ENT Concept Book

Concept Based Learning
Video Companion on Each Chapter
Next Generation
Comprehensive Review Series
“EAR NOSE AND

THROAT”
Active Recall Based

Integrated Edition
Published by Delhi Academy of Medical Sciences (P) Ltd.
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ISBN : 978-93-89309-30-0
First Published 1999, Delhi Academy of Medical Sciences
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Contents
OTOLOGY 01 – 68
Chapter 1 Anatomy of Ear 03 – 20
Chapter 2 Audiometry 21 – 34
Chapter 3 Disorders of Ear 35 – 54
Chapter 4 High Yielding Topics of Ear 55 – 68
LARYNX 69 – 104
Chapter 5 Anatomy of Larynx 71 – 78
Chapter 6 Disorders of Larynx 79 – 90
Chapter 7 Tumors of Larynx and Their Management 91 – 104
RHINOLOGY 105 – 140
Chapter 8 Applied Clinical Anatomy in Rhinology 107 – 114
Chapter 9 Clinical Disorders in Rhinology 115 – 134
Chapter 10 Malignancy in Rhinology 135 – 140
PHARYNX 141 – 162
Chapter 11 Clinical Anatomy of Pharynx 143 – 148
Chapter 12 Clinical Disorders of Pharynx 149 – 158
Chapter 13 Malignancy of Pharynx 159 – 164
ORAL CAVITY 165 – 179
Chapter 14 Applied Anatomy of Oral Cavity & Misc Topics 167 – 179
G Y
L O
TO
O
1 Anatomy of Ear
CONCEPTS
Â Concept 1.1 Clinical Anatomy of External Ear
Â Concept 1.2 Middle Ear and Mastoid Anatomy
Â Concept 1.3 Clinical Anatomy of Inner Ear

4 | Ear Nose and Throat
Concept 1.1: Clinical Anatomy of External Ear
Learning Objective: To Learn the Clinical Applied Anatomy of External Ear
Time Needed
1st reading 15 mins
2 look
nd
5 mins
Pinna Develops from 1st and 2nd Branchial Arch
From 1st Arch Tragus From 2nd Arch Rest of Pinna

Hillocks of his Precursors of pinna: They are 6 in number.
Anatomy of Ear | 5
Disorders of the Outer Ear
Anotia Congenital absence of pinna
Cleft pinna Congenital fissure of the pinna
Coloboma lobuli Congenital fissure of the earlobe
Macrotia Congenital excessive enlargement of the auricle
Microtia Congenital small pinna
Melotia Congenital displacement of the pinna
Low-set-ears Congenitally displaced pinna
Polyotia Additional pinna on one or both sides
Preauricular tags Small appendage anterior to pinna
Scroll ear Rim (helix) of pinna is rolled forward and inward
Sensory Innervation of the Auricle

Nerve Derived from Region Supplied
Greater auricular Cervical plexus C2, C3 Medial surface and posterior part of lateral
surface of pinna
Lesser occipital Cervical plexus C2 Superior portion of medial surface
Auricular Vagus Concha and antihelix
Auriculo-temporal Mandibular division of trigeminal Tragus, crus of the helix and adjacent helix
nerve
Facial Supplies root of concha
Common Auricular Defects

Pre-Auricuiar sinus Formation: 1st and 2nd hillocks fail to fuse
Bat Ear Antihelix poorly formed
Wildermuth Ear Helix underdeveloped, antihelix is prominent
Mozart’s Ear Helix and antihelix are found fused
Protruding Ear Auriculocephalic angle >30°, caused from loss of formation of the antihelical fold
or overgrowth or protrusion of the conchal cartilage
External Auditory Canal (EAC)
• Develops from: dorsal end of the 1st Branchial cleft.

• Length: 24 mm = 8 mm: Cartilaginous, 16 mm: Bony.
• Fissures of santorini: Defects in cartilaginous part of the EAC.
• Hair follicles are seen in outer cartilaginous part, so furunculosis is seen in this part.
• Foramen of Huschke: Defects in bony part of EAC.
• Isthmus of EAC:
• Narrowest part of EAC: 6 mm.
• 6 mm lateral to tympanic membrane.
• Foreign bodies lodged beyond the isthmus are difficult to be retrieved.
Collaural Fistula:
Formation: Is a 1st branchial cleft anomaly, arises from failure of fusion of the ventral part of the 1st cleft.
Opening: Upper part: opens in the floor of the external auditory canal.
Lower part: Between the angle of the mandible and the sternocleidomastoid muscle.
Anatomy of Ear | 7
Concept 1.2: Middle Ear and Mastoid Anatomy
Learning Objective: To Learn the Clinical Applied Anatomy of Middle Ear and Mastoid
Time Needed
1st reading 20 mins
2 look
nd
10 mins
Tympanic Membrane (TM):

TM Consists of 3 Layers:
As it develops from ectoderm, endoderm and mesoderm.
• Outer epithelial layer which is continuous with skin in the meatus.
• Inner mucosal layer which is continuous with mucosa of middle ear.
• Middle fibrous layer which encloses handle of malleus and has 3 types of fibers-
radial, circular and parabolic.
Normal TM:
• Pearly white.
• Shiny.
• Concavity on its lateral surface more marked at tip of malleus (Umbo).
• Cone of light in anterio inferior quadrant.
• Normal TM is mobile.
poster anteri
ior or
Tympanic membrane (left).

