steroids
Endotracheal intubation or tracheostomy if there is marked respiratory obstruction
ACUTE & CHRONIC INFLAMMATIONS OF LARYNX
1. ACUTE LARYNGITIS
ETIOLOGY- I. Infectious type- URTI- Viral
Bacterial
Exanthematous fevers (measles, chickenpox, whooping cough)
II. Non-infectious type- Vocal abuse
Allergy
Thermal/ chemical burns
Laryngeal trauma (endotracheal intubation)
CLINICAL FEATURES- SYMPTOMS- 1. Hoarseness 》 complete voice loss
2. Discomfort/pain in throat after talking
3. Dry irritating cough, worse at night
4. General symptoms of head cold, rawness/dryness of throat, malaise & fever
SIGNS- Early stages- erythema & Edema of epiglottis, Aryepiglottic folds, arytenoids, ventricular
bands
Vocal cords white
Later stages- increased hyperemia & swelling
Vocal cords red, swollen
Sticky secretions between cords & inter-arytenoid region
TREATMENT- Vocal rest
Avoid Smoking & alcohol
Steam inhalation
Cough sedatives
Antibiotics
Analgesics
Steroids
2. ACUTE EPIGLOTTITIS / SUPRAGLOTTIC LARYNGITIS
DEFINITION- acute Inflammatory condition confined to supraglottic structures (epiglottis,
Aryepiglottic folds & arytenoids)
ETIOLOGY- 2-7 years
H.influenzae B
CLINICAL FEATURES- Abrupt onset with rapid progression
Sore throat & dysphagia
Dyspnoea & stridor
Fever & severe pain in throat
Hot potato voice
SIGNS- Red, swollen epiglottis
Edema & congestion of supraglottic structures
Tripod sign
Thumb sign on X-ray neck
DIAGNOSIS- IDL
X-ray soft tissue neck lateral view
TREATMENT- Hospitalization
Antibiotics
Steroids
Adequate hydration
Humidification & oxygen
Intubation/ tracheostomy
3. ACUTE LARYNGO- TRACHEO-BRONCHITIS
ETIOLOGY- 6 months- 3 years
Males
Viral infections
Secondary bacterial infections
CLINICAL FEATURES- URTI
Hoarseness
Croupy cough
Dyspnoea & inspiratory stridor
Signs of upper airway obstruction (suprasternal & intercostal recession)
Antibiotics
Humidification
Parentral fluids
Steroids
Adrenaline
Intubation/ tracheostomy
4. LARYNGEAL DIPHTHERIA
ETIOLOGY- secondary to faucial diphtheria
< 10 years
Pathology- 1. Formation of tough pseudo membrane over larynx & trachea
2. Exotoxin
CLINICAL FEATURES- I. General symptoms- insidious onset with low grade fever, sore throat &
malaise
Tachycardia & thready pulse
II. Laryngeal symptoms- hoarseness, croupy cough, inspiratory stridor & increasing Dyspnoea
III. Membrane- greyish white over tonsils, soft palate & pharynx
Adherent & removal leaves bleeding surface
IV. Cervical lymphadenopathy (bull neck appearance)
DIAGNOSIS- Clinical examination
Smear & culture
TREATMENT- Diphtheria antitoxin
Antibiotics
Maintenance of airway
Complete Bedrest
COMPLICATIONS- 1. Asphyxia & death
2. Toxic myocarditis & circulatory failure
3. Palatal paralysis
4. Laryngeal & pharyngeal paralysis
4. LARYNGEAL EDEMA
ETIOLOGY- 1. Infections- a. Acute epiglottitis, laryngo- tracheo -bronchitis, TB, Syphilis of larynx
b. Infection in neighbourhood
2. Trauma
3. Neoplasms
4. Allergy
5. Radiation
6. Systemic diseases
CLINICAL FEATURES- Airway obstruction
Inspiratory stridor
IDL- Edema of supra/subglottic region
TREATMENT- Intubation/tracheostomy
Adrenaline
Steroids
5. CHRONIC LARYNGITIS
A. WITHOUT HYPERPLASIA (CHRONIC HYPEREMIC LARYNGITIS)
ETIOLOGY- Incompletely resolved acute simple laryngitis
Chronic infections in PNS, teeth, tonsils, chest
Occupational factors
Smoking & alcohol
Persistent trauma of cough
Vocal abuse
Constant hawking
Discomfort in throat
Dry irritating cough
Hyperemia of laryngeal structures
Dull red, rounded Vocal cords
Flecks of viscid mucus on vocal cords & inter-arytenoid region
TREATMENT- Eliminate URTI/LRTI
Avoidance of irritating factors
Voice rest & speech therapy
Steam inhalation
Expectorants
B. HYPERTROPHIC/HYPERPLASTIC
ETIOLOGY- same
CLINICAL FEATURES- Males
30- 50 years
Hoarseness
Constant hawking
Dry cough
Tiredness of voice
Discomfort in throat
Laryngeal mucosa dusky red & thickened
Vocal cords red & swollen
Ventricular bands red & swollen
Mobility of cords impaired
TREATMENT- I. Conservative
II. Surgical- Stripping of vocal cords
Removal of hyperaemic, oedematous mucosa
6. POLYPOID DEGENERATION OF VOCAL CORDS/REINKE EDEMA
DEFINITION- bilateral symmetrical swelling of whole of membranous parts of vocal cords
Middle aged men & women
ETIOLOGY- Voice abuse
Heavy smoking
Chronic sinusitis
Laryngopharyngeal reflex
Myxoedema
False cords for voice production
Low pitched rough voice
IDL- Vocal cords fusiform swelling with pale translucent look
Ventricular bands hyperaemic & hypertrophic
TREATMENT- Vocal cords decortication
Voice rest
Speech therapy
7. PACHYDERMA LARYNGIS
8. ATROPHIC LARYNGITIS/LARYNGITIS SICCA
9. TB OF LARYNX
ETIOLOGY- Secondary to Pulmonary TB
Middle aged men
Bronchogenic/hematogenous routes
CLINICAL FEATURES- SYMPTOMS- Weakness of voice
Severe pain radiating to ears
Marked dysphagia with painful swallowing
SIGNS- Vocal cords hyperaemia
Swelling in inter-arytenoid region (mamillated appearance)
Vocal cords ulceration (mouse nibbled appearance)
Superficial ragged ulceration on arytenoids & inter-arytenoid region
Granulation tissue in inter-arytenoid region
"Turban epiglottis "(pseudo-oedema)
Swelling of ventricular bands & Aryepiglottic folds
Marked pallor of surrounding mucosa
DIAGNOSIS- Biopsy
X-ray Chest
Sputum examination
TREATMENT- Anti TB treatment
Voice rest
10. LUPUS OF LARYNX
11. SYPHILIS OF LARYNX
12. LEPROSY OF LARYNX
13. SCLEROMA OF LARYNX
14. LARYNGEAL MYCOSIS
HEAD & NECK SPACE INFECTIONS
1. PAROTID ABSCESS
DEFINITION- Suppuration of parotid space deep to superficial layer of deep cervical fascia
Contents- Parotid & associated LN, facial nerve, ECA & retromandibular vein
ETIOLOGY- Dehydration (Postsurgical cases, debilitating patients)
Infections from oral cavity
Bacteria- S.aureus
CLINICAL FEATURES- Swelling, redness, induration & tenderness in parotid area & at
mandible angle
Usually unilateral
Fluctuation difficult to elicit
Stenson duct opening congested
Pus on pressure over parotid
Toxic, high fever, dehydrated
DIAGNOSIS- Aspiration for culture & sensitivity
Ultrasound
CT scan
TREATMENT- Correct dehydration
Improve oral hygiene
Promote salivary flow
IV antibiotics
Surgical drainage under GA/LA (preauricular incision)
2. LUDWIG ANGINA
DEFINITION- infection of Submandibular space
ETIOLOGY- 1. Dental infection
2. Submandibular Sialadenitis, oral mucosa injuries, mandible fractures
CLINICAL FEATURES- Odynophagia
Varying degrees of trismus
Sublingual space- Structures in floor of mouth swollen
Tongue pushed up & back
Submaxillary space- Submental & Submandibular regions swollen & tender
Woody hard feel
Cellulitis
Tongue pushed up & back
Laryngeal Edema
TREATMENT- 1. Systemic antibiotics
2. Incision & drainage- A. Intraoral
B. External
3. Tracheostomy
COMPLICATIONS- 1. Para & retropharyngeal abscess
2. Airway obstruction
3. Septicaemia
4. Aspiration pneumonia
3. PERITONSILLAR ABSCESS/ QUINSY
DEFINITION- pus collection in peri-tonsilllar space
ETIOLOGY- 1. Acute tonsillitis complication
2. FB
CLINICAL FEATURES- adults
Unilateral
I. General- fever, chills & rigors, general malaise, body aches, headache, nausea, constipation
II. Local- Severe pain in throat
Odynophagia
Muffled, thick voice (hot potato voice)
Foul breath
Ipsilateral Earache
Trismus
EXAMINATION- 1. Tonsils, pillars & soft palate on involved side congested & swollen
2. Uvula swollen, oedematous & pushed to opposite side
3. Soft palate & anterior pillar bulging above tonsils
4. Muco-pus over tonsillar region
5. Cervical lymphadenopathy
6. Torticollis
DIAGNOSIS- Contrast enhanced CT/MRI
Needle aspiration for culture & sensitivity
IV fluids
Antibiotics
Analgesics
H2O2 / saline mouth wash
Incision & drainage
Interval Tonsillectomy
Abscess/hot tonsillectomy
COMPLICATIONS- 1. Parapharyngeal abscess
2. Laryngeal Edema
3. Septicaemia
4. Pneumonitis/lung abscess
5. Jugular vein thrombosis
6. Spontaneous haemorrhage from carotid artery/jugular vein
3. RETROPHARYNGEAL ABSCESS
A. ACUTE RETROPHARYNGEAL ABSCESS
ETIOLOGY- Children- suppurative infection of retropharyngeal lymph nodes draining ear, nose
and throat
Adults- trauma or iatrogenic causes, e.g. endoscopic procedures or oral surgeries
Acute mastoiditis
CLINICAL FEATURES- Dysphagia & difficulty in breathing
Stridor & croup cough
Torticollis
Bulge in posterior pharyngeal wall
DIAGNOSIS- X-ray soft tissue neck lateral view
Contrast enhanced CT
TREATMENT- Incision & drainage
Systemic antibiotics
Tracheostomy
B. CHRONIC RETROPHARYNGEAL/PREVERTEBRAL ABSCESS
ETIOLOGY- 1. Cervical spine caries
2. TB infection of retropharyngeal LN
CLINICAL FEATURES- Discomfort in throat
Mild dysphagia
Fluctuant swelling centrally/ on 1 side of midline on posterior pharyngeal wall
TB LN in neck
DIAGNOSIS- X-ray soft tissue neck lateral view
Needle aspiration for culture & sensitivity
Contrast enhanced CT
TREATMENT- Incision & drainage of abscess
Full course of Anti TB therapy
4. PARAPHARYNGEAL/PHARYNGOMAXILLARY ABSCESS
Relations- Medial- Buccopharyngeal fascia
Posterior- Prevertebral fascia
Lateral- Medial Pterygoid
Mandible
Parotid deep surface
Contents- carotid artery, jugular vein, CN 9,10,11,12, sympathetic trunk, upper deep cervical
nodes
ETIOLOGY- 1. Pharynx- acute & chronic infections of tonsils, adenoids, Quinsy bursting
2. Teeth- dental infection
3. Ear- Bezold abscess & petrositis
4. Other spaces- Parotid, retropharyngeal & submaxillary infection
5. External trauma (penetrating neck injuries, LA injection)
CLINICAL FEATURES- I. General- Fever
Odynophagia
Sore throat
Torticollis
Signs of toxaemia
II. Specific- A. Anterior compartment- 1. Prolapse of tonsils & tonsillar fossa
2. Trismus
3. External swelling behind angle of jaw
B. Posterior compartment- 1. Pharyngeal bulge behind posterior pillar
2. CN 9,10,11,12 & sympathetic chain paralysis
3. Parotid region swelling
DIAGNOSIS- Contrast enhanced CT scan neck
MR angiography
COMPLICATIONS- 1. Acute laryngeal Edema
2. Jugular vein thrombosis
3. Retropharyngeal abscess
4. Spread to mediastinum
5. Mycotic aneurysm of carotid artery
6. Carotid blow out with massive haemorrhage
TREATMENT- 1. Systemic antibiotics
2. Drainage of abscess
ACUTE & CHRONIC TONSILLITIS
PALATINE/FAUCIAL TONSILS
ANATOMY
Ovoid mass of lymphoid tissue in oropharynx lateral wall between anterior & posterior pillars
2 surfaces- Medial
Lateral
2 poles- Upper
Lower
Medial surface- non-keratinising stratified squamous epithelium
Crypts
Crypta magna / intra-tonsillar cleft (represents 2nd pharyngeal pouch ventral part)
Secondary crypts
Lateral surface- well defined fibrous capsule
Loose areolar tissue (para-tonsillar vein) (Tonsils dissection during tonsillectomy)
(Site of pus collection in Quinsy)
Upper pole- Semilunar fold
Supra-tonsillar fossa
Lower pole- Triangular fold
Anterior tonsillar space
Tonsillo-lingual sulcus(seat of carcinoma)
Bed of tonsils- Pharyngo-basilar fascia
Superior constrictor & palatopharyngeus
Buccopharyngeal fascia
CN 9 & styloglossus
Facial artery & ICA
Relations- Submandibular gland
Digastric posterior belly
Medial pterygoid
Angle of mandible
Importance- CN 9 & styloid process surgically approached after tonsillectomy
BLOOD SUPPLY
1. Tonsillar branch of facial artery
2. Ascending pharyngeal artery of ECA
3. Ascending palatine branch of facial artery
4. Dorsal lingual branches of lingual artery
5. Descending palatine branch of maxillary artery
VENOUS DRAINAGE
Para-tonsillar vein 》 common facial vein & pharyngeal venous plexus
LYMPHATIC DRAINAGE
Upper Deep cervical LN (jugulodigastric nodes below mandible angle)
NERVE SUPPLY
Lesser palatine branches of sphenopalatine ganglion (CN 5)
CN 9
FUNCTIONS
1. Local immunity
2. Surveillance mechanism
ACUTE TONSILLITIS
TYPES- 1. Acute catarrhal/ superficial tonsillitis
2. Acute follicular tonsillitis
3. Acute parenchymatous tonsillitis
4. Acute membranous tonsillitis
ETIOLOGY- Causative organisms- Streptococcus pneumoniae (β-hemolytic) [90%]
Staphylococcus
Pneumococcus
Haemophilus influenzae
Diphtheroids
Viral infections
Predisposing Factors- Upper respiratory tract infections
Chronic sinusitis
Chronic tonsillitis
Lower body resistance
Blood dyscrasias
Exposure to contagious infection
Excessive use of cold drinks
Excessive pollution
Foreign body impaction
CLINICAL FEATURES- SYMPTOMS- 1. Sore throat
2. Difficulty in swallowing
3. Fever
4. Earache (Referred pain/acute OM)
5. Constitutional symptoms (headache, general body aches, malaise & constipation)
6. Abdominal pain (mesenteric lymphadenitis)
SIGNS- 1. Fetid breath & coated tongue
2. Enlarged, red tonsils
3. Markedly congested pillars
4. Crypts filled with purulent material (Irwin Moore sign/septic squeeze)
5. Enlarged jugulodigastric nodes
6. Soft palate & uvula hyperaemia
Grading- Grade I- Enlarged in tonsillar fossa
Grade II- Reaching upto anterior pillar
Grade III- Between anterior pillar & uvula
Grade IV- Reaching upto uvula
DIAGNOSIS- Hb,TLC, DLC
Throat swab for culture & sensitivity
TREATMENT- Bedrest
Plenty of fluids
Soft, warm, simple diet
Vitamins
Antibiotics for 7-10 days
NSAIDS
KMnO4 gargle
Lozenges with LA action
COMPLICATIONS- 1. Chronic tonsillitis
2. Peritonsillar abscess
3. Parapharyngeal abscess
4. Cervical abscess
5. Acute OM
6. RF
7. Acute glomerulonephritis
8. SABE
D/d - 1. Diphtheria
2. Vincent angina
3. Infectious mononucleosis
4. Agranulocytosis
5. Leukaemia
6. Aphthous ulcers
7. Malignancy tonsils
8. Traumatic ulcer
9. Candidial tonsils infection
FAUCIAL DIPHTHERIA
CHRONIC TONSILLITIS
ETIOLOGY- 1. Complication of acute tonsillitis
2. Subclinical tonsils infection without acute attack
3. Chronic sinusitis/ teeth infection
TYPES- 1. Chronic follicular tonsillitis
2. Chronice Parenchymatous tonsillitis
3. Chronic fibroid tonsillitis
CLINICAL FEATURES- 1. Recurrent attacks of acute tonsillitis
2. Chronic irritation in throat with cough
3. Halitosis
4. Thick speech
5. Difficulty in swallowing
6. Choking spells at night
EXAMINATION- 1. Varying degree of tonsillar enlargement
2. Yellowish pus beads on tonsils medial surface
3. Anterior pillar flushing
4. Jugulodigastric nodes enlarged
TREATMENT- I. Conservative- Improve general health & diet
Treat coexisting teeth, nose, PNS infections
II. Surgical- Tonsillectomy
COMPLICATIONS- 1. Peritonsillar abscess
2. Parapharyngeal abscess
3. Intra-tonsillar abscess
4. Tonsillolith
5. Tonsillar cysts
6. Focus of infection in RF, Acute GN, Eye & skin disorders
DISEASES OF LINGUAL TONSILS
1. ACUTE LINGUAL TONSILLITIS
2. LINGUAL TONSILS HYPERTROPHY
3. LINGUAL TONSILS ABSCESS
ACUTE & CHRONIC PHARYNGITIS
ACUTE PHARYNGITIS
ETIOLOGY- Viral (common cold, measles, influenza)
Bacteria (Streptococcus, Pneumococcus or Haemophilus influenzae)
Certain drugs such as arsenic, mercury
Dental sepsis
CLINICAL FEATURES- Milder infections- Discomfort in throat
Malaise
Low grade fever
Congested pharynx
Moderate & severe- Pain in throat
Dysphagia
Headache
Malaise
High fever
Erythema, exudates & enlargement of tonsils & lymphoid follicles on posterior pharyngeal wall
Very Severe- soft palate & uvula Edema
DIAGNOSIS- Culture of throat swab
TREATMENT- I. General- Bedrest
Plenty of fluids
Warm saline gargle
Pharyngeal irrigations
Analgesics
Lignocaine viscous before meals
II. Specific- IM Penicillin G
Erythromycin
Diphtheria antitoxin
VIRAL INFECTIONS CAUSING PHARYNGITIS
1. HERPANGINA
2. INFECTICIOUS MONONUCLEOSIS
3. CYTOMEGALOVIRUS
4. PHARYNGOCONJUNCTIVAL FEVER
5. ACUTE LYMPHONODULAR PHARYNGITIS
6. MEASLES & CHICKENPOX
FUNGAL PHARYNGITIS
MISCELLANEOUS CAUSES OF PHARYNGITIS
CHRONIC PHARYNGITIS
Pathology- Hypertrophy of mucosa, Sero-mucinous glands, subepithelial lymphoid follicles &
muscular coat of pharynx
TYPES- 1. Chronic catarrhal pharyngitis
2. Chronic hypertrophic/ granular pharyngitis
ETIOLOGY- 1. Persistent infection in neighbourhood (chronic rhinitis & sinusitis)
2. Mouth breathing- a. Obstruction in nose
b. Obstruction in nasopharynx
c. Protruding teeth
d. Habitual
3. Chronic irritants (heavy Smoking, tobacco chewing, heavy drinking, highly spiced foods)
4. Environmental pollution
5. Faulty voice production (certain professionals, pharyngeal neurosis)
CLINICAL FEATURES- SYMPTOMS- 1. Discomfort/pain in throat specially in morning
2. FB sensation in throat
3. Tiredness of voice
4. Cough
SIGNS- I. Chronic catarrhal pharyngitis- congestion of posterior pharyngeal wall
Engorgement of vessels
Faucial pillars thickened
Increased mucus secretion
II. Chronic hypertrophic pharyngitis- pharyngeal wall thick & oedematous with congested
mucosa & dilated vessels
Posterior pharyngeal wall studded with reddish nodules
Lateral pharyngeal bands hypertrophy
Uvula elongated & oedematous
TREATMENT- Treat the cause
Voice rest & speech therapy
Warm saline gargle
Mandl paints
Cautery of lymphoid granules with 10-25 % AgNO3
ATROPHIC PHARYNGITIS
KERATOSIS PHARYNGIS
TUMORS OF HYPOPHARYNX
I. BENIGN TUMORS
1. PAPILLOMA
2. ADENOMA
3. LIPOMA
4. FIBROMA
5. LEIOMYOMA
II. MALIGNANT TUMORS
A. CARCINOMA PYRIFORM SINUS
B. CARCINOMA POST CRICOID REGION
C. CARCINOMA POSTERIOR PHARYNGEAL WALL
III. PHARYNGEAL POUCH/HYPOPHARYNGEAL /ZENKER DIVERTICULUM
DEFINITION- Pulsion diverticulum where pharyngeal mucosa herniates through Killian
dehiscence
ETIOLOGY- unknown
Cricopharyngeal sphincter spasm
In-coordinated contractions during deglutition
Seen after 60 years
PATHOLOGY- starts in midline
Mouth of sac wider than oesophagus opening
CLINICAL FEATURES- Dysphagia
Gurgling sound on swallowing
Undigested food regurgitation at night when recumbent 》 cough & aspiration
pneumonia
Malnourished
Rarely Carcinoma
DIAGNOSIS- Ba Swallow
TREATMENT- 1. Excision of pouch & cricopharyngeal myotomy
2. Dohlman procedure
3. Endoscopic laser treatment
TUMORS OF OROPHARYNX
I. BENIGN TUMORS
1. PAPILLOMA
2. HEMANGIOMAS
3. PLEOMORPHIC ADENOMA
4. MUCOUS CYST
5. LIPOMA
6. FIBROMA
7. NEUROMA
COMMON SITES- 1. Posterior 1/3 /base of tongue
2. Tonsils & tonsillar fossa
3. Faucial palatine arch (soft palate & anterior pillar)
4. Posterior & lateral pharyngeal wall
Grossly- 1. Superficially spreading
2. Exophytic
3. Ulcerative
4. Infiltrative
Histologically- 1. SCC
2. Lymphoepithelioma
3. Adenocarcinoma
4. Lymphoma
CLASSIFICATION- TNM classification
DIAGNOSIS- IDL
Palpation under anaesthesia
Biopsy
CT scan
SPREAD- 1. Local
2. Lymphatic
3. Hematogenous
TREATMENT- 1. Surgery alone
2. Radiation alone
3. Surgery +RT
4. Chemotherapy alone/ as adjunct
5. Palliative therapy
III. PARAPHARYNGEAL TUMORS
IV. STYALGIA/ EAGLE SYNDROME
TUMORS OF NASOPHARYNX
I. BENIGN TUMORS
1. NASOPHARYNGEAL FIBROMA/ JUVENILE NASOPHARYNGEAL ANGIOFIBROMA
ETIOLOGY- unknown
Adolescent males
2nd decade
Testosterone dependent
Site of origin- posterior part nasal cavity close to superior margin sphenopalatine foramen
Growth- grow into nasal cavity, nasopharynx & into pterygopalatine fossa behind posterior wall
of maxillary sinus
Laterally extend into pterygomaxillary fossa & to infratemporal fossa & cheek
PATHOLOGY- vascular & fibrous tissue in variable ratio
Vessels just endothelium lined spaces with no elastic/muscle coat(Severe bleeding not
controlled by adrenaline application)
No capsule
EXTENSIONS- 1. Nasal cavity
2. PNS
3. Pterygomaxillary fossa, infratemporal fossa & cheek
4. Orbits
5. Cranial cavity- A. Anterior cranial fossa
B. Middle Cranial fossa
CLINICAL FEATURES- 1. Age & Sex- Males
10-20 years
2. Profuse, Recurrent, spontaneous epistaxis
3. Progressive nasal obstruction & denasal speech
4. Conductive hearing loss & OME
5. Mass in nasopharynx(sessile, lobulated/smooth,pink/purplish,firm & obstruct 1/both choanae)
6. Other clinical features( nasal bridge Broadening, proptosis, cheek/infratemporal fossa
swelling, involvement of 2,3,4,6 CN)
DIAGNOSIS:- Biopsy avoided
Biopsy under GA
CT scan head with Contrast enhancement (antral sign/Holman- Miller sign)
MRI
Carotid angiography
Arrangement for blood transfusion
TREATMENT- I. Surgical- Surgical excision
Approach- 1. Transpalatine
2. Transpalatine + Sublabial (Sardana)
3. Lateral Rhinotomy with medial maxillectomy- a. Facial incision
b. Degloving approach
4. Endoscopic removal
5. Transmaxillary
6. Maxillary swing/ facial translocation/Wei operation
7. Infratemporal fossa
8. Intracranial- Extracranial
II. RT
III. Hormonal therapy
IV. CT
Management of Recurrent tumors- 1. Observation
2. Revision surgery & removal
3. Radiation
2. CHOANAL POLYP
3. SQUAMOUS PAPILLOMA
4. THORNWALDT CYST
6. CRANIOPHARYNGIOMA
7. PARAGANGLIOMA
8. HAMARTOMA
9. CONGENITAL TUMORS- HAIRY POLYP
TERATOMA
EPIGNATHI
10. CHORISTOMA
1. LYMPHOMA
2. RHABDOMYOSARCOMA
3. CHORDOMA
4. PLASMACYTOMA
5. HEMANGIOPERICYTOMA
6. MALIGNANT SALIVARY GLANDS TUMORS
7. MELANOMA
8. NASOPHARYNGEAL CANCER
ETIOLOGY- 1. Genetic
2. Viral(EBV)(VCA,EA)
3. Environmental(air pollution, tobacco & opium Smoking, nitrosoamines from dry salted fish,
smoke from burning incense sticks)
PATHOLOGY- Type I- Keratinising carcinoma
Type II- Non keratinising differentiated carcinoma
Type III- non keratinising undifferentiated carcinoma
Grossly- 3 forms- 1. Proliferative
2. Ulcerative
3. Infiltrative
SPREAD- 1. Local- a. Anterior
b. Inferior
c. Lateral
d. Upward
2. Lymphatic
3. Distant metastases (lung, bone, liver)
CLINICAL FEATURES- 1. Age- 5th-7th decade
2. Sex- Males
3. Nasal- Nasal obstruction
Nasal discharge
Rhinolalia clausa
Epistaxis
4. Otologic- Conductive hearing loss
Serous/suppurative OM
Tinnitus & dizziness
Unilateral serous OM
5.Ophthalmoneurologic-Squint & diplopia(CN 6)
Ophthalmoplegia(3,4,6 CN)
Facial pain & reduced corneal reflex (CN 5)
Exophthalmos & Blindness (CN 2)
Jugular foramen syndrome (CN 9,10,11)
Horner's syndrome
Trotter triad(conductive deafness, ipsilateral temporoparietal neuralgia & palatal paralysis)
6. Cervical nodal metastases
7. Distant metastases- Cervical lymphadenopathy
Hearing loss
Nasal obstruction
Epistaxis
CN palsies
Headache
Earache
Neck pain
Weight loss
DIAGNOSIS:- 1. Endoscopic evaluation
2. Imaging studies- a. CT/MRI nasopharynx & neck
b. X-ray/CT chest
c. CT/ultrasound abdomen
d. PET scan
3. Biopsy under GA/LA using endoscopes
4. Audiogram
TREATMENT- 1. Radiotherapy
2. Chemotherapy (cisplatin/cisplatin with 5-FU)
3. Recurrent & residual disease- a. Positive nodes in neck- Radical neck dissection with
SCM,CN 11, IJV removal
b. Persistent disease in nasopharynx- 2nd course of external radiation
Brachytherapy
Nasopharyngectomy
ENT- ADENOIDS & OTHER INFLAMMATION OF NASOPHARYNX
ADENOIDS/NASOPHARYNGEAL TONSILS/LUSCHKA TONSILS

