ENT LUMINAIRE

EAR
1. Normal tympanic membrane (draw both sides rt,lt)
2. Middle ear cleft.
3. Medial wall of middle ear.
4. Membranous labyrinth.
5. Section through cochlea.
6. Structure of organ of corti.
7. Central auditory pathway.
8. Types of post aural incision.
9. Ear ossicles.
10. Normal pure tone audiogram
11. Nerve supply of external ear.
12. Audiogram of Conductive deafness &senorineural deafness
13. Various curves of tympanogram
14. Pure tone audiogram in Otosclerosis(Carhart’s notch)-13.2
15. Type of tympanic membrane perforations(of rt& Lt ear)-11.7
16. Audiogram showing Mixed deafness
17. Internal acoustic meatus(pg 124)
NOSE
1. Structure of lateral wall of nose.
2. Nerve supply of lateral wall of nose.
3. Anatomy of nasal septum.
4. Blood supply of nasal septum.
5. Blood supply of lateral wall of nose.

ORAL CAVITY, PHARYNX, LARYNX& ESOPHAGUS

1. Arterial supply of tonsil.
2. Spaces in relation to pharynx where abscesses can form.
3. Laryngeal web.
4. Vocal nodules.
5. Structures seen on posterior rhinoscopy.
6. Structure seen on indirect laryngoscopy.
7. Position of vocal cord.
8. Oesophagus showing various constrictions.
9. Oral cavity.
10.Tonsillar bed.
11.Waldeyer’s ring.
ANATOMY OF EAR
SHORT NOTES(Include nerve/blood supply,diagram,development wherever required)
1. External Acoustic Canal (pg 4)
2. Fissures Of Santorini( DO Study Definition,Clinical Significance) (pg 4)
3. Tympanic Membrane ( pg 4)
4. Korner’s septum- importance-pg8
5. McEwans Triangle ( pg 7)
6. Medial Wall Of Middle Ear ( pg 6)
7. Mastoid Antrum( pg 7)
8. Mastoid Air Cell System ( pg 8)
9. Ossicles Of Middle Ear(pg 8)
10.Intra Tympanic Muscles (Origin,Insertion,NerveSupply,Action)(pg 9)
11.Tympanic Plexus (Formation,Supply)(pg 10)
12.Chorda Tympani (pg 10)
13.Inner Ear Fluids ( pg 12)
14.Bony And Membranous Labyrinth (pg 11)
15.Organ Of Corti-Fig V Imp ( pg 16)
16.Hair Cells (pg 16)
17.Auditory Pathways (pg 17)
18.Impedence Matching, Phase Differential B/W Oval And Round Window(pg 18)
19.Electrical Potentials Of Cochlea And 8th Nerve ( pg 19)
20.Structure OfCrista.Macula (pg 20)
21.Vestibular Pathway (pg 20)
22.Vertigo-At Least 4 Central And 4 Peripheral Causes Of Vertigo With Treatment
23.Sensation level pg 24
24.Masking (pg 24)
25.Tuning Fork Tests(pg 26-27)
26.Pure Tone Audiometry-Uses ( pg 27)
27.Tympanometry-Curves,Dig Also (pg 29)
28.Acoustic Reflex And Significance (pg 30)
29.Recruitment And Other Special Test (pg 31)
30.Tone decay test – pg 31
31.Oto Acoustic Emission ( pg32)
32.Conductive Hearing Loss-PTA Finding Diagram Also ( pg 37, 38)
33.Ototoxicity ( pg 39)
34.Sudden Hearing Loss-Causes (pg-41)
35.Presbyacusis (pg 41)
 36.Non Organic Hearing Loss (pg 42)

ASSESSMENT OF HEARING

DIAGRAM
1. Types of tympanogram
2. Pg34-symbols used in audiogram charting: PTA in various pathologies can be asked
to draw
SHORT NOTES
1. Tuning fork test, interpretation [26]
2. Uses of PTA [pg27][Code: ALARMS-Audiogram uses:-Hearing Loss measurement.
Hearing Aid prescription, Records for future reference, Medico legal
importance, Speech reception threshold prediction]
3. Tympanometry [pg29], Types of tympanogram-also known as curve of impedance
audiometry: diagrams and egs [pg30]
4. Threshold tone decay test: more than 25db acoustic neuroma, less than 20db
Meniere’s d/s [pg 31]
5. BERA [pg32}
6. Oto-acoustic emission OAE/welch allynOAE[pg33]
7. Recruitment (for viva)[pg31]
8. Roll over phenomenon (for viva)[pg28]
9. SISI test[pg 31]

DISORDERS OF VESTIBLAR SYSTEM

1. Peripheral vestibular disorders and central vestibular disorders (table 7.1 pg 51)
2. Epleys manoeuvre (pg 51)
3. Vestibular neuronitis(pg 52)
4. Vestibulotoxicdrugs(pg 52)
5. Wallenberg syndrome (pg 52)

DISEASES OF EXTERNAL EAR

1. Pre-auricular pit or sinus (pg 54)
2. Cauiflowerear(pg 55)
3. Keloid of auricle(pg 56)
4. Perichondritis(pg 56)
5. Furuncle (pg 56)
6. Diffuse otitis externa (pg 57-58)
 7. Otomycosis (pg 58)
8. Herpes zoster oticus (pg 58,62)
9. Malignant otitis externa (pg 58)
10.Impacted wax or cerumen (pg 59-60)
11.Foreign bodies of ear(pg 60)
12.Keratosis obturans(pg 61)
13.Traumatic perforation – pg 62 (imp, causes, treatment)
14.Retracted tympanic membrane – pg61
15.Tympanosclerosis –pg62
16.Perforations of tympanic membrane – pg89
17.Aural syringing-pg60

ASSESSMENT OF VESTUBULAR FUNCTION

1. Fistula Test (pg 47)
2. Caloric Test (pg 48)
3. Hall Pike Manvoure(Pg 47)

EUSTACHIAN TUBE AND ITS DISORDERS

1. Functions of Eustachian tube(pg 64)
2. Valsalvatest(pg 65)
3. Politzer test (pg 65)
4. Eustachian tube catheterisation(pg 65)
5. Toynbees test (pg 65)
6. Patulous Eustachian tube (pg 67)
DISORDERS OF MIDDLE EAR
1. Serous otitis media (glue ear)(pg 71-73) (ESSAY)
2. Aero otitis media (otitic barotrauma)(pg 74)
3. Differences between ASOM and AOM
4. Cholesteatoma (pg 75-77)(imp)
5. Differences between tubo tympanic and atticoantraldisease(table 11.1 pg 77 )
6. Classification (pg 85)
7. Acute mastoiditis (pg 85-87)
8. Abscesses in relation to mastoid-Bezold abscess, Citelli’s abscess imp (pg 87)
9. Masked mastoiditis (pg 88-89)
10.Petrositis and Gardenigo’s syndrome (pg 89)
11.Lateral sinus thrombophlebitis- pg 95 (essay)
12.Paracusis willisi-pg98
 13.Medical treatment of otosclerosis-pg99(imp)

OTOSCLEROSIS
Schwartz sign-(pg 98)
Stapedectomy-steps,contraindications(pg 100)

FACIAL NERVE AND ITS DISORDERS

1. Bellspalsy(pg 105)
2. Melkersson’s syndrome (106 )
3. Herpes zoster oticus (pg 107)
4. Complications of facial;nerve paralysis (pg 109)
5. Topognosis of facial palsy(pg 109)

MENIERE’S DISEASE
1. Variants of Meniere’s disease (pg 113)
2. Tullio phenomenon-pg112

TUMORS OF EXTERNAL EAR

1. Tumours of auricle (pg 117)
2. Tumours of external auditory canal (pg 118)

3. Glomus tumour-pathology,clinicalfeatures,diagnosis,treatment

ACOUSTIC NEUROMA
Acoustic neuroma (pg 124) imp
DDs-table 18.1
THE DEAF CHILD
1. Aetiology (pg 127)
2. Waardenburg’s syndrome (pg 129)
3. Syndromes associated with hearing loss (pg 129)
4. Assessment of hearing in infants and children (pg 131)