1. Malleus
2. Anterior mallear fold
3. Posterior mallear fold
4. Pars flaccida (Shrapnel’s membrane)
5. Projection of the long process of the incus
6. Pars tensa
7. Annulus.
Nerve Suppy of Tympanic Membrane
Arterial Supply of Tympanic Membrane
Middle ear: With Eustachian tube, aditus, antrum and mastoid air cells is called
middle ear cleft.
Middle ear is sometimes divided into
• Mesotympanum: opposite the pars tensa. (Narrowest part)
• Epitympanum: (attic) above the pars tensa.( Widest part)
• Hypotympanum: below the pars tensa.
• Protympanum: portion of middle ear around the tympanic orifice of the eustachian
tube.
Anatomy of Ear | 9
Fig.: Middle ear
Middle Ear Spaces:

The middle ear space contains several spaces of clinical significance. The sinus tympani
is located between the labyrinthine wall and the pyramidal eminence. This area is a
common site for recurrence of cholesteatoma.
The facial recess is found between the tympanic annulus and pyramidal eminence. This
recess provides improved access to the middle ear space during a tympanomastoidectomy.
Fig.: Middle ear space

The facial recess is found between the tympanic annulus and pyramidal
eminence. This recess provides improved access to the middle ear space during a
tympanomastoidectomy.
Oval window (fenestra vestibuli):
• This is an oval shaped opening connecting the tympanic cavity with the vestibule,
is closed by the foot plate of stapes and its surrounding annular ligament.
• The size of the oval window varies, but on an average it is 3.25 mm long and 1.75
mm wide. The fenestra cochlea (round window) lies just below and behind
the oval window. It is closed in life by a membrane known as the round window
membrane (secondary tympanic membrane). The diameter of the round window
membrane is between 1.8 to 2.3 mm.
Tympanic Plexus
• Is found over the promontory.
• It is formed by the tympanic branch of the glossopharyngeal nerve, carotico tympanic
nerves which supplies the sympathetic component. The tympanic plexus provide the
following branches:
Fig.: The Ossicular Chain, medial Aspect
Middle Ear Muscles:

• Tensor tympani
Attached to malleus.
Innervated by Vth/trigeminal nerve.
• Stapedius
Attached to stapes.
Innervated by VIIth/facial nerve.
Anatomy of Ear | 11
• Middle Ear Muscle Function:
Help maintain ossicles in proper position.
Protect inner ear from excessive sound levels:
▫ When ear is exposed to sound levels above 70 dB, the muscles contract,
decreasing amount of energy transferred to inner ear.
This protective reflex termed “acoustic reflex”
Antrum:
• Roof → a thin bony plate → tegmen tympani, which separates them from → middle
cranial.
• Medial wall separates it from: - lateral SCC- Endolymphatic Sac - Dura of posterior
cranial Fossa
• Lat. Wall: 1.5 cm thick of squamous bone
• Posteriorly: Sigmoid Sinus
• Floor: Jugular bulb
Anatomy of Ear | 13
Concept 1.3: Clinical Anatomy of Inner Ear
Learning Objective: To Learn the Clinical Applied Anatomy of Inner Ear
Time Needed
1st reading 20 mins
2 look
nd
10 mins
Cochlea
Anterior part 2,3/4 turns around modiolus
3 comps:SV,ST()and SM endolymph 30 mm long
Modiolus
Spongy bone Central axis in the cochlea
Base directed toward IAC, transmits VIII n. and
vessels to cochlea
ROSENTHAL’S CANAL: housing spiral ganglia

SCALA VESTIBULE
• Uppermost compartment
• Closed by oval window and stapes footplate.
SCALA TYMPANI
• Lowermost closed by round window (2nd Tympanic membrane)
PROMONTARY:
• Basal coil of cochlea
• Bulge in medial wall of middle ear.
HELICOTREMA
• Communication between SV and ST at apex of cochlea
Anatomy of Ear | 15
Vestibule
Central Portion
Relations
• Anteriorly: Scala vestibuli of the cochlea
• Postero superiorly: with the five openings of the semicircular canals.
• Laterally: oval window + footplate of stapes surrounded by annular ligament.
Includes
• Elliptical recess: Lodge à utricle
• Spherical recess: Lodge à saccule
Semi Circular Canals
• Posterior =Longest
• Superior
• Horizontal = Lateral = Shortest
• 2/3 of a circle, 8 mm in diameter.
DILATED END = AMPULLA = CONTAIN SENSORY END - ORGAN
• Each canal has an ampullated end which opens independently into the vestibule and
a non ampullated end.
• The non ampullated ends of posterior and superior canals unite to form a common
channel called crus commune.Thus, the three canals open into the vestibule by five
openings
Utricle and Saccule.

• It is also connected to the saccule through utriculosaccular duct.
• The sensory epithelium =macula = linear acceleration and deceleration.
Semicircular ducts.
• Three in number.
• They open in the utricle.
Endolymphatic Duct and SAC
• Endolymphatic duct is formed by the union of two ducts, one each from the saccule
and the utricle.
• It passes through the vestibular aqueduct.
Sensory Organs
Organ of Corti
Hair Cells
• Strategically positioned on the basilar membrane of the organ of Corti are three
rows of outer hair cells (OHCs) and one row of inner hair cells (IHCs).
• Separating these hair cells are supporting cells: Deiters cells, also called
phalangeal cells, which separate and support both the OHCs and the IHCs.
Basilar Membrane
• The basilar membrane is a stiff structural element within the cochlea of the
inner ear which separates two liquid-filled tubes that run along the coil of the cochlea,
the scala media and the scala tympani.
Characteristic Outer hair cell Inner hair cell

Number 12,000 3500
Location Farther from modiolus nearer
No. of rows 3-4 1
Shape of hair cells Cylindrical Flask shape
No. of rows of cilia 6-7 per cell 2-4 row per cell
Steriocilia arrangement W or V shape Shallow U shape
Length of steriocilia Long & thin Short & fat
Motility Motile Nonmotile
Otolith
Saccule and Utricle.
• The receptors, called maculae (meaning “spot”), are patches of hair cells topped by
small, calcium carbonate crystals called otoconia.
• The saccule and utricle lie at 90 degrees to each other.
The ampulla is a localized dilatation at one end of the semicircular duct.
A patch of innervated hair cells is found at the base of the ampulla in a structure
termed a crista (meaning crest).
The crista contains hair cells with stereocilia oriented in a consistent direction.
The cupula, a thin vane, sits atop this crest.
Anatomy of Ear | 17
WORKSHEET
MCQ OF “ANATOMY OF EAR” FROM DQB
EXTRA POINTS FROM DQB