ANATOMY
At junction of roof & posterior wall of nasopharynx
Vertical ridges of lymphoid tissue separated by deep clefts
Covering epithelium- 3 types- Ciliated Pseudostratified columnar
Stratified squamous
Transitional
No crypts & capsule
Present at birth, physiological enlargement till 6 years, tend to atrophy at puberty & almost
completely disappear by 20
BLOOD SUPPLY
1. Ascending palatine branch of facial
2. Ascending pharyngeal branch of ECA
3. Pharyngeal branch of 3rd part of maxillary
4. Ascending cervical branch of inferior thyroid artery of thyrocervical trunk
LYMPHATIC DRAINAGE
Into upper jugular LN directly/ indirectly via retropharyngeal & parapharyngeal LN
NERVE SUPPLY
CN 9,10
APPLIED- ADENOIDS HYPERTROPHY
ETIOLOGY- physiological enlargement in children
Tendency for generalized lymphoid hyperplasia
Recurrent attacks of rhinitis, sinusitis/ chronic tonsillitis
URT allergy
CLINICAL FEATURES- SYMPTOMS- I. Nasal
1. Nasal obstruction
2. Nasal discharge
3. Sinusitis (chronic maxillary sinusitis)
4. Epistaxis with nose blowing
5. Voice changes (toneless & loss of nasal quality)
II. Aural
1. Tubal obstruction
2. Recurrent attacks of acute OM
3. CSOM
4. OME
III. General
1. Adenoid facies- Elongated face with dull expressions
Open mouth
Prominent, crowded upper teeth
Hitched up upper lip
Pinched in appearance of nose
Highly arched hard palate
Gums hyperplasia
Maxilla hypoplasia
Loss of nasolabial folds
Underslung mandible
2. Pulmonary hypertension
3. Aprosexia
DIAGNOSIS:- Posterior rhinoscopy
Rigid/ flexible nasopharygoscope
Blood Investigations
X-ray soft tissue nasopharynx lateral view
Digital palpation
Nasal endoscopy
TREATMENT- Breathing exercises
Decongestants nasal drops
Antihistamines
Antibiotics
Surgical- Adenoidectomy
Myringotomy
ACUTE NASOPHARYNGITIS
ETIOLOGY- Isolated infection
Generalized URTI
Causative organisms- Viruses (rhino,influenza, parainfluenza, adeno)
Bacteria (streptococcus, pneumococcus, H.influenzae )
CLINICAL FEATURES- Dryness & burning of throat above soft palate
Pain & discomfort localized to back of nose
Mild dysphagia
Pyrexia
Congested & swollen mucosa with whitish exudate
TREATMENT- Analgesics
Chemotherapy
Nasal decongestants drops
CHRONIC NASOPHARYNGITIS
ETIOLOGY- Chronic infections of nose, PNS, pharynx
Heavy smokers
Alcoholics
Exposure to dust & fumes
CLINICAL FEATURES- Postnasal discharge
Crusting with irritation at back of nose
Hawking/ inspiratory snorting
Congested mucosa
Mucopus/ dry crusts
Chronic adenoiditis
TREATMENT- Avoid smoking & alcohol
Alkaline nasal douches
Steam inhalation
THORNWALDT DISEASE/ PHARYNGEAL BURSITIS
CLINICAL FEATURES- 1. Persistent Postnasal discharge with crusting
3. ET obstruction & serous OM
4. Dull type Occipital headache
5. Recurrent sore throat
6. Low Grade fever
Cystic & fluctuant swelling in nasopharynx posterior wall
TREATMENT- Antibiotics
Marsupialisation of cystic swelling & adequate removal of lining membrane
ENT- ANATOMY & PHYSIOLOGY OF PHARYNX
fibromuscular tube forming upper part of air & food passages

12-14 cm in length, width above 3.5 cm at base of skull and below 1.5 cm at pharyngo-
esophageal junction
From base of skull-level of 6th cervical vertebra (lower border of cricoid cartilage)(ends into
pharyngoesophagus junction at cricopharynx)
Lined by squamous stratified epithelium except in nasopharynx where lining pseudostratified
columnar ciliated epithelium
STRUCTURE OF PHARYNGEAL WALL
From within outwards
1. MM- continuous with mm of ET, nasal cavity, mouth, larynx & esophagus
2. Pharyngeal aponeurosis/ Pharyngobasilar fascia- thick near skull base & thin inferiorly
3. Muscular coat- A. External layer- Superior constrictor
Middle constrictor
Inferior constrictor
B. Internal layer- Stylopharyngeus
Salpingopharyngeus
Palatopharyngeus
4. Buccopharyngeal fascia
KILLIAN DEHISCENCE
Potential gap between oblique fibres of Thyropharyngeus & Transverse fibers of
cricopharyngeus
"Gateway of tears" (perforation during oesophagoscopy)
Site for herniation of pharyngeal mucosa (Pharyngeal pouch)
WALDEYER RING
Internal- Nasopharyngeal tonsils/adenoids
Palatine tonsils
Lingual tonsils
Tubal tonsils
Lateral pharyngeal bands
Nodules in posterior pharyngeal wall
External- Occipital LN
Pre auricular LN
Post auricular LN
Parotid LN
Facial LN
Submandibular LN
Submental LN
Anterior cervical LN
Superficial cervical LN
PHARYNGEAL SPACES
1. Retropharyngeal- from skull base- trachea bifurcation
2. Parapharyngeal- contains carotid vessels, jugular vein, last 4 CN & cervical sympathetic
chain
DIVISIONS- I. Nasopharynx/ Epipharynx
Behind nasal cavities
From skull base- soft palate/level of horizontal plane through hard palate
Roof- Basisphenoid
Basiocciput
Posterior wall- arch of atlas vertebra
Floor- Soft palate
Nasopharyngeal isthmus
Anterior wall- Choanae
Lateral wall- pharyngeal opening of ET
Torus tubarius
Fossa of Rosenmuller
Salpingopharyngeal fold
ADENOIDS
NASOPHARYNGEAL BURSA
From pharyngeal mucosa- basiocciput periosteum
Notochord attachment to pharyngeal endoderm during embryonic life
Thornwaldt disease
RATHKE POUCH
Dimple above adenoids
Reminiscent of Buccal mucosa invagination to form pituitary anterior lobe
TUBAL TONSILS
SINUS OF MORGAGNI
Space between skull base & superior constrictor upper free border
ET, Levator veli palatini, tensor veli palatini, ascending Palatine artery
PASSAVANT RIDGE
mucosal ridge raised by palatopharyngeus fibres
Posterior & lateral walls of nasopharyngeal isthmus
Contact with soft palate during contraction 》 cut off nasopharynx from oropharynx
during speech/deglutition
II. Oropharynx
From plane of hard palate- plane of hyoid bone
Oropharyngeal isthmus
Boundaries- Posterior wall- C2, upper part C3
Anterior wall- Base of tongue
Lingual tonsils
Valleculae
Lateral wall- Palatine/faucial tonsils
Anterior pillar/palatoglossal arch
Posterior pillar/ palatopharyngeal arch
Tonsillar fossa
III. Laryngopharynx/ Hypopharynx
Superior limit- plane from hyoid body- posterior pharyngeal wall
Inferior limit- Cricoid cartilage lower border
C3-6
Subdivided into 3 regions- 1. Pyriform sinus/fossa
From pharyngoepiglottic fold- esophagus upper end
Lateral- Thyrohyoid membrane
Thyroid cartilage
Medial- Aryepiglottic fold
Arytenoids & cricoid posterolateral surfaces
Importance- Lateral channel for food
FB dislodgement
ILN easy access for anaesthesia
Referred pain to ear in carcinoma
2. Post cricoid region
Between upper & lower borders cricoid lamina
Common site for Carcinoma in female with Plummer Vinson syndrome
3. Posterior pharyngeal wall
From hyoid - level of cricoarytenoid joint
Blood Supply of Pharynx
Ascending pharyngeal branch of external carotid
Ascending palatine branch of facial (branch of external carotid)
Greater Palatine branch of maxillary
Venous drainage through pharyngeal plexus into IJV
Nerve Supply
By pharyngeal plexus of nerves,which is formed by:
Branch of vagus(X nerve)(Motor supply)
Branches of glossopharyngeal (IX nerve) (Sensory supply)
Sympathetic plexus
Lymphatic Drainage
Into retropharyngeal & jugulo digastric nodes
Waldeyer’s ring has no afferents & efferents drain into cervical lymph nodes
FUNCTIONS
Nasopharynx- 1. Conduit for air
2. Ventilate middle ear & equalize air pressure on TM both sides
3. Swallowing, vomiting, gagging & speech (Passavant ridge)
4. Resonating chamber during voice production
5. Drainage channel for mucus secreted by nasal & nasopharyngeal glands
Oropharynx- 1. Conduit for air & food
2. Pharyngeal phase of deglutition
3. Vocal tract for certain sounds
4. Taste appreciation
5. Local defense & immunity against harmful intruders into air & food passages
Laryngopharynx- 1. Conduit for air & food
2. Vocal tract for resonance of certain sounds
3. Deglutition
NON NEOPLASTIC DISORDERS OF SALIVARY GLANDS
1. MUMPS/VIRAL PAROTITIS
Viral infection by paramyxoviruses
Contacted by droplet infection & fomites
Virus excreted through salivary, nasal & urinary excretions
CLINICAL FEATURES- Fever
Malaise
Anorexia
Muscular pain
Unilateral parotid swelling ,subside in a week
COMPLICATIONS- Orchitis
Ophritis
Pancreatitis
Aseptic meningitis/meningoencephalitis
Unilateral SNHL
Thyroiditis
Myocarditis
Nephritis
Arthritis
DIAGNOSIS:- 1. Serum & urinary amylase
2. Serology- Serum IgG & IgM
TREATMENT- Proper hydration
Rest
Analgesics
Cold/hot compresses
Avoid saliva secretagogues
Orchitis- cold compresses
Support to scrotum
PREVENTION- MMR
2. ACUTE SUPPURATIVE PAROTITIS
3. CHRONIC RECURRENT SIALADENITIS
4. SIALECTASIS
5. GRANULOMATOUS INFECTIONS OF SALIVARY GLANDS- A. TB
B. ACTINOMYCOSIS
C. TOXOPLASMOSIS
6. SIALOLITHIASIS/SALIVARY CALCULI
7. SJOGREN SYNDROME/SICCA SYNDROME- A. PRIMARY
B. SECONDARY
8. SIALOMETAPLASIA
9. SIALADENOSIS
NEOPLASMS OF SALIVARY GLANDS
I. BENIGN TUMORS
2. ADENOLYMPHOMA/PAPILLARY CYSTADENOMA LYMPHOMATOSUM/WARTHIN TUMOR
3. ONCOCYTOMA/OXYPHIL ADENOMA
4. HEMANGIOMAS
5. LYMPHANGIOMAS
6. LIPOMA
7. NEUROFIBROMA
1. MUCOEPIDERMOID CARCINOMA
2. ADENOID CYSTIC CARCINOMA/CYLINDROMA
3. ACINIC CELL CARCINOMA
4. ADENOCARCINOMA
5. MALIGNANT MIXED TUMOR
6. SCC
7. UNDIFFERENTIATED CARCINOMA
8. LYMPHOMA
9. SARCOMA
10. FREY SYNDROME/GUSTATORY SWEATING
ENT- TUMORS OF ORAL CAVITY
CLASSIFICATION:- I. BENIGN TUMORS

A. SOLID TUMORS
1. PAPILLOMA
2. FIBROMA/ FIBROEPITHELIAL POLYP
3. HAEMANGIOMAS - A. CAPILLARY
B. CAVERNOUS
C. MIXED
4. LYMPHANGIOMA
5. TORUS
6. PYOGENIC GRANULOMA
7. PREGNANCY GRANULOMA
8. GRANULAR CELL MYOBLASTOMA/TUMOR
9. MINOR SALIVARY GLANDS NEOPLASMS
10. SOLITARY FIBROUS TUMOR
B. CYSTIC LESIONS
1. MUCOCOELE
2. RANULA
3. DERMOID
II. PREMALIGNANT LESIONS
1. LEUKOPLAKIA
DEFINITION- (WHO) clinical white patch that cannot be characterized clinically & pathologically
as any other disease
ETIOLOGY- Smoking
Tobacco chewing
Alcohol abuse
Chronic trauma (ill fitting dentures/cheek bites)
SMF
Hyper plastic candidiasis
Plummer Vinson syndrome
SITES- Buccal mucosa
Oral commissures
Age- 4th decade
Sex - Males
CLINICAL TYPES- 1. Homogeneous varieties
2. Nodular/ speckled
3. Erosive/ Erythroleukoplakia
HISTOLOGY- epithelial dysplasia
Malignant potential
D/D- Lichen planus
DLE
Candidiasis
White spongy nevus
MANAGEMENT- Disappear spontaneously
Biopsy
Surgical excision/ ablation with LASER/ cryotherapy
2. ERYTHROPLAKIA
3. MELANOSIS & MUCOSAL HYPERPIGMENTATION
III. MALIGNANT LESIONS
CARCINOMA ORAL CAVITY
ETIOLOGY- 1. Smoking
2. Tobacco chewing
3. Alcohol
4. Dietary deficiencies
5. Dental sepsis, jagged sharp teeth & ill fitting dentures
SITES IN LIP & ORAL CAVITY (AJCC,2002)- 1. Mucosal lip
2. Buccal mucosa
3. Oral tongue
4. Hard palate
5. Lower alveolar ridge
6. Upper alveolar ridge
7. Floor of mouth
8. RMT
CLINICAL FEATURES- Ulcerative mass
Raised margins
Otalgia
Difficulty in opening the mouth
SPREAD- 1. Local
2. Lymphatic
3. Hematogenous
CLASSIFICATION:- TNM- Primary tumors (T)
T1- <= 2 cm
T2- 2-4 cm
T3- > 4 cm
T4(lip)- invade adjacent structures
T4a( oral cavity)- invade adjacent structures
Regional LN (N)
N1- single ipsilateral LN <= 3 cm
N2- single ipsilateral LN 3-6 cm
N3- LN metastasis > 6 cm
Distant metastases (M)
M0- no distant metastases
M1- distant metastases
TREATMENT- Stage I and II- surgery with or without radical neck dissection
Stage III surgery followed by radiotherapy
Stage IV- palliative treatment in the form of chemotherapy or radiotherapy with or without
surgical treatment
ENT- COMMON DISORDERS OF ORAL CAVITY
ULCERS OF ORAL CAVITY