REHABILITATION OF HEARING IMPAIRED

1. Hearing aids (pg 134)
2. Cochlear implants(pg 138)
3. Bone anchored hearing aids-BAHA (pg 136)
OTALGIA-causes(pg 143)

TINNITUS-types,causes,treatment (pg 145)

CHAPTER 23
Lateral wall of nasal cavity – Blood supply, contents, nerve supply) (151)

CHAPTER 24
1. Olfactory pathway, anosmia, parosmia (157)
2. Functions of nose
3. Air conditioning of inspired air
4. Protection of lower airway
CHAPTER 25
1. Saddle nose (158)
2. Rhinophyma (160)
3. Furuncle (160)
4. Vestibulitis (161) Acute and chronic forms

CHAPTER 26
1. Jarjaway and chevallet fracture of nasal septum (163)
2. Little’sArea (162)
3. Septal -hematoma,Abscess,Perforation-causes

CHAPTER 27
1. Coryza-common cold(168)
2. Atrophic rhinitis(170)
3. Rhinitis sicca and Caseosa(171)

CHAPTER 28
1. Rhinoscleroma-Stages and diagnosis(172)
2. Rhinosporiodosis(174)
3. WegenersGranulomatosis(174)

CHAPTER 29
1. Foreign bodies (176)
 2. Rhinolith(176)
3. Nasal myiasis(176)
4. Choanal Atresia (177)
5. CSF rhinorrhoea (178)
6. Diff b/w CSF & nasal secretions (179)

CHAPTER 30
Allergic Rhinitis(180)

CHAPTER 31
1. Rhinitis Medicamentosa (184)
2. Vasomotor rhinitis (183)

CHAPTER 32
Ethmoidalpolyp(185)
Antrochoanalpolyp(186)
Treatement of ethmoidalpolyp(186)
D/d Nasal polyp(188)
Treatment of recurrent antrochoanal polyp
CHAPTER 33
Little’s Area(190)
Anterior and posterior nasal packing (191)

CHAPTER 34
1. Fracture nasal Bone (!95)
2. Fracture of zygoma, orbital floor (197)
3. Types of fracture maxilla(198)
4. Oroantral fistula (200)

CHAPTER 35
1. Development and functions of paranasal sinuses (202)

CHAPTER 36, 37
2. Acute sinusitis(204) (etiopathology, maxillary, frontal imp.)
3. Chronic sinusitis (208)

CHAPTER 38
 1. Mucocoele of PNS(211)
2. Complication of PNS(211.Table 38.1)
3. Orbital complication of sinusitis

CHAPTER 39
1. Inverted papilloma or ringertz tumour or transitional cell papilloma(216)
2. Intranasal meningoencephalocele (217)

CHAPTER 40
1. Carcinoma of maxillary sinus(221)
2. Osteomeatal Complex
3. Ohngren’s line –pg221 (extends from medial canthus of eye to angle of mandible)

CHAPTER 41
1. Lymphatic drainage of oral cavity

CHAPTER42
2. Vincent’s infection(229)
3. Aphthous ulcers (230)
4. Behcet’ssyndrome(236)
5. Fordyce’s spots(233)
6. Geographical tongue(232)

CHAPTER 43
1. Squamous papilloma(236)
2. Torus(237)
3. Mucocele(237)
4. Leukoplakia(238)
5. Kaposi‘s sarcoma

CHAPTER 44
1. Sjogren’s syndrome(Sicca syndrome)(245)

CHAPTER 45-54
1. Pleomorphic adenoma(247)
2. Frey’s syndrome or gustatory sweating(249)
3. Ludwig’s Angina….277
 4. Waldeyer’s ring….254
5. Nasopharynx….254
6. Killian’s dehiscence…259
7. Pyriform fossa….257
8. Adenoid facies….259
9. Keratosis pharyngitis….270
10.Crypta magna….271
11.Blood supply of tonsil….274
12.DD of membrane over tonsil Code:-[VIMALA Took My CD ie. Vincent’s agna,IMN,
Malignancy
tonsil,Aphthousulcer,Leukemia,Agranulocytosis,Traumaticulcer,
Membraneoustonsillitis,Candidiasis,Diphtheria]
13.Faucial diphtheria….274
14.Tonsilllolith…276
15.Peritonsilarabcess(quinsy)….278
16.Retropharyngeal &parapharyngeal abscess….280,281
17.Stylalgia(Eagle’s syndrome)….287
18.Pharyngeal pouch….289
19.Malignant tumour of oropharynx…284
20.Sleep apnoea…292

CHAPTER 55
1. Laryngeal cartilages [299]
2. Laryngeal abductors[300]

CHAPTER 57
1. Acute epiglottitis [307]
2. Laryngeal diphtheria [308]
3. Reinke’s oedema/polypiod degeneration of vocal cords or B/L diffuse polyposis
[311,323][UQ]
4. Contact ulcer[311,323]
5. Tuberculosis larynx[312]
6. Atrophic laryngitis / laryngitis sicca [312]

CHAPTER 58
1. Laryngomalacia/congenital Laryngeal stridor [314][UQ]
 2. Laryngeal web[314]
3. Laryngocoele; types, symptoms, diagnosis , treatment [324][UQ 2009]
4. Stridor ;aetiology, management, laryngeal causes in children [315][UQ]

CHAPTER 59
1. Bilateral recurrent l Laryngeal nerve palsy [318]
2. Benign tumors of larynx [tab 60.1,pg 322]

CHAPTER 60
1. Vocal nodules/singer’s nodes/screamer’s nodes [322][UQ 2011]
2. Vocal polyp;aetiology,symptoms,treatment[323]
3. Leukoplakia/keratosis [323]
4. Squamous papilloma; juvenile&adult onset [324]
5. Left vocal cord paralysis [321][UQ]
6. Premalignant conditions in larynx[UQ]

CHAPTERS 61-64
1. Causes of hoarseness[333]
2. Ventricular dysphonia [334]
3. Tracheostomy [UQ] function, indicators, types, complications
4. Laryngeal foreign body [343]
5. Heimlich manouvre[344]
6. Direct laryngoscopy [432]

CHAPTERS 65-68
1. Esophageal proliferation[349]
2. Benign structures of esophagus[350]
3. Cardiac achalasia [352]
4. Dysphagia – Oesophageal causes [354]
5. Dysphagia Lusoria[354, 458]
6. Foreign body Oesophagus [356]
7. Oesophagoscopy -indications [436]

RECENT ADVANCES
1. Types of lasers [ch69,pg361]
2. ENT manifestations of AIDS [ch73, pg374]
3. Use of lasers in ENT
 4. Occult primaries in ENT

Section 7: Operative Surgery ( Chapter 76-92)

1. Endaural approach [410]
2. Cortical mastoidectomy /Schwartz operation-indications [411]
3. Radical mastoidectomy –complications [414]
4. Modified Radical mastoidectomy [415]
5. Myringoplasty-graft materials, types, specific complications [416-417]
6. Antral wash-indications, complications [418]
7. Antral puncture
8. Caldwell Luc operation- indications, complications [421]
9. Sub mucous resection [423]
10. Septoplasty [425]
11. FESS (functional endoscopic sinus surgery)[429]
12. Rigid bronchoscopy [434]
13. Oesophagoscopy [436]
14. Tonsillectomy- indications, contraindications, complications [438]
15. Adenoidectomy- indications, contraindications, complications [442]