Anatomy of Ear | 19
IMPORTANT TABLES (ACTIVE RECALL)
Anotia
Cleft pinna
Coloboma lobuli
Macrotia
Microtia
Melotia
Common Auricular Defects

Pre-Auricuiar sinus
Bat Ear
Wildermuth Ear
Mozart’s Ear
Protruding Ear
Characteristic Feature Outer Hair Cells Inner Hair Cells

2 Audiometry
CONCEPTS
Â Concept 2.1 Basics of Sound Transmission
Â Concept 2.2 Pure Tone Audiometry
Â Concept 2.3 Tuning Fork Tests
Â Concept 2.4 Speech Audiometry
Â Concept 2.5 Impedance Audiometry
Â Concept 2.6 Electrocochleography & Bera

Concept 2.1: Basics of Sound Transmission
Learning Objective: To Learn the Basics of Sound Transmission
Time Needed
1st reading 10 mins
2 look
nd
5 mins
Sound can be transmitted from the ear canal to the cochlea by two mechanisms
• Ossicular and Acoustic coupling
1.3: 1 LEVER ACTION
21: 1 14:1
17:1
90 mm3 55 mm3
Frequency: It is no. of cycles per second. Unit of frequency is Hertz.
Pure Tone: A single frequency sound is called a pure tone eg a sound of 250, 500 or
1000 Hz.
In PTA we measure threshold of hearing in decibels for various pure tones from 125 to
8000 Hz.
Intensity: It is the strength of sound which determines its loudness. At a distance of
one meter intensity of
• Whisper – 30 dB
• Normal conversation – 60 dB
• Shout – 90 dB
• Discomfort of the ear – 120 dB Complex Sound: Sound with more than one
frequency eg: Human voice
Masking - It is a phenomenon to produce inaudibility of one sound by the presentation
of another sound.
Masking of non test ear is essential in all bone conduction tests but for air conduction
tests, it is required only when interaural difference of hearing exceeds 40 dB.
Speech Test:
6 meters is taken as normal for both conversational and whisper.
Normally a person hears conversation at 12 metres (40 feet).
Spondee words (football, day dream) or number with letters (X3B, 5CD).
Degree of hearing loss Hearing loss range (dB HL)
Normal 10 to 25
Mild 26 to 40
Moderate 41 to 60
Severe 61 to 80
Profound 81 +
Audiometry | 23
Concept 2.2: Pure Tone Audiometry
Learning Objective: To Learn the Concepts of Pure Tone Audiometry
Time Needed
1st reading 10 mins
2 look
nd
5 mins
Pure Tone Testing

Air Conduction
• O indicates right ear
• X indicates left ear

Low Frequency Sensorineural hearing loss
High Frequency hearing loss

Audiometry | 25
Concept 2.3: Tuning Fork Tests
Learning Objective: To Learn the Concepts of Tuning Fork Tests
Time Needed
1st reading 10 mins
2 look
nd
5 mins
Tuning Fork Tests:

1. Rinnie Test:
In this AC of the ear is compared with its BC.
It is +ve when AC > BC (normal / SN deafness).
If -ve Rinne, BC > AC in conductive deafness.
False -ve rinne: Severe unilateral SNHL. This is prevented by masking the non
test ear.
2. Weber Test:
Normally, it is heard equally in both the ears.
Lateralised to the worse ear in conductive deafness.
Lateralised to the better ear in SN deafness.
3. Absolute bone conduction (ABC) test: In this patient’s bone conduction is
compared with that of the examiner. EAM of both the patient and the examiner should
be occluded. In SN deafness, patient hears for a shorter duration.
Weber without Weber lateralizes left Weber lateralizes right
lateralization
Rinne both ears Normal/bilateral Sensorineural loss in right Sensorineural loss in left
AC>BC sensorineural loss
Rinne left BC>AC Conductive loss in left Combined loss: conductive
and sensorineural loss in
left
Rinne right BC>AC Combined loss: conductive Conductive loss in right
and sensorineural loss in
right
Rinne both ears Conductive loss in Combined loss in right and Combined loss in left and
BC>AC both ears conductive loss on left conductive loss on right
Extra Edge:
Pseudohypacusis
• STENGER’S Test.
• Lee’s Speech Delay Test.
• Lombard Test.
High Frequency Audiometry: Ototoxic Drugs

Concept 2.4: Speech Audiometry
Learning Objective: To Learn the Concepts of Speech Audiometry
Time Needed
1st reading 10 mins
2 look
nd
5 mins
Speech Audiometry:
• There are two basic components of the speech audiometry test battery: Speech
Reception.
• Threshold and Speech Discrimination. “Speech Discrimination” is often also referred
to as “Speech Understanding” or “Word Understanding.”
Speech Reception Threshold:

• The lowest level at which he or she can repeat 50% is the “speech reception threshold”
or “SRT.”
Speech Discrimination (SD):

Speech discrimination (SD) testing is generally performed at supra-threshold
presentation levels as described above. That is, rather than seeking some type of
threshold, the aim is to assess how well an individual can understand words that should
be fully audible based on their level of hearing (as measured via pure tones and
SRT).
A level of 30 dB above SRT may be used, or other levels may be preferred,
depending on the specific aims of the tester.
Audiometry | 27
Extra Edge:
Average Hearing Loss Seen in Different Lesions of Conductive apparatus
1. Complete obstruction of ear canal: 30 dB.
2. Perforation of tympanic membrane: 10 – 40 dB (It varies and is directly proportional to
the size of perforation).
3. Ossicular interruption with intact drum: 54 dB.
4. Ossicular interruption with perforation: 38 dB.
5. Closure of oval window: 60 dB.
Concept 2.5: Impedance Audiometry
Learning Objective: To Learn the Concepts of Impedance Audiometry
Time Needed
1st reading 15 mins
2 look
nd
5 mins
Impedance Audiometry
• To differentiate ossicular fixation from ossicular dislocation in cases of conductive
deafness.
• To find fluid in middle ear in serous otitis media.
• To assess function of eustachian tube.
• By eliciting stapedial reflex, it can be used to.
Localise lesions of facial nerve and find prognosis of facial paralysis.
Find recruitment.
Detect malingerers.
The following tests have been included under the battery of impedence
audiometry:
Tympanometry Eustachian tube function Acoustic reflex threshold
Acoustic reflex decay Tests to identify perilymph fistula
Audiometry | 29
Fig.: Tympanometry
Stapedial/Acoustic Reflex:
A tone of 70 – 100 dB HL will cause stapedial muscle to contract.
Concept 2.6: Electrocochleography & Bera
Learning Objective: To Learn the Basics of Electrocochleography and Bera
Time Needed
1st reading 15 mins
2 look
nd
10 mins
ELECTROCOCHLEOGRAPHY is a procedure to record the potentials generated