A. INFECTION- VIRAL
1. HERPANGINA
2. HERPETIC GINGIVOSTOMATITIS
A. Primary infection
B. Secondary infection/Recurrent Herpes
3. HAND, FOOT & MOUTH DISEASE
BACTERIAL
1. VINCENT INFECTION/ACUTE NECROTIZING ULCERATIVE GINGIVITIS
2. SPECIFIC BACTERIAL INFECTIONS (TB, Syphilis, Actinomycosis)
FUNGAL
MONILIASIS/CANDIDIASIS
1. THRUSH
2. CHRONIC HYPERTROPHIC CANDIDIASIS
B. IMMUNE DISORDERS
1. APHTHOUS ULCERS
Recurrent & superficial ulcers usually involving movable mucosa
ETIOLOGY- Unknown
Autoimmune process
Nutritional deficiencies (B12, B9 & Fe)
Viral/bacterial infections
Food allergies
Hormonal changes
Stress
CLINICAL FEATURES- Minor form- 2-10 mm
Multiple with central necrotic area & red halo
Heal In 2 weeks without leaving scar
Major form- 2-4 cm
Heal with a scar
Soon followed by another ulcer
TREATMENT- Topical Steroids application
Cauterization with 10% AgNO3
Tetracycline
Pain- Lignocaine viscous
NSAIDS
2. BEHCET SYNDROME/ OCULO-ORO- GENITAL SYNDROME
C. TRAUMA
TRAUMATIC ULCERS- 1. PHYSICAL
2. CHEMICAL
3. THERMAL
D. NEOPLASMS
E. SKIN DISORDERS
1. ERYTHEMA MULTIFORME
2. PEMPHIGUS VULGARIS
3. BENIGN MUCOUS MEMBRANE PEMPHIGOID
(BMMP)
4. LICHEN PLANUS- A. RETICULAR
B. EROSIVE
5. CHRONIC DLE
F. BLOOD DISORDERS
G. DRUGS ALLERGY
H. VITAMIN DEFICIENCY
I. MISCELLANEOUS
RADIATION MUCOSITIS
MISCELLANEOUS LESIONS OF TONGUE & ORAL CAVITY
1. MEDIAN RHOMBOID GLOSSITIS
2. GEOGRAPHICAL TONGUE
3. HAIRY TONGUE
4. FISSURED TONGUE
5. ANKYLOGLOSSIA/TONGUE TIE
6. FORDYCE SPOTS
7. NICOTINE STOMATITIS
SUBMUCOUS FIBROSIS (SMF)
DEFINITION- Chronic insidious process characterised by juxtaepithelial deposition of fibrous
tissue in oral cavity & pharynx
ETIOLOGY- 1. Socioeconomic status
2. Tobacco chewing
3. Areca nuts
4. Alcohol
5. Nutritional
6. Immune process
7. Multifactorial
PATHOGENESIS- Early cases- PMN leukocyte, eosinophils, few lymphocytes
Advanced cases- Lymphocytes & plasma cells
PATHOLOGY- Fibroelastotic transformation of connective tissue in lamina propria with epithelial
atrophy
Maybe associated with Leukoplakia & SCC
CLINICAL FEATURES- 20-40 years
SYMPTOMS- Intolerance to spicy foods
Mouth soreness with constant burning sensation worsened during meals
Repeated vesicular eruptions on palate & pillars
Difficulty to open mouth fully
Difficulty to protrude tongue
SIGNS- changes most marked over soft palate, faucial pillars & buccal mucosa
Initial stages- patchy mm redness + vesicles formation
Later stages- mucosa blanching with suppleness loss
Fibrotic bands
Fibrosis & scarring also in muscles layer
Progressive Trismus
Bad orodental hygiene
Dental caries
Oral cavity examination difficult
TREATMENT- I. Medical- 1. Topical steroids injection (Dexamethasone + hylase)(biweekly for 8-
10 weeks)
2. Avoid irritants
3. Treat existent anemia/ vitamin deficiency
4. Encourage jaw opening exercises
II. Surgical- 1. Simple release of fibrosis & skin grafting
2. Bilateral tongue flaps
3. Nasolabial flaps
4. Island palatal mucoperiosteal flap
5. Bilateral radial forearm free flap
6. Surgical excision & buccal fat pad graft
7. Superficial temporal fascia & split skin graft
8. Coronoidectomy & temporal muscle myotomy
ENT- ALLERGIC RHINITIS
DEFINITION- Symptomatic nose disorder induced by IgE mediated inflammation after allergen
exposure
ETIOLOGY- Inhalant allergens (pollens, molds, insects, animals, house dust, dust mite,
ingestants, drugs)
Genetic predisposition
TYPES- Seasonal/Hay fever/summer/cold/rose fever
Perennial
Predisposing factors- Heredity
Endocrine
Psychological
PATHOGENESIS- Allergic reaction- a. Immediate/ early phase (within 5-30 minutes)
b. Late/delayed phase (2-8 hours after exposure)
CLASSIFICATION:-New ARIA classification: I. Duration- A. Intermittent(< 4 days/week or < 4
weeks)
B. Persistent (> 4 days/week or > 4 weeks)
II. Severity- A. Mild
B. Moderate- Severe(>= 1 of following symptoms- sleep disturbance, daily activities impairment,
school/work impairment, troublesome symptoms)
CLINICAL FEATURES- SYMPTOMS- Seasonal- Paroxysmal Sneezing
Nasal obstruction
Watery nasal discharge
Itching in nose
Perennial- Frequent colds
Persistent stuffy nose
Anosmia
Postnasal drip
Chronic cough
Hearing impairment
SIGNS- Nasal- Transverse nasal crease/Allergic salute
Pale, edematous nasal mucosa
Swollen turbinates
Thin watery/mucoid discharge
Ocular- Edema of lids
Congestion & cobblestone appearance of conjunctiva
Allergic shiners
Otologic- Retracted TM/Serous OM
Pharyngeal- Granular pharyngitis
Prolonged mouth breathing
Laryngeal- Hoarseness
Vocal cords Edema
INVESTIGATIONS- 1. TC & DC
2. Nasal smear
3. Skin tests- A. Skin prick test
B. Specific IgE measurement
4. RAST
5. Nasal provocation test
COMPLICATIONS- Recurrent sinusitis
Nasal polypi
Serous OM
Orthodontic problems & other ill- effects of mouth breathing
Asthma
TREATMENT- I. Allergen avoidance
II. Treatment with drugs- 1. Antihistaminics
2. Sympathomimetic drugs (oral/topical)
3. Corticosteroids
4. Na cromoglycate
5. Anticholinergics
6. LT receptor antagonists
7. Anti IgE
III. Immunotherapy/Hypo sensitization
Step-care approach- Oral antihistamines/intranasal cromolyn Na
Intranasal corticosteroids
Combination (oral non sedating antihistamines + intranasal steroids)
Short course of steroids & immunotherapy
Oral decongestants + antihistamines/short course of intranasal decongestants
Avoid allergens & irritants
ENT- ORAL CAVITY
1. LIPS
Parts- Oral
Pharyngeal
4 anatomic sites- Tip
Dorsal surface
Lateral surface
Ventral surface
Muscles- Extrinsic- Genioglossus
Hyoglossus
Styloglossus
Palatoglossus
Intrinsic- Superior longitudinal
Inferior longitudinal
Vertical
Transverse
2. BUCCAL/ CHEEK MUCOSA
3. GUMS/ GINGIVAE
4. RETROMOLAR TRIGONE
Apex- Maxillary tuberosity
Base- Posterior most molar
5. HARD PALATE
6. ORAL TONGUE (ANTERIOR 2/3)
7. FLOOR OF MOUTH
LYMPHATIC DRAINAGE- 1. Lips- Lower- Medial- Submental LN
Lateral- Submandibular LN
2. Buccal mucosa- submandibular & submental LN
3. Upper & lower alveolar ridges- Submandibular & submental LN
4. Hard palate- Upper deep cervical & lateral retropharyngeal LN
5. Floor of mouth- Anterior- Submandibular LN
Posterior- Upper deep cervical LN
6. Tongue- Tip- Submental & jugulo-omohyoid LN
Lateral- ipsilateral Submandibular & deep cervical LN
Central & base- Deep cervical LN of both sides
ENT
CHOLESTEATOMA/EPIDERMOSIS/KERATOMA
Definition- Cystic structure lined by Keratinised squamous epithelium resting on fibrous stroma
in ME/Mastoid
2 Parts- Matrix
Keratin debris
ORIGIN- 1. Congenital cell nests
2. Retraction pockets (Wittmaack theory)
3. Basal cell hyperplasia (Ruedi theory)
4. Epithelial invasion(Habermann theory)
5. Metaplasia(Sade theory)
CLASSIFICATION:- 1. CONGENITAL- Epidermal Cell Rests
Intact TM
Conductive Hearing Loss
3 SITES- ME(TM, Mesotympanum)
Petrous Apex
CP Angle
2. PRIMARY ACQUIRED- A. Pars Flaccida Invagination
B. Basal Cell Hyperplasia
C. Squamous Metaplasia
3. SECONDARY ACQUIRED- A. Squamous Epithelium Migration
B. Metaplasia
Effects- 1. Chemical theory
2. Ischemic theory
3. Enzymatic theory
CSOM
Definition- long standing infection of part/ whole of mucoperiosteal lining of ME cleft
characterised by discharge, conductive hearing loss & TM perforation
CLASSIFICATION:- OLDER- 1. TUBOTYMPANIC/ SAFE/ BENIGN- ME cleft anteroinferior part
Profuse discharge
Central perforation
Granulation rare
Pale polyp
Cholesteatoma absent
Complications rare
Mild- moderate conductive deafness
2. ATTICOANTRAL/ UNSAFE/ DANGEROUS- ME cleft posterosuperior part
Scanty discharge
Marginal perforation
Granulation common
Red, fleshy polyp
Cholesteatoma present
Complications common
Conductive/ mixed deafness
NEWER- A. MUCOSAL DISEASE- 1. ACTIVE
2. INACTIVE (Permanent Perforation)
3. HEALED(Adhesive OM)
B. SQUAMOSAL DISEASE- 1. RETRACTION POCKETS
2. ACTIVE ( CHOLESTEATOMA + DISCHARGE)
ETIOLOGY- I. TTD- 1. ASOM Sequelae
2. Ascending infections via ET
3. Persistent mucous otorrhoea
II. AAD- 1. Cholesteatoma
Sclerotic Mastoid
PATHOLOGY- I. TTD- 1. Pars tensa perforation
2. ME mucosa
3. Polyp
4. Ossicular chain
5. Tympanosclerosis
6. Fibrosis & adhesions
II. AAD- 1. Cholesteatoma
2. Osteitis & granulation tissue
3. Ossicular necrosis
4. Cholesterol granuloma
Bacteriology- Aerobic - Pseudomonas
Proteus
E.coli
Staph.aureus
Streptococci
Anaerobic- B.fragilis
CLINICAL FEATURES- SYMPTOMS- I. TTD- 1. Ear discharge- mucoid/ mucopurulent
Non foul smelling
Painless
2. Conductive hearing loss
Round window shielding effect
3. Central TM Perforation
4. ME mucosa
II. AAD- 1. Ear discharge- scanty
Foul smelling
Cholesteatoma hearer
3. Bleeding
4. Tinnitus
5. Facial nerve paralysis / twitching
SIGNS- AAD- 1. Attic/ PS Marginal TM perforation
2. Retraction pocket
Stages- I - not contact incus
II - contact incus, ME mucosa intact
III - ME Atelectasis
IV - Adhesive OM
Sade Classification of PT retraction- Grade I- Slight TM retraction over annulus
Grade II- Severe TM retraction touching incus long process
Grade III- Atelectasis (touches promontory)
Grade IV- Adhesive OM (adherent to promontory)
TOS Classification of PF retraction- Grade I- Small attic dimple
Grade II- PF retracted maximally & draped over malleus neck
Grade III- Grade II + Scutum erosion
Grade IV- Deep retraction with unreachable accumulated keratin
3. Cholesteatoma
TTD- 1. Central TM perforation
Investigations- 1. Examination under microscope
2. Audiogram
3. Tuning Fork Tests
4. Culture & sensitivity of ear discharge
5. Mastoid X-ray/ CT Temporal bone
6. Patch test
TREATMENT- I. TTD- 1. Aural Toilet- Dry Mopping
Wet Mopping
Syringing
2. Topical & Systemic Antibiotics
3. Surgery- Myringoplasty with/without ossicular reconstruction
Tympanoplasty
II. AAD- 1. Surgical- A. CWD Procedures- Modified Radical Mastoidectomy
B. CWU Procedures
2. Reconstructive Surgery- Myringoplasty
Tympanoplasty
3. Conservative- repeated suction clearance & periodic follow up
COMPLICATIONS
INFLUENCING FACTORS- 1. Age
2. Poor socio economic groups
3. Virulence of organisms
4. Immunocompromised host
5. Preformed pathways
6. Cholesteatoma
PATHWAYS- 1. Direct bone erosion
2. Venous thrombophlebitis
3. Preformed pathways- congenital dehiscence
Patent sutures
Previous skull fractures
Surgical defects
Infection from labyrinth
Oval & round windows
CLASSIFICATION:- I. INTRA TEMPORAL- 1. MASTOIDITIS
2. PETROSITIS
3. FACIAL PARALYSIS
4. LABYRINTHITIS
II. INTRA CRANIAL- 1. EXTRA DURAL ABSCESS
2. SUB DURAL ABSCESS
3. MENINGITIS
4. BRAIN ABSCESS
5. LATERAL SINUS THROMBO PHLEBITIS
6. OTITIC HYDROCEPHALUS
OM SEQUELAE- 1. TM perforation
2. Ossicular erosion
3. Atelectasis & Adhesive OM
4. Tympanosclerosis
5. Cholesteatoma
7. SNHL
8. Speech impairment
9. Learning disabilities
ACUTE MASTOIDITIS
Definition- inflammation of mucosal lining of antrum & mastoid air cell system
ETIOLOGY- ASOM
Highly virulent organisms
Lowered patient resistance
Beta- hemolytic streptococci
Pathology- 1. Pus production under tension
2. Hyperemic decalcification & osteoclastic resorption
Types- AM without periosteitis / osteitis
AM with periosteitis
AM with osteitis
CLINICAL FEATURES- SYMPTOMS- 1. Pain behind ear
2. Fever
3. Ear discharge > 3 weeks
SIGNS- 1. Mastoid tenderness over antrum/ supra meatal triangle
2. Light house effect
3. PS meatal wall sagging
4. TM perforation
5. Swelling over mastoid
7. General findings
8. Negative tragal sign
9. Retro auricular swelling
Investigations- 1. Blood counts
2. ESR
3. X-Ray Mastoid
4. Ear swab
D/d- Mastoid LN Suppuration
Meatus Furunclosis
Infected sebaceous cyst
Antibiotics
Myringotomy
Cortical mastoidectomy
COMPLICATIONS- Sub periosteal abscess
Other complications of CSOM
ABSCESSES- 1. Post Auricular
2. Zygomatic
3. Bezold
4. Meatal/ Luc
5. Citelli
6. Para/ Retro Pharyngeal
MASKED/ LATENT MASTOIDITIS
Definition- slow destruction of mastoid air cells without acute signs & symptoms
ETIOLOGY- inadequate antibiotic therapy
Drug resistance
CLINICAL FEATURES- child
Mild pain behind ear
Persistent hearing loss
TM thick
TREATMENT- Cortical Mastoidectomy
Full antibiotics dose
PETROSITIS
Pathology- postero superior tract
Antero inferior tract
CLINICAL FEATURES- Gradenigo syndrome- Triad of external rectus palsy+deep-seated
ear/retro-orbital pain+ persistent ear discharge
Persistent ear discharge with/without deep-seated pain
Fever, headache, vomiting, neck rigidity
Facial paralysis
Recurrent vertigo
DIAGNOSIS:- CT Temporal bone
MRI
TREATMENT- Cortical/Modified Radical/Radical Mastoidectomy
Fistulous tract curettage & enlargement
IV antibiotics
FACIAL NERVE PARALYSIS
ASOM- Bony canal dehiscence
Recover fully with systemic antibiotics
Myringotomy/ Cortical Mastoidectomy
CSOM- Cholesteatoma/Penetrating granulation tissue
Insidious, slowly progressive
ME & Mastoid urgent exploration
Nerve resection & graft
LABYRINTHITIS
TYPES- 1. Circumscribed
2. Diffuse Serous
3. Diffuse suppurative
CIRCUMSCRIBED LABYRINTHITIS/FISTULA OF LABYRINTH
Thinning/ erosion of Bony capsule of labyrinth (horizontal SCC)
ETIOLOGY- 1. CSOM with Cholesteatoma
2. ME neoplasms
3. Surgical/ accidental trauma
CLINICAL FEATURES- Transient vertigo induced by pressure on tragus , ear cleaning/Valsalva
maneuver
DIAGNOSIS:- Fistula test- 1. Pressure on tragus
2. Siegel speculum- Quick component towards affected ear (ampullopetal endolymph flow)
Negative pressure application- Quick component towards healthy ear (Ampullofugal
displacement)
TREATMENT- Mastoid exploration
DIFFUSE SEROUS LABYRINTHITIS
Reversible, diffuse intralabyrinthine inflammation without pus formation
ETIOLOGY- 1. Pre existing Circumscribed Labyrinthitis
2. ME cleft acute infections
3. Following Stapedectomy/fenestration operation
CLINICAL FEATURES- Mild cases- vertigo & nausea
Severe cases- marked nausea, vomiting & spontaneous nystagmus(quick component towards
affected ear)
TREATMENT- Medical- 1. Head immobilized with affected ear above
2. Antibacterial therapy
3. Labyrinthine sedatives (Prochlorperazine, Dimenhydrinate)
4. Myringotomy
Surgical- Cortical/Modified Radical Mastoidectomy
DIFFUSE SUPPURATIVE LABYRINTHITIS
Diffuse cryogenic infection of labyrinth with permanent loss of vestibular & cochlear functions
ETIOLOGY- Serous Labyrinthitis
CLINICAL FEATURES- Severe vertigo with nausea & vomiting
Spontaneous nystagmus (quick component towards healthy ear)
Total hearing loss
Markedly toxic patient
TREATMENT- Mastoid exploration
Rarely labyrinth drainage
EXTRADURAL ABSCESS
Definition- pus collection between bone & Dura
Pathology- ASOM- hyperemic dura decalcification
CSOM- Cholesteatoma
Spread by venous thrombo phlebitis
Peri sinus abscess
CLINICAL FEATURES- asymptomatic & silent
Discovered accidentally
1. Persistent headache on affected side
2. Severe otalgia
3. General malaise with low grade fever
4. Pulsatile purulent ear discharge
5. Headache disappears with free pus flow ( spontaneous abscess drainage)
DIAGNOSIS:- Contrast enhanced CT/MRI
TREATMENT- 1. Cortical/ Modified Radical/ Radical Mastoidectomy
2. Antibiotics cover for minimum 5 days
SUBDURAL ABSCESS
Definition- pus collection between dura & arachnoid
Pathology- Bone/ dura erosion
Thrombo phlebitis
CLINICAL FEATURES- 1. Meningeal irritation- headache, fever, malaise, increasing
drowsiness, neck rigidity & positive Kernig sign
2. Cortical venous thrombo phlebitis- aphasia, hemiplegia, hemianopia
Jacksonian type of epileptic fits
3. Raised ICT- papilledema, ptosis,dilated pupil, other CN involvement
Diagnosis:- CT/MRI
TREATMENT- LP not done
Burr holes series/ Craniotomy
IV antibiotics
Mastoidectomy
MENINGITIS
Definition- leptomeninges inflammation usually with bacterial CSF invasion in sub arachnoid
space
Mode of infection- blood borne ( infants & children)
Chronic ear disease ( adults) by bone erosion/ retrograde thrombo phlebitis
CLINICAL FEATURES- 1. Fever with chills & rigors
2. Headache
3. Neck rigidity
4. Photophobia & mental irritability
5. Nausea & vomiting
6. Drowsiness
7. CN palsies & hemiplegia
8. Positive Kernig sign
9. Positive Brudzinski sign
10. Papilledema
11. Tendon reflexes exaggerated
Diagnosis:- Contrast enhanced CT/MRI
LP & CSF Examination
Culture & antibiotics sensitivity
Treatment- Medical- IV Antibiotics
Steroids
Surgical- Myringotomy/ Cortical Mastoidectomy
Radical/ Modified Radical Mastoidectomy
OTOGENIC BRAIN ABSCESS
CSOM with Cholesteatoma (adults)
ASOM( children)
Mode of infection- ME infection direct extension through Tegmen/ Retrograde Thrombo phlebitis
Cerebellar abscess
Bacteriology- Aerobic- Pyogenic Staphylococcus
Streptococcus hemolyticus
Proteus
E.coli
Pseudomonas
Anaerobic- B.fragilis
Pepto streptococcus
Pathology- 1. Stage of invasion / Initial encephalitis
2. Stage of Localization/ Latent abscess
3. Stage of enlargement/ Manifest abscess
4. Stage of termination/ Abscess rupture
CLINICAL FEATURES- I. Raised ICT- 1. Headache
2. Nausea & vomiting
3. Level of consciousness
4. Papilledema
5. Slow pulse & subnormal temperature
II. Localizing features- A. Temporal lobe abscess- 1. Nominal aphasia
2. Homonymous hemianopia
3. Contralateral motor paralysis
4. Epileptic fits
5. Pupillary changes & CN3 palsy
B. Cerebellar abscess- 1. Headache
2. Spontaneous nystagmus
3. Ipsilateral hypotonia & weakness
4. Ipsilateral ataxia
5. Past Pointing & intention tremors
6. Dysdiadochokinesia
Investigations- 1. Skull X-ray
2. CT scan
3. X-ray/ CT Mastoid
4. LP
Treatment- Medical- High dose IV antibiotics ( Chloramphenicol, 3rd generation cephalo sporin,
Aminoglycosides, Metronidazole)
Steroids
Suction clearance
Topical ear drops
Neurosurgical- 1. Repeated aspirations through Burr holes
2. Abscess excision
3. Abscess open incision & pus evacuation
Otologic- Antibiotics
Radical Mastoidectomy
LATERAL SINUS THROMBOPHLEBITIS/ SIGMOID SINUS THROMBOSIS
Definition- Inflammation of inner wall of lateral venous sinus with intra sinus thrombus formation
ETIOLOGY- Acute coalescent mastoiditis
Masked Mastoiditis
CSOM
Cholesteatoma
Pathology- 1. Peri Sinus abscess formation
2. Endophlebitis & Mural thrombus formation
3. Sinus lumen obliteration & intra sinus abscess
4. Thrombus extension
Bacteriology- acute cases- hemolytic streptococcus
Pneumococcus
Staphylococcus
Chronic cases- B.proteus
Pseudomonas
E.coli
Staphylococcus
CLINICAL FEATURES- 1. Hectic Picket fence type fever with rigors
2. Headache
3. Progressive anemia & emaciation
4. Griesinger sign
5. Papilledema
6. Tober- Ayer test
7. Crowe- Beck test
8. Tenderness along jugular vein
Investigations- 1. Blood smear
2. Blood culture
3. CSF Examination
4. X-ray Mastoid
5. Contrast enhanced CT- delta sign
6. Culture & sensitivity
COMPLICATIONS- 1. Septicemia & pyemic abscess
2. Meningitis & subdural abscess
3. Cerebellar abscess
4. Jugular bulb & vein thrombosis
5. Cavernous sinus thrombosis
6. Otitic Hydrocephalus
Treatment- 1. IV antibiotics
2. Mastoidectomy & Sinus exposure
3. IJV ligation
4. Anticoagulants therapy
5. Supportive- repeated blood transfusions
OTITIC HYDROCEPHALUS
Definition- raised ICT with normal CSF findings
MECHANISM- Lateral Sinus thrombosis accompanying ME infections
Superior sagittal Sinus thrombus extension
CLINICAL FEATURES- SYMPTOMS- 1. Severe headache, nausea & vomiting
2. Diplopia
3. Blurring of vision
SIGNS- 1. Papilledema
2. Nystagmus
3. LP - increased CSF pressure
TREATMENT- Acetzolamide
Steroids
Repeated LP
Lumbar drain placement
Lumboperitoneal shunt
Antibiotics
Mastoid exploration
ENT
LARYNX
ANATOMY- C3-C6
CARTILAGES- I. UNPAIRED- 1. THYROID
Vocal cords attachment
Cricothyrotomy
2. CRICOID- only cartilage to form complete ring
Posterior Part- Lamina
Anterior Part- Arch
3. EPIGLOTTIS- Anterior wall of laryngeal inlet
Hyoepiglottic ligament
Petiole
Pre epiglottic space(Ca of supraglottic larynx/base of tongue)
Tubercle of epiglottis
Several pits(perforations/ supraglottic cancer spread)
II. PAIRED- 1. ARYTENOIDS- Base (cricoarytenoid joint)
Muscular process (intrinsic laryngeal muscles)
Vocal process (vocal cords)
Apex(corniculate cartilage)
2. CORNICULATE/ CARTILAGE OF SANTORINI
3. CUNEIFORM/CARTILAGE OF WRISBERG
JOINTS- 1. CRICOARYTENOID- Rotatory & gliding movements
2. CRICOTHYROID
MEMBRANES & LIGAMENTS- I. EXTRINSIC- 1. THYROHYOID MEMBRANE
2. CRICOTRACHEAL MEMBRANE
3. HYOEPIGLOTTIC LIGAMENT
II. INTRINSIC- 1. CRICOVOCAL MEMBRANE- Upper border- Vocal ligament
Lower border- Conus elasticus(subglottic FB)
2. QUADRANGULAR MEMBRANE
3. CRICOTHYROID LIGAMENT
4. THYROEPIGLOTTIC LIGAMENT
MUSCLES- I. INTRINSIC- A. ACTING ON VOCAL CORDS- 1. ABDUCTOR- POSTERIOR
CRICOARYTENOID
2. ADDUCTOR- LATERAL CRICOARYTENOID
INTERARYTENOID
THYROARYTENOID
3. TENSOR- CRICOTHYROID
VOCALIS
B. ACTING ON LARYNGEAL INLET- 1. OPENER- THYROEPIGLOTTIC
2. CLOSER- INTERARYTENOID
ARYEPIGLOTTIC
II. EXTRINSIC- A. ELEVATOR- 1. PRIMARY- STYLOPHARYNGEUS
SALPINGOPHARYNGEUS
PALATOPHARYNGEUS
THYROHYOID
2. SECONDARY- MYLOHYOID
DIGASTRIC
STYLOHYOID
GENIOHYOID
B. DEPRESSORS- STERNOHYOID
STERNOTHYROID
OMOHYOID
CAVITY- INLET OF LARYNX
1. VESTIBULE
2. VENTRICLE/ SINUS OF LARYNX
3. SUBGLOTTIS/ SUBGLOTTIC SPACE
VOCAL FOLDS/ TRUE VOCAL CORDS
STRUCTURE- 1. EPITHELIUM
2. LAMINA PROPRIA- A. SUPERFICIAL LAYER
B. INTERMEDIATE LAYER
C. DEEP LAYER
MOVEMENTS
VESTIBULAR FOLDS/ FALSE VOCAL CORDS
GLOTTIS/RIMA GLOTTIDIS
EPIGLOTTIS
Saccule of larynx- pouch of anterior part of sinus of larynx between vestibular folds & inner
surface of thyroid cartilage
MUCOUS MEMBRANE
BLOOD SUPPLY- Superior laryngeal artery & vein- above the vocal cords
Inferior laryngeal artery & vein below vocal cords
LYMPHATIC DRAINAGE- Glottis- Vocal cords- no lymphatics ( lymphatic watershed)( except
delphian node on cricothyroid membrane)
Supraglottis- after piercing thyrohyoid membrane end in upper deep cervical chain(on IJV)
Subglottis- through prelaryngeal & paratracheal lymph nodes into lower deep cervical and
mediastinal lymph nodes
Aryepiglottic fold- richest lymphatic supply
NERVE SUPPLY
SPACES- 1. PRE EPIGLOTTIC SPACE OF BOYER- Contents- Lymphatics
Fat
Areolar tissue
Boundaries- Front- Upper part of thyroid cartilage & thyrohyoid membrane
Behind- Infrahyoid epiglottis & quadrangular membrane
Above- Hyoepiglottic ligament
Importance- spread in carcinoma larynx & has to be cleared in laryngectomy
2. PARAGLOTTIC- Boundaries- Laterally—thyroid cartilage
Medially—ventricle & quadrangular membrane
Posteriorly—pyriform sinus
Anteriorly— space of Boyer
Importance- Growths can present in the neck through cricothyroid membrane.
3. REINKE- Boundaries- Superiorly- mm of vocal cord
Inferiorly- vocal cords
Anteriorly- anterior commissure
Posteriorly- vocal process of arytenoid cartilage
Importance- Reinke edema
Prevents spread of glottic carcinoma to deeper structures
PHYSIOLOGY- 1. LOWER AIRWAYS PROTECTION- A. Sphincteric closure of laryngeal
opening
B. Cessation of respiration
C. Cough reflex
2. PHONATION(aerodynamic myoelastic theory of voice production)- A. Vocal cords adduction
B. Infraglottic air pressure
C. Opening of Vocal cords
3. RESPIRATION
4. CHEST FIXATION
PAEDIATRIC LARYNX- High position
Cartilages soft & collapse easily
Flat thyroid cartilage
Small & conical larynx
Submucosal tissues comparatively loose
FB OF AIR PASSAGES
PREDISPOSING FACTORS- 1. Age: Children < 5 years
2. Unconsciousness: (coma, deep sleep, alcoholic intoxication, or anesthesia)
3. Disturbed swallowing: Coughing, laughing, talking, crying, or tapping on back during
swallowing
4. CN IX and CN X lesions: Paralysis of pharynx and larynx
Nature- 1. Irritating type
2. Nonirritating type
CLINICAL FEATURES- STAGES- 1. Initial period of choking, gagging & wheezing
2. Symptomless interval
3. Later symptoms
SITES- 1. Laryngeal- a. Complete obstruction 》 death
b. Partial obstruction- stridor, hoarseness of voice, respiratory difficulty
2. Tracheal- choking, stridor, wheezing, coughing, palpatory thud, audible slap
3. Bronchi- a. Cough, wheeze & diminished air entry to lung
b. Respiratory distress with FB swelling
c. Lung collapse/ Atelectasis, obstructive emphysema, pneumonitis, shifting FB, acute
laryngotracheobronchitis, pulmonary infections, lung abscess, spontaneous pneumothorax
DIAGNOSIS:- 1. Soft tissue PA & Lateral view
2. X-ray Chest - a. PA & Lateral view
B. At end of inspiration & expiration
3. Fluoroscopy/video fluoroscopy
4. CT Chest
5. Bronchograms
6. Laryngoscopy & bronchoscopy
TREATMENT- I. Medical: Antibiotics, steroids and oxygen administered immediately, and
continued after the bronchoscopy
II. A. Laryngeal FB- 1. Cricothyrotomy/ emergency tracheostomy
2. Direct laryngoscopy/laryngofissure
3. Heimlich’s maneuver
B. Tracheal & bronchial FB- 1. Bronchoscopy under GA
FB OF FOOD PASSAGES
SITES- 1. Tonsils
2. Base of tongue/ vallecula
3. Posterior pharyngeal wall
4. Pyriform fossa
5. Esophagus- A. Cricopharyngeal sphincter
B. Bronchoaortic constriction
C. Cardiac end
ETIOLOGY- 1. Age- < 5 years
2. Loss of protective mechanism- upper dentures, unconsciousness, deep sleep, epileptic
seizures, alcohol intoxication
3. Carelessness
4. Narrowed esophageal lumen- strictures, carcinoma
5. Psychotic
CLINICAL FEATURES- SYMPTOMS- 1. History of Initial choking/ gagging
2. Discomfort/ pain
3. Dysphagia
4. Drooling of saliva
5. Respiratory distress
6. Substernal/epigastric pain
7. Partial obstruction
SIGNS- 1. Tenderness in lower part of neck R/L of trachea
2. Pooling of secretions in pyriform fossa
3. Protruding FB
Investigations- 1. X-ray soft tissue neck PA & lateral view
2. X-ray Chest PA & lateral view
3. Oesophagoscopy
4. Barium Swallow
MANAGEMENT- 1. Endoscopic removal
2. Cervical esophagotomy
3. Transthoracic esophagotomy
4. FB passed into stomach
COMPLICATIONS- 1. Respiratory obstruction
2. Periesophageal cellulitis & abscess
3. Perforation
4. Tracheoesophageal fistula
5. Ulceration & strictures
6. Disc batteries- 1 hour- damage to mucosa
2-4 hours- muscles coat
8-12 hours- perforation
ENT
ESOPHAGUS DISORDERS
1. ACUTE ESOPHAGITIS
2. ESOPHAGUS PERFORATION
3. CORROSIVE BURNS OF ESOPHAGUS
4. BENIGN STRICTURES
5. HIATUS HERNIA
6. PLUMMER-VINSON/PATTERSON BROWN KELLY SYNDROME
Females, > 40 years
Atrophy of mm of alimentary tract, sub epithelial fibrosis in lower part of laryngo pharynx & iron
deficiency anemia
CLINICAL FEATURES- Dysphagia immediately after trying to swallow food
Iron-deficiency anemia
Glossitis
Angular stomatitis
Koilonychias (spooning of nails)
Achlorhydria
Potential of Malignant conversion- carcinoma of tongue, buccal mucosa, pharynx, esophagus or
stomach
Postcricoid carcinoma(10%)
DIAGNOSIS:- 1. Barium swallow: web (subepithelial fibrosis) in postcricoid region
2. Esophagoscopy: hypopharyngeal web
TREATMENT- 1. Oral/parenteral iron
2. Vitamins B12 and B6
3. Esophagoscopy and dilatation of webbed area with bougies
7. GLOBUS/ HYSTERICUS PHARYNGEUS
8. MOTILITY DISORDERS- I. HYPERMOTILITY- A. CRICOPHARYNGEAL SPASM
B. DIFFUSE ESOPHAGEAL SPASM
C. NUTCRACKER ESOPHAGUS
II. HYPOMOTILITY- A. CARDIAC ACHALASIA
B. GERD
Damage of esophageal mucosa due to abnormal reflux of gastric content
ETIOLOGY- High levels of progesterone in pregnancy
Sliding hiatus hernia
Fatty foods, chocolate & peppermints
Tobacco smoking & alcohol
Drugs
CLINICAL FEATURES- I. Typical: 1. Heartburn & acid regurgitation after meal when patient
recumbent
2. Dysphagia, odynophagia & belching
3. Angina-like chest pain, which worsens after sublingual nitroglycerin, while lying in bed at night
II. Atypical GERD symptoms/ extraesophageal GERD- 1. Dental erosions
2. Reflux laryngitis or laryngoesophageal reflux (Hoarseness of voice)
3. Asthma-like symptoms
DIAGNOSIS:- 1. Clinical
2. Esophagogastroduodenoscopy
3. Ambulatory 24-hour pH monitoring
4. Bernstein test
Subgroup- 1. Nonerosive reflux disease
2. Reflux esophagitis
3. Barrett esophagus
TREATMENT- I. Lifestyle modifications: Weight loss,Small & frequent meals, Avoid fats, sweets,
chocolate, tomatoes, onions, alcohol & caffeine at bedtime, Finish dinner 3 hours before going
to bed, Elevation of head end of bed during sleep
II. Medical treatment: Antacids,H2 receptor antagonists,Proton pump inhibitors, Prokinetic
drugs( 30 minutes before meal)
III.Antireflux surgery: Nissen’s fundoplication
IV. Recent developments- Endoscopic suturing, Injection of biopolymers in LES, Radiofrequency
delivery to gastroesophageal junction (GEJ)
COMPLICATIONS- Esophagitis
Ulcers in esophagus
Hemorrhage
Peptic stricture in esophagus
Aspiration pneumonia
Barrett’s esophagus
OME
Globus hystericus
C. SCLERODERMA
D. SCHATZKI RING
NEOPLASMS- I. BENIGN- 1. LEIOMYOMA
2. MUCOSAL POLYPS
3. LIPOMA
4. FIBROMA
5. HEMANGIOMAS
II. MALIGNANT- CARCINOMA OF ESOPHAGUS
ETIOLOGY- Smoking
Alcohol
Tobacco chewing
Preexisting pathologic lesions
Plummer Vinson syndrome
Pathology- 1. SCC
2. Adenocarcinoma
SPREAD- 1. Direct
2. Lymphatic
3. Blood Borne
CLINICAL FEATURES- 1. Early symptoms- substernal discomfort and preference for soft or
liquid food
2. Progressive dysphagia & emaciation
3. Pain
4. Aspiration problems
DIAGNOSIS:- 1. Ba Swallow
2. Esophagoscopy
3. Bronchoscopy
4. CT scan
TREATMENT- RT
Surgery
Palliation
DYSPHAGIA
ETIOLOGY- I. Pre Esophageal- A. Oral Phase- 1. Disturbance in Mastication(trismus, mandible
fractures)
2. Disturbance in Lubrication(xerostomia)
3. Disturbance in Tongue mobility(tongue tumors)
4. Palate Defects (cleft palate)
5. Buccal Cavity & Floor of Mouth Lesions (Ludwig angina)
B. Pharyngeal Phase-1. Obstructive Pharynx Lesions(tumors)
2. Inflammatory Conditions(acute tonsillitis, Quinsy, retro/para pharyngeal abscess)
3. Spasmodic Conditions (tetanus)
4. Paralytic Conditions (CVA, bulbar palsy)
II. Esophageal- 1. Lumen (FB,strictures, atresia)
2. Wall- a. Hypomotility Disorders
b. Hypermotility Disorders
3. Outside the Wall (hiatus hernia, thyroid lesions)
INVESTIGATIONS- 1. History- A. Sudden Onset (FB/ food impaction)
B. Progressive (malignancy)
C. Intermittent (spasmodic)
D. More to Liquid(paralytic)
E. More to Solid(malignancy/ strictures)
F. Intolerance to Acid Food/ Fruit Juices(ulcerative)
2. Clinical Examination
3. Blood Examination
4. Radiography- A. X-ray Chest
B. Lateral View Neck
C. Ba Swallow
5. Manometric & pH Studies
6. Oesophagoscopy
7. Other Investigations- a. Bronchoscopy
b. Cardiac catheterization
c. Thyroid scan
ENT
THYROID GLAND & DISORDERS