CLINICAL QUESTION : (10 marks) EAR

1. Secretory Otitis Media
2. Chronic Suppurative Otitis Media (Also Difference b/w canal wall up & canal wall
down procedures)
3. Otosclerosis
4. Meniere’s disease
5. Acute Mastoiditis
6. ASOM-(Treatment of asom-6A”s…. AURAL TOILET, ANTIBIOTICS,
ANTIFLAMATORY, ANALGESICS, WATER AWAY,
AMPROLITE(MUCOLYTICS)
CLINICAL QUESTIONS (10 Marks) NOSE
1. Deviated nasal septum (aetiology, types, clinical features ,treatment)(pg 163)
2. Atrophic Rhinitis (types, etiology)[Aetiology of primary-code HERNIA-Hereditary
Endocrinal disturbances, Racial, Nutritional deficiencies, Infective,
Autoimmune](pg 163)
3. Nasal polypi(types ,difference b/w ethmoidal & antrochonal, DD’s ) (185)
 4. Epistaxis (causes, site , management, difference between anterior and posterior
epistaxis) (Pg. 190)
5. Frontal sinusitis (aetiology, clinical features, treatment ,complications) (206)
6. Chronic maxillary sinusitis (209)
7. CSF rhinorrhoea (aetiology, Differentiating from running nose, diagnosis &
treatment)

CLINICAL QUESTIONS .THROAT, ORAL CAVITY.PHARYNX

1. Submucous fibrosis
2. Mumps
3. Carcinoma Oral Cavity
4. Acute tonsillitis(272)
5. Retropharyngeal abscess(280)

ESSAY(always mention which ear-rt/lt)

1. A 20 year old lady presented in OP department with history of bilateral progressive
hearing loss and tinnitus. Examination revealed a normal tympanic membrane and
conductive hearing loss.
a) Most probable diagnosis (Otosclerosis)
b) Two Differential Diagnosis
c) What will you look for during Otoscopy?
d) How will you investigate this patient?
e) What is the medical management of this condition?
f) What is the surgical management of this condition?
2. A 65 year old man presented with change of voice for three months. On Indirect
Laryngoscopy, there was a proliferating swelling on the right vocal cord and the vocal
cord is not mobile
a) Diagnosis (Ca Larynx)
b) Etiological factors of the above condition
c) Clinical features of the above condition
d) Investigations for the above condition
e) Treatment for the above condition
3. A 25 year old lady presented with pain and scanty foul smelling discharge from the ear
for the last two years. On observation, there was perforation in the pars flaccida
a) Diagnosis (Atticoantal disease)
 b) Etiological factors and theories of the above condition
c) Clinical features of the above condition
d) Treatment of the above condition
e) Complications of the above condition
4. A 60 year old male patient is brought to the casualty with profuse bleeding from the
nose bilaterally
a) Describe emergency management
b) Enumerate various local causes of epistaxis
c) Define Little’s area and state its clinical importance
5. A 40 year old patient who is a known diabetic came with history of pain and ear
discharge of 3 days duration
a) Diagnosis
b) What are the tympanic membrane findings in ASOM?
c) Aetiological factors of ASOM
d) Complications of ASOM
e) Describe the different stages of ASOM
f) DD”s –otitis externa, myringitis..
6. A 25 year old female came with history of nasal obstruction, headache, loss of smell
sensation and thick greenish secretion from her nose
a) What is your diagnosis?
b) Etiological factors in Atrophic Rhinitis?
c) Clinical features of Atrophic Rhinitis
d) Differential Diagnosis of Atrophic Rhinitis
e) Treatment of Atrophic Rhinitis
7. A 6 year old child presented with defective speech, mouth breathing and snoring.
Clinical examination reveals a dull, opaque tympanic membrane on both sides.
Tuningfork tests show Rinne’s Test negative bilaterally, Weber central, ABC normal
a) Diagnosis
b) Typical Otoscopic findings that you get in this condition
c) What are the relevant investigations to be done?
d) What is the treatment of the above case?
e) What are the sequelae of the ear condition if left untreated?

8. A 30 year old male with history of foul smelling discharge from right ear for 6 years
came to the casualty with high grade fever with chills and rigor and headache. On
observation it showed papilloedema and tenderness over right side of neck.
a) Diagnosis (Lateral Sinus Thrombophlebitis)
 b) Pathology
c) Describe two clinical tests that help in the diagnosis
d) What are the relevant investigations?
e) How will you manage this case?

9. A 65 yr old smoker for many years present to the ENT OP with history of unremitting
hoarsness of 4 months duration. O/E-Proliferative growth of the left vocal cord with
impair
mobility of the vord,neck normal
• Diagnosis and TNM staging of this case (CA larynx)
• Etiopathology
• Other clinical features and TNM staging of the diseases
• Investigations
• Treatment
Questions
1) What are the indications of tracheostomy?
2) What are the types of tracheotomy?
3) Mention the different tracheostomy tubes used?
4) Mention the complications of tracheostomy?
SOUNDBYTES
1.RETRACTION OF TM: GRADING

I. retraction not touching long process of incus

II. touching long process of incus
III. Atelectasis (mobility on siegelization)
IV. Adhesive otitis media

2. CONCHAE BULLOSAE -Pneumatised middle turbinate hypertrophy

3.TRAUMATIC TM PERFORATION--Margins will be dragged & blood stained

4.GRAFT/HEALED TM- Dimeric( middle fibrous layer absent)

5. DDs OF U/L TONSILLAR ENLARGEMENT- malignancy tonsil/ lymphoma/para pharyngeal

abscess/ para pharyngeal ca/tonsillolith/ tonsilar cyst.( if pulsatile –internal carotid artery
aneurysm)

6. MALIGNANT OTITIS EXTERNA- Skull base osteomyelitis(synonym)

7.COTTLE’s area-vestibule ,nasal valve ,attic ,turbinal , choanal (pg 164)

8. LINCOLN’s HIGHWAY-(parapharyngeal abscess—carotid sheath—track down to superior

mediastinum)

9. Boundaries of FACIAL RECESS – above-fossa incudis, medially-vertical se segment of facial

nerve,,laterally-chorda tympani.

10. PROTYMPANUM- portion of middle ear around tympanic orifice of Eustachian tube.

11. WHY ANTROCHOANAL POLYP GROWS POSTERIORLY?

Maxillary ostium& accessory ostium grow posteriorly.

Post.chona wider than anterior nares.

Gravity pulls posteriorly

Mucociliary clearance
PRACTICALS
CLINICAL EVALUATION OF ENT CASES

Name: Sex:
Age: Address Occupation
History taking
1. Chief complaints:
2. History of present illness
3. Past history
4. Treatment history
5. Personal history
6. Family history
7. Menstruation history+vaccination [if women]
8. Birth history+vaccination [if child]
9. Socio-economic status
And the following
1. General examination, Vital signs
2. Systemic examination
3. Local Examination

CLINICAL EVALUATION OF EAR CASES

Chief complaints [must include site and duration]

1. Ear discharge/otorrhoea
2. Impaired hearing/hearing loss
3. Earache / otalgia
4. Tinnitus
5. Vertigo
6. History of fullness of ear
7. Itching
8. Deformity of the pinna
9. Swelling around the ear
10. H/O of etiology

H/O Present illness

1. Ear discharge
a. Site: rt/lt/bilateral h. Progress-continuous/intermittent
b. Duration i. Colour
c. Onset j. Blood stained discharge +/-
d. Severity Scanty/Profuse k. Foul smelling +/-
e. Characteristics: watery/mucoid/purulent/mucopurulent
f. Associated URT infection
g. How long does each attack last, When was the last discharge?