by the cochlea and the auditory nerve.
It measures electrical potentials arising in the cochlea and CN VIII in response
to auditory stimuli within first 5 ms.
The response is in the form of three phenomena: Cochlear microphonics, summating
potentials and the action potential of VIIIth nerve.
EcoG is useful
(i) To find threshold of hearing in young infants and children within 5–10 dB and
(ii) To differentiate lesions of cochlea from those of the VIIIth nerve.
▫ Normally the ratio between the amplitude of summating potential to the action
potential is less than 30%. An increase in this ratio is indicative of Ménière’s
disease
Fig.: Electrocochleography
Auditory Brainstem Response (ABR) Audiometry

ABR Peaks: Each peak may correlate to an anatomical location
• I–II: Eighth nerve (distal and proximal segments).
• III: Cochlear nuclei.
Audiometry | 31
• IV: Olive (superior).
• V: Lateral lemniscus (largest wave).
• VI–VII: Inferior Colliculus.
Only waves I, III, and V are observed at birth, I–V is prolonged at birth.
Extra Edge:
• Recruitment: Recruitment is typically seen in lesions of cochlea (Meinere’s disease,
presbycusis).
• Short Increment Sensitivity Index (SISI) test:
• Patients with cochlear lesions distinguish smaller changes in intensity better than
those with normal hearing conductive or retrocochlear pathology.
• This test helps in determining the site of lesion in the auditory system by determining
whether a disorder is cochlear or noncochlear.
• The diagnostic accuracy of this test depends upon the amount of hearing loss a
patient may have.
• Tone decay test - Is a measure of nerve fatigue and is used to detect retrocochlear
lesions. Normally a person can hear a tone continuously for 60 seconds.
Otoacoustic Emissions
• Otoacoustic emissions (OAE) are sounds produced by motile elements of cochlear
outer hair cells.
WORKSHEET
MCQ OF “AUDIOMETRY” FROM DQB

Audiometry | 33
The following tests have been included under the battery of impedence
audiometry:
TYMPANOGRAMS
Ad
As
C
ABR Peaks: Each peak may correlate to an anatomical location

I–II
III
IV
VI–VII
3 Disorders of Ear
CONCEPTS
Â Concept 3.1 Diseases of External Ear
Â Concept 3.2 Diseases of Middle Ear
Â Concept 3.3 Diseases of Inner Ear
Â Concept 3.4 Otosclerosis.
Â Concept 3.5 Meniere’s Disease
Â Concept 3.6 Tumors in Otology

Concept 3.1: Diseases of External Ear
Learning Objective: To Learn the Clinical Aspect of Infections of External Ear
Time Needed
1st reading 10 mins
2 look
nd
5 mins
Bat Ear (Lop Ear) Congenital Surgically corrected > 6 years

Hematoma of the Auricle Collection of blood between Result of blunt trauma- Boxers
(Cauliflower ear) auricular cartilage and its
perichondrium
Perichondritis Pseudomonas Treatment: Systemic antibiotics
and local application of 4%
Aluminium acetate compresses
Furuncle Localised acute otitis externa Locally, apply glycerin and
(Staphylococcal) ichthammol (10 percent)
Diffuse Otitis Externa Swimmers ear ??
Otitis Externa Hemorrhagica Hemorrhagic bullae on TM and
deep meatus
(Influenza)
Malignant (Necrotising) Otitis Externa

• Pseudomonas infection usually in elderly diabetics or those on immunosuppressive
drugs
• Local destruction can involve skull base, mastoid, petrous apex etc.
• There are granulations is the external auditory canal which leads to blood stained ear
discharge. Patient has severe earache.
• Cranial nerve palsies (7, 9-12) can be there.
Disorders of Ear | 37
Treatment:
• Antibiotics (3rd Generation cephalosporins: cefoperazone).
• Debridement if no response to medical treatment.
• Radionuclide gallium and technetium scan are helpful in the management.
Tuberculosis
• Otologic: painless, odorless, watery otorrhea, multiple TM perforations.
Keratosis Obturans
• Collection of pearly white mass of desquamated epithelial cells in deep meatus.
• Keratolytic agent - 2% salicylic acid in alcohol prevent recurrence.
Myringitis Bullosa
• Virus or Mycoplasma pneumonia or Influenza.
Concept 3.2: Diseases of Middle Ear
Learning Objective: To Learn the Concepts of Middle Ear Infections and Management
Time Needed
1st reading 30 mins
2 look
nd
15 mins
Acute Suppurative Otitis Media (ASOM)

Streptococcus pneumonaie and Hae- mophilus influenzae (most common causes).
Sometimes Staphylococcus aureus (< 3 months), Streptococcus pyogenes, E. coli.
1. Stage of Tubal occlusion - No fever, fluid not clinically appreciable, TM retracted
2. Stage of Pre - suppuration – High fever
3. Stage of Suppuration - TM starts Bulging
4. Stage of resolution - TM rupture, subsidence of symptoms
5. Stage of complication - If virulence of organism is high or resistence of patient is
poor
Treatment:
1. Antibacterial therapy.
2. Decongestant nasal drops.
3. Oral nasal decongestant.
In ASOM, a circumferential incision is made.
Secretory O.M./ GLUE EAR/ Otitis Media with Effusion