SURGICAL ANATOMY- 5×3×2 cm
I. CAPSULES- True capsule
False capsule
II. POSTERIOR SUSPENSORY / BERRY LIGAMENT
III. ANTERIOR SUSPENSORY LIGAMENT
IV. SLN
V. RLN
VI. NRLN
VII. ARTERY- SUPERIOR THYROID ARTERY
INFERIOR THYROID ARTERY
THYROIDEA IMA
VIII. VEINS- SUPERIOR THYROID VEIN
MIDDLE THYROID VEIN
INFERIOR THYROID VEIN
IX. LYMPHATIC DRAINAGE- CENTRAL COMPARTMENT (LEVEL 6)
SUPERIOR MEDIASTINUM( LEVEL 7)
LEVEL 1,2,4
X. PARATHYROID GLAND
XI. STRAP MUSCLES & NERVE SUPPLY
XII. RLN TRIANGLE OF LORE
XIII. LINGUAL THYROID
PHYSIOLOGY
BENIGN DISORDERS- 1. HASHIMOTO/ CHRONIC LYMPHOCYTIC THYROIDITIS
2. HYPOTHYROIDISM
3. GRAVES DISEASE
MALIGNANT DISORDERS- 1. PAPILLARY THYROID CARCINOMA (65-70%)
3rd-4th decade
Follicular cells of thyroid
FNAC- Orphan Annie eye appearance
Psammoma bodies
RISK FACTORS- 1. Ionizing radiation
2. Familial- Cowden syndrome
Gardener syndrome
CLINICAL FEATURES- 1. Asymptomatic thyroid mass
2. Metastatic nodes in neck
3. Symptoms of local invasion of strap muscles, trachea, esophagus, laryngeal nerves
4. Pulmonary/ bony metastases with/ without mass In neck
DIAGNOSIS:- FNAC
Ultrasound
TFT
CT/MRI
TREATMENT- 1. Lobectomy with isthmusectomy
2. Total/ near total thyroidectomy
3. Segmental excision
4. Cervical LN dissection
Follow up
2. FOLLICULAR CARCINOMA
3. HURTHLE CELL CARCINOMA
4. ANAPLASTIC CARCINOMA
5. MEDULLARY CARCINOMA (5%)
Parafollicular C cells
50-60 years
Both sexes
ETIOLOGY- 1. Sporadic - unifocal
2. Familial- multifocal, bilateral
MEN II A
MEN II B
Non MEN
CLINICAL FEATURES- neck mass with cervical LN
Pain, Dyspnea , dysphagia & voice hoarseness
Distant metastases in mediastinum, lung & bone
Variant- Mixed medullary carcinoma
DIAGNOSIS:- FNAC
Elevated Calcitonin levels
RET proto oncogene mutation
Serum Ca levels
24 hours urine for catecholamines/ metanephrine
TREATMENT- 1. Total thyroidectomy
2. Comphrensive neck dissection
3. Pheochromocytoma removal
4. Postoperative followup
6. LYMPHOMA
7. METASTASES TO THYROID
THYROID NODULE (4-7%)
50-60 years
1. COLLOID NODULE
2. ADENOMA- A. FOLLICULAR ADENOMA
B. HURTHLE CELL ADENOMA
3. THYROID CYST
4. REGENERATIVE NODULE
5. DOMINANT NODULE
6. AUTONOMOUS/ TOXIC NODULE
7. CARCINOMA
8. METASTATIC DEPOSITS IN THYROID
EVALUATION- 1. History
2. Physical Examination
3. TFT
4. Ultrasound
5. Thyroid Scan
6. FNAC
7. CT/MRI
MANAGEMENT- 1. Suppressive Therapy
2. Radioactive I2 Coblation
3. Surgery
4. Follow up
THYROID SURGERY
INDICATIONS- 1. Thyroid Cancer
2. Cancer Suspicion
3. Compressive Symptoms
4. Cosmetic
TYPES- 1. Hemi Thyroidectomy / Thyroid Lobectomy
2. Subtotal Thyroidectomy
3. Near Total Thyroidectomy
4. Total Thyroidectomy
5. Isthmusectomy
6. Completion Thyroidectomy
PREOPERATIVE WORKUP- 1. History
2. Physical Examination
3. TFT
4. IDL
5. FNAC
6. TPO Ab
7. Calcitonin Levels
8. Serum Ca Levels
9. Ultrasound
10. Thyroid Scan
11. CT Chest
12. Other Investigations
ANAESTHESIA- GA+ Endotracheal Intubation
POSITION- Supine + Neck Extension (Rose)
STEPS- 1. Incision
2. Elevation of Flaps
3. Strap Muscles Separation
4. Thyroid Palpation
5. Vessels Ligation & Thyroid Lobe Dissection
6. Superior Thyroid Pedicle & Upper Pole Dissection
7. Parathyroid & Blood Supply Preservation
8. Isthmus Division & thyroid Lobe Separation
9. Wound Irrigation
10. Wound Closure
COMPLICATIONS- 1. Haematoma
2. Airway Obstruction
3. RLN Injury
4. SLN Injury
5. Wound infection
6. Hypocalcaemia
7. Pneumothorax
8. Hypothyroidism
ENT
HIV-AIDS & ENT MANIFESTATIONS

Modes of transmission- 1. Sexual contact
2. Non sterile skin piercing instruments
3. Blood & blood products
4. Infected mothers to infant
Structure of HIV 1 virion- 1. Lipid membrane
2. Envelope glycoprotein- a. Gp 120
b. Gp 21
3. Viral core proteins- a. Matrix protein p17
b. Capsid protein p24
c. Nucleocapsid protein p6,7
d. ssRNA
e. Viral enzymes
Life cycle- 1. Binding to CD 4+ receptor
2. Fusion
3. Reverse transcription
4. Integration
5. Synthesis
6. Functional viral proteins
Course of disease- 1. Initial viraemia
2. Latent period
3. Advanced disease
ENT MANIFESTATIONS- TYPES- 1. Opportunistic infection
2. Unusual Malignancies
3. Neurological disorders
I. EAR- Kaposi sarcoma
Seborrheic dermatitis of EAC
Malignant OE
Serous OM
Acute OM
Pseudomonas & candida infections of EE & ME
Mycobacterial infections
SNHL
Ramsay Hunt Syndrome
Facial paralysis
II. NOSE & PNS- Herpetic lesions
Recurrent sinusitis
Chronic sinusitis
Fungal sinusitis
Kaposi sarcoma
Lymphoma B- cell
Burkitt lymphoma
III. ORAL CAVITY & OROPHARYNX- Candida infections
Herpetic lesions of palate, buccal mucosa, lips/ gums
Giant aphthous ulcers
Adenotonsillar hypertrophy
Generalized lymphadenopathy
Kaposi sarcoma of palate
NHL of tonsils/ tongue
Hairy leukoplakia
Gingivitis
IV. LARYNX- Laryngitis (fungal, viral/ tubercular)
Kaposi sarcoma
NHL
V. SALIVARY glands- Parotitis
Xerostomia
Diffuse Parotid enlargement
Lymphepithelial cyst of parotid
Kaposi sarcoma
NHL
VI. NECK- Lymphadenopathy
DIAGNOSIS:- 1. ELISA
2. Western Blot
3. CD4 count
4. p24 antigen assay
5. PCR
MANAGEMENT- 1. Wash the exposed areas
2. ELISA
3. Drug prophylaxis
Universal safety precautions
Drugs- 1. NNRTI
2. NRTI
3. PI
4. Fusion inhibitors
5. Integrase inhibitors
ENT
LARYNGOTRACHEAL TRAUMA
ETIOLOGY- 1. Automobile accident
2. Blow/ kick on neck
3. Neck striking against stretched wire/ cable
4. Strangulation
5. Penetrating injuries
Pathology- 1. Bruises
2.Tear & laceration of mucosa 》SC emphysema
3. Fractures: Compound (external/internal) or comminuted fractures of laryngeal framework A.
Hyoid bone
B. Thyroid cartilage (vertical or transverse)
C. Cricoid cartilage
D. Upper tracheal cartilages
4. Hematoma & edema of supraglottic or subglottic region
5. Dislocation of joints- A. Cricoarytenoid joints
B. Cricothyroid joint
6. Laryngotracheal separation
CLINICAL FEATURES- SYMPTOMS- 1. Stridor
2. Hoarseness of voice or aphonia
3. Pain and difficulty in swallowing
4. Aspiration of food, blood and secretions
5. Local laryngeal pain may be marked on speaking or swallowing
6. Hemoptysis
SIGNS- 1. Cervical bruises or abrasions
2. Tenderness in the laryngeal area
3. Subcutaneous emphysema
4. Flattening of thyroid prominence and anterior cervical contour
5. Gap & crepitus between fractured fragments of thyroid and cricoid cartilages or hyoid bone
6. Cricoid cartilage may get separated from larynx or trachea
DIAGNOSIS:- 1. Laryngoscopy- A. Fiberoptic laryngoscopy (flexible through the nose)
B. IDL/ Rigid endoscopy of the larynx
2. X-ray soft tissue neck lateral view
3. CT scan
4. X-ray chest(pneumothorax)
5. Gastrografin swallow(esophageal tears)
COMPLICATIONS- 1. Laryngeal stenosis (Supra glottic, glottic or subglottic)
2. Perichondritis & Laryngeal abscess
3. Vocal cord paralysis
TREATMENT- I. Conservative- 1. Watch out for respiratory distress
2. Voice rest
3. Humidification of inspired air
4. Steroids
5. Antibiotics
II. Surgical- 1. Management of impaired airway (tracheostomy)
2. Open reduction- A. Wire and titanium miniplate
B. Absorbable sutures
C. Removal of loose fragments of cartilage and avulsed epiglottis and arytenoids
D. Anchoring(Arytenoid & epiglottis repositioned in their normal position)
E. End to end anastomosis
F. Internal splint of laryngeal structures
ENT
SNORING & SLEEP APNEA

SNORING
Definition- rough, rattling inspiratory noise produced by vibration of pendulous soft palate, or
occasionally of vocal cords, during sleep
Terms- 1. Apnea index
2. Hypopnea
3. RDI/apnea- hypopnea index
4. Arousal
5. Arousal index
6. Sleep efficiency
7. Multiple sleep latency test/ nap study
TYPES- 1. Primary snoring: apnea-hypopnea index < 5 events/hour of sleep
2. Upper airway resistance syndrome: apnea- hypopnea index < 5 events/hour of sleep but
elevated arousal index (> 5 times/hour)
3. Complicated (associated with OSA)
MECHANISM- pharynx muscles relaxed 》 partial obstruction 》 vibration of soft
palate, tonsillar pillars & base of tongue
ETIOLOGY- 1. Adenoids hypertrophy (children)
2. Nose & nasopharynx - septal deviation, turbinate hypertrophy, nasal polypi
3. Oral cavity & oropharynx- tonsillitis, enlarged soft palate & uvula
4. Larynx & Laryngopharynx- laryngeal stenosis, omega shaped epiglotitis
Sites- soft palate, tonsillar pillars, hypopharynx
CLINICAL FEATURES- SYMPTOMS- excessive daytime sleepiness
Morning headache
General fatigue
Memory loss
Irritability & depression
Decreased libido
Increased risk of road accidents
TREATMENT- 1. Avoid alcohol, sedatives, hypnotic
2. Weight reduction
3. Sleeping on the side
4. Removal of obstructing lesions
5. Uvulopalatoplasty(UPP)(cold knife/RAUP/LAUP)
SLEEP APNEA
Definition- intermittent cessation of breathing for 10 seconds or longer during sleep
TYPES- 1. Obstructive sleep apnea syndrome: transient upper airway obstruction 》
intermittent cessation of air flow or breathing though normal respiratory effort
Apnea-hypopnea index > 5 events/hour of sleep
2. Central sleep apnea: Intermittent failure in respiratory drive centers in CNS 》
cessation in air flow or breathing
No obstruction in upper respiratory tract
3. Mixed sleep apnea: components of both central and obstructive sleep apnea
Pickwickian syndrome: characterized by obesity and hypersomnolence
Pathophysiology- obstruction at any level of upper respiratory tract (from nose-true vocal cords)
Muscle relaxation & negative pressure 》 collapse & obstruction of airway in
patients(redundant tissue or narrow airway) 》oxyhemoglobin desaturation 》
arousal 》patient to lighter level of sleep 》upper respiratory airway established
again with loud snorting breathing
COMPLICATIONS- 1. CHF/ cor pulmonale
2. CVA
3. Polycythemia & hypertension
4. Atrial & ventricular arrhythmias & LHF
5. Anginal attack
6. Snoring spouse syndrome
7. Memory loss
8. Decreased libido
9. Traffic accidents
10. Peripheral Edema
CLINICAL FEATURES- SYMPTOMS- 1. Snoring
2. Daytime somnolence
3. Drowsiness at work
4. Morning headache & fatigue
5. Restless sleep
6. Periods of apnea (cessation of breathing)
7. Sudden awakening & gasping for air
8. Decreased libido & impotence
9. Indigestion & gastroesophageal reflux disease
10. Hypertension
11. Decreased cognitive function including memory loss
12. Personality changes, depression & psychosis
13. Nocturnal headache, sweating, enuresis
CLINICAL EVALUATION- I. History
II. Physical examination- 1. BMI
2. Collar size
3. Complete head & neck examination
4. Muller manuevre
III. Systemic examination
IV. Cephalometric Radiograph
V. Polysomnography- EEG
ECG
EOM
EMG
Pulse Oximetry
Nasal & oral airflow
Sleep position
BP
Esophageal pressure
VI. Split night polysomnography
TREATMENT- I. Medical- 1. Change in lifestyle
2. Positional therapy
3. Intraoral devices (MAD, TRD)
4. CPAP
II. Surgical- 1. Nasal surgery
2. Oropharyngeal surgery
3. Tonsillectomy &/ adenoidectomy
4. Advancement genioplasty with hyoid suspension
5. Tongue base radiofrequency
6. Maxillomandibular advancement osteotomy
7. Permanent tracheostomy
ENT
OPERATIVE PROCEDURES IV
1. TRACHEOSTOMY
DEFINITION- opening in anterior wall of trachea created & converted into stoma on skin surface
Tracheotomy- opening trachea
Functions- 1. Obstruction- Bypass obstruction in upper airway from pharynx to larynx
2. Improves alveolar ventilation- a. Decrease dead space
b.Reduces resistance to airflow
3. Protection against aspiration of secretions and blood
4. Secretions removal: Pharyngeal secretions(bulbar paralysis and coma)
Blood(Bleeding from pharynx, larynx and maxillofacial injuries)
5. Packing
6. Suction clearance of tracheobronchial secretions
7. Intermittent positive pressure respiration (IPPR)
8. Anesthesia(laryngo-pharyngeal growths & marked trismus of oral submucous fibrosis)
INDICATIONS- I. Respiratory obstruction- A. Infections- 1. Acute laryngo- tracheo- bronchitis,
acute epiglottitis,diphtheria
2. Ludwig angina,Quinsy,Retropharyngeal abscess
B. Trauma- 1. External injury to larynx & trachea
2. Endoscopy
3. Fractures of mandible & maxillofacial injuries
C. Neoplasms- benign & malignant of larynx, pharynx, upper trachea, tongue, thyroid
D. FB larynx
E. Bilateral abductor paralysis
F. Congenital anomalies- 1. T-O fistula, laryngeal web
2. Bilateral choanal atresia
II. Retained secretions- A. Inability to cough- 1. Coma(head injuries, CV strokes, accidents,
narcotic poisoning)
2. Paralysis of respiratory muscles(spinal injuries, polio, Guillain-Barre syndrome & myasthenia
gravis)
3. Spasm of respiratory muscles(tetanus, eclampsia, strychnine poisoning)
B. Painful cough: Chest injuries, multiple rib fractures, pneumonia
C. Aspiration of secretions: Bulbar polio, polyneuritis, bilateral laryngeal paralysis
III. Respiratory insufficiency: Emphysema, chronic bronchitis, bronchiectasis & atelectasis
TYPES- I. 1. Emergency
2. Elective/ tranquil/orderly/routine- A. Therapeutic
B. Prophylactic
3. Permanent
4. Mini/ Cricothyroidotomy
II. 1. High
2. Mid
3. Low
Anaesthesia- endotracheal intubation
Position- supine + neck extension
STEPS- 1. Skin Incision:- vertical midline cervical incision from cricoid cartilage to just above
sternal notch(most frequently used)
Transverse incision—5 cm above sternal notch
2. Strap Muscles: first separated in midline & then retracted laterally
3. Thyroid Isthmus: either displaced upwards or divided between clamps
4. Trachea: After injecting few drops of 4% lignocaine, trachea incised with vertical incision in
region between second to fourth tracheal rings & then converted into circular opening
5. Tracheal Hook (blunt and sharp): Blunt tracheal hook retracts thyroid isthmus, & exposes
trachea.
6. Tracheal Dilator keeps cut tracheal edges open
7. Tracheostomy Tube: appropriate size of tracheostomy tube inserted & secured by tapes
Postoperative care- 1. Constant supervision
2. Suction
3. Prevention of crusting & tracheitis
4. Care of tracheostomy tube
5. Decannulation
COMPLICATIONS- 1. Immediate- a.Hemorrhage
b. Apnea
c. Pneumothorax
d. Vocal cord palsy
e. Tracheoesophageal fistula
f. Aspiration of blood
g. False passage
2.Intermediate- a. Bleeding: Reactionary & secondary
b. Displacement of tube
c. Obstruction of tube
d. Subcutaneous emphysema
e. Pneumomediastinum & pneumothorax
f. Crusting in trachea
g. Tracheitis & stomal cellulitis
h. Tracheobronchitis
i. Severe infections: mediastinitis, clavicular osteomyelitis, & necrotizing fasciitis
j. Atelectasis & lung abscess
k. Local wound infection & granulations
3.Late: a. Hemorrhage
b. Laryngeal stenosis
c. Tracheal stenosis
d. Tracheoesophageal fistula
e. Difficult decannulation
f. Persistent tracheocutaneous fistula
g. Keloid or unsightly scar
h. Corrosion of tracheostomy tube
2. SMR
INDICATIONS- 1. DNS causing nasal obstruction & recurrent headaches
2.DNS causing PNS & ME obstruction
3. Recurrent epistaxis
4. Septorhinoplasty
5. Hypophysectomy/ vidian neurectomy
CONTRAINDICATIONS- 1. < 17 years
2. Bleeding diathesis
3. Acute episode of respiratory infection
4. Untreated DM/ hypertension
Anaesthesia- LA/GA
Position- reclining with head end raised
STEPS- 1. Nasal septum infiltration
2. Incision
3. Mucoperichondreal & periosteal flap elevation
4. Cartilage incision
5. Opposite mucoperichondrium & periosteum elevation
6. Cartilage & bone removal
7. Stitching
8. Packing
Postoperative care- 1. Position
2. Diet
3. Analgesics
4. Antibiotics
5. Nasal packs
6. Silk stitch
7. Avoid trauma
COMPLICATIONS- 1. Bleeding
2. Septal hematoma
3. Septal abscess
4. Perforation
5. Bridge depression
6. Columella retraction
7. Deviation persistence
8. Nasal septum flapping
9. Toxic shock syndrome
3. SEPTOPLASTY
INDICATIONS- 1. DNS 》 nasal obstruction on 1/ both sides
2. Septorhinoplasty
3. Recurrent epistaxis
4. Sinusitis
5. Septal deviation 》headache
6. Endoscopic DCR
7. Transseptal trans- Sphenoidal approach
8. Septal deviation 》sleep apnea / hypopnoea syndrome
CONTRAINDICATIONS- 1. Acute nasal/ sinus infection
2. Untreated DM
3. Hypertension
4. Bleeding diathesis
Anaesthesia- GA/LA
Position- supine + head extension
Types of incision- 1. Killian
2. Transfixion
3. Hemitransfixion
4. Horizontal on the spur
TECHNIQUE- 1. Incision- 2–3 mm curvilinear incision above caudal end of septal cartilage on
concave side
2. Flaps and Tunnels: Mucoperichondrial flap raised only on concave side & creates superior
tunnel
3. Separation of septum from perpendicular plate of ethmoid & trimming of inferior cartilaginous
portion displaced from maxillary crest
4. a.Mucoperiosteal flap elevated on both sides of maxillary crest & creates two inferior tunnels
b. Superior & inferior tunnels on concave side joined after cutting fibrous tissue with sharp knife
5. Septal Cartilage separated from vomer and ethmoid plate
6. Maxillary Crest: If needed, fractured to realign septal cartilage
7. Bony Septum: corrected with removal of the deformed parts(scoring, cross hatching,
morcelizing, shaving/wedge excision)
Other Options:a. Septorhinoplasty
b. Endoscopic sinus surgery
c. Laser surgery
8. Closure: Trans-septal sutures keep mucoperichondrial flaps together
9. Nose packed
Postoperative care- 1. Observation
2. Avoid strenuous exercise
3. Pack
4. Saline spray/ steam inhalation
5. Nasal decongestants
6. Nasal splints
7. Avoid trauma
COMPLICATIONS- 1. Bleeding
2. Septal hematoma & abscess
3. Septal perforation
4. Supratip depression
5. Saddle nose deformity
6. Columellar retraction
7. Septal deviation persistence
8. CSF rhinorrhoea
9. TSS
4. MRM
INDICATIONS- 1. Cholesteatoma in attic/ Antrum
2. Localised chronic OM
Anaesthesia- GA/LA
Position- supine + head to 1 side + ear uppermost
STEPS- 1. Incision (post/endaural)
2. Soft tissue retraction & mastoid area exposure
3. Cortical bone removal & attic & Antrum exposure
4. Removal of diseased tissue
5. Facial ridge lowered
6. Mastoid cavity smoothened & irrigated with normal saline
7. Hearing mechanism reconstruction
8. Meatoplasty & wound closure
Postoperative care- 1. Dressing
2. Antibiotics
3. Cavity care
COMPLICATIONS- 1. Facial paralysis
2. Pinna perichondritis
3. Injury to dura/sigmoid sinus
4. Labyrinthitis
5. Severe conductive deafness (>= 50dB)
6. Cavity problems
ENT
OPERATIVE PROCEDURES III

1. DIRECT LARYNGOSCOPY
INDICATIONS- I. Diagnostic- 1. Infants & young children
2. Unsuccessful IDL
3. Examination of hidden areas of hypopharynx & larynx
4. Extent of growth & biopsy
II. Therapeutic- 1. Removal of benign lesions of larynx
2. Removal of FB from larynx & hypopharynx
3. Laryngeal strictures removal
CONTRAINDICATIONS- 1. Cervical spine injuries/disease
2. Moderate/ marked respiratory obstruction
3. Recent coronary occlusion/ cardiac decompression
Anaesthesia- GA/LA
Position- Barking dog position (neck flexion + head extension at a-o joint)
PROCEDURE- 1. Protection of teeth and lips
2. Lubrication
3. Holding of scope
4. Introduction of scope
5. Lifting of epiglottis(without levering laryngoscope on upper teeth or jaw)
6. Interior of larynx- tip of anterior commissure laryngoscope advanced further between
vestibular folds (to examine ventricles & anterior commissure) & vocal cords (to examine the
subglottic region)
Structures examined serially, include tongue base, valleculae, epiglottis, pyriform sinuses,
aryepiglottic folds, arytenoids, postcricoid region, false cords, anterior and posterior
commissure, ventricles, vocal cords, subglottic region and mobility of vocal cords and arytenoids
7. Telescope
Postoperative care- 1. Position
2. Observation
3. Follow up
COMPLICATIONS- 1. Injury to lips & tongue
2. Injury to teeth
3. Bleeding
4. Laryngeal edema
2. BRONCHOSCOPY
TYPES- Rigid
Flexible fiberoptic
INDICATIONS- I. Diagnostic- 1. Symptoms Dyspnea associated with wheezing/stridor
Hemoptysis
Unexplained chronic cough
Hoarseness of voice
Fever or chest pain suggestive of pulmonary infections
2. X-ray chest findings- Atelectasis: Segment, lobe/lung
Opacity: Segment or lobe
Obstructive emphysema
Hilar or mediastinal shadows
Pleural effusions
3. Vocal cord paralysis
4. Collection of bronchial secretions: Culture and sensitivity, acid-fast bacilli, fungus, or
malignant cells
II. Therapeutic- 1. Foreign body removal
2. Suction clearance of secretions, blood clots or inspissated mucus plugs(Head injuries, chest
trauma, thoracic or abdominal surgery, or coma)
3. Assessment or placement of endotracheal tubes/double lumen tubes
4. Guided percutaneous tracheostomy
5. Thermal ablation and removal of tumors
6. Debridement of benign stenosis
7. Balloon dilation
8. Placement of airway stent
Anaesthesia- GA/ topical surface anaesthesia
Position- Barking dog position
TECHNIQUES- 1. Direct method
2. Through Laryngoscope
STEPS- 1. Lubrication of scope
2. Protection of teeth and lips
3. Holding of scope
4. Introduction of scope: directed perpendicularly until uvula passed
5. Larynx: Rotate bronchoscope 90° clockwise to bring beveled tip in axis of glottis and enter
into trachea
Rotate back scope into its original position
6. Tracheobronchial tree
7. Telescope
8. Biopsy
9. Collection of secretions
Postoperative care- 1.Position
2. Observation
COMPLICATIONS- 1. Injury to teeth and lips
2. Transient fever
3. Bleeding and hemoptysis
4. Hypoxia & cardiac arrest
5. Laryngeal spasm/edema
Precautions- 1. Select proper size of bronchoscope
2. No force applied against closed glottis
3. Avoid repeated removal and introduction of bronchoscope as far as possible
4. Maintain IV line & administer injections of antibiotic & steroid especially in infants and children
3. OESOPHAGOSCOPY
TYPES- Rigid
Flexible fiberoptic
Transnasal
INDICATIONS- I. Diagnostic- 1. Symptoms: Dysphagia, odynophagia, aphagia, sensation of
lump or “sticking” in throat, retrosternal burning, hematemesis & persistent regurgitation
2. Signs: Vocal cord palsy
3. Investigation findings –a.Radiological evidence of extrinsic/intrinsic esophageal disorders
b. Abnormal esophageal manometry
c. Abnormal esophageal pH recording
4. Diseases: Malignancy esophagus, cardiac achalasia, strictures, infectious esophagitis,
diverticulum, reflux esophagitis, hiatus hernia, esophageal varices, caustic ingestion, secondary
neck node with unknown primary, surveillance for second primary, penetrating trauma to thorax
to rule out esophageal injury
II. Therapeutic- 5. Foreign body
6. Impacted food
7. Dilatation of esophageal strictures, stenosis or cardiac achalasia
8. Removal of benign neoplasms like fibroma, papilloma, & cysts
9. Insertion of Soutar’s/MB tube in palliative treatment of esophageal carcinoma
10. Tracheoesophageal puncture after total laryngectomy
11. Treatment of diverticulum/varices
CONTRAINDICATIONS- I. Absolute:-1. Coagulopathy
2. Perforation of esophagus: Spontaneous, traumatic or iatrogenic
II. Relative: Advanced heart, liver or kidney disease
III. Severe trismus
IV. Cervical spine lesions
V. Receding mandible
VI. Aneurysm of aorta
Anaesthesia- GA/LA
Position- Barking dog position
TECHNIQUE- 1. Protection of teeth & lips
2. Lubrication of scope
3. Holding of scope
4. Identification of arytenoids
5. Passing cricopharyngeal sphincter
6. Crossing aortic arch & left bronchus
7. Passing cardiac end
Postoperative care- 1. Features of esophageal perforation
2. Diet
COMPLICATIONS- 1. Injury to lips & teeth
2. Injury to arytenoids
3. Injury to pharyngeal mucosa
4. Esophagus perforation
5. Trachea compression
ENT
OPERATIVE PROCEDURES II
A. TONSILLECTOMY
INDICATIONS- SIGN Criteria- A. ABSOLUTE- 1. Recurrent throat infections- SIGN criteria- a.
>=7 episodes/year
b. 5 episodes/year for 2 years
c. 3 episodes/ year for 3 years
d. >= 2 weeks of lost school/ work in 1 year
2. Peri tonsillar abscess
3. Tonsillitis with febrile seizures
4. Tonsils hypertrophy- a. Sleep apnea
b. Difficulty in deglutition
c. Interference with speech
5. Malignancy suspicion
B. Relative- 1. Diphtheria carriers not responding to treatment
2. Streptococcal carriers
3. Chronic tonsillitis with halitosis
4. Recurrent streptococcal tonsillitis
C. Part of other operation- 1. Palatopharyngoplasty
2. Glossopharyngeal neurectomy
3. Styloid process removal
CONTRAINDICATIONS- A. 1. Active infection/acute tonsillitis
2. Aneurysm of internal carotid artery
3. Age below 3 years
4. Active menstruation
5. (Relative) Anemia (Hb < 10 gm %)
B. Bleeding and clotting disorders
C. Cleft palate, submucous cleft
D. Uncontrolled systemic diseases like HT, DM
E. Polio epidemic
Anaesthesia- GA with endotracheal intubation
LA(adults)
Position- Rose position (supine +head extension)
TECHNIQUES- I. Cold method- 1. Dissection & snare
2. Guillotine method
3. Intracapsular tonsillectomy with debrider
4. Harmonic scalpel
5. Plasma mediated ablation/dissection
6. Cryosurgery
II. Hot methods- 1. Electrocautery
2. Laser tonsillectomy
3. Radiofrequency
STEPS- 1. Boyle Davis mouth gag introduction
2. Tonsil holding forceps
3. Incision from tonsils to anterior pillar
4. Tonsil dissection
5. Dissection till lower pole
6. Tonsillar snare
7. Gauge sponge
8. Haemostasis
Postoperative care- 1. Immediate general care
2. Diet
3. Oral hygiene
4. Analgesics
5. Antibiotics
COMPLICATIONS- A. Immediate- 1. Primary hemorrhage
2. Reactionary hemorrhage
3. Injury to tonsillar pillar, uvula,soft palate, tongue/ superior constrictor
4. Injury to teeth
5. Blood aspiration
6. Facial Edema
7. Surgical emphysema
B. Delayed- 1. Secondary hemorrhage
2. Infection
3. Lung complication
4. Scarring in soft palate & pillars
5. Lingual tonsils hypertrophy
B. ADENOIDECTOMY
INDICATIONS- 1. Adenoid hypertrophy
2. Recurrent RS
3. Chronic OME
4. Recurrent ear discharge in benign CSOM
5. Dental malocclusion
CONTRAINDICATIONS- 1. Cleft/submucous palate
2. Hemorrhagic diagnosis
3. Acute URTI
Anaesthesia- GA with oral endotracheal intubation
Position- Rose position
STEPS- 1. Boyle Davis mouth gag insertion
2. Adenoid curette with guard
3. Adenoids shaving
4. Haemostasis
TECHNIQUES- 1. Transoral curettage
2. Endoscopic
3. Suction diathermy
4. Microdebrider
5. Coblation
Postoperative care
COMPLICATIONS- 1. Haemorrhage
2. Injury to ET opening
3. Injury to pharyngeal musculature & vertebrae
4. Grisel syndrome
5. Velopharyngeal insufficiency
6. Nasopharyngeal stenosis
7. Recurrence
ENT
NEOPLASMS- NASAL CAVITY