2. Impaired hearing
a. side g. History of fever
b. duration h. history of drug abuse
c. Onset: since birth/acquired i..h/o topical ototoxicity
d. progress: progressive/intermttent/stable j. Family history of deafness
e. Painful or uncomfortable k. related to pregnancy
f. H/O noise induced trauma

3. Ear pain
a. site
b. duration
c. onset
d. type: burning/ prickling/ throbbing/stabbing
e. severity: disturbs sleep constantly
f. localisation of pain [referred pain]
1. behind the ear
2. ear
3. deep in the ear
g. aggravating factors / relieving factors
chewing, eating, sneezing, lying on the affected ear , applying pressure on
the tragus, pulling auricle , association with otorrhoea

4. Tinnitus
a. Side
b. duration
c. progress: progressive/continuous/intermittent/constant
d. character – hissing, buzzing, stammering, bell sound
e. high pitched / low pitched
 f. sleep disturbance[+/-]
g. h/o drug abuse: salicylates, quinines, aminoglycoside

5. Vertigo
a. duration
b. episodes: constant/periodic
c. frequency of attacks
d. aggravating causes: increased by change of position
e. relieving factors
f. association with hearing loss/otorrhoea
g. accompanied by nausea, vomiting

6. H/o fullness of ear

7. H/o of itching and irritation of the ear
8. Any pinna deformity
9. Any swelling around ear
10. H/o of etiology
Nasal obstruction/nasal discharge
Post nasal discharge
Facial pain
Throat pain
Dysphagia/odynophagia
Change of voice
H/o any intracranial complication - headache, nausea, vomiting

LOCAL EXAMINATION
·
PHYSICAL EXAMINATION OF THE EAR

1. Pinna
Size: microtia/macrotia
Shape: contour abnormalities/ cauliflower ear
Position:
Redness: abscess/furuncle
Swelling: hematoma/abscess
Scars: trauma/operation/burns
Ulceration
2. Preauricular region
Scar, trauma, previous operation
Swelling: zygomatic abscess, lymph nodes
Sinus: mastoid fistula
3. Post auricular
Scar, trauma, previous operation
Swelling: mastoid abscess, lymph nodes, oedema in lateral sinus
Fistula: mastoid fistula
4. External auditory canal
Size of the meatus: narrow/ wide
Contents of lumen: wax/debris/ discharge/ granulation
Swelling ofthe wall: furuncle/papilloma/neoplasm/osteoma
5. Tympanic membrane
a. cone of light+/-
b. Colour ::
Normally-pearly white
Red — Acute otitis media
Blue— Secondary otitis
media/otosclerosis/hemotympanumTympanosclerosis: chalky plaque
c. Surface of the membrane
Perforation seen in CSOM
Perforation may be central [pars tensa], attic [pars flaccida],
marginal[at the periphery involving the annulus.
Central perforation may be small/medium/large/subtotal/total]
d. Position of tympanic membrane
Bulged: eg ASOM, hemotympanum, neoplasm
Retracted: serous otitis media, tubal obstruction, retraction pocket
6. Middle ear mucosa
a. Pale/congested
b. oedematous/dry crusty discharge
d. granulation
e. polypoidal
7. Mastoid
a. swelling
b. obliteration of retroauricular groove
c. fistula
d. scar
 In mastoiditis, tenderness is elicited by applying pressure at 3 sites:
1. over the antrum
2. over the tip
3. over the part between the mastoid and antrum

Functional examination of the ear

·Auditory function
Tuning fork test
1. Rinne test
2. Weber’s test
3. Absolute bone conduction test
·Vestibular function
1. Fistula test
2. Positional test
3. Spontaneous nystagmus

Give complete diagnosis: eg. Rt/Lt CSOM , active/inactive

EXAMINATION OF NASAL CASES

History Taking
Chief complaints
· Nasal obstruction
· Nasal discharge
· Facial ache/headache
· Disturbance of smell
· Sneezing
· Bad odour
· Hawking sensation
· Cough with/without expectoration
· Change in voice
· Snoring
· Epistaxis
· Swelling or deformity of the face
 H/O PRESENT ILLNESS

Nasal obstuction
· Site, duration, severity, progressive or not, allergy, relieved with medication
Nasal discharge
· Site,duration, type(watery, mucoid, purulent), colour, blood stained, foul
smelling, crusting,
Facial pain / headache
· site
· side
· duration
· character
· periodicity
aggravating factors and relieving factors
H/o smell disturbance
· Loss of smell: duration
· Foul smell
· h/o allergy
· h/o bouts of sneezing, watery eyes.
· Precipitating factors
Bad odour
Hawking sensation: post nasal drip
Cough with or without expectoration
H/o change of voice
· Snoring / Epistaxis
· Duration,
· Quality: mild/ moderate/ severe
· Aggravating factors
· Relieving factors
• Swelling / deformity of face
LOCAL EXAMINATION
Examination of face
· Examination of external nose
· Examination of vestibule
· Examination of the paranasal sinuses
· Examination of the nasal cavity -Anterior rhinoscopy& Posterior rhinoscopy
Examination of the external framework
 · Signs of inflammation: furuncle, septal abscess
· Scars: trauma, operation
· Sinus: congenital dermoid
· Swelling: glioma,dermoid
· Crease in tip of nose: allergic salute
· Signs of neoplasm: basal cell ca or sq cell ca
Cold spatula test
Examination of the vestibule
· Anterior nares
· Scar/swelling/ulcer
· Columella
· Intact or dislocated
Examination of the nasal cavity
Anterior rhinoscopy
* Nasal passage
· Narrow: DNS/ poylps/hypertrophy of turbinates
· Wide: atrophic rhinitis
* Nasal septum: DNS/spur/ulcer/perforation/ swelling/growth
* Nasal mucosa: oedema/dry/crust/granulation
* Floor of nose
· Defect: cleft palate/fistula
· Swelling: dental cyst
· Neoplasm: hemangioma
· Granulations (foreign body or osteitis)
* Roof
· seen in cases of atrophic rhinitis
* Lateral wall
· turbinates and their corresponding meatus can be visualised
1. Colour of mucosa
congested in inflamation
pale in allergy
2. Size of turbinates
hypertrophied in hypertrophic rhinitis [enlarged and swollen]
atrophied in atrophic rhinitis[small and rudimentary]
3 Crusts
Atrophic rhinitis, rhinitis sicca, rhinitis caseosa, wegeners granuloma
4 Discharge: seen in middle meatus, indicates infection of sinuses.
 Pus / mucoidal discharge/source of epistaxis
5 Mass: polyp/rhinosporidiosis/ carcinoma/ foreignbody
if mass is present describe: site, size, color, surface, multiple/ single.
6 Probing test -.sensitivity, bleeds on touch, consistency, mobile, margin.

Posterior rhinoscopy
if possible, look for,
1. Hypertrophy of posterior ends of middle turbinate
2. Discharge in the middle meatus
3. Atresia/choanal polyp
4. Enlargement of the adenoids
5. Growth in the nasopharynx as JNA/NPC
6. Eustachian tube opening
7. Tubal elevation

Examination of the paranasal sinuses:

Elicit tenderness
Give complete diagnosis

CLINICAL EVALUATION OF THROAT CASE

This consist of
1) Examination of oral cavity
2) Examination of oropharynx
3) Examination of larynx and hypo pharynx
History taking
Chief complaints
a) Sore throat
b) Odynophagia
c) Dysphagia - Epiglottits, aspiration of secretion due to laryngeal paralysis
d) Disorders of voice - Hoarseness, aphonia, puberphonia or fatigability of voice
e) Earache
f) Snoring
g) Halitosis
h) Hearing loss
i) Abnormal appearance
j) Respiratory obstruction
 k) Cough & expectoration
l) Repeated cleaning of throat
m) Pain in throat
n) Mass in neck
o) Neck pain

H/o present illness

H/o throat pain / sore throat
· Site
· Duration
· Number of attacks per month / year
· Recurrent +/-
· Aggravating factors
· Relieving factors
H/O dysphagia
· Duration
· Onset - Gradual or sudden
· Liquids/ Solids/ Semisolids
· Pain while swallowing
· Progressive or non progressive
· H/o F/B swallowing +/-
· H/o Tonsillectomy
H/o of feeling of lump in the throat / irritation
H/O of Dyspnoea
· Inspiratory / expiratory
· Spasm in chest +/-
· H/o FB swallowing
H/O of Change of voice / Hoarseness
· Duration
· Onset- Acute/ Chronic .
H/o of smoking
· Occupation .
Hemoptosis
· H/O Voice abuse .
Cough
· With/without expectoration
· Associate fever (esp evening rise of temp)
 · Weight loss
· Loss of appetite
H/o Headache

H/o regurgitation
· Hawking
· Excessive secretions
· Stridor
· Duration
· Onset
· Progress
· In children
· Mouth breathing - night time
· H/o of bilateral nasal obstruction & discharge
· H/o ear pain or blocked sensation
· H/o respiratory tract infection
· Change of voice
· Nausea &vomitting and fever with or without chills and rigors
· Loss of weight
· H/o GI disorders
· Other History