• Sterile fluid accumulates in middle ear (Non - suppurative).
• Seen in school going children (5 – 8 years).
• Impedance audiometry: Type – B curve.
Treatment
1. Medical:
Decongestants, antiallergic, antibiotics, middle ear aeration.
2. Surgical:
Myringotomy and Grommet Insertion (in anteroinferior quadrant).
Adenoidectomy is an importnant part of treatment.
Chronic Suppurative Otitis Media

Feature Tubotympanic Atticoantral
1. Discharge Copious, odourless Scanty, foul-smelling
2. Perforation Central Attic or marginal
3. Polyps Pale coloured Fleshy
4. Cholesteatoma Absent Present
5. Complication Rare Common
Aural Polyp should never be Avulsed but cut because it may be Attached to
Vllth N./ Stapes/Semicircular Canal
Ossicular erosion can happen in CSOM.
Most common ossicle to be damaged: Incus (long process)> stapes> malleus).
Management of Tubotympanic Disease:
Tympanoplasty
Definition: Repair of the tympanic membrane (TM) with inspection of middle ear and
possible ossicular chain reconstruction
• Indications:
Prevent recurrent disease
Improve hearing
Provide a dry ear canal
Enable patient to bathe and swim freely
• Commonly used materials:
Temporalis fascia
Perichondrium/cartilage
Periosteum
Alloderm
• Techniques:
Overlay
Underlay
Approaches:
• Transcanal:
For most cases.
• Post auricular:
For lateral grafts
Good for kids
• Endaural:
When canalplasty is needed
Good for kids
Type 1: Placing a graft (myringoplasty) after inspecting the ossicles.
Type 2: Malleus absent, graft placed over incus.
Type 3: M
alleus, incus absent—graft is placed over stapes. This is called
myringostapediopexy or columella tympanoplasty.
Type 4: M
alleus, incus and stapes head are absent. Only foot plate is there. The graft is
placed over round window whereas oval window is kept exposed. This is done
to maintain the phase difference between two windows.
Type 5: Also called fenestration procedure. It was done in the past for otosclerosis.
Complications:
• Persistent / recurrent perforation
• Cholesteatoma (ME, drum, EAC)
• Dysguesia
• Blunting
• Lateralization
• SNHL / vertigo
• Facial nerve injury
Ossiculoplasty (OCR):
• Appropriate candidates:
Resolved otorrhea with no middle ear disease
Conductive or mixed hearing loss
No eustachian tube dysfunction (ideal)
▫ Need enough middle ear space and aeration to allow for prosthesis and function
Partial Ossicular Replacement Prosthesis (PORP)- Types
Fig.: Partial Ossicular Replacement Prosthesis (Porp)- Types
Atticoantral Disease
Posterior epitympanum (Prussack’s space): commonest site of origin of
cholesteatoma
• Wittmaack’s theory: Retarction pocket.
• Habermann’s theory: Epithelial Invasion.
• Ruedi’s theory: Basal cell hyperplasia.
• Sade’s theory: Metaplasia.
Sade classification of retraction of pars tensa:
• Grade 1: Mild retraction.
• Grade 2: Severe retraction–retracted TM touching incus or stapes.
• Grade 3: Atelectatic TM–TM touching promontory but moves on seigelisation.
• Grade 4: Adhesive TM–TM touching promontory, does not move on seigelisation

classification of pars flaccida.
Tos classification of pars flaccida:
• Stage I: Pars flaccid is dimpled and is more retracted than normal. It is not
adherent to the malleus.
• Stage II: In this stage the retraction pocket is adherent to the handle of malleus.
The full extent of the retraction pocket can be clearly seen.
• Stage III: In this stage part of the retraction pocket may be hidden. There may
also be associated erosion of the outer attic wall (scutum).
• Stage IV: In this stage there is definite severe erosion of the outer attic wall.
The extent of the retraction pocket cannot be clearly seen as most of it is hidden from
the view.
Mastoidectomy:
Canal wall down (CWD) procedures:
• Modified radical mastoidectomy
• Radical mastoidectomy
• Atticotomy
Canal wall up (CWU) procedures:
• Cortical mastoidectomy (Schwartz operation)
• Combined approach tympanoplasty
Condition Treatment of choice
• Atticoantral CSOM (unsafe CSOM) • MRM