I. BENIGN- 1. SQUAMOUS PAPILLOMA
2. INVERTED/TRANSITIONAL CELL PAPILLOMA/RINGERTZ TUMOR/SCHNEIDERIAN
PAPILLOMA
4. SCHWANNOMA
5. MENINGIOMA
6. HAEMANGIOMAS- A. CAPILLARY/BLEEDING POLYPUS OF SEPTUM
B. CAVERNOUS
7. CHONDROMA
8. ANGIOFIBROMA
9. INTRANASAL MENINGOENCEPHALOCOELE
10. GLIOMA
11. NASAL DERMOID
II. MALIGNANT- 1. CARCINOMA OF NASAL CAVITY- A. SCC
B. ADENOCARCINOMA & ADENOID CYSTIC CARCINOMA
2. MALIGNANT MELANOMA
3. ESTHESIONEUROBLASTOMA/ OLFACTORY NEUROBLASTOMA
4. HAEMANGIOPERICYTOMA
5. LYMPHOMA
6. PLASMACYTOMA
7. SARCOMAS
PNS
I. BENIGN- 1. OSTEOMAS
2. FIBROUS DYSPLASIA
3. OSSIFYING FIBROMA
4. AMELOBLASTOMA/ADAMANTIOMA
II. MALIGNANT- 1. CARCINOMA OF MAXILLARY SINUS
2. ETHMOID SINUS MALIGNANCY
3. FRONTAL SINUS MALIGNANCY
4. SPHENOID SINUS MALIGNANCY
ENT
OPERATIVE PROCEDURES - I
I. SINUS OPERATIONS- PRE- OPERATIVE ASSESSMENT
1. History
2. Examination
3. Nasal endoscopy examination
4. Preoperative antibiotics & steroids
5. CT nose & PNS
6. MRI
PROCEDURES - A. DNE/ SINUSCOPY
ADVANTAGES- brighter illumination, magnification & angled view
Indications- 1. Diagnose any disease of nose & PNS
2. Locate the site of nose bleed
3. Biopsy from nose, PNS and nasopharynx lesions
4. Assess response to treatment of nose, PNS and naso-pharynx diseases
Anaesthesia- Topical (4% Xylocaine + vasoconstrictor)
Position- sitting/ supine
Instruments- 1. 4 mm 0° and 30° sinuscopes
2. 2.7 mm 0° and 30° sinuscopes(children & narrow nasal cavity)
3. Freer’s elevator
4. Suction cannula
5. Biopsy forceps
6. Antifog solution/savlon
TECHNIQUE- 3 standard paths
First pass (0° sinuscope):- examines nasal vestibule, nasal cavity in general, septum, inferior
meatus and nasopharynx
Scope passed up to nasopharynx through inferior meatus
Slight pressure over lacrimal sac may show opening of NLD in inferior meatus
Note septal deviation or spur, nature of nasal discharge, and color of mucous membrane,
opening of ET, walls of nasopharynx, & upper surface of soft palate & uvula
Withdraw slightly & examine margins of choana & posterior ends of turbinates
Second pass (0° sinuscope): examines posterior part of middle turbinate, spheno ethmoidal
recess, superior meatus, superior turbinate & openings of sphenoid sinus & posterior ethmoid
sinuses
Scope passed medial to posterior part of middle turbinate & progresses up to spheno ethmoidal
recess between nasal septum & superior turbinate
Third pass (30° sinuscope): examines osteomeatal complex in middle meatus such as uncinate
process, bulla ethmoidalis, hiatus semilunaris, sinus of turbinate, basal lamina, & frontal recess
Sinuscope passed into middle meatus usually from anterior aspect but in some cases entered
from behind where wider & structures examined from behind forward
If needed middle turbinate can be gently retracted medially with help of Freer elevator
COMPLICATIONS- 1. Bleeding(improper manipulation of instruments/suction)(application of
vasoconstrictor pledgets)
B. ENDOSCOPIC SINUS SURGERY
INDICATIONS- 1. Chronic bacterial sinusitis unresponsive to treatment
2. Recurrent acute bacterial sinusitis
3. Polypoidal RS
4. Antrochoanal polyp
5. Mucocele (frontoethmoid/sphenoid)
6. Epistaxis control
7. FB removal
8. Endoscopic septoplasty
9. Fungal sinusitis (fungal ball/ nasal polypi)
CONTRAINDICATIONS- 1. Lack of proper instrumentation
2. Inaccessible disease by endoscopic procedures
3. Threatened intracranial/ orbital complication
Anaesthesia- GA
Position- supine with head resting
TECHNIQUE- 1. Anterior to Posterior (Stammberger)
2. Posterior to Anterior(Wigand)
STEPS- 1. Removal of cotton pledgets
2. Complete DNE
3. Anaesthesia injection
4. Surgical- Uncinectomy
Identification & enlargement of maxillary ostium
Bullectomy
Penetration of basal lamina & Posterior ethmoid cells removal
Frontal recess clearance & frontal sinusotomy
Sphenoidotomy
Nasal packs
Postoperative care- 1. Nasal pack removal
2. Antibiotics
3. Antihistamines
4. Analgesics
5. Steroid nasal spray
6. Nasal irrigations
7. Endoscopic toilet
COMPLICATIONS-I. Minor- 1.Minor bleeding
2. Hyposmia
3. Synechia
4. Headache
5. Periorbital ecchymosis
6. Periorbital emphysema
7. Dental pain
8. Facial pain
II. Major-A. Orbital- 1. Orbital hematoma
2. Extraocular muscle injury(Diplopia)
3. Injury optic nerve(Blindness)
4. Decreased visual acuity
5. Nasolacrimal duct/sac injury
6. Lamina papyracea injury
B. Intracranial- 1. Fracture of skull base
2. Intracranial bleeding
3. CSF rhinorrhea, stroke
4. Meningitis, brain injury
5. Carotid injury, death
6. Pneumoencephalus
7. Others: Anosmia, bleeding
C. FESS
PRINCIPLES- 1. Improves mucociliary clearance pathways of osteomeatal unit
2. Obstruction to drainage of ostia removed in osteomeatal complex
ADVANTAGES- 1. Good illumination & visualization of areas
2. Absence of external scar
3.Minimal hospitalization
4. Good for documentation & teaching purposes
5. Postoperative morbidity minimal
INDICATIONS- I.Diagnostic- 1. To see inaccessible areas in nose & nasopharynx
2. To diagnose cause of sinusitis, nose bleed, headache & anosmia
3. To find out site of leak in CSF rhinorrhoea
4. To examine nasopharynx for eustachian tube & other lesions
5. To diagnose & biopsy/follow-up in tumors of nose, PNS & nasopharynx
II. Therapeutic- 1. Chronic sinusitis
2. Acute recurrent sinusitis
3. Nasal polyposis
4. Frontoethmoidal mucoceles
5. Allergic fungal sinusitis & mycetoma
6. Evaluation & repair of CSF leaks
7. Orbital & optic nerve decompression
8. Repair of blowout fractures
9. Intranasal DCR
10. Choanal atresia
11. Hypophysectomy
12. Septal & Turbinate surgery
13. Management of epistaxis
14. Drainage of periorbital abscess
15. To remove hidden FB in nose or PNS
CONTRAINDICATIONS- 1.Acute sinusitis associated with intracranial complications/ orbital
cellulitis/visual field defects/ osteomyelitis
2. Infiltrative lesions
3. Markedly stenosed frontonasal duct
4. Aggressive invasive fungal infections of PNS like mucormycosis
5. Advanced malignancy
Instruments- 1. 0° & 30° sinuscopes
2. Light source and cable
3. Sickle knife
4. Straight & angled forceps
5. Straight and curved suction cannulas
METHOD-1. Preoperative CT of sinus
2.Preferably under LA/GA
3. Supine position with elevation of head
4.0° & 30° endoscopes commonly used along with special Blakesly straight & angled forceps
5.After 1st pass sinuscope moved medial to middle turbinate to see sphenoethmoidal
recess,opening of posterior ethmoids & sphenoidal sinus(2nd pass)
6.3rd pass, when endoscope passed into middle meatus to see OMC(key area)
7.Uncinate process, ethmoidal bulla, hiatus semilunaris & frontal recess visualized
8.Uncinectomy done to visualize opening of maxillary sinus
9.Ethmoidal Bulla if enlarged also removed by opening at its medial & inferior portion with
Blakesley’s forceps
Posterior ethmoidectomy done by identifying ground lamella posterior to bulla, which is pierced
by upcutting forceps
10.Any other pathology also dealt
11.Gel foam /light pack is kept to be removed after 24 hours
ENT
COMPLICATIONS OF SINUSITIS
Methods of Spread of Infection- 1. By direct continuity
2.Thrombophlebitis of diploic veins 》infection of bone marrow
3. Embolism
4. Perivascular lymphatics
5. Perineural sheath.
I. LOCAL- A. MUCOCOELE/MUCOPYOCOELE OF PNS & MUCUS RETENTION CYST
Either retention cyst of mucous glands of sinus or maybe due to blockage of sinus ostium,
resulting in thinning & expansion of sinus wall
Frontal & ethmoidal sinuses usually involved
If infection superadded, called pyocele
ETIOLOGY- 1. Chronic obstruction to sinus ostium
2. Cystic dilatation of mucus glands of sinus mucosa
Maxillary mucocele- incidental finding on radiographs & rarely require specific treatment
If needed, aspirated through puncture of either inferior meatus or canine fossa
FRONTOETHMOIDAL MUCOCELE- most common type
CLINICAL FEATURES- frontal headache, proptosis, deep nasal or periorbital pain and diplopia
Swelling cystic & non-tender; eggshell crackling may be elicited
Imaging:- Radiograph- clouding of sinus with sclerosis of surrounding skull & loss of scalloped
outline of frontal sinus
TREATMENT- surgical removal (frontoethmoidectomy)/endoscopic marsupialization into nasal
cavity
ETHMOIDAL MUCOCELE- bulge in middle meatus & can be drained by uncapping ethmoidal
bulge (or with external ethmoid operation) & establishing free drainage
SPHENOETHMOIDAL MUCOCELE
CLINICAL FEATURES- headache (occipital & vertex)/deep nasal pain, diplopia, visual field
disturbance & eyeball displacement
Exophthalmos always present & pain localized to orbit or forehead
Imaging:- Radiographic findings confirm diagnosis
Slow expansion 》 destruction of sphenoid & posterior ethmoid sinuses
TREATMENT- opening widely into nasal cavity
Endoscopic sinus surgery(FESS)
External: Ethmoidectomy with sphenoidotomy
B. OSTEOMYELITIS
Infection of bone marrow
OSTEOMYELITIS OF MAXILLA- more common in infants and children
Usually start in dental sac & spread to maxilla
Primary infection rarely causes osteomyelitis
CLINICAL FEATURES- erythema, swelling of cheek, edema of lower lid, purulent nasal
discharge & fever
Subperiosteal abscess & fistulae in infraorbital region, alveolus or palate, or in zygoma
Sequestration of bone
TREATMENT- large doses of antibiotics, drainage of abscess & removal of sequestra
COMPLICATIONS- Damage to temporary or permanent tooth-buds, maldevelopment of maxilla,
oroantral fistula, persistently draining sinus and epiphora
OSTEOMYELITIS OF FRONTAL BONE- more common in adults
ETIOLOGY- from acute infection of frontal sinus(maybe direct/through thrombophlebitis)
Other causes- trauma and surgery
Pott’s puffy tumor: subperiosteal abscess over anterior surface of frontal
sinus》swelling of overlying soft tissue
Extradural abscess
TREATMENT- large doses of antibiotics, drainage of abscess and trephining of frontal sinus
through its floor.
May require removal of sequestra & necrotic bone with osteoplastic flap
II. ORBITAL- Purulent frontal & ethmoidal sinusitis
Travel into orbit through thin lamina papyracea & thrombophlebitis
1. INFLAMMATORY LIDS EDEMA- only reactionary
No erythema/tenderness of lids
Only preseptal space
Upper(frontal),lower(maxillary) & both (ethmoid)
2. SUBPERIOSTEAL ABSCESS- Ethmoid- medial wall of orbit (forward, downward & laterally)
Frontal- just above & behind medial canthus(downward & laterally)
Maxillary- floor of orbit (upward & forward)
3. ORBITAL CELLULITIS- spread between orbital fat, EO muscles, vessels & nerves
Lids Edema, Exophthalmos, conjunctiva chemosis, restricted eyeball movements
Partial/total vision loss
Risk of meningitis & cavernous sinus thrombosis
4. SUPERIOR ORBITAL FISSURE SYNDROME- deep orbital pain,frontal headache &
progressive paralysis of CN 6,3 &4
5. ORBITAL APEX SYNDROME- SOFS+ CN 2, maxillary (V2)
6. ORBITAL ABSCESS- along lamina papyracea
/ floor of frontal sinus
CT scan/ ultrasound orbit
IV antibiotics & abscess drainage
III. INTRACRANIAL- 1. MENINGITIS & ENCEPHALITIS
2. EXTRADURAL ABSCESS
3. SUBDURAL ABSCESS
4. CAVERNOUS SINUS THROMBOSIS
ETIOLOGY- Sinusitis (ethmoid,sphenoid & frontal)
Easy spread of infection
CLINICAL FEATURES- onset abrupt with chills & rigors
Acutely ill
Eyelids swollen with chemosis & proptosis
CN 3,4 & 6 》 total ophthalmoplegia
Pupil dilated & fixed, optic disc congested & Edema with vision diminution
V1 sensation diminished
CSF normal
DIAGNOSIS:- CT scan
Blood culture
TREATMENT- IV antibiotics
Drainage of infected sinus
IV. DESCENDING- 1. OM
2. PHARYNGITIS & TONSILLITIS
3. PERSISTENT LARYNGITIS & TRACHEO BRONCHITIS
V. FOCAL
ENT
CHRONIC RHINOSINUSITIS
DEFINITION- chronic inflammation of mucosa of nasal & PNS >3 months which has resulted in
irreversible degenerative changes
ETIOLOGY- infection (bacteria/fungus)
Inflammatory (allergy, eosinophilic vasculitis, sarcoidosis)
TYPES- I. CRS WITHOUT POLYPS
BACTERIAL
Bacteriology- Staphylococcus aureus
Pseudomonas
Klebsiella pneumoniae
E.coli
Predisposing factors- 1. Structural deformities- DNS,Concha bullosa & prominent agent nasi
2. Mucociliary clearance impairment- infection, inflammation, smoking, toxins
3. Cystic fibrosis & Young syndrome
4. Osteomyelitis/ Osteitis
5. Dental infection
6. Asthma
7. Allergy
8. Biofilm
CLINICAL FEATURES- SYMPTOMS- 1. Nasal obstruction
2. Nasal/postnasal purulent discharge
3. Facial pain & pressure
4. Smell disturbance (Hyposmia/Anosmia)
Signs- 1. Edema of nasal mucosa in anterior/ posterior osteomeatal complex
2. Purulent discharge
DIAGNOSIS:- atleast 2 symptoms & 1 sign
Nasal endoscopy without & with nasal decongestant
CT scan
TREATMENT- I. Medical- 1. Antibiotics- macrolide
2. Saline irrigations
3. Topical decongestants
4. Steroid sprays
5. Anti allergy treatment- Antihistamines
LT antagonists
II. Surgical- FESS
II. CRS WITH POLYPOSIS
ETIOLOGY- 1. Primary ciliary dyskinesia
2. Cystic fibrosis
3. Samter triad
4. Asthma
5. Churg Strauss syndrome
6. Allergic fungal sinusitis
DIAGNOSIS:- CT scan
MRI with Contrast
TREATMENT- I. Medical- 1. Systemic steroids
2. Steroid nasal spray
3. Nasal irrigation
4. Antibiotics
5. Allergy management
6. Asthma treatment
II. Surgical- FESS
OLDER SURGICAL TECHNIQUES
MAXILLARY- 1. Antral puncture & irrigations
2. Intranasal antrostomy
3. Caldwell Luc operation
FRONTAL- 1. Intranasal drainage operation
2. Frontal sinus trephination
3. External frontoethmoidectomy(Howarth/Lynch operation)
4. Osteoplastic flap operation
ETHMOID- 1. Intranasal Ethmoidectomy
2. External Ethmoidectomy
SPHENOID- Sphenoidotomy
FUNGAL SINUSITIS
Causative organisms- Aspergillus
Alternaria
Mucor
Rhizopus
ETIOLOGY- 1. Traumatic cases with compound fractures
2. Uncontrolled diabetics
3. Debilitated patients
4. Patients on immunosuppressants, antibiotics or steroids
CLINICAL FEATURES- 1. FUNGAL BALL/ MYCETOMA- CT- hyperdense area with no bony
erosion or expansion
TREATMENT- Surgical removal
Adequate sinus drainage
No antifungal
2. ALLERGIC FUNGAL SINUSITIS- in atopic/asthmatic patients due to allergic reaction to
fungus
Eosinophils,Charcot–Leyden crystals & fungal hyphae
No sinus fungal invasion
CT- hyperdense area with no bony erosion or expansion
TREATMENT- endoscopic surgical sinus clearance
Provision of drainage & ventilation
Pre & post operative steroid
3. CHRONIC INVASIVE SINUSITIS- chronic immunocompromised patients
CT- opacification of sinus with bone erosion
Intra-cranial/orbital invasion
4. FULMINANT FUNGAL SINUSITIS- immunocompromised patients such as in diabetics,
cancer or AIDS
Mucor- rhinocerebral disease(black eschar in inferior turbinate,palate/sinus)(Surgical
debridement & IV Amphotericin B)
Aspergillus- acute fulminant sinusitis (antifungal & surgery)
ENT
ACUTE RHINOSINUSITIS
DEFINITION- inflammation of PNS mucosa associated with inflammation of nasal mucosa
CLASSIFICATION:- RHINOSINUSITIS TASK FORCE, 2007
1. Acute RS- symptoms <4 weeks with complete resolution
2. Sub acute RS- 4-12 weeks
3. Chronic RS- >=4 episodes/ year, each lasting 7-10 days with complete resolution in between
episodes
Acute exacerbation of chronic RS
Pansinusitis- applied to inflammation of all paranasal sinuses
ETIOLOGY- 1. Nasal infections
2. Tooth infection
3. Swimming & bathing
4. Trauma
5. Mechanical obstruction
6. General diseases
Other Contributing Factors- 1. Poor general environment
2. Low resistance
3. Undue exposure to crowded cities/people
4. Anatomical obstructions
5. Association with chest conditions
Causative organisms- Viruses- Rhinovirus Parainfluenzae I & II
Enteric cytopathogenic human orphan (ECHO)28
CoxsackieA21
Respiratory syncitial virus
Bacteria- Pneumococci(29%)
Streptococci
Staphylococci(6.6%)
Haemophilus influenzae(48%)
Escherichia coli
Micrococcus catarrhalis
Bacillus pfeiffer
B. freidlander
Specific Infections- fungi, syphilis, tuberculosis & leprosy
PATHOLOGY- 5 stages: 1. Catarrhal stage
2. Exudative stage
3. Suppurative stage
4. Stage of complications
5. Stage of resolution
Clinically:- Catarrhal type
Suppurative type
Acute Catarrhal Type- (earliest change)edema & mucus secretion with few leukocytes, but no
destruction of mm
Acute Suppurative Type- severe inflammation with leukocytes and pus pouring out with necrosis
of mm or may become polypoidal
CLINICAL FEATURES- SYMPTOMS- General - Malaise, headache, fever(not very high), sore
throat, facial pain and periorbital edema
Local- 1.Feeling of discomfort in postnasal space
3. Loss of vocal resonance (dead voice)
4. Loss of sense of smell
5. Nasal/postnasal discharge/drip
6. Cough
7. Pain in sinuses-a.Antral pain: along infraorbital margins & referred to upper teeth or gums on
affected side
b. Ethmoidal pain: localized over bridge of nose & inner canthus of eye & referred to parietal
eminence
c. Frontal sinus pain: localized to forehead & pain periodical in nature, i.e. starts hour or two
after getting up from bed & vanishes during afternoon
d. Sphenoidal pain:occipital/vertical headache and sometimes referred to mastoid process
Pain may be felt behind eyeball due to close proximity with Vth nerve
SIGNS- External-1. Flushing of cheek with swelling of cheek, which may spread to lower lid in
maxillary sinusitis
Upper lid may be swollen in frontal sinusitis
Ethmoiditis- swelling at the inner canthus of same eye
2. Tenderness over affected sinus-a. Cheek: Maxillary sinusitis
b. Floor of sinus: Frontal sinusitis
c. Inner canthus: Ethmoids
Differential Diagnosis- 1. Dental neuralgias, caries, apical infection or abscess
2. Temporomandibular neuralgia (TN) (Costen syndrome)(pain aggravated by movements of
joint)
3. Trigeminal neuralgia
4. Migraine
5. Temporal arteritis
6. Nasopharyngeal tumors
7. Brainstem lesions
8.Herpetic/post herpetic neuralgia
9. Insect bite
10. Neoplasm of sinuses.
Anterior rhinoscopy & sinuscopy- Shows red, shiny and swollen mucous membrane near ostium
of the sinus, and trickle of pus may also be seen
INVESTIGATIONS- 1. Hematology- TLC & DLC) increased.
2. Culture sensitivity test
3. Transillumination test-a. Maxillary sinus—absence of infraorbital crescent of light and
pupillary glow absence indicate sinusitis.
b.Frontal sinus transillumination not informative
4. X-ray paranasal sinuses (PNS)
5. Computed tomography (CT)
TREATMENT- I. Prophylactic- 1. Strengthen first line of defence, i.e. mucous/ciliary blanket
2. Sunshine, good ventilation, and proper humidity
3. Good diet rich in vitamins
4. Avoid flying and swimming with cold
5. Use of vaccines (autogenous vaccines)
II. Medical- 1. Antibiotics (Amoxicillin with/without clavulanate for 10-14
days/Doxycycline/Levofloxacin)
2. Analgesics
3. Local decongestants
4. Saline irrigations
5. Antihistaminics
6. Intranasal steroids
III. Surgical- 1. Antral lavage
2. Trephination of frontal sinus
3. External ethmoidectomy
COMPLICATIONS- 1. Osteomyelitis of maxilla & frontal bone
2. Orbital cellulitis
3. Orbital abscess formation
4. Intracranial complications like cavernous sinus thrombosis, meningitis & intracranial abscess
5. Chronic sinusitis
6. Middle ear infection
7. Pharyngitis
8. Laryngitis/tracheobronchitis
9. Mucocele/pyocele
10. Oroantral fistula
ENT
ANATOMY OF PNS
Clinically divided into 2 groups:- Anterior group (maxillary, frontal & anterior ethmoids)
Posterior group(posterior ethmoids & sphenoid sinus)
MAXILLARY SINUSES/Antrum of Highmore- largest sinus in body of maxilla
Sometimes referred as conductor of orchestra. Pyramidal
Apex directed laterally into zygomatic process of maxilla and base forming lateral wall of nose
33mm×23mm×34 mm
Capacity- 15-30 ml
IMPORTANT RELATIONS- ROOF- floor of orbit
Traversed by infraorbital canal, which transmits infra orbital nerve & vessel
FLOOR- 1.25cm below the nasal floor
Alveolar process of maxilla related to1st premolar- third molar area
POSTERIOR WALL- Thin plate of bone separating cavity from pterygopalatine & infratemporal
fossa
Pterygopalatine fossa(triangular space between maxilla, palatine & pterygoid process of
sphenoid) (internal maxillary artery,vidian nerve & sphenopalatine ganglion)
ANTERIOR WALL- zygomatic process of maxilla and medially by canine ridge
Infraorbital foramen closely related
MEDIAL/ NASAL WALL- nasal surface of maxilla below & in front Perpendicular plate of palatine
bone posteriorly & uncinate process of ethmoid bone & descending part of lacrimal bone
OSTIA- 3-4 mm in diameter & high up in posterolateral wall & opens in middle meatus through
posterior part of ethmoidal infundibulum
ACCESSORY OSTIUM(30%)- slightly posterior to normal ostium
LINING- Pseudostratified columnar ciliated epithelium(thin and relatively less vascular +few
mucous glands)
BLOOD SUPPLY- branches of maxillary, facial, infraorbital & greater palatine arteries
Veins- anterior facial vein & pterygoid venous plexus
Lymphatics- submandibular LN
Nerve Supply- maxillary nerve through superior alveolar, anterior palatine & infraorbital nerve
FRONTAL SINUSES(2)
unequal, divided by bony septum, which is seldom in the midline
3.16cm×2.58cm×1.8cm
Pyramid
Capacity- 5-7 cc(adult)
Behind supercilliary arches & in triangular area formed by nasion, point 3 cm above nasion &
medial third of supraorbital margin
Opens into anterior part of middle meatus either through ethmoidal infudibulum or through
frontonasal duct
IMPORTANT RELATIONS- ANTERIOR WALL(1-5 mm)- Outer table of frontal bone
POSTERIOR WALL- inner table(separates from anterior cranial fossa)
FLOOR(separates from orbital cavity)- slopes downwards towards opening of frontonasal duct
into frontal recess of middle meatus
Superiorly- extends to variable distance between outer & inner tables of skull
Supraorbital artery, vein & nerve supply sinus & lymphatic drainage to submandibular LN
ETHMOIDAL SINUSES (8-18)
within lateral part of ethmoid bone between nasal cavity & orbit(honeycomb appearance) called
ethmoidal labyrinth
Pyramidal
4-5 cm×2.5-3 cm×1.5 cm
Divided into 2 groups- Anterior smaller group (numerous air cells)(agger nasi cells, bullar cells,
supraorbital cells, frontoethmoid cells, Haller cells & frontal cells)(1–8)- open into upper part of
hiatus semilunaris in middle meatus
Bulla ethmoidalis also called middle ethmoidal group of sinuses
Anterior & posterior ethmoidal cells separated by ground lamella
Posterior group(larger with few cells)- opens into superior meatus
Optic nerve lies in close proximity to cells (Onodi cell)
IMPORTANT RELATIONS- ROOF- Superiorly- closely related to cranial cavity & meninges
Roof of ethmoidal labyrinth formed medially by cribriform plate (fovea ethmoid)
Main part of roof contributed by orbital plate of frontal bone
FLOOR/INFERIOR WALL- anteriorly by orbital plate of maxilla & posteriorly by orbital process of
palatine bone
Related to maxillary sinus
LATERAL/ORBITAL WALL- by lamina papyracea, (separates from orbit)
Anteriorly- deficient & hence completed by lacrimal bone and posteriorly with lesser wing of
sphenoid bone
Lamina papyracea also articulates inferiorly with maxilla & superiorly with the frontal bone
(important landmark as indicates roof of ethmoid sinuses in external ethmoidectomy)
Formed by middle & superior turbinate bones
Posteriorly- separated from sphenoid sinus by thin bony septum
ARTERIAL SUPPLY- Anterior & posterior ethmoidal branches of ophthalmic & sphenopalatine
artery( should be taken care of during ethmoidectomy)
Venous drainage- corresponding veins
Nerve Supply- branches of maxillary nerve and ophthalmic nerve (nasociliary branch)(form
anterior & posterior ethmoidal nerves)
SPHENOID SINUSES
in body of sphenoid bone (situated in the posterior part of nasal cavity)
2 R and L sinuses rarely symmetrical & separated by thin septa
Rudimentary at birth but begin to grow after third year
Capacity - 0.5-30 ml(average-7.5 ml) 2cm×1.8cm×2 cm
OSTIUM- upper part of anterior wall & opens into sphenoethmoidal recess
Bones of Bertin also called sphenoidal turbinates initially cover anterior wall of sinus but after 10
years,fuse with it.
Various Types of Sphenoid Sinuses- sellar, presellar, mixed and conchal(sellar most common
type)
IMPORTANT RELATIONS- ROOF- Posterior part related with pituitary gland and optic chiasma
Anterior part of roof related to frontal lobe & olfactory tract.
FLOOR- roof of nasopharynx & vidian nerve. Anteriorly- related to supra orbital fissure,III,IV &
VII CN & ophthalmic division of V nerve
Posteriorly- Thick wall separates from pons & basilar artery
Laterally- cavernous sinus, internal carotid artery, cranial nerves III, IV, VI and all division of
trigeminal nerve
BLOOD SUPPLY- posterior ethmoid & sphenopalatine artery
Veins drain into veins of nasal cavity
Nerve Supply- branches of sphenopalatine ganglion
Lymphatics- retropharyngeal LN
FUNCTIONS OF PNS- Possible functions:- 1.Air conditioning, i.e.warming and moistening
2.Reduction of skull weight
3. Increases olfactory area (in animals)
4. Heat insulation
5. Vocal resonance
6. Provides mechanical rigidity to skull
7. Pressure dampening
8. Secretion of mucus to keep nasal chambers moist
9. Absorption of shock to face & skull during injuries
10.Regulation of intranasal pressure
ENT
NASAL POLYPI
DEFINITION- non- neoplastic masses of edematous nasal/ sinus mucosa
TYPES- I. SIMPLE- 1. ANTROCHOANAL
2. BILATERAL ETHMOIDAL
II. FUNGAL
III. MALIGNANT
ANTROCHOANAL/KILLIAN POLYP
Arises from mm of floor & medial wall of maxillary sinus close to accessory ostium, comes out &
starts growing towards choana & nasal cavity
PARTS- 1. Antral
2. Choanal
3. Nasal
ETIOLOGY- exact cause unknown
Children & young adults
Allergy
Chronic sinus infection
CLINICAL FEATURES- SYMPTOMS- Nasal obstruction(unilateral)
Mucoidal discharge
Snoring
Change of voice (hyponasality)(thick & dull)
Conductive deafness
SIGNS- once bilobed, seen clearly
Posterior rhinoscopy- smooth, greyish white, spherical mass in choana & maybe seen projecting
below soft palate
Radiography- opaque maxillary antrum on affected side, while lateral projection- polypoidal
swelling in nasopharynx with column of air behind mass
Missed on anterior rhinoscopy
D/d- 1. Blob of mucus
2. Hypertrophied middle turbinate
3. Angiofibroma
4. Other neoplasms
DIAGNOSIS:- 1. Blood for Hb, TLC, DLC, AEC, BT & CT
2. Complete urine examination
3. Nasal smear for eosinophils
4. Culture & sensitivity of nasal discharge
5.Radiological examination:– X-ray PNS (Water’s view)
CT scan PNS, particularly osteomeatal complex both coronal & axial sections
6.Histopathological examination
7. X-ray soft tissue nasopharynx lateral view
TREATMENT- I. Medical- 1. Antihistaminics
2. Steroids
3. Immunotherapy
4. Deep Breathing Exercises
5. Avoidance of Known Allergic Factors
II. Surgical- 1. FESS
2. Caldwell Luc Operation
3. Simple Polypectomy
4. Polypectomy by Micro Debrider
BILATERAL ETHMOIDAL POLYPI
mostly arise from ethmoidal labyrinth of cells /mucosa of middle turbinate & middle meatus,
uncinate process, bulla ethmoidalis & ostia of sinuses
ETIOLOGY- 1. Chronic Rhinosinusitis
2. Asthma
3. Aspirin intolerance
4. Cystic fibrosis
5. Allergic fungal sinusitis
6. Kartagener syndrome
7. Young syndrome
8. Churg Strauss syndrome
9. Nasal mastocytosis
10. NARE syndrome
PATHOLOGY- Macroscopically smooth masses, translucent, white, opaque/yellowish to pink in
color on naked eye examination
Microscopically, simple edematous hyper trophied mm covered by columnar ciliated epithelium
CLINICAL FEATURES- SYMPTOMS- adults
Nasal obstruction(unilateral/bilateral)
Anosmia & loss of taste
Rhinorrhea maybe watery/mucopurulent & Sneezing
Frontal headache
Broadening of nose causing frog face deformity
Mass protruding from nostril
SIGNS- Anterior rhinoscopy- smooth, glossy, multiple, mobile, bluish gray masses (bunch of
grapes)
On probing, soft, insensitive & movable, not fragile,does not bleed on touch & non tender.
Posterior rhinoscopy- may or may not show any mass
DIAGNOSIS:- 1. Blood for Hb, TLC, DLC, AEC, BT & CT
2. Complete urine examination
3. Nasal smear for eosinophils
4. Culture & sensitivity of nasal discharge
5.Radiological examination:– X-ray PNS (Water’s view)
CT scan PNS, particularly osteomeatal complex both coronal & axial sections
6.Histopathological examination
7. X-ray soft tissue nasopharynx lateral view
TREATMENT- I. Medical- 1. Antihistaminics
2. Steroids
3. Immunotherapy
4. Deep Breathing Exercises
5. Avoidance of Known Allergic Factors
II. Surgical- 1. FESS
2. Polypectomy
3. Intranasal Ethmoidectomy
4. Extranasal Ethmoidectomy
5. Transantral Ethmoidectomy
ENT
VASOMOTOR/INTRINSIC RHINITIS
Definition- non- allergic rhinitis clinically stimulating nasal allergy with symptoms of nasal
obstruction, rhinorrhoea & sneezing
PATHOGENESIS- disturbance in vasomotor balance between sympathetic & parasympathetic
1. Psychogenic factors
2. Endocrine factors
3. Physical agents
4. Drugs
PATHOLOGY- Nasal mucosa- edema, vascular dilatation, round cell infiltration & increased
glandular activity
CLINICAL FEATURES- SYMPTOMS- 1. Paroxysmal sneezing
2. Excessive rhinorrhoea
4. Postnasal drip
SIGNS- nasal mucosa over turbinates congested & hypertrophic
COMPLICATIONS- nasal polypi
Hypertrophic rhinitis
Sinusitis
TREATMENT- I. Medical- 1. Avoidance of physical factors
2. Antihistaminics & Oral Nasal Decongestants
3. Topical Steroids
4. Systemic steroids
5. Psychological factors removal
II. Surgical- 1. Reduce size of Nasal turbinates
2. Vidian neurectomy
NON- ALLERGIC RHINITIS
1. DRUG- INDUCED RHINITIS
2. RHINITIS MEDICAMENTOSA
3. RHINITIS OF PREGNANCY
4. HONEYMOON RHINITIS
5. EMOTIONAL RHINITIS
6. RHINITIS DUE TO HYPOTHYROIDISM
7. GUSTATORY RHINITIS
8. NON AIRFLOW RHINITIS
ENT
GRANULOMATOUS DISEASES OF NOSE
I. BACTERIAL INFECTIONS- 1. RHINOSCLEROMA
DEFINITION- chronic granulomatous disease caused by Gram negative Klebsiella
rhinoscleromatis
PATHOLOGY- Nose》 nasopharynx, oropharynx, larynx, trachea, bronchi
Mode of infection unknown
Both sexes
CLINICAL FEATURES- 1. Atrophic stage- foul smelling purulent discharge & crusting
2. Granulomatous stage- granulomatous, painless, non ulcerative nodules in nasal mucosa
Woody feel
3. Cicatricial stage- stenosis of nares
Distortion of upper lip
Adhesions in nose, nasopharynx, oropharynx
Subglottic stenosis with respiratory distress
DIAGNOSIS:- Biopsy- submucosa infiltration with plasma cells, lymphocytes, Mikulicz cells &
Rusell bodies
Culture
TREATMENT- Streptomycin (1 g/day)+ Tetracycline (2 g/day ) for minimum 4-6 weeks &
repeated if necessary after 1 month
Stopped after 2 negative consecutive cultures
Steroids
Surgical
2. SYPHILIS- A. ACQUIRED- PRIMARY
SECONDARY
TERTIARY
B. CONGENITAL- EARLY FORM
LATE FORM
3. TB
4. LUPUS VULGARIS
5. LEPROSY
II. FUNGAL INFECTIONS- 1.RHINOSPORIDIOSIS
DEFINITION- chronic granulomatous disease caused by Rhinosporidium seeberi
ETIOLOGIC AGENT- protozoa/fish parasite (DRIP clade)
LIFE CYCLE- A. TROPHIC STAGE
B. DEVELOPMENT OF SPORANGIUM
C. PRODUCTION OF ENDOSPORES
CLINICAL FEATURES- affects nose & nasopharynx
Acquired through contaminated water
Leafy polypoidal mass, pink to purple & attached to nasal septum/lateral wall
Very vascular & bleed on touch
Surface studded with white dots
Nasal discharge, blood tinged
Nasal stuffiness
Frank epistaxis
DIAGNOSIS:- Biopsy- several sporangia filled with spores maybe through chitinous wall
TREATMENT- Complete mass excision with diathermy knife & base cauterization
Dapsone
2. ASPERGILLOSIS
3. MUCORMYCOSIS
4. OTHER INFECTIONS
III. GRANULOMAS OF UNSPECIFIED ETIOLOGY- 1. WEGENER GRANULOMATOSIS
2. T- CELL LYMPHOMA
3. SARCOIDOSIS
ENT
ACUTE RHINITIS
A. VIRAL RHINITIS- 1. COMMON COLD/ CORYZA
ETIOLOGY- Adeno, Picornanavi, Rhino, Coxsackie & ECHO VIRUS
Airborne Droplets
IP- 1-4 days
CLINICAL FEATURES- Burning Sensation At back of Nose
Nasal Stuffiness
Rhinorrhoea
Sneezing
TREATMENT- Bedrest
Plenty of Fluids
Antihistamines
Nasal Decongestants
Analgesics
Antibiotics
COMPLICATIONS- Sinusitis
Pharyngitis
Tonsillitis
Bronchitis
Pneumonia
OM
2. INFLUENZAL RHINITIS
3. RHINITIS ASSOCIATED WITH EXANTHEMAS
B. BACTERIAL- NON SPECIFIC INFECTIONS
DIPHTHERITIC RHINITIS
C. IRRITATIVE RHINITIS
CHRONIC RHINITIS
A. CHRONIC SIMPLE RHINITIS
ETIOLOGY-1.Nasal Infection Persistence (Sinusitis, Tonsillitis & Adenoids)
2. Chronic Irritation (Dust, Smoking )
3. Nasal Obstruction (DNS, Synchae)
4. Vasomotor Rhinitis
5. Endocrine/ Metabolic Factors
PATHOLOGY- MM Edema & Hyperemia
Seromucinous Glands Hypertrophy & Increased Goblet Cells
Blood Sinusoids Distended
CLINICAL FEATURES- 1. Nasal Obstruction
2. Nasal Discharge
3. Headache
4. Swollen Turbinates
5. Post Nasal Discharge
TREATMENT- 1. Treat The Cause
2. Nasal Irritation With Alkaline Solution
3. Nasal Decongestants
4. Antibiotics
B. HYPERTROPHIC RHINITIS
ETIOLOGY- Recurrent Nasal Infections
Chronic Sinusitis
Chronic Nasal Mucosa Irritation
Prolonged Nasal Drops
Vasomotor Rhinitis
Allergic Rhinitis
CLINICAL FEATURES- SYMPTOMS- Nasal Obstruction
Nasal Discharge
Headache
Anosmia
SIGNS- Turbinate Hypertrophy
Turbinate Mucosa Thick & Non Pitting
Little Shrinkage With Vasoconstrictor Drugs
Mulberry Appearance
TREATMENT- 1. Linear Cauterization
2. Submucosal Diathermy
3. Turbinate Cryosurgery
4. Partial/ Complete Turbinectomy
5. Submucous Turbinate Resection
6. LASERs
COMPENSATORY HYPERTROPHIC RHINITIS (marked DNS on 1 side)
C. ATROPHIC RHINITIS/OZAENA
DEFINITION- chronic nasal inflammation characterised by nasal mucosa & turbinates atrophy
TYPES- Primary
Secondary
ETIOLOGY- Primary- Hereditary
Endocrine (Menopause)
Racial (white)
Nutritional deficiencies (A,D,Fe)
Infections (Klebsiella, Proteus, E.coli, Staphylococcus, Streptococcus)
Autoimmune
Secondary- Syphilis
Lupus
Leprosy
Rhinoscleroma
Long standing purulent sinusitis
RT
Excessive surgical removal
PATHOLOGY- Seromucinous glands, Blood vessels sinusoids & nerve elements atrophy
Obliterative endarteritis
Turbinates resorption
Replaced by stratified squamous epithelium
CLINICAL FEATURES- Females
Puberty
Merciful anosmia
Nasal obstruction
Epistaxis
Greenish/ grayish black dry crusts
Pale mucosa
Septal perforation
Nasal vestibule dermatitis
Atrophic pharyngitis
Atrophic laryngitis (cough, voice hoarseness)
PNS- opaque on X-ray
TREATMENT- I. Medical- a. Nasal irrigation & crusts removal
b. 25% glucose in glycerine
c. Local antibiotics
d. Estradiol spray
e. Placental extract
f. Systemic Streptomycin
g. KI
II. Surgical- A. Young operation
Modified Young operation
B. Narrowing nasal cavity- i. Submucosal teflon paste injection
ii. Insertion of fat,cartilage, bone/ teflon strips
iii. Section & medial displacement of lateral wall
D. RHINITIS SICCA
E. RHINITIS CASEOSA
ENT
DISORDERS OF EXTERNAL NOSE & NASAL VESTIBULE