LOCAL EXAMINATION

Examination of oral cavity, oropharynx & Larynx and hypopharynx

1. Lips
2. Angles of mouth
3. Gingiva buccal ,Gingivo labial folds
4. Vestibule of mouth, Retromolartrigone, teeth
5. Palate-hard & soft
6. Tongue-Anterior two third
7. Floor of mouth
8. Tonsillarpillors -Ant & Post
9. Tonsills -Size/ Congestion / Presence of follicles
10. Uvula & soft palate
11. Posterior pharyngeal wall
Congestion
 Lymphnode hyperplasia
Posterior nasal drip
Hypopharynx and larynx (indirect laryngoscopy -Say patient gagged if not able to do it)
· ILS
· Base of tongue
· Glossoepiglottic fold
· Vallecullae
· Epiglottis
· Aryepiglottic fold
· Ventricular bands
· Arytenoids
· Vocal cords
· Pyriform fossa
Nodes
· Number of nodes
· Size of the nodes
· Consistency
· Metastatic nodes are fixed
· Hyperplastic nodes are soft
· Lymphoma nodes are rubbery and firm
· Discrete or matted nodes
· Tenderness (Inflammatory nodes are tender)
· Fixity to overlying skin or deeper structures
· Mobility
EXAMINATION OF NECK

Laryngeal framework
Laryngeal crepitus
Position of trachea
Thyroid
b/l carotid palpable or not
jugular tenderness +/-
lymph nodes

GIVE COMPLETE DIAGNOSIS

CASES KEPT FOR CLINICAL EXAMINATION

 ·* Chronic suppurative otitis media -Tubo tympanic disease (long case)
· Aural polyp
· Bell’s palsy
·*Deviated nasal septum
·* Chronic sinusitis / Atrophic rhinits
·*Bilateral Ethmoidal polyps
·* AntroChoanal polyps
·* Rhinosporidiosis
· Septal perforation
· Tumour maxilla
·* Chronic Tonsillitis
· Tonsil Cyst
· Malignant ulcer tonsill
· Neck node
· Thyroglossal cyst

IMPORTANT AREAS TO BE NOTED FOR VIVA

CSOM :
1.etiopathogenesis, diagnosis, management
2.why EUM essential for CSOM?
3. Canal wall up/ down with eg;
4.Grafts in myringoplasty[ temporalis fascia[why?], fascia lata, tragal perichondrium,
saphenous vein,cadavericdura-dura not prefered now- creutzfeldt Jacob disease]
5.complications of surgery, types of tympanoplasty , imp. Landmarks in surgery
6. referedotalgia
7. tuningfork test- method, why 512Hz prefered
8 OAE, BERA
9.Tympanicmemb.perforation-types
10.difference b/w overlay &underlay technique

TONSILLITIS
1.Etiopathogenesis, a/c,c/c—differences.
Signs of c/c tonsillitis :.irwinemoore sign[pressure on ant. Pillar produce pus:], anterior pillar
congestion, non tenderjugulodigastric node.
2. Grading of tonsillitis
1. Enlargement within the pillar
2. Upto the pillar
3. b/w pillar & midline
4. upto midline

3.. tonsillectomy- indications[criteria-paradise], steps, complications,contraindications(polio

epidemic—polio virus in nasopharynx –during surgery can cause bulbar poliomyelitis).
Reactionary h’ge is the most dangerous (patient is sedated hence chance of aspiration, if at all
ligation surgery is to be done;2 GA given at short interval is riskier)
4.adenoidectomy-indications, steps, complications[grieselsyndrome,management]

DNS
1.etiopathogenesis, types, management
2.sluder’s neuralgia ( spheno palatine nerve), cottle,s line (line joining spine of frontal bone &
spine of maxilla)
3. diff. b/w septoplasty& SMR
4. Absolute indications of septoplasty[ age<17, dislocation ant. To cottle,s line, as part of
septorhinoplasty]
5. non-septal indications-vidianneurectomy, trans septal trans sphenoid hypophysectomy
,graft for tympanoplasty

SPOTTERS
 Postaural scar—complications,indications,aural incisions(410)
 Preauricular sinus—causes ,Rx,complication(54)
 Patient with tracheostomy tube insitu –indication,complication,type of tube,
management of complication,difficulties in decannulation(pg339),
indications for portex tube ,type of laryngeal cartilage.
 Ryles tube ,complication,
 Mastoid dressing –indications,complication(cavity)-korners septum
 Audiogram- SNHL,CHL, otosclerosis[causes,treatment]
  Anterior Nasal pack - Indications,complications,methods of controlling
epistaxis(191)
 post nasal pack(192) - indication, procedures.( sedatives are contraindicated
due to fear of aspiration.)
 Tympanogram : graphs..
.
1. Thudicums Nasal Speculum
Uses
a. Anterior Rhinoscopy(structrues seen in anterior rhinoscopy)
b. Removal of FB
c. Nasal Packing

2. St. Clair Thomson’s Long Blade Nasal Speculum

a. Used only after anaesthetizing
b. Used in SMR/Septoplasty
3. Rose Eustachian Tube Catheter
Metallic catheter with a curved proximal end and a ring at its base.12-15 cm in
length.
Uses
a. To know the patency of the ET
b. To inflate the middle ear
c. Remove FB from the nose
d. Instill medications into the middle ear
Complications
· Epistaxis
· Syncope
· Eustachian tube stenosis (not used nowadays for ear procedures)
Use of the ring at the end of the tube?
· To know the direction of tip of tube
Tests of Eustachian tube dysfunctions
1. Valsalva manoeuvre
2. Toynbee manoeuvre
3. Frenzel manoeuvre
4. Politzerization
5. Siegalisation
6. Endoscopy
7. CT Scan
 8. MRI
9. X-ray after radioopaque dye inj
10. Catheterisation
11. Saccharin/Methyleneblue test

4. Tilley LichwitzAntrum Puncture Trocar and Cannula

Uses
a. Confirm presence of pus in chronic maxillary sinus
b. Drainage of maxillary sinus in case of chronic maxillary sinusitis - Oro antral
fistula
c. Proofpuncture in case of malignancy of maxillary sinus
Anaesthesia:
Local anaesthesia with 4% lignocaine & adrenaline pack in inferior & middle meatus
for 10-15 min- Adults, General Anaesthesia - Children
Position:
Sitting position in adults & Rose’s position in children
Complications
1. Hemorrhage (most common)
2. Puncture of anterior wall of maxillary sinus resulting in swelling of cheek.
3. Puncture of orbital wall
4. Osteomyelitis / Osteitis
5. Air embolism
Indication for antral puncture
· Chronic maxillary sinusitis not responding to medical management
· To collect specimen of antral contents for culture & sensitivity
· Antrum is punctured through inferior meatus.
· Irrigation done by -Normal Saline at 37°C
Contraindications
A. Acute maxillary sinusitis Age below 3 years
B. Bleeding disorders
C. Clotting disorders
D. Disruption of maxilla
X ray PNS Waters view is a must to r/o maxillary hypoplasia before antral puncture

5. HIGGINSON’S RUBBER SYRINGE

Uses
· Antral wash
 · Nasal douching in atrophic rhinitis
Parts
· Bulb with red rubber tubing in either side one ends in a valve & the other in
nozzle
· Valve end is dipped in water and the nozzle end attached to trochar and Canula.
Valve makes the flow of the fluid in only one direction
· Capacity of ball - 50 ml or 60 ml
· Made of red rubber

6. BALLENGER’S SWIVEL KNIFE

Uses:
For removing the quadrilateral(septal) cartilage in SMR
Knife can rotate around the bar for 360°
Why called swivel?
· Cutting blade can revolve around the two bars
Indications of SMR
1. DNS causing nasal obstruction, head ache or sinusitis
2 As a part of hypophysectomy(trans-septal, trans- sphenoidal
3. Recurrent epistaxis due to septal spur
4. Cosmetic reasons
5. Rhinoplasty
6. Trans-septalvidianneurectomy
7. Cartilage graft in tympanoplasty
Contraindications:
1. A/c RTI
2. Age <17yrs
3. Bleeding diathesis
4. Uncontrolled DM, HT
5. Anterior/ Dorsal deviation of septum
 Notes:
1. Deviation anterior to Cottles line is called anterior dislocation
2. Cottles line is the line joining nasal spine of frontal bone & nasal spine of maxilla
3. Cottles test is pulling the cheek laterally backward to open nasal valve. Done
to check whether obstruction is in the valvular area or not. Lower border of
upper lateral cartilage , anterior end of inferior turbinate & corresponding area
on septum form nasal valve. An obstruction here causes 3/4th reduction of
airflow
4. Cottle’s approach is septoplasty
5. Cottles elevator is used in septoplasty to elevate mucoperichondrial flap
6. Cottles areas- Vestibular, Valvular, Turbinate, Attic, Posterior choanal.
Deviation in areas 1&2 require septoplasty, 3&5 require SMR or septoplasty&
forSeptorhinoplasty
7. Anterior deviation of nasal septum, patient’s age <17 yrs&septal surgery
associated with rhinoplasticprocedures(septum cannot support) form specific
indications of septoplasty.