• Unsafe CSOM with hearing loss • MRM
• Unsafe CSOM with Vertigo • MRM
• Unsafe CSOM with Facial nerve Paralysis • MRM
• Unsafe CSOM with Labyrinthine fistula • MRM
• Unsafe CSOM with Acute mastoiditis • MRM
• Unsafe CSOM with Brain abscess • Referred to Neurosurgeon
• Unsafe CSOM with Subdural empyema • Referred to Neurosurgeon (BURR HOLE surgery)
• Unsafe CSOM with Hydrocephalus • Ventriculo- peritoneal shunting
• Unsafe CSOM with Extradural abscess • MRM + open the dural plate and drain the Abscess
• Unsafe CSOM with sigmoid sinus thrombosis • MRM + open the sinus plate and clear the and
hrombus
Complications of CSOM:
Extradural abscess (mostly asymptomatic).
Subdural abscess: Surgical intervention (with neurosurgeon): BURR HOLE SURGERY.
Lateral sinus thrombophlebitis: Symptoms:
• Fever: Picket fence fever/ Hectic fever due to septic emboli in blood.
• Progressive anaemia and emaciation
• Otalgia.
• Neck pain with mastoid tenderness.
Signs:
• Pallor: Due to the hemolytic nature of the infected organism.
• Griesinger’s sign: Pitting oedema over the occipital region (due to mastoid emissary
vein thrombosis).
• Tobey-Ayer test/Quekenstedt test: Tests the change in the C.S.F following
compression of either jugular veins.
• Crowe-Beck Test: Pressure on jugular vein of the healthy side produces engorgement
of the retinal and supraorbital veins.
Investigations:
• CECT: Delta sign: Enhancement of the sinus walls but no contents.
• Meningitis: (leptomeningitis)
Management of Lateral Sinus Thrombophlebitis
• Intravenous antibacterial Therapy
• Mastoidectomy Ligation canal up procedure Canal down procedure
• Anti of internal
• Coagulant therapy Juglar vein
Otogenic Brain Abscess:
• Temporal lobe abscess: Cerebellar abscess = 2:1.
• Organisms: Commonest: Anaerobic streptococci.
• Nominal Aphasia, homonymous hemianopia, focal epilepsy.
Otitic Hydrocephalus:
• Rarest complication.
• Age group: Adolescents and children.
• Increased ICT following middle ear infection (onset: many weeks after ASOM many
years after CSOM).
Treatment (aim to ↓ pressure to prevent optic damage)
• Diuretics.
• Steroids.
• Hyperosmolar dehydrating agents.
• Long term: Thecoperitoneal shunting.
Facial Paralysis - seen in ASOM and CSOM
• ASOM: Cause is congenital dehiscence of the fallopian canal.
• CSOM: Cholesteatoma eroding fallopian canal.
Labyrinthitis: In ASOM: Spread to labyrinth through
• Round window.
• Stapedectomy site.
• Cochlear aqueduct.
• Endolymphatic sac.
Labyrinthine fistula:
• Commonest site: Dome of the lateral semicircular canal.
• Features of nystagmus in the various fistulae.
• Lateral semicircular canal: Horizontal: towards the N ear.
• Superior semicircular canal: Rotatory: towards the N ear.
• Posterior semicircular canal: vertical
Petrositis: Infection of petrous apex air cells.
Gradenigo’s Syndrome (DDD)
• Diplopia (VI)
• Deep seated orbital pain (V)
• Persistent ear Discharge
Treatment: → Medical Treatment I/V antibiotic: followed by surgery.
Concept 3.3: Diseases of Inner Ear
Learning Objective: To Learn the Clinical Aspect of Infections of Inner Ear
Time Needed
1st reading 15 mins
2 look
nd
5 mins
Labyrinthitis
Three types of labyrinthitis:
• Circumscribed labyrinthitis
• Diffuse serous labyrinthitis
• Diffuse suppurative labyrinthitis
Circumscribed Labyrinthitis (Fistula of Labyrinth)

Horizontal semicircular canal.
Causes
1. Chronic suppurative otitis media with cholesteatoma is the most common cause.
2. Neoplasms of middle ear, e.g. carcinoma or glomus tumour.
3. Surgical or accidental trauma to labyrinth.
A part of membranous labyrinth is exposed and becomes sensitive to pressure changes.
Transient vertigo often induced by pressure on tragus
It is diagnosed by “fistula test” which can be performed in two ways.
1. Pressure on tragus.
2. Siegel’s speculum. When positive pressure is applied to ear canal, patient complains
of vertigo usually with nystagmus.
The quick component of nystagmus would be towards the affected ear
(ampullopetal displacement of cupula).
Ampullopetal flow of endolymph (as also ampullopetal displacement of
cupula) whether in rotation, caloric or fistula test causes nystagmus to same side.
If negative pressure is applied, again it would induce vertigo and nystagmus but
this time the quick component of nystagmus would be directed to the (opposite)
healthy side due to ampullofugal displacement of cupula.
Treatment
In chronic suppurative otitis media or cholesteatoma, mastoid exploration is often
required to eliminate the cause. Systemic antibiotic therapy should be instituted before
and after operation to prevent spread of infection into the labyrinth.
Diffuse Serous Labyrinthitis

It is diffuse intra labyrinthine inflammation without pus formation and is a reversible
condition if treated early.
Aetiology
1. Most often it arises from pre-existing circumscribed labyrinthitis associated with
chronic middle ear suppuration or cholesteatoma.
2. In acute infections of middle ear cleft, inflammation spreads through annular ligament
or the round window.
3. It can follow stapedectomy or fenestration operation.
Clinical features. Mild cases complain of vertigo and nausea but in severe cases,
vertigo is worse with marked nausea, vomiting and even spontaneous nystagmus.
Quick component of nystagmus is towards the affected ear.
As the inflammation is diffuse, cochlea is also affected with some degree of sensorineural
hearing loss.
Treatment
• Medical
1. Patient is put to bed, his head immobilized with affected ear above.
2. Antibacterial therapy is given in full doses to control infection.
3. Labyrinthine sedatives, e
4. Myringotomy
• Surgical. Cortical mastoidectomy (in acute mastoiditis) or modified radical
mastoidectomy (in chronic middle ear infection or cholesteatoma)
Diffuse Suppurative Labyrinthitis

Diffuse pyogenic infection of the labyrinth with permanent loss of vestibular/cochlear
functions.
Aetiology. It usually follows serous labyrinthitis, pyogenic organisms entering through
a pathological or surgical fistula.
Clinical features
• There is severe vertigo with nausea and vomiting due to acute vestibular failure.
• Spontaneous nystagmus will be observed with its quick component towards the
healthy side.
• Patient is markedly toxic.
• Relief from vertigo is seen after 3–6 weeks due to adaptation.
Treatment. It is same as for serous labyrinthitis.
Suppurative Labyrinthitis: 4 stages