EXTERNAL NOSE DISEASES
1. CELLULITIS
2. NASAL DEFORMITIES- SADDLE NOSE
HUMP NOSE
CROOKED/ DEVIATED NOSE
3. TUMORS:- A. CONGENITAL- DERMOID CYST
I. Simple dermoid- midline swelling under nose anterior to nasal bones
No external deformity
II. Dermoid with sinus- a. External pit- children & infants
Pit/sinus over nose dorsum
Hair protrusion
b. Intracranial connection- between nasal bones & upper part of septum
Through Cribriform plate/Foramen caecum
Attached to dura
Meningitis
TREATMENT- Splitting of nasal bones +cyst removal
Intracranial connection- Associated neurosurgical approach
ENCEPHALOCOELE/ MENINGOENCEPHALOCOELE
GLIOMA
B. BENIGN- RHINOPHYMA/ POTATO TUMOR
Slow growing, benign tumor of external nose
Sebaceous glands hypertrophy at tip of nose
Pink lobulated mass with superficial vascular dilation
Middle aged Male
CLINICAL FEATURES- Unsightly appearance
Nasal obstruction
Vision obstruction
TREATMENT- Sharp knife
CO2 LASER
Complete excision & skin graft
PAPILLOMA/SKIN WART
HAEMANGIOMA
PIGMENTED NAEVUS
SEBORRHEIC KERATOSIS
NEUROFIBROMA
TUMOR OF SWEAT GLANDS
C. MALIGNANT- BCC/ RODENT ULCERS
SCC/ EPITHELIOMA
MELANOMA
NASAL VESTIBULE DISEASES
1. FURUNCLE/ BOIL
DEFINITION- acute hair follicles infection by Staphylococcus aureus
ETIOLOGY- Trauma- Nose picking
Hair pulling
CLINICAL FEATURES- painful & tender lesion
May spread to skin of nasal tip & dorsum (red & swollen)
Rupture in vestibule
Localised redness
COMPLICATIONS- Upper lip cellulitis
Septal abscess
Cavernous sinus thrombosis
TREATMENT- Warm compresses
Analgesics
Topical & Systemic antibiotics
Incision & drainage
2. VESTIBULITIS
3. STENOSIS & ATRESIA OF THE NARES
4. TUMORS:- NASO- ALVEOLAR CYST
PAPILLOMA/WART
SCC
NASAL SEPTUM DISEASES
1. FRACTURES OF NASAL SEPTUM
ETIOPATHOGENESIS- Trauma on Nose From Front, Side/ Below
Trauma To Lower Nose
Profuse Epistaxis
Septal Hematoma
Saddle Nose Deformity
A. Jarjaway Fracture
B. Chevallet Fracture
TREATMENT- Early Recognition & Treatment
Mattress Sutures & Nasal Packing
COMPLICATIONS- Deviation Of Cartilaginous nose
Asymmetry Of Nasal Tip, Columella/ Nostril
2. DNS
ETIOLOGY- I. Trauma- a. Lateral nose blow
b. Crushing frontal blow
c. Natal- forceps delivery
d. Antenatal- abnormal uterine postures
e. Childhood injuries
II. Developmental errors- a. Unequal growth between palate & skull base
b. Mouth breathing (adenoids hypertrophy)
c. Cleft lip & palate
d. Tumors & polyps
e. Dental abnormalities
III. Race- Caucasians
IV. Heredity
TYPES- I. Anterior dislocation
II. C shaped
III. S shaped
IV. Spurs
V. Thickening
CLINICAL FEATURES- A. Nasal obstruction- I. Unilateral
II. Bilateral (S shaped)
High septal deviation > low
B. Headache (spurs)
C. Sinusitis
D. Epistaxis
E. Anosmia
F. External deformity
G. Middle ear infection
SITES- 1. Vestibular
2. Nasal valve (Cottle test)
3. Attic
4. Turbinal
5. Choanal
TREATMENT- Asymptomatic- no treatment
Mechanical nasal obstruction- Surgery
A. SMR
B. Septoplasty(> 17 years)
COMPLICATIONS- Mouth breathing
Sleep apnea
Recurrent/ chronic rhinosinusitis
Middle ear infection
Atrophic rhinitis
Asthma
3. SEPTAL HAEMATOMA
DEFINITION- Blood collection under mucoperiosteum/mucoperichondrium of nasal septum
ETIOLOGY- Nasal trauma
Septal surgery
Bleeding disorders
CLINICAL FEATURES- Bilateral nasal obstruction
Frontal headache
Pressure sense over nasal bridge
Bilateral septal swelling (soft, round, smooth, fluctuant)
TREATMENT- Small- Aspiration with wide bore needle
Larger- Incision & drainage (small AP incision parallel to nasal floor)
Nasal cavity Packing
COMPLICATIONS- Thickened septum
Septal abscess
4. SEPTAL ABSCESS
ETIOLOGY- Secondary infection of septal hematoma
Furuncle- a. Nose
b. Upper lip
Acute infections (Typhoid, measles)
Diabetics
CLINICAL FEATURES- Bilateral nasal obstruction
Pain & tenderness over nasal bridge
Fever with chills
Frontal headache
Red, swollen skin
Smooth, bilateral swelling with fluctuation & congestion of nasal mucosa
Enlarged, tender Submandibular LN
COMPLICATIONS- Saddle nose deformity
Septal perforation
Meningitis
Cavernous sinus thrombosis
TREATMENT- I. Incision & drainage- earliest
Most dependent part & septal mucosa part excised
Pus & necrosed cartilage pieces suction
Reopened daily for 2-3 days
II. Systemic antibiotics- atleast 10 days
Culture & sensitivity
5. NASAL SEPTUM PERFORATION
ETIOLOGY- A. Traumatic Perforation - SMR
Chemical Cauterization
Galvano Cautery
Habitual Nose Picking
B. Pathological Perforation- Septal Abscess
Nasal Myiasis
Rhinolith/ Neglected FB
Chronic Granulomatous Condition
Wegener Granuloma
C. Drugs & Chemicals- Prolonged Steroids Use
Cocaine Addicts
Certain Occupations
D. Idiopathic
CLINICAL FEATURES- Small Anterior Perforation- Whistling Sound During Respiration
Larger Perforation- Crusts/ Severe Epistaxis
TREATMENT- Biopsy(Granulation/Edge )
Plastic Flaps (Inactive Small)
Alkaline Nasal Douches & Bland Ointment (Larger)
Thin Silastic button
MISCELLANEOUS DISORDERS OF NASAL CAVITY
I. FB
ETIOLOGY- Children
TYPES- Organic
Inorganic
CLINICAL FEATURES- History
Unilateral Foul Smelling Blood Stained Nasal Discharge
DIAGNOSIS:- X-Ray
TREATMENT- Removal under LA/ GA
METHOD- Blunt Hook
Nasal Endoscope
COMPLICATIONS- Nasal Infection
Sinusitis
Rhinolith
Inhalation Into Tracheobronchial Tree
II. RHINOLITH
Definition- stone formation in nasal cavity
ETIOLOGY- Exogenous FB, Blood clot/ inspissated secretions
Slow deposition of Ca & Mg salts
CLINICAL FEATURES- adults
Unilateral nasal obstruction
Foul smelling blood stained nasal discharge
Frank epistaxis
Neuralgic pain
Examination- grey brown/ greenish black mass with irregular surface & stony hard feel
Granulations
TREATMENT- Removal under GA
Lateral Rhinotomy
III. NASAL MYIASIS
ETIOLOGY- Genus Chrysomyia
Atrophic rhinitis
Syphilis
Leprosy
Infected wounds
CLINICAL FEATURES- first 3/4 days- intense irritation, sneezing, lacrimation, headache
Thin blood stained nasal discharge
Eyelids & lips puffy
Extensive destruction of Nose, PNS,Soft Tissue Face, Palate, Eyeball
TREATMENT- Instillation of Chloroform Water & Oil
Nasal Douche with Warm Saline
Isolation with Mosquito Net
Forceps Removal
Nasal Hygiene
IV. NASAL SYNECHIAE
V. CHOANAL ATRESIA
VI. CSF RHINORRHOEA
Definition- CSF leakage into nose
ETIOLOGY- 1. Trauma- Accidental
Surgical- FESS, Skull base surgery
2. Inflammation - Sinus mucocoele, Fungal sinusitis
3. Neoplasms - Benign
Malignant
4. Congenital lesions- meningocoele
5. Idiopathic
Sites of leakage- Anterior cranial fossa- Cribriform plate
Roof of ethmoid air cells
Frontal sinus
Middle cranial fossa- sphenoid sinus
Temporal bone fracture- CSF Otorhinorrhoea
CLINICAL FEATURES- thin watery clear discharge
DIAGNOSIS:- Reservoir sign
Double target sign
Nasal endoscopy
Oto/ micro scopic examination
Beta-2 transferrin in CSF
Beta trace protein in CSF
HRCT
MRI
Intra thecal fluorescein study
CT Cisternogram
TREATMENT- I. Conservative- bed rest
Elevation of bed head end
Stool softener
Avoid nose blowing
Antibiotics
Lumbar drain
II. Surgical- 1. Neurosurgical intracranial approach
2. Extradural approach
3. Transnasal endoscopic approach
EPISTAXIS
DEFINITION- Bleeding from inside the nose
ETIOLOGY- I. Local- A. Nose- 1. Trauma- Fingernail injuries
Intranasal surgery
Fractures of middle 1/3 face & skull base
2. Infections- a. Acute- Viral rhinitis
Diphtheria
Acute sinusitis
b. Chronic- Atrophic Rhinitis
Rhinosporidiosis
TB
Septal perforation
3. FB- a. Living
b. Non living
4. Neoplasms- a. Benign- Papilloma, hemangioma
b. Malignant- Carcinoma, Sarcoma
5. DNS
B. Nasopharynx- 1. Adenoiditis
2. Juvenile Angiofibroma
3. Malignant tumors
II. General- A. CVS- Hypertension
Arteriosclerosis
MS
Pregnancy
B. Hematological- Hemophilia
Vitamin K deficiency
Aplastic anemia
Leukaemia
Scurvy
C. Liver- Cirrhosis
D. Kidney- Chronic nephritis
E. Drugs- Aspirin, anticoagulants
F. Vicarious menstruation
III. Idiopathic
SITES- 1. Little area
2. Above middle turbinate
3. Below middle turbinate
4. Posterior part nasal cavity
5. Diffuse
6. Nasopharynx
CLASSIFICATION:- A. Anterior(Children)
B. Posterior(adults)(coffee colored vomitus)
History- Mode of onset- a. Spontaneous
b. Trauma
Duration & frequency
Amount
Site
Type- a. Anterior
b. Posterior
Known medical ailment
Drugs intake
DIAGNOSIS:- CBC
BT,CT,PT,aPTT
X-ray chest
CT/MRI
Angiography
TREATMENT- A. General- 1. Home care
a. Prevention- Avoid frequent nose picking
Increase ambient humidity with bedroom humidifier
b. Treatment- Pinch nose with thumb & index finger for 5 minutes
Cotton soaked in decongestants drops
Lean no further than 45°
Trotter method
Cold compresses over nose
2. Reassurance & mild sedation
3. Monitor vitals
4. Intermittent O2
5. Antibiotics
B. Cauterization(anterior)- 1. Chemical (mild)(AgNO3 bead)
2. Electrocautery
3. Endoscopic
C. Anterior nasal Packing- Indications- Active anterior epistaxis
Cauterization failure
No site localized
STEPS- 1. Nose cleared of clots by suction
2. Packing (1m ribbon gauge & 25 mm wide in adults & 12 mm in children)- a. Horizontal
(soaked in liquid paraffin)
b. Vertical
3. Removal after 24 hours/2-3 days
4. Systemic antibiotics
D. Posterior nasal Packing- a. Gauze
b. Foley catheter
c. Nasal balloon
E. Arterial embolization
F. Arterial ligation- a. ECA
b. Maxillary artery- i. Transantral
ii. Endoscopic
c. Ethmoidal artery
G. Surgical- a. SMR(persistent nasal septal bleeding)
b. Osler Weber Rendu disease/ Hereditary Hemorrhagic Telangiectasia- i. Ar/KTP/Nd- YAG
LASER
ii. Septodermoplasty
ENT
ANATOMY OF NOSE
EXTERNAL NOSE
Pyramidal
OSTEOCARTILAGINOUS FRAMEWORK
BONY PART
Upper 1/3 - Bony (2 Nasal Bones)
Lower 2/3- Cartilaginous
CARTILAGINOUS PART
1. Upper Lateral Cartilages- Limen vestibule/Nasal valve/ Limen nasi
2. Lower Lateral/Alar Cartilages
3. Lesser Alar/Sesamoid Cartilages
4. Septal Cartilage
Supratip depression deformity
NASAL MUSCULATURE
PROCERUS, NASALIS, LEVATOR LABII SUPERIORIS ALAEQUE NASI, ANTERIOR &
POSTERIOR DILATOR NARES & DEPRESSOR SEPTII
NASAL SKIN
Dangerous area of face/ danger triangular area(nasion- angles of mouth)(external nose+ upper
lip)(cavernous sinus thrombosis)
INTERNAL NOSE
R & L NASAL CAVITIES
NASAL SEPTUM
NARES/ NOSTRILS
CHOANAE
VESTIBULE OF NOSE
Vibrissae
Limen nasi
1. Nasal valve
2. Nasal valve area
NASAL CAVITY PROPER
LATERAL WALL- 3/ occasionally 4 turbinates/ conchae
Meatuses
INFERIOR TURBINATE
INFERIOR MEATUS- Hasner Valve
MIDDLE TURBINATE- Ground/Basal Lamina (Anterior 1/3- sagittal, middle 1/3- frontal, posterior
1/3- horizontal)
Anterior group of PNS
Posterior group
MIDDLE MEATUS- Uncinate Process (AS-PI)
Hiatus Semilunaris(1-2 mm)
Anterior & Posterior Fontanelle
Infundibulum
Bulla Ethmoidalis
Supra/ Retro Bullar Recesses
Lateral Sinus/ Sinus Lateralis of Grunwald
Hiatus Semilunaris Superior
Atrium of MM
Agger Nasi
Concha Bullosa
Haller Cells
Maxillary Sinuses
SUPERIOR TURBINATE
SUPERIOR MEATUS- Onodi Cell
Posterior Ethmoidal Sinus
SPHENOETHMOIDAL RECESS - Sphenoidal Sinus
SUPREME TURBINATE
MEDIAL WALL- NASAL SEPTUM- 1. COLUMELLAR SEPTUM
2. MEMBRANOUS SEPTUM
3. SEPTUM PROPER
MAJOR contributions- perpendicular plate of ethmoid
Vomer
Septal/ quadrilateral cartilage
MINOR contributions- Crest of nasal bones
Nasal spine of frontal bone
Rostrum of sphenoid
Crest of Palatine bone
Crest maxilla
Anterior nasal spine of maxilla
ROOF
Nasal Bones
Body of Sphenoid
Cribriform Plate of Ethmoid
FLOOR
Palatine Process of Maxilla
Horizontal Part of Palatine Bone
LINING MEMBRANE OF INTERNAL NOSE
1. VESTIBULE (SKIN)
2. OLFACTORY REGION(UPPER 1/3 LATERAL WALL + NASAL SEPTUM + NASAL CAVITY
ROOF)
3. RESPIRATORY REGION- LOWER 2/3 NASAL CAVITY
VARIABLE THICKNESS MM
PSEUDO STRATIFIED CILIATED COLUMNAR EPITHELIUM
NERVE SUPPLY- 1. OLFACTORY NERVES
2. NERVES OF COMMON SENSATION- ANTERIOR ETHMOIDAL NERVE (ANTERIOR &
SUPERIOR PART NASAL CAVITY)
BRANCHES OF SPHENOPALATINE GANGLION(POSTERIOR 2/3 NASAL CAVITY)
BRANCHES OF INFRAORBITAL NERVE (VESTIBULE OF NOSE)
3. AUTONOMIC NERVES - PARASYMPATHETIC (GREATER SUPERFICIAL PETROSAL
NERVE)
SYMPATHETIC (UPPER 2 THORACIC SEGMENTS)
LYMPHATIC DRAINAGE- EXTERNAL NOSE & ANTERIOR PART NASAL CAVITY-
SUBMANDIBULAR LN
REST - DIRECTLY/ RETROPHARYNGEAL LN》 UPPER JUGULAR LN
BLOOD SUPPLY
NASAL SEPTUM- ICA- OPHTHALMIC ARTERY BRANCHES- 1. ANTERIOR ETHMOIDAL
2. POSTERIOR ETHMOIDAL
ECA- MAXILLARY ARTERY- 1. SPHENOPALATINE
2. SEPTAL BRANCH GREATER PALATINE
FACIAL ARTERY- 3. SEPTAL BRANCH SUPERIOR LABIAL
LATERAL WALL- ICA- OPHTHALMIC ARTERY- 1. ANTERIOR ETHMOIDAL
2. POSTERIOR ETHMOIDAL
ECA- SPHENOPALATINE ARTERY- 1. POSTERIOR LATERAL NASAL BRANCHES
MAXILLARY ARTERY- 2. GREATER PALATINE
3. NASAL BRANCH ANTERIOR SUPERIOR DENTAL
4. BRANCHES TO NASAL VESTIBULE
LITTLE'S AREA
Importance- 1. Fingernail trauma
2. Epistaxis site in infants & children
3. Site of origin of bleeding polypus/hemangioma
4. Drying effect of inspiratory currents
RETROCOLUMELLAR VEIN
WOODRUFF PLEXUS (POSTERIOR EPISTAXIS)
PHYSIOLOGY OF NOSE
FUNCTIONS- 1. RESPIRATION- QUIET RESPIRATION
EXPIRATION
NASAL CYCLE
2. AIR CONDITIONING OF INSPIRED AIR- A. FILTRATION & PURIFICATION
B. TEMPERATURE CONTROL OF INSPIRED AIR
C. HUMIDIFICATION
3. PROTECTION OF LOWER AIRWAY- A. MUCOCILIARY MECHANISM - MUCOUS BLANKET
B. ENZYMES & IMMUNOGLOBULINS
C. SNEEZING
4. VOCAL RESONANCE
5. NASAL REFLEXES
6. OLFACTION- A. OLFACTORY PATHWAYS
SMELL DISORDERS- ANOSMIA
HYPOSMIA
PAROSMIA
TESTS- SMELL COMMON ODORS
QUANTITATIVE ESTIMATION (QUANTITATIVE OLFACTOMETRY)
ENT
ME DISORDERS
I. ASOM
Definition- acute ME inflammation by pyogenic organisms
ETIOLOGY- Infants & children of lower socioeconomic groups
Viral infections of URT
Route of infection- A. ET- 1. Anatomical obstruction: Big adenoids & nasopharyngeal tumors
2. Infections: Adenoiditis, tonsillitis, rhinitis, sinusitis, pharyngitis
3. Forceful blowing of nose
4. Swimming
5. Iatrogenic: Postnasal packing and after adenoidectomy
6. Feeding bottle
B. EE- 1. Pre-existing TM perforation
C. ME- 1. Fracture of temporal bone
D. BLOOD BORNE
Predisposing Factors
1. Reduced immunity
2. Barotrauma
3. Exanthematous fevers(Measles, diphtheria, whooping cough)
4.Palatal disorders(cleft palate & palatal palsy)
5. Nasal allergy(Inhalants and foods)
Bacteriology- Streptococcus pneumoniae, Haemophilus influenzae, Branhamella catarrhalis
Streptococcus pyogenes, Staphylococcus aureus
CLINICAL FEATURES
I. Stage of tubal occlusion- edema & hyperemia of nasopharynx & ET occludes ET 》
absorption of air & creation of negative ME pressure
Symptoms- Mild deafness
Ear fullness & ear pain
No fever
Signs- Retracted TM- relative shortening & more horizontal position of malleus handle,
prominent lateral process of malleus & loss of light reflex
Conductive hearing loss
II. Stage of presuppuration- Prolonged tubal occlusion 》 invasion of pyogenic
organism into ME 》 mucosal hyperemia》 Inflammatory exudates in ME
Symptoms- Marked throbbing ear pain
High degree of fever and restlessness
Bubbling sound in ear
Deafness
Signs- PT congested & bulging out with cart- wheel appearance (leash of blood vessels along
handle of malleus & at periphery of TM) & loss of light reflex
Tuning fork tests- conductive hearing loss
III. Stage of suppuration- formation of pus in ME & in mastoid air cells
TM bulging
Symptoms- Excruciating ear pain
Increasing deafness
Constitutional symptoms- rising fever with vomiting, diarrhea & convulsions
Signs- TM red and bulging to the point of rupture with loss of landmarks
Handle of malleus engulfed by swollen & protruding TM
Yellow spot on TM where rupture imminent Tenderness over mastoid antrum in region of
suprameatal triangle
Clouding of air cells in X-ray of mastoid
IV. Stage of resolution- TM ruptures 》otorrhea and subsidence of other symptoms
Inflammatory process begins resolving Symptoms- Otorrhea(Blood tinged ear
discharge (serosanguinous) later becomes mucopurulent)
Ear pain & fever subside
Signs- EAC filled with blood tinged/ mucopurulent discharge, which may be pulsatile
(lighthouse sign)
Perforation of PT in anteroinferior quadrant
V. Stage of complication: In majority of children AOM self limiting & responds well to medical
treatment
If virulence of organism high & resistance of child poor, infection may spread beyond ME space
complications occur in second week Constitutional & infectious sign & symptoms reappear
DIAGNOSIS:- Tuning Fork Tests
CT Temporal
Culture & sensitivity
TREATMENT- 1. Antibacterial therapy( single IM dose of ceftriaxone 5-day course/ 10–14 days
course of oral antibiotics)(first line of amoxicillin (40 mg/kg/day in 3 divided doses))
2. Decongestant nasal drops (Ephedrine/Oxymetazoline/Xylometazoline)
3. Oral nasal decongestants(Pseudoephedrine)
4. Analgesics & antipyretics
5. Ear Toilet
6. Dry local heat
7. Myringotomy
II. ACUTE NECROTIZING OM
III. OME/ SEROUS/ SECRETORY/MUCOID OM/ GLUE EAR
Definition- insidious condition of collection of non-purulent, thin which may become thick &
sticky, nearly sterile effusion in ME cleft >= 3 months
Pathogenesis- 1. ET malfunction
2. Increased secretory activity of ME mucosa
ETIOLOGY- 1. Malfunctioning of Eustachian tube- Adenoid hyperplasia & infection
Chronic rhinitis, sinusitis, tonsillitis
Benign & malignant tumors of nose, PNS & nasopharynx
Cleft palate and palatal paralysis
2. Allergy
3. Unresolved OM
4. Viral infections
Symptoms- 1. Insidious conductive hearing loss (rarely exceeds 40 dB)
2. Delayed & defective speech
3. Mild earaches
Otoscopy- Dull,opaque TM with loss of light reflex
Retracted, less mobile or immobile TM
Outward brisk movement of TM on reducing pressure in EAC with pneumatic otoscope
Dark, fluid-filled ME obscures vision of long process of incus
Thin leash of blood vessels along malleus handle/ TM periphery
INVESTIGATIONS- 1. TUNING FORK TESTS
2. AUDIOMETRY
3. IMPEDANCE AUDIOMETRY
4. X-ray Mastoid
5. Tympanometry
TREATMENT- I. Medical- 1. Decongestants
2. Anti allergic measures
3. Antibiotics
4. ME Aeration- Valsalva manuevre
II. Surgical- 1. Myringotomy & fluid aspiration
2. Grommet insertion
3. Tympanotomy/ Cortical Mastoidectomy
4. Surgical treatment of causative factor
Sequelae - 1. Atrophic TM & Atelectasis of ME
2. Ossicular necrosis
3. Tympanosclerosis
4. Retraction pockets & Cholesteatoma
5. Cholesterol granuloma
6. TM perforation
7. SNHL
8. Adhesive OM
IV. RECURRENT ACUTE OM
V. AERO- OM/ OTITIC BAROTRAUMA
Definition- non- suppurative condition due to failure of ET to maintain ME pressure at ambient
atmospheric level
Etiopathology- 1. Pressure changes
2. ET dysfunction- adenoids, rhinitis / DNS
CLINICAL FEATURES- deafness relieved by swallowing and yawning
Severe Earache
Conductive/ SN hearing loss
Vertigo uncommon
TM retracted & congested
ME - air bubbles/ hemorrhagic effusion
TREATMENT- Repeated swallowing, yawning and Valsalva maneuver
Antibiotics, analgesics, decongestants (topical nasal drops and oral tablets)
Myringo puncture with injection of air into ME
Myringotomy with grommet insertion in refractory cases
Prevention- Avoid flying and diving during rhinitis
Decongestion of nose before the flight especially before the descent
Repeated swallowing during descent
Never sleep during the descent
Perform intermittently Valsalva maneuvers Treatment of the cause of ET dysfunction
ENT
EE DISORDERS
I. DISEASES OF THE PINNA
A. CONGENITAL DISORDERS- 1. ANOTIA
2. MICROTIA
3. MACROTIA
4. BAT/ PROMINENT/ PROTRUDING EAR
5. CUP/LOP EAR
6. CRYPTOTIA/ POCKET EAR
7. COLOBOMA
8. MINOR DEFORMITIES- TRAGUS ABSENCE, DARWIN TUBERCLE,STAHL EAR, SATYR
EAR
9. EAR LOBULE DEFORMITIES
10. PRE AURICULAR TAGS/ APPENDAGES
11. PRE AURICULAR PITS/ SINUS
B. TRAUMA TO THE AURICLE- 1. HAEMATOMA
2. LACERATIONS
3. AVULSION OF PINNA
4. FROSTBITE
5. KELOID OF AURICLE
C. INFLAMMATORY DISORDERS- 1. PERICHONDRITIS
2. RELAPSING POLYCHONDRITIS
3. CHONDRO DERMATITIS NODULARIS CHRONICA HELICIS
D. TUMORS:- 1. BENIGN- PRE AURICULAR SINUS/ CYST
SEBACEOUS CYST
DERMOID CYST
KELOIDS
HAEMANGIOMAS- CAPILLARY,CAVERNOUS, VASCULAR MALFORMATIONS
PAPILLOMA/ WART
CUTANEOUS HORN
KERATOACANTHOMA
NEUROFIBROMA
2. MALIGNANT- SCC
BCC
MELANOMA
II. DISEASES OF EAC
A. CONGENITAL DISORDERS- 1. EAC ATRESIA
2. COLLAURAL FISTULA
B. TRAUMA- 1. MINOR LACERATIONS
2. MAJOR LACERATIONS
C. INFLAMMATORY- 1. INFECTIVE GROUP- BACTERIAL- LOCALIZED OE/FURUNCLE
DIFFUSE OE
MALIGNANT OE
FUNGAL- OTOMYCOSIS
VIRAL- HERPES ZOSTER OTICUS
OE HAEMORRHAGICA
2. REACTIVE GROUP- ECZEMATOUS OE
SEBORRHEIC OE
NEURO DERMATITIS
FURUNCLE
Definition- Staphylococcal hair Follicles infection
Only in Cartilaginous part
Single/ multiple
CLINICAL FEATURES- Severe pain & tenderness (out of proportion)
Painful movements
Posterior meatal wall- edema over Mastoid + retro auricular groove obliteration
Peri auricular LN enlarged & tender
TREATMENT- Systemic antibiotics
Analgesics
Local heat
Ear pack of 10% ichthammol glycerine
RECURRENT- DM Exclusion
DIFFUSE OE
Definition- diffuse inflammation of meatal skin spreading to involve pinna & TM epidermal layer
ETIOLOGY- Hot & humid weather
Swimmers
Trauma to meatal skin
Invasion by pathogenic organisms ( secondary to ME infection, allergy sensitization to topical
ear drops)
Bacteriology- Staphylococcus aureus
Pseudomonas
B.proteus
E.coli
CLINICAL FEATURES- ACUTE PHASE- hot burning sensation
Pain aggravated by jaw movements
Thin serous discharge ( later thick & purulent)
Meatal lining inflamed & swollen
Conductive hearing loss
Regional LN enlarged & tender
CHRONIC PHASE- irritation & strong desire to itch
Scanty discharge 》 crusts
Meatal skin thick & swollen
Meatal stenosis
TREATMENT- ACUTE PHASE- 1. Ear Toilet
2. Medicated wicks with antibiotics steroid preparation
3. Antibiotics
4. Analgesics
CHRONIC PHASE- 1. Medicated wicks with 10% ichthammol glycerine
2. Ear Toilet
3. Topical antibiotics steroid cream
4. Surgical excision + split skin graft
COMPLICATIONS- 1. Cellulitis
2. Perichondritis/ chondritis
3. Medial canal fibrosis
4. Malignant OE
OTOMYCOSIS
Definition- fungal infection of ear canal
Organisms- A.niger, A.fumigatus, C.albicans
ETIOLOGY- hot & humid weather
Secondary fungal growth following topical antibiotics
CLINICAL FEATURES- Intense itching, discomfort, or ear pain
Discharge with musty odor and ear blockage
Sodden, red and edematous meatal skin
Otoscopy- A.niger- black headed filamentous growth
A.fumigatus - pale blue/ green deposits
C.albicans- white/ creamy deposits
TREATMENT- Antifungal agents: Povidine iodine, 2% salicylic acid in alcohol (Nystatin,
Clotrimazole)
Should be continued for a week after the apparent cure.
Dry ear(syringing ,suction/ mopping)
Antibiotic/steroid ear drops
MALIGNANT/ NECROTIZING OE
Definition- Rare OE caused by Pseudomonas infection in immunocompromised patients which
progressively spreads to skull base and intracranial structures
ETIOLOGY- Causative microorganisms: Pseudomonas aeruginosa
Staphylococcus aureus
Staphylococcus epidermidis
Immunocompromised patients: Elderly diabetics, HIV/AIDS, myeloid malignancies, anticancer
drugs & organ transplant recipients
CLINICAL FEATURES- Severe otalgia & otorrhea
Granulations in the floor of EAC at bony-cartilaginous junction(Hallmark finding)
Facial nerve paralysis
Advanced stage: IX, X and XI CN palsy
Intracranial spread: Headache, fever, neck stiffness & altered levels of consciousness
Spread of infection to neighbouring structures like TMJ, mastoid, ME and petrous
Children: Acute onset of painful otorrhea with immunosuppression, DM/SJS & poor general
health
Investigations- Bacterial and fungal culture
High-resolution computed tomography (HRCT) scan
Single-photon emission tomography (SPECT) with radio-nuclide tracers
Gallium 67 scan
Technetium 99 bone scans
Treatment- DM control
Ear Toilet
Antibiotics(Oral or parenteral)- ciprofloxacin for 6–8 weeks or longer( tobramycin, ticarcillin and
third generation cephalosporins)
Hyperbaric oxygen therapy
Treatment of cause of immunosuppression
Surgical debridement of nonviable sequestra of bone
D. TUMORS:- 1. BENIGN- OSTEOMA
EXOSTOSES
CERUMINOMA
SEBACEOUS ADENOMA
PAPILLOMA
2. MALIGNANT- SCC
BCC
ADENOCARCINOMA
MALIGNANT CERUMINOMA
MALIGNANT MELANOMA
E. MISCELLANEOUS- 1. IMPACTED WAX/ CERUMEN
COMPONENTS- Sebaceous gland’s secretion
Ceruminous gland’s secretion
Hairs
Desquamated epithelial debris and keratin
Dirt
FACTORS- Narrow and tortuous ear canal
Stiff hair
Exostosis
Excessive secretion of wax & dusty occupations
Self-cleaning of ear wax
CLINICAL FEATURES- Hearing loss or sense of blocked ear
Tinnitus and giddiness
Reflex cough
Wax granuloma
TREATMENT- removal by either syringing/other ear instruments(Instrumental manipulation by
skilled hands preferably under ear microscopy)(Cerumen hook, scoop or Jobson-Horne probe)
Wax softening agents(5% soda bicarbonate in equal parts of glycerin & water,Hydrogen
peroxide,Liquid paraffin,Olive oil, Paradichlorobenzene 2%)
2. FB OF EAR
TYPES- Nonliving–Hygroscopic- Grain seeds
Non-hygroscopic
Living: Flying/crawling insects
CLINICAL FEATURES- Adults- broken end of matchstick/overlooked cotton swab
Vegetable FBs swell up with time & get impacted in EAC(suppuration)
Living FBs- intense irritation and pain
Injury to TM, ME structures, IE (subluxation of stapes into vestibule)(hairpin/bullet)
TREATMENT- Antibiotics
Ear drops(glycerin and absolute alcohol drops)(Hygroscopic FB)
Removal under ear microscope
Methods:- Forceps removal(Soft & irregular FBs)
Syringing(Seed grains & smooth objects)
Hooking out(Wax hook/vectis)
Insects- First killed by instilling oil, spirit, chloroform/ water & then removed
Postaural approach
Removal under general anesthesia
COMPLICATIONS- Injury to TM & ME structures
Secondary infection
3. KERATOSIS OBTURANS
Definition- collection of pearly white mass of desquamated epithelial cells in the deep meatus
ETIOLOGY- 1/ both ears
5-20 years
CLINICAL FEATURES- Severe otalgia
Deafness, tinnitus & ear discharge
Pearly white mass of keratin material filling ear canal
Thickening & mucosalization of TM
Blunting of periannular canal skin
Widening of canal & facial nerve palsy
TREATMENT- Treatment of secondary OE
Removal of epithelial debris under ear microscopy(syringing /instrutmentation)
Prophylaxis(Cleaning of canal before occurrence of inflammation and infection)
Use of keratolytic agent like 2% salicylic acid in alcohol(Recurrent)
4. ACQUIRED ATRESIA & STENOSIS OF MEATUS
III. TM DISORDERS
1. RETRACTED TM
2. MYRINGITIS BULLOSA
3. HERPES ZOSTER OTICUS
4. MYRINGITIS GRANULOSA
5. TRAUMATIC RUPTURE
6. ATROPHIC TM
7. RETRACTION POCKETS & ATELECTASIS
8. TYMPANOSCLEROSIS
9. PERFORATION
ENT
DEAF CHILD
Definition- children with profound/ total deafness(>90dB) with failure to develop speech(deaf-
mute/deaf & dumb)
ETIOLOGY- A. PRENATAL CAUSES- 1. INFANT FACTORS- a. Scheibel dysplasia
b. Alexander dysplasia
c. Bing- Siebenmann dysplasia
d. Michel aplasia
e. Mondini dysplasia
f. Enlarged vestibular aqueduct
g. SCC malformations
2. MATERNAL FACTORS- a. Infections during pregnancy (TORCHES)
b. Drugs during pregnancy
c. Radiation exposure in first trimester
d. Other factors
B. PERINATAL CAUSES- 1. Anoxia
2. Prematurity & low birth weight
3. Birth injuries
4. Neonatal jaundice
5. Neonatal meningitis
6. Sepsis
7. Time spent in NICU
8. Ototoxic drugs
C. POSTNATAL CAUSES- 1. Genetic- familial progressive SNHL/ in association with certain
syndromes
2. Non- genetic
EVALUATION- DEAF CHILD- FINDING THE CAUSE- 1. SUSPICION OF HEARING LOSS- a.
Sleep through loud noise unperturbed/fail to startle to loud noises
b. Failure to develop speech at 1-2 years
2. RISK FACTORS FOR HEARING LOSS IN CHILDREN- a. Family history of hearing loss
b. Prenatal infections
c. Craniofacial anomalies
d. Birth weight < 1.5 kg
e. Hyperbilirubinemia
f. Ototoxic drugs
g. Bacterial meningitis
h. APGAR score 0-4
i. Mechanical ventilation >=5 mins
j. Stigmata
ASSESSMENT OF HEARING IN INFANTS & CHILDREN
1. SCREENING PROCEDURES- A. OTO ACOUSTIC EMISSIONS (OAE)
B. AUDITORY BRAINSTEM RESPONSES (ABR)
AROUSAL TEST
AUDITORY RESPONSE CRADLE
2. BEHAVIOR OBSERVATION AUDIOMETRY
3. DISTRACTION TECHNIQUES(6-7 months)
4. CONDITIONING TECHNIQUES- A. VISUAL REINFORCEMENT AUDIOMETRY ( VRA)
B. PLAY AUDIOMETRY
C. SPEECH AUDIOMETRY
5. OBJECTIVE TESTS- A. EVOKED RESPONSES AUDIOMETRY- I.
ELECTROCOCHLEOGRAPHY
II. AUDITORY BRAINSTEM RESPONSE
B. OAE
C. IMPEDANCE AUDIOMETRY
MANAGEMENT- 1. Parental guidance
2. Hearing aids
3. Cochlear implants
4. Development of speech & language- A. Auditory- oral communication
B. Manual communication
C. Total communication
5. Education of the deaf
6. Vocational guidance
ENT
FACIAL NERVE & DISORDERS