7. LUC’S FORCEP’S
Uses
· in various nasal surgeries
· as a substitute for tonsil holding forceps

8. ST CLAIR THOMSON POST NASAL MIRROR

Uses:
Posterior rhinoscopy
Structures seen:-
· Roof of nasopharynx
· Posterior choana
 · Posterior aspect of nasal septum
· Posterior end of infturbinates
· Eustachian cushions
Q.Size of the mirror? (indicated behind the mirror)
Ask the patient to breath through the nose while keeping mouth open

9. SIMPSON’S AURAL SYRINGE

Uses:
1. Removal of FB from ear
2. Removal of wax
3. Caloric test 4. Enema
Precautions
a. Saline at body temperature
b. Direction of water towards posterior superior canal wall, not TM
· Protects TM. Allow water to get behind the mass
c. Tip of syringe should be blunt ]
d. Dry mopping after syringing
Contraindications
· Perforated TM-ASOM/CSOM
· Hygroscopic FB & button batteries
· Otitis externa
· CSF otorrhea
Side Effects
· Trauma to EAC - otitis externa
· TM rupture
· Activates latent otitis media
· Vertigo
· Vasovagal attack
TYPES
2. types- Adult, Paediatric
· Capacity - 150 ML (Adult)
Why normal saline at body temperature
· Otherwise it will cause Labyrinthine stimulation and vertigo.
PROCEDURE:
Patient in sitting position with head slightly tilted to the side of procedure.
Shoulders covered with towel and a kidney tray placed near the ear. water boiled
 and cooled to body temperature is syringed in the direction of posterosuperior
canal wall after pulling the pinna upwards and backwards

10. JOBSON HORNE’S PROBE & RING CURETTE

Uses:
a. Probe end
· Cotton swab carrier for cleaning discharge
· for tracing a sinus track
· Curette
· Removal of wax, FB

11. MOLLISON’S SELF - RETAINING HEMOSTATIC MASTOID RETRACTOR

Uses
1. Mastoid Surgery
2. Harvesting graft in myringoplasty
3. Tympanoplasty
4. Laryngofissure surgery
5. Frontal trephining
6. Ext. frontoethmoidectomy
7. Craniotomy
Advantages
1. Self retaining
2. Secures hemostasis
3. Retracts laterally away from field of operation.

12. BOYLE DAVIS MOUTH GAG

Parts 1. Tongue plate
2. Jaw piece
Uses
1. Surgeries of oral cavity: Surgeries of palate-Palatopharyngoplasty
2. Surgeries of oropharynx: Tonsillar surgeries
3. Surgeries of nasopharynx:Adenoidectomy, antrochoanal polyp,
postnasal angiofibroma, rhinosporidiosis
Complications
1. Injury to incisor tooth
2. Swelling of lips / teeth/gums/palate
3. TM joint dislocations
 Demonstrate how to hold the instrument and asses the parts?
Indications of tonsillectomy:
Absolute:
1. Recurrent infections of throat
a. 7 or more episodes in 1 year or
b. 5 or more episodes for 2 yrs or
c. 3 or more episodes for 3 yrs or
d. 2 weeks or more of lost school or work in 1 year
2. Peritonsillarabscess(quincy )
3. Tonsillitis causing febrile seizures
4. Hypertrophy of tonsils causing airway obstruction(sleep apnoea), dysphagia,
interference with speech
5. Suspicion of malignancy
Relative:
1. Diphtheria carriers not responding to antibiotics
2. Streptococcal carriers acting as source of infection for others
3. Chronic tonsillitis with bad taste or halitosis
4. Recurrent streptococcal tonsillitis in a patient with valvular heart disease
As part of other surgeries:
1. Palatopharyngoplasty to correct sleep apnoea
2. Glossopharyngeal neurectomy
3. Removal of styloidprocess( Eagles syndrome)
Contraindications
1. Hb<10g%; during mensus
2. A/c URTI
3. Submucous cleft palate
4. Children <3 yrs
5. Bleeding disorders
6. At the time of polio epidemics
7. Uncontrolled systemic d/s like DM, HT, Cardiac d/s, Asthma
Notes:
1. Daughtys tongue blade is connected via DRAFFINS BIPOD and
MAGAURAN”S PLATE
2. Position is rose’s position where neck is extended by placing a pillow under the
shoulder and a head ring is placed to stabilize the head

13. LACKS TONGUE DEPRESSOR

 · Doughty’s tongue blade / depressor is the one with a slot for ET tube
· Place the tongue depressor in midline in the anterior 2/3rd of the tongue to
prevent gagging.
. Uses: to depress tongue, for cold spatula test

14. EVE’S TONSILLAR SNARE

Uses
· In tonsillectomy to snare the lower pole of tonsil
Advantages
· Crushes the tissue & vessels, bleeding is less
(crushing releases thromboplastin which is a powerful vasoconstricitor and
assist clotting)
Q.Why inferior pole of the tonsil crushed?
Most of the vessels enter & leave from the inferior pole
Other snares
· Aural Snare (Cutting type) used for cutting aural polys {Krause}
· Nasal Snare (avulsion type) {Glegg}
Q. Averagebloodlose in Tonsillectomy? 50 mL.
Q. interval/cold tonsillectomy
Tonsillectomy done after a period of 6 to 8 wks of acute attack of peritonsillar abscess
Q.Wire used & its G uage’
Piano wire, 18-22 FG
Q.Structures passing through the inferior pole?
· Ascending pharyngeal artery
· Lesser palatine artery
· Dennis Brown Vein?
· Para tonsillar veins
· Abscess tonsillectomy?
· Emergency tonsillectomy done during A/C Quinsy
Blood supply of tonsils: branches of external carotid
1. Dorsal lingual branches of lingual artery
2. Ascending palatine and tonsillar branches of facial artery
3. Tonsillar branches of ascending pharyngeal
4. Descending palatine branch of maxillary artery
Tonsillectomy types:Hot& Cold methods
Hot methods:
1. Electrocautery
 2. Laser tonsillectomy &tonsillotomy
3. Coblation tonsillectomy
4. Radio frequency
Cold methods:
1. Dissection & snare method(followed here)
2. Gullotine method
3. Intracapsular tonsillectomy with debrider
4. Harmonic scalpel(ultrasound)
5. Plasma mediated ablation method
6. Cryosurgical technique
Notes:
1. Paratonsillarveins(Dennis Brown Veins)- commonly torn in tonsillectomy
2. Cold/interval tonsillectomy - done 4-6 wks after quinsy
3. Hot/abscess tonsillectomy- done during acute quinsy
4. Structures passing through lower pole of tonsils- Triangular fold, dorsal lingual
branch of lingual artery, lymphatics
Complications of tonsillectomy:
Immediate:
1. Primary haemorrhage
2. Reactionary haemorrhage
3. Injury to pillars, uvula, soft palate, tongue, teeth
4. Aspiration of blood
5. Facial edema
6. Surgical emphysema
Delayed:
1. Secondary haemorrhage- sepsis, premature seperation of membranes
2. Infections of tonsillar fossa causing otitis media
3. Lung complications- atelectasis, lung abscess, aspiration
4. Scarring of soft palate & pillars
5. Tonsillar remnants leading to recurrent infections
6. Hypertrophy of lingual tonsils