1. Serous or irritative: Production of Ig rich exudates in the perilymph.
2. Acute or purulent: bacterial and leukocyte invation of the perilymphatic scala-end
organ necrosis.
3. Fibrous or latent: proliferation of fibroblasts and granulation tissue in the perilymph
4. Osseous or sclerotic: new bone deposition throughout the involved labyrinth.
Concept 3.4: Otosclerosis.
Learning Objective: To Learn the Clinical Concepts of Otosclerosis.
Time Needed
1st reading 10 mins
2 look
nd
5 mins
Otosclerosis (Otospongiosis)
Irregularly laid spongy bone replace dense enchondral layer of bony otic capsule.
Age of onset - 20 -30 years Paracusis Willisii Speech - Soft speech
Deafness - Usually B/L, painless, progressive
Deafness increases during pregnancy, menopause, after trauma or operation
May be associated with osteogenesis imperfecta (h/o multiple fractures)
Vander Hoeve Syndrome - Triad of O.I., blue sclera and deafness
1. Stapedial Otosclerosis
Anterior focus: Most common.
Posterior focus - Behind the oval window.
Circumferential - Around Stapes footplate margins.
Biscuit type - In the footplate but annular ligament free.
Obliterative type – Completely obliterates the oval window.
2. Cochlear Otosclerosis - Involves region of round window or other areas in the otic
capsule.
3. Histologic Otosclerosis – Asymptomatic.
Tinnitus - More commonly in cochlear otosclerosis and in active lesions.
Vertigo – Uncommon.
Signs:
Schwatze Sign Normal ET function
Negative Rinnie (BC > AC) Weber lateralized to worse ear
Carhart’s notch (loss at 2000 Hz)
ABC is normal but is reduced in cochlear otosclerosis Loss of air conduction more for lower frequencies
• Investigation of choice: Impedance audiometry (As graph).

• Surgical – Stapedotomy > Stapedectomy is the treatment of choice.
• Prosthesis employed - Teflon piston, stainless steel, tefwire or fat.
Medical Management:
• Sodium Fluoride
• Bisphosphonates
Concept 3.5: Meniere’s Disease
Learning Objective: To Learn the Clinical Concepts of Meniere’s Disease.
Time Needed
1st reading 20 mins
2 look
nd
10 mins
Meniere’s Disease (Endolymphatic Hydrops)

Non lethal Deafness (Fluctuating SNHL). Usually unilateral
Vertigo (Recurrent episodes).
Non - communicable Vertigo: Lasts for 24 minutes to
Tinnitus (Sudden onset).
24 hours
Aural fullness
35 - 60 yrs No focal neurological symptoms
Males > Females
• Diplacusis: A tone of one frequency appears normal in one ear and of higher pitch
in other ear.
• Recruitment - Patients of M.D. cannot tolerate amplification of sound.
• They are poor candidates for hearing aids.
Normal TM ABC is reduced Lower frequencies are affected.
Rinnie test +ve Hennebert’s Sign
Weber lateralized to better ear Tullio Phenomenon
• SISI and Tone decay test show the cochlear nature of disease (Differentiates it from
Acoustic neuroma).
• Electrocochleography: Best objective test.
Lermoyez Syndrome Here symptoms of MD are in reverse order.

1st there is deterioration of hearing followed by attack of vertigo, at
which time hearing recovers
Tumarkin’s otolithic catastrophes Drop attacks without associated autonomic or neurologic symptoms
in patients with severe vestibular disease, usually due to Meniere’s
disease.
Secondary M.D. Congenital/acquired syphilis (7%). Otosclerosis.

Leukaemia. Paget’s disease.
Post stapedectomy cases.
Treatment:
Surgical treatment - Used only when medical treatment fails.

1. Conservative procedures - in cases when vertigo is disabling but hearing is still
useful and needs to be preserved
Decompression of endolymphatic sac.
Endolymphatic shunt operation.
Sacculostomy.
Section of vestibular nerve.
2. Destructive procedure: Totally destroy cochlear and vestibular function.
Used only when cochlear function is not serviceable.
Labyrinthectomy
Concept 3.6: Tumors in Otology
Learning Objective: To Learn the Clinical Concepts of Tumors in Otology and
Management
Time Needed
1 reading
st
20 mins
2 look
nd
10 mins
Acoustic Neuroma (VIIIth nerve Schwannoma or Neurilemmoma)

Most Commonly Arise from the Inferior Division of the Vestibular Nerve.
Tumours may be:
• Intracanalicular (confined to internal auditory canal).
• Medium size (upto 2.5 cm diameter).
• Large size (> 2.5 cm).
Clinical features:
Progressive SNHL Tinnitus
Imbalance, true vertigo is rarely seen Marked difficulty in understanding speech
Vth nerve is the earliest nerve to be involved VIIth nerve Sensory fibers are affected first
Involvement of Vth nerve indicates tumor is 2.5 cm (approximately) in diameter and

occupies CP angle.
Investigations:
• PTA - SNHL more for higher frequencies (Rinnie, Weber, ABC).
• Speech discrimination is poor.
• Recruitment phenomenon is absent.
• Tone decay test shows retrocochlear type of lesion.
• Vestibular test: Diminished / absent response in 96% of patients.
• Radiological test - Plain X rays give +ve findings in 80% patients.
CT Scan: even 0.5 cm extension into posterior fossa can be detected.
Vertebral angiography: to differentiate from other tumors.
BERA: There is delay in wave V.
MRI: Superior to CT Scan (Intrameatal tumor can be diagnosed easily).
• Treatment: Surgical removal.
Glomus Tumor
Benign, non encapsulated Extremely vascular Most common benign
Arises from glomus bodies Seen in 40 - 50 years Females affected 5 times more
Locally invasive
Clinical features:
• Earliest symptoms are deafness and tinnitus (Pulsatile) (Synchronous with pulse).
• Conductive deafness.
• “Rising Sun” appearance - Red reflex through intact TM. Seen when tumor arises from
floor of middle ear.
• BROWN’S SIGN (blanching of the TM with positive pressure).
• Pulsation Sign is +ve.
• Vertigo and facial paralysis may appear.
• Audible bruit.
Investigations:
• Serum levels of catecholamines or their breakdown products in urine.
• Skull and mastoid Xray.
• CT Scan with enhancement.
• MRI.
• Angiography.
Treatment:
Surgical Radiation Embolisation
Carcinoma Middle Ear and Mastoid