ANATOMY- PONS- PAROTID
MIXED NERVE
FUNCTIONS- TASTE & GENERAL SENSATION
SECRETOMOTOR FIBRES TO SALIVARY & LACRIMAL GLANDS
COMPONENTS- 1. SPECIAL VISCERAL EFFERENT
2. GENERAL VISCERAL EFFERENT
3. SPECIAL VISCERAL AFFERENT
4. GENERAL SOMATIC AFFERENT
NUCLEUS - PONS
COURSE OF NERVE- NUCLEUS
SENSORY ROOT( NERVE OF WRISBERG)
BRAINSTEM (PONTO- MEDULLARY JUNCTION)
POSTERIOR CRANIAL FOSSA
IAM
BONY FACIAL CANAL
STYLO MASTOID FORAMEN
PARTS- 1. INTRACRANIAL (15-17 mm)
2. INTRA TEMPORAL- A. MEATAL SEGMENT (8-10 mm)
B. LABYRINTHINE SEGMENT (4 mm)
C. TYMPANIC/HORIZONTAL SEGMENT (11 mm)
D. MASTOID/VERTICAL SEGMENT (13 mm)
3. EXTRA CRANIAL
BRANCHES- 1. GREATER SUPERFICIAL PETROSAL NERVE
2. NERVE TO STAPEDIUS
3. CHORDA TYMPANI
4. COMMUNICATING BRANCH
5. POSTERIOR AURICULAR NERVE
6. MUSCULAR BRANCHES
7. PERIPHERAL BRANCHES
BLOOD SUPPLY- 1. ANTERIOR INFERIOR CEREBELLAR ARTERY
2. LABYRINTHINE ARTERY
3. SUPERFICIAL PETROSAL ARTERY
4. STYLO MASTOID ARTERY
EXTERNAL PLEXUS
INTERNAL PLEXUS
SURGICAL LANDMARKS- ME & MASTOID- 1. PROCESSUS COCHLEARIFORMIS
2. OVAL WINDOW & HORIZONTAL CANAL
3. INCUS SHORT PROCESS
4. PYRAMID
5. TYMPANO MASTOID SUTURE
6. DIGASTRIC RIDGE
PAROTID- 1. CARTILAGINOUS POINTER
2. TYMPANO MASTOID SUTURE
3. STYLOID PROCESS
4. DIGASTRIC POSTERIOR BELLY
VARIANTS- 1. BONY DEHISCENCE
2. NERVE PROLAPSE
3. HUMP
4. BIFURCATION & TRIFURCATION
5. BIFURCATION & ENCLOSING STAPES
6. BETWEEN OVAL & ROUND WINDOWS
STRUCTURE- AXON
MYELIN SHEATH
NEURILEMMA
ENDO NEURIUM
PERI NEURIUM
EPI NEURIUM
SEVERITY OF NERVE INJURY- 1. NEURAPRAXIA
2.AXONOTEMESIS
3. NEUROTEMESIS
SUNDERLAND CLASSIFICATION
ELECTRO DIAGNOSTIC TESTS- 1. MINIMAL NERVE EXCITABILITY TEST
2. MAXIMAL STIMULATION TEST ( MST)
3. ELECTRO NEURONOGRAPHY(ENoG)
4. ELECTRO MYO GRAPHY(EMG)
FACIAL PARALYSIS
CAUSES- I. CENTRAL/UMN- 1. BRAIN ABSCESS
2. PONTINE GLIOMA
3. POLIOMYELITIS
4. MS
II. PERIPHERAL/LMN- A. INTRA CRANIAL PART- 1. ACOUSTIC NEUROMA
2. MENINGITIS
B. INTRA TEMPORAL PART- 1. IDIOPATHIC- BELL PALSY
MELKERSSON SYNDROME( TRIAD OF FACIAL PARALYSIS, LIPS SWELLING & FISSURED
TONGUE)- RECURRENT FACIAL PARALYSIS
BILATERAL FACIAL PARALYSIS
2. INFECTIONS- ASOM
CSOM
HERPES ZOSTER OTICUS(RAMSAY HUNT SYNDROME)
MALIGNANT OE
3. TRAUMA- ACCIDENTAL- TEMPORAL BONE FRACTURES
SURGICAL- MASTOIDECTOMY
4. NEOPLASMS- EE & ME
GLOMUS TUMOR
C. EXTRA CRANIAL PART- 1. PAROTID MALIGNANCIES
2. PAROTID SURGERY
3. SYSTEMIC DISEASES- DM
HYPOTHYROIDISM
PAN
SARCOIDOSIS
BELL PALSY
Definition- idiopathic peripheral facial paralysis/ paresis of acute onset
Both sexes
Positive family history
Risk more in DM & pregnancy
ETIOLOGY- 1. Viral infections- HSV,HZV,EBV
2. Vascular Ischemia- Primary Ischemia
Secondary Ischemia
3. Heredity
4. Autoimmune disorders
CLINICAL FEATURES- sudden onset
Unable to close eye
Bell phenomenon
Saliva dribbling from angle of mouth
Facial asymmetry
Epiphora
Noise intolerance
Loss of taste
DIAGNOSIS:- Exclusion
Careful history
Complete otological & head & neck examination
X-ray
CBC
NERVE EXCITABILITY TEST
TOPODIAGNOSIS
Treatment- I. GENERAL- 1. Reassurance
2. Analgesics
3. Care of the eye(artificial tears, proper cover)
4. Physiotherapy/ massage of facial muscles
II. Medical- 1. Steroids
2. Other drugs- vasodilators, vitamins, mast cell inhibitors, anti histaminics
III. SURGICAL- 1. Nerve Decompression
2. End- to- end anastomosis
3. Nerve Graft
4. Hypoglossal- Facial anastomosis
5. Plastic Procedures
TOPODIAGNOSTIC TESTS- 1. SCHIRMER TEST
2. STAPEDIAL REFLEX
3. TASTE TEST
4. SUBMANDIBULAR SALIVARY FLOW TEST
COMPLICATIONS- 1. INCOMPLETE RECOVERY
2. EXPOSURE KERATITIS
3. SYNKINESIS
4. TICS & SPASMS
5. CONTRACTURES
6. CROCODILE TEARS
7. FREY SYNDROME
8. PSYCHOLOGICAL & SOCIAL PROBLEMS
HYPERKINETIC DISORDERS- 1. HEMI FACIAL SPASM
2. BLEPHARO SPASM
ENT
EUSTACHIAN/ AUDITORY/ PHARYNGOTYMPANIC TUBE