15. MOLLISONS BLUNT TONSILLAR DISSECTOR & ANT PILLAR

RETRACTOR
1.Dissecting end
· To divide mucosa close to anterior
· To follow the exposed capsule down to the base of tonsil with minimal trauma.
 2.Retracting end
· To retract the anterior pillar
(a) to look for bleeding points
(b) any tags of tonsillar tissue left
(c) formalcing incision
Precautions
· Avoid injury to uvula, ant.pillar, post, pillar

16. DENNIS BROWN TONSIL HOLDING FORCEPS

· To hold the tonsil during dissection

17. NEGUS LIGATURE SLIPPER

Uses
· To slip the ligature over the tip of Negus or Wilson forceps during the ligation
of blood vessels following tonsillectomy

18. WAUGH’S LONG DISSECTING FORCEPS WITH TOOTH

· To catch the bleeding point
· To pick cotton balls

19. ST. CLAIR THOMSON QUINSY DRAINING FORCEPS

Uses:
To drain peritonsillar abscess
Site of Incision:
· Point of maximum bulge
OR
· Just lateral to the point of junction of anterior pillar with a line drawn through
the base of uvula
OR
· Through crypta magna
Q. Hot tonsillectomy ?

Q.Define Quinsy-abscess b/w capsule of tonsil and tonsillar bed

DD’s of Quinsy :Tonsillar cyst, tonsillolith, intra-tonsillar abscess, parapharyngeal
abcess, sq. cell carcinoma of tonsils, NHL
DD’s of unilateral tonsillar involvement: Tonsillar cyst, tonsillolith, quinsy, malignancy,
carotid artery aneurysms, Phegmen tonsils
 Complications:
1. Parapharyngeal abscess
2. Laryngeal edema
3. Septicemia
4. Lung abscess, aspiration pneumonia
5. Jugular vein thrombosis

20. LARYNGEAL MIRROR

 21. FULLER’S BI VALVED TRACHEOSTOMY TUBE
Parts
1. Outer biflanged tube
2. Inner tube with an opening in the posterior wall
· Inner tube is always longer than the outer so the outer tube never gets blocked
by secretions, if inner tube is blocked, it can be cleaned leaving patent outer tube
in place.
Advantages
1. Acts as a tracheal dilator
2. Posterior wall opening of inner tube helps in
· Phonation
· Re educating the patient for normal speech during decannulation
· To determine whether normal air passage is established or nor, by blocking the
tracheostomy stoma.
Disadvantage
· Biflanged tube tip is sharp, hence is an irritant
· Flanges are weak, can break and can become FB bronchus

22. JACKSON’S METALLIC TRACHEOSTOMY TUBE

Parts
1. Outer tube with lock mechanism
2. Inner tube
3. Pilot obturator
Advantage
· Lock prevents inner tube from falling out during cough.
· Fuller’s tube flanges can beapproximated& acts as a tracheal dilator. Jackson’s
cannot and hence pilot is used which acts as a tracheal dilator.
· Jackson’s has a locking mechanism
· Jackson’s doesn’t have an inner opening as fuller hence all the exhaled air is
directed towards the opening of the tube and the pressure exerted there pushes
the inner tube out resulting, in decannulation
Size (both Jackson & Fuller)
Adult male 32, female 30.

23. PORTEX CUFFED TRACHEOSTOMY TUBE

Advantages
 1. Prevents aspirations
2. Can be connected to ambubag
3. During Radiotherapy
4. MRI/CT
Disadvantages
· Tracheal necrosis
· Cannot be kept for too long
Precaution: Deflate cuff at regular intervals
Q. Surgical Emphysema after Tracheostomy Management?
A. Remove sutures
B. Depress cought (4% xylocaine)
C. Avoid Movements of tube

24. LARYNGEAL SPECULUM / DIRECT LARYNGOSCOPE

It is actually laryngeal speculum as it has got a sliding plate which can be re
moved facilitating endotracheal intubations. this is an advantage. Held in the left hand
with thumb mark at the bend.
Indications
Diagnostic :
1. Where indirect laryngoscopy not possible as in infants and children
2. Where indirect laryngoscopy not possible due to excessive gag reflex or over
hanging epiglottis
3. To examine the hidden areas of larynx- i.eInfrahyoid epiglottis, ventricles,
anterior commisure, subglottis,posterior cricoid region.
Therapeutic
1. Removal of benign lesion like papilloma, fibroma, vocal nodule, polyp or cyst.
2. Removal of foreign bodies from larynx and hypopharynx
3. Dilatation of strictures
Contraindications
1. Diseases of cervical spine
2. Moderate dyspnoea unless tracheostomy has been done
3. Recent MI
Macintosh Laryngoscope= Anaesthetist’s laryngoscope. It can be lifted on reaching
vallecullae itself unlike the other one which can be lifted only after reaching the
epiglottis.
Position of Patient
 · Boyce position: Patient supine, flexion at lower cervical spine, extension
at Atlanto- Axial joint
Complications
1. Injury to lips/tongue/teeth
2. Laryngospasm
3. Bradycardia
4. Cardiac arrest

25. ST. CLAIR THOMSON ADENOID CURETTE WITH OR WITHOUT GUARD

Uses
· Adenoidectomy - producing obstruction with SOM
Use of guard / cage
· Prevents the slipping of adenoid tissue into nasopharynx/laryrnx
· Cage also ensures complete removal
Q.Inadenotonsillectomy which is done first?
· Adenoidectomy
Q.Griesel’s syndrome, management?
Injury to atlanto - occipital joint: To prevent it we have to flex the head while
removing adenoids.
Management:
· Cervical traction
· Analgesics
· Antiinflammatory
· I/V antibiotics
Indications of adenoidectomy:
1. Adenoid hypertrophy causing snoring, mouth breathing, sleep apnoea or speech
abnormalities
2. Recurrent rhinosinusitis
3. CSOM associated with adenoid hyperplasia
4. Recurrent ear discharge in benign CSOM
5. Dental malocclusion
Contraindications of adenoidectomy
1. Cleft palate or submucous cleft palate( causes velopharyngeal insufficiency)
2. Haemorrhagic diathesis
3. A/c URTI
Complications of adenoidectomy:
1. Haemorrrhage
 2. Injury to Eustachian tube, pharyngeal musculature and vertebrae
3. Velopharyngealinsufficiency(recovers in 2 wks)
4. Recurrence
Notes:
1. Physiotherapy for VPI- Inflate & deflate a balloon as it strengthens palatal
muscles
2. Adenoid curette is held in right hand & a dagger like movement is made at
wrist while left hand slighltyflexes the head to make nasopharynx in line to
avoid injury to mucosa
3. Extra care should be taken in Down’s patients as 0-20% of them have atlanto
axial instability
4. Griessels syndrome: Infection spreads to paraspinal muscles & ligaments
causing atlanto axial dislocation leading to compression of spinal cord at that
level & thus quadriplegia. This is very rare.
5. Hemostasis is achieved by nasopharyngeal pack kept for a period double of
bleeding time of that patient or till tonsillectomy is completed in adenotonsillec
tomy. Adenoid tags cause fresh bleeding after removal of pack. Then palpate,
remove tags and re-pack. If bleeding continues with no local cause then keep
post nasal pack for 24 hrs.
6. Other instruments with same name:
a. St. Clair Thomsons nasal speculum ( in our op)
b. St. Clair Thomsons quinsy draining forceps
Adenoid diagnosis is confirmed by x-ray nasopharynx, digital palpation, posterior
rhinoscopy, DNE
26. GARDINER- BROWN TUNING FORK
Parts
1. Prongs
2. Shoulder
3. Base
4. Stem
5. Foot piece
Q. frequency used- 512Hz
Falls within speech frequency ( 500 -2000 Hz)
Minimum overtones
Optimal decay time
Lesser vibration
Q. Distance between TF& auricle -2.5 cm
 Activated by striking at the junction of upper 1/3rd and lower 2/3rd (minimum
overtones heard) of its prongs ideally against a rubber piece or bony prominence of examiners
hand.