ANATOMY - 36 mm
45° with horizontal
Nasopharynx- tympanic cavity
2 parts- Bony (PL)(12 mm)
Fibrocartilaginous(AM)(24 mm)
ISTHMUS
TYMPANIC END
PHARYNGEAL END- TORUS TUBARIUS
STRUCTURE- MUSCLES- TENSOR VELI PALATINI
LEVATOR VELI PALATINI
SALPINGOPHARYNGEUS
Dilatory tubae muscle
Elastin hinge
Ostmann fat pad
Lining- pseudo stratified ciliated columnar epithelium with mucus secreting goblet cells
Submucosa- sero mucinous glands
Nerve supply- CN 9 tympanic branch
TVP- Mandibular branch CN5
LVP,S- Pharyngeal plexus(CN 11)
Functions- 1. Ventilation & regulation of ME pressure
2. Protective functions
3. ME secretions clearance
Function tests- 1. Valsalva test
2. Politzer test
3. Catheterisation
4. Toynbee test
5. Tympanometry (Inflation- Deflation test)
6. Radiological test
7. Saccharine/ Methylene blue test
8. Sonotubometry
DISORDERS- 1. Tubal blockage- A. Mechanical- a. Intrinsic causes- inflammation, allergy
b. Extrinsic causes- nasopharyn tumor, adenoids
B. Functional- collapse
C. Both
Symptoms- otalgia, hearing loss, popping sensation, tinnitus, equilibrium disturbance
Signs- retracted TM
Congestion along malleus handle & pars tensa
2. Adenoids
3. Cleft palate
4. Down syndrome
5. Barotrauma
ENT
VESTIBULAR FUNCTION ASSESSMENT

I. CLINICAL- A. SPONTANEOUS NYSTAGMUS
B. FISTULA TEST
C. ROMBERG TEST
D. GAIT
E. PAST POINTING & FALLING
F. DIX- HALLPIKE MANOEUVRE (POSITIONAL TEST)
G. CEREBELLAR DYSFUNCTION TEST
II. LABORATORY- A. CALORIC TEST- 1. MODIFIED KOBRAK TEST
2. FITZGERALD- HALLPIKE TEST (BITHERMAL CALORIC TEST)- a.CANAL PARESIS
b. DIRECTIONAL PREPONDERANCE
3. COLD- AIR CALORIC TEST
B. ELECTRONYSTAGMOGRAPHY
C. OPTOKINETIC TEST
D. ROTATION TEST
E. GALVANIC TEST
F. POSTUROGRAPHY
G. VESTIBULAR EVOKED MYOGENIC POTENTIALS (VEMP)
DISORDERS- I. PERIPHERAL- 1. MENIERE DISEASE
2. BPPV
3. VESTIBULAR NEURONITIS
4. LABYRINTHITIS- CIRCUMSCRIBED
SEROUS
PURULENT
5. VESTIBULOTOXIC DRUGS
6. HEAD TRAUMA
7. PERILYMPH FISTULA
8. SYPHILIS
9. ACOUSTIC NEUROMA
II. CENTRAL- 1. VERTEBROBASILAR INSUFFICIENCY
2. POSTEROINFERIOR CEREBELLAR ARTERY SYNDROME (WALLENBERG SYNDROME)
3. BASILAR MIGRAINE
4. CEREBELLAR DISEASE
5. MULTIPLE SCLEROSIS
6. BRAINSTEM & 4TH VENTRICLE FLOOR TUMORS
7. EPILEPSY
8. CERVICAL VERTIGO
OTHER CAUSES OF VERTIGO- 1. OCULAR
2. PSYCHOGENIC
ENT
ACOUSTIC NEUROMA/ VESTIBULAR SCHWANNOMA/NEURILEMMOMA/8TH NERVE

TUMOR
Pathology- benign,encapsulated, extremely slow growing tumor of CN 8
Microscopy- elongated spindle cells with red shaped nuclei in rows/palisades
Origin- Schwann cells of vestibular/ cochlear division of CN8 within IAC
Growth- Cerebellopontine angle
CN 5,9,10,11
Brainstem displacement
Cerebellum pressure
Raised ICT
Classification:- 1. Intracanalicular(IAC)
2. Small size (<1.5 cm)
3. Medium size (1.5-4 cm)
4. Large size (>4 cm)
CLINICAL FEATURES- 1.Age- 40-60 years
2. Sex- both equally
3. Cochleovestibular symptoms- progressive unilateral SNHL,tinnitus, marked difficulty in
understanding speech, out of proportion pure tone hearing loss
Vestibular symptoms- imbalance/ unsteadiness
4. CN involvement- CN5- reduced corneal sensitivity, face numbness/paraesthesia
CN 7- Hitzelberger sign,loss of taste, reduced lacrimation on Schirmer test, delayed blink reflex
CN 9,10- dysphagia, hoarseness
Other CN(11,12,3,4,6)
5. Brainstem involvement - ataxia, weakness & numbness of arms & legs, exaggerated tendon
reflexes
6. Cerebellar involvement- pressure symptoms
7. Raised ICT- headache, nausea, vomiting, diplopia,papilledema
DIAGNOSIS:-:- Investigations- 1. Audiological tests- a. Pure Tone Audiometry- SNHL
b. Speech Audiometry- poor speech discrimination
c. Recruitment phenomenon absent
d. SISI - 0-20 % score
e. Threshold Tone Decay Test- retrocochlear lesion
2. Stapedial reflex decay test
3. Vestibular tests- Caloric Test
4. Neurological tests- complete CNS examination
Fundus examination
5. Radiological tests- Plain X-Rays
CT scan
MRI with gadolinium contrast
Vertebral angiography
6. Evoked Response Audiometry (BERA)
7. CSF examination
D/d- Meniere disease
Other cerebellopontine angle tumors
Treatment- Surgery- Tumor removal
APPROACH- Middle cranial fossa
Trans labyrinthine
Suboccipital
Combined trans labyrinthine- suboccipital
Radiotherapy- Conventional
X-Ray/Gamma knife
Cyber knife
ENT
MENIERE DISEASE/ENDOLYMPHATIC HYDROPS
Definition- IE disorder where endolymphatic system distended with endolymph
Pathology- Endolymphatic system distension ( cochlear duct + saccule + utricle + SCC)
RM marked bulging
Etiology- not known
Theories- 1. Defective absorption by endolymphatic sac
2. Vasomotor disturbance - sympathetic overactivity 》Internal auditory artery
spasm》cochlear/ vestibular sensory neuro epithelium function interference
3. Allergy- foodstuff/ inhalants
4. Na- water retention
5. Hypothyroidism
6. Autoimmune & viral etiologies
M>F
Unilateral
Cardinal symptoms- 1. Episodic vertigo
Tullio phenomenon
2. Fluctuating hearing loss - sound distortion
Intolerance to loud sounds
3. Tinnitus
4. Sense of fullness/ pressure in involved ear
5. Other features
Examination- 1. Otoscopy- No TM abnormality
2. Nystagmus- quick component towards unaffected ear
3. Tuning Fork Tests:- SNHL
Rinne Positive
ABC reduced
Weber lateralised to better ear
INVESTIGATIONS- 1. Pure Tone Audiometry
2. Speech Audiometry
3. Special Audiometry Tests- A. Recruitment Test positive
B. SISI Test - > 70%
C. Tone Decay Test- < 20 dB
4. Electrocochleography
5. Caloric Test- reduced response on affected side
6. Glycerol Test- improvement in hearing
Variants- 1. Cochlear Hydrops
2. Vestibular Hydrops
3. Drop Attacks/ Tumarkin's Otolithic crisis
4. Lermoyez Syndrome
DIAGNOSIS:-:- AAOHNS
1. Certain
2. Definite
3. Probable
4. Possible
Staging- stage 1,2,3,4
TREATMENT- A. General- 1. Reassurance
2. Smoking cessation
3. Low salt diet
4. Avoid excess water intake
5. Avoid over indulgence in coffee, tea,alcohol
6. Avoid stress
7. Avoid activities requiring good body balance
B. Management of acute attack- 1. Reassurance
2. Bed rest
3. IV fluids and electrolytes administration
4. Vestibular sedatives
5. Vasodilators
C. Management of chronic attack- 1. Vestibular sedatives
2. Vasodilators
3. Diuretics
4. Propantheline bromide
5. Allergen elimination
6. Hormones
Intratympanic gentamicin therapy ( chemical labyrinthectomy)
Microwick
D. Surgical- 1. Conservative procedures- a. Endolymphatic sac decompression
b. Endolymphatic shunt operation
c. Sacculotomy/ Fick operation
d. Vestibular nerve section
e. Vestibular labyrinth ultrasonic destruction
2. Destructive procedures- Labyrinthectomy
3. Intermittent low pressure pulse therapy ( Meniett device therapy)
ENT
OTOSCLEROSIS/OTOSPONGIOSIS
LABYRINTH ANATOMY:- 1. Otic/ membranous/ endo lymphatic labyrinth(endolymph)-Utricle+
Saccule+Cochlea+SC Ducts+Endo lymphatic duct +Endo lymphatic sac
2. Periotic/perilymphatic labyrinth/space(perilymph)- Vestibule+ ST+SV+ Perilymphatic spce of
SCC +Periotic duct
3. Otic capsule- 3 layers- a. Endosteal
b. Enchondral
c. Periosteal
Definition- primary disease of bony labyrinth where 1 or more foci of irregularly laid spongy bone
replace part of normally dense enchondral layer of bony otic capsule
ETIOLOGY- not known
1. Anatomical basis- areas of cartilage rests
Fissula ante fenestram(stapedial)
2. Heredity- autosomal dominant trait with incomplete penetrance and variable expressivity
3. Race
4. Sex- F>M
5. Age of onset- 20-30 years
6. Effect of other factors- Pregnancy
Menopause
Accident
Major operation
Osteogenesis imperfecta
Van der Hoeve syndrome
7. Viral infection - measles
TYPES- 1. Stapedial- stapes fixation
Conductive deafness
Anterior focus (faf)
Posterior focus
Circumferential
Biscuit type
Obliterative type
2. Cochlear- SNHL
Round window
3. Histologic- asymptomatic
PATHOLOGY
Gross- chalky white, grayish,yellow lesions
Red due to increased vascularity(active and rapidly progressive focus)
Microscopic- spongy bone in dense enchondral layer of otic capsule
Immature active lesions- blue mantles with HE stain
Mature foci- less vascularity
More bone and fibrillar substance laying
Red
SYMPTOMS- 1. Painless, progressive bilateral conductive hearing loss of insidious onset
2. Paracusis willisii
3. Tinnitus (cochlear)
4. Vertigo
5. Monotonous, well modulated soft speech
Signs- 1. Schwartze sign
2. ET function normal
3. Negative Rinne for 256 & 512 Hz
Weber lateralised to affected ear
ABC normal
Pure Tone Audiometry loss of air conduction more for lower frequencies
Carhart notch
Mixed hearing loss
Speech Audiometry normal discrimination score
Tympanometry normal in early cases & later curve of ossicular stiffness
Stapedial reflex absent
D/d:- serous OM
Adhesive OM
Tympanosclerosis
Attic fixation of malleus head
Ossicular discontinuity
Congenital stapes fixation
TREATMENT
I. Medical- sodium fluoride
II. Surgical- A. Stapedectomy/ Stapedotomy with prosthesis placement
Patients selection- hearing threshold 30 dB/ worse
Average air bone gap at least 15 dB
Speech discrimination score 60% / more
CI- 1. Only hearing ear
2. Associated Meniere disease
3. Young children
4. Professional athletes, high construction workers, divers, frequent air travelers
5. Noisy surroundings work
6. Otitis externa, TM perforation, Exostosis
Steps- 1. Meatal incision and tympanomeatal flap elevation
2. Stapes area exposure
3. Stapes superstructure removal
4. Hole creation in stapes footplate
5. Prosthesis placement
6. Tympanomeatal flap repositioning
Complications- 1. Tympanomeatal flap tear
2. Injury to Chorda Tympani
3. Injury to CN7
4. Vertigo-a. Early
b. Late
5. Perilymph fistula/ granuloma
6. Conductive loss
7. SNHL
8. Dead ear
B. Stapes mobilization
C. Lempert fenestration operation
III. Hearing aids
ENT
ANATOMY OF EAR
I.EXTERNAL EAR:- A. PINNA/AURICLE
B. EXTERNAL ACOUSTIC CANAL
C. TYMPANIC MEMBRANE
A. PINNA:- HELIX CRUS
ANTI HELIX
TRAGUS
ANTI TRAGUS
CONCHA(RHINOPLASTY GRAFT
TYMPANOPLASTY GRAFT)
CYMBA CONCHA
LOBULE
TRIANGULAR FOSSA
INCISURA TERMINALIS(ENDAURAL INCISION)
EXTRINSIC MUSCLES- ANTERIOR, SUPERIOR AND POSTERIOR AURICULARIS
6 INTRINSIC MUSCLES
N.S.:- CN V3( AURICULOTEMPORAL)
CN 7
CN 10( AURICULAR BRANCH)
GREATER AURICULAR
LESSER OCCIPITAL
B. EAC:- 24 mm
FIRST BRACHIAL CLEFT
CARTILAGINOUS- 8mm
FISSURES OF SANTORINI( PAROTID/SUPERFICIAL MASTOID INFECTION)
SKIN GLANDS
HAIR FOLLICLES (FURUNCLE)
BONY- 16mm
ISTHMUS (6 cm lateral to TM)(FB)
ANTERIOR RECESS(DISCHARGE/DEBRIS OF EXTERNAL AND MIDDLE EAR INFECTIONS)
FORAMEN OF HUSCHKE(PAROTID INFECTION)
EPITHELIAL MIGRATION
N.S.:- CN V3
CN 10
CN 7
HITZELBERGER SIGN
VASOVAGAL REFLEX
APPETITE
RAMSAY HUNT SYNDROME
C. TM:- 9-10 × 8-9 × 0.1 mm
55° with EAC
ALL 3 GERMINAL LAYERS
PARS TENSA- ANNULUS TYMPANICUS
UMBO
CONE OF LIGHT
NOTCH OF RIVINUS
PARS FLACCIDA/SHRAPNEL MEMBRANE- PRRUSACK SPACE(between scutum & attic)
LAYERS- OUTER EPITHELIAL
MIDDLE FIBROUS
INNER MUCOSAL
SEIGALIZATION/MOBILITY
N.S.-CN V3
CN 10/ARNOLD NERVE
CN 9/JACOBSON NERVE
II. MIDDLE EAR/TYMPANIC CAVITY:- ME+EUSTACHIAN TUBE +ADDITUS
+ANTRUM+MASTOID AIR CELLS
CONTENTS- OSSICLES
MUSCLES (STAPEDIUS, TENSOR TYMPANI)
CHORDA TYMPANI
TYMPANIC PLEXUS
RELATIONS
PARTS- MESOTYMPANUM(TRANSVERSE DIAMETER =2mm)
ATTIC/EPITYMPANUM(6mm )
HYPOTYMPANUM(4mm)
PROTYMPANUM
BOUNDARIES- 1.ROOF/ TEGMENTAL WALL- TEGMEN TYMPANI
TEGMEN ANTRI
2. FLOOR/JUGULAR WALL
3. ANTERIOR/CAROTID WALL- ET OPENING
TENSOR TYMPANI CANAL
CHORDA TYMPANI CANAL/canal of Heugier
ANTERIOR MALLEOLAR Ligament Attachment (Glasserian fissure)
4. POSTERIOR/MASTOID WALL- PYRAMID
ADITUS
FACIAL NERVE
FACIAL/SUPRAPYRAMIDAL RECESS/POSTERIOR SINUS
SINUS/ INFRAPYRAMIDAL TYMPANI (between subiculum & ponticulus)
POSTERIOR TYMPANOTOMY/ FACIAL RECESS APPROACH
5.MEDIAL/ LABYRINTHINE WALL- PROMONTRY
OVAL WINDOW/FENESTRA VESTIBULI
ROUND WINDOW /FENESTRA COCHLEAE
CANAL FOR FACIAL NERVE/Fallopian canal
LATERAL SCC prominence
PROCESSUS COCHLEARIFORMIS( FACIAL NERVE FIRST GENU)
6.LATERAL/ MEMBRANOUS WALL- TM
SCUTUM
OSSICLES-1. MALLEUS-HEAD
NECK
HANDLE/MANUBRIUM
LATERAL PROCESS (ANTERIOR AND POSTERIOR MALLEOLAR FOLDS)
2. INCUS- BODY
SHORT PROCESS
LONG PROCESS (IS JOINT)
3.STAPES- HEAD
NECK
ANTERIOR CRURA
POSTERIOR CRURA
FOOTPLATE
INTRATYMPANIC MUSCLES-1. TENSOR TYMPANI- O- Bony tunnel below osseous part ET
I- Below Malleus neck
N.S.- CN V3
2.STAPEDIUS-O- conical cavity & canal within pyramid
I- Stapes neck
N.S.- CN 7
FUNCTIONS-ME MECHANICS DAMPENING
GAIN CONTROL MECHANISM
SELF GENERATED NOISE REDUCTION
INTRATYMPANIC NERVES-1. TYMPANIC PLEXUS- JACOBSON
SYMPATHETIC FIBRES
FREY SYNDROME
2. CHORDA TYMPANI
MASTOID ANTRUM- 9×14×7mm
ROOF-TEGMEN ANTRI
LATERAL WALL- SUPRAMEATAL/MACEWAN TRIANGLE (SPINE OF HENLE)
TRAUTMAN TRIANGLE - BONY LABYRINTH
SIGMOID SINUS
SUPERIOR PETROSAL SINUS
MEDIAL WALL
ANTERIOR WALL
POSTERIOR WALL
FLOOR
MASTOID AIR CELLS-TYPES- DEVELOPMENT-1.WELL PNEUMATISED/CELLULAR
2. DIPLOEIC
3. SCLETORIC/ACELLULAR
LOCATION- ZYGOMATIC
TEGMEN
PERISINUS
RETROFACIAL
PERILABYRINTHINE
PERITUBAL
TIP
MARGINAL
SQUAMOSAL
KORNER SEPTUM
B.S.- 1.ECA- MAXILLARY- A.ANTERIOR TYMPANIC
MIDDLE MENINGEAL
ARTERY OF PTERYGOID CANAL
B.POSTERIOR AURICULAR- STYLOMASTOID
C.ASCENDING PHARYNGEAL- TYMPANIC BRANCH
2.ICA- CAROTICO TYMPANIC BRANCH
LYMPHATIC- RETROPHARYNGEAL(ET)
PAROTID
III. IE- A. BONY LABYRINTH- 1.VESTIBULE(5mm)-LATERAL WALL- OVAL WINDOW
MEDIAL WALL- SPHERICAL RECESS (SACULE)
ELLIPTICAL RECESS ( UTRICLE)
VESTIBULAR CREST & COCHLEAR RECESS
AQUEDUCT OPENING
POSTEROSUPERIOR - 5 SCC OPENING
ANTERIOR- COCHLEA
LARGE VESTIBULAR AQUEDUCT SYNDROME
2. SCC- LATERAL/ HORIZONTAL (12-15mm)
POSTERIOR (18-22mm)
SUPERIOR/ ANTERIOR ( 15-20mm)
CRUS COMMUNE(POSTERIOR +SUPERIOR)(4mm)
3. COCHLEA- 2.5-2.75 TURNS
BY 20 WEEKS
MODIOLUS
OSSEOUS SPIRAL LAMINA/ROSENTHAL CANAL
SCALA VESTIBULI
SCALA TYMPANI
SCALA MEDIA
PROMONTORY
HELICOTREMA
ROUND WINDOW
AQUEDUCT OF COCHLEA
MEMBRANOUS LABYRINTH- 1. COCHLEAR DUCT/ SCALA MEDIA/Membranous cochlea-
BASILAR MEMBRANE
- ZONA ARCUATA
- ZONA PECTINATA
REISSNER MEMBRANE
STRIA VASCULARIS
2. UTRICLE- MACULA
UTRICULOSACULAR DUCT
3. SACCULE- MACULA
DUCTUS REUNIENS
MENIERE DISEASE
4. SEMICIRCULAR DUCTS- CRISTA AMPULARRIS
5. ENDOLYMPHATIC DUCT & SAC
MENIERE DISEASE
FLUIDS- PERILYMPH- BLOOD SERUM FILTRATE
CSF
Na ions
ENDOLYMPH- STRIA VASCULARIS
UTRICLE DARK CELLS AND SC DUCT AMPULATED ENDS
K ions
ORGAN OF CORTI- TUNNEL OF CORTI
HAIR CELLS - INNER
OUTER
SUPPORTING CELLS
TECTORIAL MEMBRANE
VESTIBULAR RECEPTORS- 1.CRISTAE- CUPULA
SENSORY EPITHELIAL CELLS- TYPE 1
TYPE 2
2. MACULAE- SENSORY NEURO EPITHELIUM
OTOLITHIC MEMBRANE
B.S.- INTERNAL AUDITORY/ LABYRINTHINE- 1.ANTERIOR VESTIBULAR
2. COMMON COCHLEAR -A. MAIN COCHLEAR
B. VESTIBULO COCHLEAR - POSTERIOR VESTIBULAR
COCHLEAR BRANCH
IAC- 1cm
BILL BAR
CONTENTS- VESTIBULO COCHLEAR NERVE
FACIAL NERVE INCLUDING NERVOUS INTERMEDIUS
INTERNAL AUDITORY ARTERY & VEIN
AUDITORY NEURAL PATHWAY- FROM PERIPHERAL TO CENTRAL- 8TH NERVE ( HAIR
CELLS)
COCHLEAR NUCLEI (2ND ORDER)
OLIVARY COMPLEX ( SUPERIOR) (3RD ORDER)
LATERAL LEMNISCUS
INFERIOR COLLICULUS(4TH ORDER)
MEDIAL GENICULATE BODY (5TH ORDER)
AUDITORY CORTEX
FIRST ORDER NEURONS- BIPOLAR NEURONS SPIRAL GANGLION 8TH NERVE
PHYSIOLOGY OF HEARING- 1. MECHANICAL SOUND ENERGY CONDUCTION (EE & ME
CONDUCTIVE APPARATUS)
2. MECHANICAL ENERGY TRANSDUCTION TO ELECTRICAL IMPULSES ( COCHLEAR
SENSORY SYSTEM)
3. ELECTRICAL IMPULSES CONDUCTION TO BRAIN (CN 8, BRAINSTEM, THALAMUS &
TEMPORAL LOBE NEURAL PATHWAY)
A. SOUND CONDUCTION - PINNA- COLLECTION
LOCALIZATION
CONCENTRATION
IMPEDANCE MATCHING MECHANISM- OSSICLES LEVER ACTION
TM HYDRAULIC ACTION
CURVED MEMBRANE EFFECT
PHASE DIFFERENTIAL BETWEEN ROUND & OVAL WINDOW - 2 WINDOWS ACOUSTIC
SEPARATION
AERATION
EE & ME NATURAL RESONANCE
TRANSDUCTION- TRAVELLING WAVE THEORY OF VON BEKESY
TONOTOPIC GRADIENT IN COCHLEA
ELECTRICAL IMPULSES- COCHLEA- ENDO COCHLEAR POTENTIAL
COCHLEAR MICROPHONIC
SUMMATING POTENTIAL
8TH NERVE- COMPOUND AP
ASSESSMENT OF HEARING
A.CLINICAL:- 1. FINGER FRICTION TEST
2. WATCH TEST
3. SPEECH TESTS
4. TUNING FORK TESTS:- I. RINNE TEST
II. WEBER TEST
III. ABSOLUTE BONE CONDUCTION(ABC) TEST
IV. SCHWABACH TEST
V. BING TEST
VI. GELLE TEST
B. AUDIOMETRIC :- 1. PURE TONE AUDIOMETRY
2. SPEECH AUDIOMETRY:- I. SPEECH RECEPTION THRESHOLD (SRT)
II. SPEECH DISCRIMINATION SCORE
3. BEKESY AUDIOMETRY
4. IMPEDANCE AUDIOMETRY :- I. TYMPANOMETRY
II. ACOUSTIC REFLEX
C. SPECIAL TESTS :- 1. RECRUITMENT
2. SHORT INCREMENT SENSITIVITY INDEX (SISI) TEST
3. THRESHOLD TONE DECAY TEST
4. EVOKED RESPONSE AUDIOMETRY- A. Ecog
B. ABR
5. AUDITORY STEADY STATE RESPONSE (ASSR)
6. OTO ACOUSTIC EMISSIONS (OAE)
7. CENTRAL AUDITORY TESTS
8. HEARING ASSESSMENT IN INFANTS & CHILDREN

ENT Voice & Speech Disorders

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ENT Voice & Speech Disorders

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ENT

VOICE & SPEECH DISORDERS

BENIGN TUMORS OF LARYNX

NERVE SUPPLY OF LARYNX

CONGENITAL LESIONS OF LARYNX & STRIDOR

CONGENITAL LESIONS OF LARYNX

ACUTE & CHRONIC INFLAMMATIONS OF LARYNX

HEAD & NECK SPACE INFECTIONS

ACUTE & CHRONIC TONSILLITIS

ACUTE & CHRONIC PHARYNGITIS

ENT- ADENOIDS & OTHER INFLAMMATION OF NASOPHARYNX

ADENOIDS/NASOPHARYNGEAL TONSILS/LUSCHKA TONSILS

ENT- ANATOMY & PHYSIOLOGY OF PHARYNX

fibromuscular tube forming upper part of air & food passages

NON NEOPLASTIC DISORDERS OF SALIVARY GLANDS

ENT- TUMORS OF ORAL CAVITY

CLASSIFICATION:- I. BENIGN TUMORS

ENT- COMMON DISORDERS OF ORAL CAVITY

ULCERS OF ORAL CAVITY

ENT- ALLERGIC RHINITIS

THYROID GLAND & DISORDERS

HIV-AIDS & ENT MANIFESTATIONS

SNORING & SLEEP APNEA

OPERATIVE PROCEDURES III

NEOPLASMS- NASAL CAVITY

DISORDERS OF EXTERNAL NOSE & NASAL VESTIBULE

FACIAL NERVE & DISORDERS

EUSTACHIAN/ AUDITORY/ PHARYNGOTYMPANIC TUBE

VESTIBULAR FUNCTION ASSESSMENT

ACOUSTIC NEUROMA/ VESTIBULAR SCHWANNOMA/NEURILEMMOMA/8TH NERVE

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