27. CHEVALIER JACKSON’S OESOPHAGOSCOPE

It does not have holes unlike bronchoscope. 50 cm long.
TYPES
1. Rigid
2. Flexible fibre optic
Indications
Diagnostic
1. Evaluation of dysphagia, hemetemesis and retrosternal burning
2. As a part of panendoscopy
3. To take biopsy
Therapeutic
1. Removal of foreign body
2. Dilataion of strictures
3. Removal of benign lesions
4. Palliative treatment in malignancy
5. Hemetemesis control by injecting scleroscents in oesophageal varices
6. Treatment of pharyngeal pouch ( Dolman’s surgery).
Position :
Boyce/ Barking dog / Morning air sniffing position. Neck flexed over thorax and
head extended at the atlanto- occipital joint. This is attained by placing a pillow under the neck
of the patient.
Notes:
killian’s dehiscence - it is between obliquefibres of thyropharyngeus and transverse
fibres of cricopharyngeouswhich are parts of inferior constrictor. It is called Gateway of
tears.
First symptom of perforation is inter-scapular pain and first sign is surgical
emphysema of neck.
In suspected perforation , if lumen of esophagus is visible then introduce a ryles
tube and NPO. If lumen not visible, provide IV fluids, parentral nutrition, broad spectrum
antibiotic coverage . If perforation not heal spontaneously, then opt for surgical
closure using flap or primary sutures.
 Panendoscopy= triple endoscopy= Nasopharyngeal laryngoscopy+ Oesophagoscopy
+Bronchoscopy. It is usually done in occult primary where secondary in necck nodes are
present.
Parts
1. Handle 2. Shaft 3. Eye piece
4. Light source 5. Light carrier
Complications
A - Arrhythmia
Aspiration pneumonia
Aortic aneurysm rupture
Air in pleura - pneumothorax
B - Bleeding
C - Cervical spine injury
D - Depression of respiratory centre
E - Oesophageal perforation
T - Trauma to lips and tooth
Q.Oesophagoscopy is done under GA or LA?
· Preferably under GA. All scopies to be done under GA. If contraindicated, LA.
Here all scopies done under LA. If contraindicated, GA

28. BRONCHOSCOPE
· Openings at the distal part-to ventilate the opposite bronchus.
· Sharp distal end
· Types: 1. Rigid bronchoscopy
2. Flexible fibre optic - bronchoscopy
Uses
1.Diagnostic
Examine the bronchial tree
Take biopsy
As a part of panendoscopy
2. Therapeutic
FB removal
Bronchial aspiration
Removal of benign lesions
Removal of mucus plugs in trachea
Dilatation in laryngo-tracheal stenosis
Complications
 1. Trauma to surrounding structure
2. Laryngeal edema
3. Hemorrhage
4. Bronchospasm
5. Aspiration
Types
1. Chevalier Jackson
2. Negus type
3. Mc Gibbon type
4. Fibre optic with micro photography
In chevalier Jackson, light is near the object
Notes
Position is Boyce position.
Flexible fibre optic bronchoscope can be used to visualise even the sub- segmental
bronchioles.

29 . CLEF ARROWSMITH SAFETY PIN CLOSING FORCEPS

OTHER INSTRUMENTS FOR NASAL SURGERIES

1. X-RAY PNS-WATER’S VIEW-showing haziness of rt maxillary sinus

DD:
· Maxillary sinusitis(if air fluid level is present ,a/c sinusitis . if no air fluid level,
don’t comment as a/c or c/c
· Mucocele
· AC polyp
· Malignancy
· Cystic lesions-dental and dentigerous cyst (dentigerous cyst arises in relation
to unerrupted tooth
· Haemosinus /haemoantrum
· Foreign body(usually dental amalgum)
Other views
· Occipitofrontal /Caldwell view- ideal for frontal sinus
· Lateral view- ideal for sphenoid sinus
 · Oblique view-ideal for ethmoid sinus
· Submentovertical view/ skull base view-sphenoid sinus
Management of sinusitis
2. X-ray showing nose and paranasalsinus,waters view open mouth showing haziness of rt
maxillary sinus with expansion and erosion of bony walls
· Diagnosis – malignancy of right maxillary sinus
· Symptoms,management

3. X-ray of nasopharynx,lateral view showing a soft tissue opacity arising from roof
and posterior wall of nasopharynxie, enlarged adenoids
· Crescent sign – seen in antrochoanalpolyp,not in adenoid
· DD:adenoids,nasopharyngealmalignancy,angiofibroma(crescent sign absent),AC
polyp,rhinosporidiosis(crescent sign present)
· Crescent sign is column of air between mass and roof of nasal cavity

4. X-ray ,lateral oblique view of skull showing nasal bone —undisplaced fracture
· DD:vascular marking on bone
· Management of nasal bone fracture
Displaced withodema-wait till odema subsides (7-10) days-closed reduction
Displaced without odema-early intervention (reduction with walshamasches
forceps(walsham –for nasal bone &asche’s for septal fracture
Undisplaced –no treatment required
If patient comes late(16-20 days)- rhinoplasty

5. X-ray soft tissue neck ,lateral view with lower part of skull and upper part of chest
showing widening of pre-vertebral soft tissue shadow with air fluid level and compression
of tracheal air column with intact cervical spine ,straightened.
Diagnosis- a/c retropharyngeal abcess
· Significant widening is greater than ¾ th thickness of vertebral body
· Straightening of spine due to painful spasm of paravertebral muscles
· Air fluid level is due to gas producing organism infection
· a/c R.Pabcess in adults- foreign body
· a/c R.Pabcess in kids –suppuration of retropharyngeal lymph nodes following ARI
· c/c always secondary to caries spine ,TB spine showing collapse and destruction
of spine.
Management of a/c R.Pabcess
 . Admit the patient .
Start on antibiotics ·
I &D under LA after preliminary tracheostomy with cuffed potex tracheostomy tube
· If bulge in oral cavity –intraoral I & D
· If bulge lower down –do hypopharyngoscopy and I & D at site of maximum bulge
· Give systemic antibiotics
Management of c/c R.P abcess
· Immobilize spine
· Anti TB drugs
· I &D – external drainage because TB prone for fistula formation
Complications- laryngeal oedema, aspiration pneumonia, lung abcess, para
pharyngeal abcess, mediastinalabcess ,septicemia

6. X-ray soft tissue neck lateral view showing open safety pin with open end down at level
of c5-c6
· Unsafe foreign body on cricopharynx
· Clef-arrowsmith forceps- to close safety pin
· Oesophagoscopy under GA and removal using foreign body removal forceps

7. X-ray PA view chest with neck and upper part of abdomen showing round radioo
paque shadow in coronal plane at junction of neck with thorax- probably coin in
cricopharynx
· Cricopharynx is narrowest region of oesophagus,plane of cricopharyngeal inlet
is in coronal plane
· In larynx(glottis) due to vocal cords ,coin lies in saggital plane
Management –oesophagoscopy/hypopharyngoscopy under GA using FB
removing forceps

8. X-ray mastoid lateral oblique view (laws view)showing cavity in mastoid bone
Causes of cavity in mastoid
· Cholesteatoma(smooth cavity with surrounding sclerosis)
· Surgical cavity(irregular cavity with no surrounding sclerosis)
· Malignancies of temporal bone(smooth cavity with eroded bony margins)
Uses of x-ray mastoid
· To know cellularity of mastoid
Cellular-80%
Sclerotic-15%
 Diploic-5%
· To know anatomical landmarks
· To rule out coalescent mastoiditis/cavity in mastoid

9. X-ray PNS –with rudimentary frontal sinus(look for DNS in x –ray)

· Normal frontal sinus has scalloped appearance

10. X-ray with broken inner tube of tracheostomy tube in bronchus