Commonest primary middle ear malignancy
40 - 60 years More commonly in females SCC is the most common variety
Most cases (75%) have long standing ear discharge Seen in Radium Dial painters
LN involvement occurs late
Clinical features
• Chronic foul smelling discharge especially blood stained.
• Pain usually severe (at night).
• Facial palsy.
• Granulations / polyps.
• Increase in deafness / vertigo.
Diagnosis is made only on biopsy.
Treatment: Combination of Surgery and Radiotherapy.
Squamous Cell Carcinoma of Pinna

Site of predilection is helix Metastasis to LN occurs late
Painless nodule or ulcer In males in their fifties

Treatment
• Small lesions with no nodal metastasis - local excision with 1cm of healthy area.
• Large lesions / lesions within 1cm of EAC and lesions with nodal metastasis.
• Total amputation of pinna with removal of parotid gland and cervical lymph nodes.
Basal Cell Carcinoma of Pinna

Helix and tragus Nodule with central crust (bleeds on removal).
Men > 50 yrs In males in their fifties
Ulcer(raised or bladed end) May involve cartilage or bone
• Metastases usually do not occur.
• Treatment: Superficial lesions not involving cartilage – Radiation
WORKSHEET
MCQ OF “DISORDERS OF EAR” FROM DQB

Chronic Suppurative Otitis Media
Feature Tubotympanic Atticoantral
1. Discharge
2. Perforation
3. Polyps
4. Cholesteatoma
5. Complication
Features of Otosclerosis
Schwatze Sign
Rinnie
PTA\
ABC
ET function
Weber
Features of Meniere’s Disease
Lermoyez Syndrome
Tumarkin’s otolithic catastrophes
Secondary M.D.
IOC
Treatment of choice
Features of Acoustic Neuroma

4 High Yielding Topics of Ear
CONCEPTS
Â Concept 4.1 Assessment Of Vestibular Functions
Â Concept 4.2 Concepts Of Facial Nerve
Â Concept 4.3 Hearing Rehabilitation

Concept 4.1: Assessment of Vestibular Functions
Learning Objective: To Learn the Clinical Application of Vestibular Function Tests
Time Needed
1st reading 15 mins
2 look
nd
5 mins
Assessment of Vestibular Functions

Clinical tests
Sign/Symptom Peripheral Central
Direction of Nystagmus Unidirectional Fast phase

opposite to lesion Central Bi/
Unidirectional
Purely Horizontal Nystagmus Uncommon Common

without torsional component
Vertical or Purely Torsional Never Present May be Present

Nystagmus
Visual Fixation Inhibits vertigo and Nystagmus No change
Severity of Vertigo Marked Often Mild
Direction of Spin Towards fast phase Varied
Direction of Fall Towards slow phase Varied
Duration of Symptoms Finite, Recurrent episodes Chronic usually
Tinnitus/Deafness Often present Usually absent
Central Abnormalities None Common
A down beating vertical nystagmus is a sign of Arnold Chiari malformation.
Lab Tests
Vestibular function:
Fistula Test:
• Fistula test is positive in labyrinthine fistula. It is best seen using seigel speculum.
• It is false negative in fistula covered by cholesteatoma, fistula in a dead labyrinth
and an improper test.
• It is false positive in congenital syphilis and some cases of Meniere’s disease, superior
SCC dehiscence syndrome (Heinnebert sign).
• It is truly negative in a normal ear.
High Yielding Topics of Ear | 57
Caloric test (Induce nystagmus by thermal stimulation)
• Each labyrinth can be tested separately
• Modified Kobrak test - Seated with head tilted 60° backwards ( H C in vertical
position). Ice water for 60 seconds (5 ml, 10 ml, 20 ml and 40 ml)
• Fitzgerald - Hallpike test (Bithermal caloric test) - Lies supine, head tilted 30°
forward
• Irrigated for 40 seconds with H2O at 30° and 44° C
• Before labelling the labyrinth dead test is repeated with water at 20° C for 4 minutes.
• 5 minutes gap between two ears.
• COWS - Cold induces nystagmus to opposite side, Warm induces nystagmus to same
side.
Cold Air Caloric Test - Done in TM Perforation

DUNDAS GRANT TUBE Freezing ethyl chloride
Misc:
• Electronystagmography - Depends on the presence of corneo - restinal potentials
• Optokinetic Test - To diagnose a central lesion
• Rotation Test: Barany’s revolving chair with head tilted 30° forward f Rotated
• Nystagmus 25 – 40 seconds
• Galvanic Test: Only test to differentiate an end organ lesion from that of vestibular
nerve.
• Posturography
Benign Paroxysmal Positional Vertigo
Vertigo in certain head positions No hearing loss Posterior SCC
Epleys exercises are beneficial Hallpike Test Vertigo for few Secs
Vestibular Neuronitis
Usually self limiting Few days to 2 – 3 weeks Sudden onset
Virus affecting vestibular ganglion No cochlear symptoms
Perilymph Fistula
Intermittent vertigo and fluctuating
SNHL Tinnitus and sense of fullness Complications of stapedectomy
Concept 4.2: Concepts of Facial Nerve
Learning Objective: To Learn the Concepts of Facial Nerve
Time Needed
1st reading 30 mins
2 look
nd
15 mins
Facial Nerve
Mixed nerve
Motor root muscles of face which develop from 2nd branchial arch
Sensory Root (Nerve of Wrisberg) - carries secretomotor fibres to lacrimal, submandibular and sublingual
salivary gland
Fig.: Facial Nerve
Motor Nucleus - Situated in the PONS:

• The facial nerve originates from the facial motor nucleus, which lies in the lateral
portion of the anterior pons and is composed of four cell groups.
• The facial nerve hooks around the nucleus of the sixth cranial (abducens) nerve.
• As a result, brainstem lesions involving the seventh nerve also usually involve the
sixth nerve.
• Mobius Syndrome: Bilateral or unilateral facial and abducens nerve palsies.
Facial Nerve:
Intracranial Segment:
• Segment from brainstem to internal auditory canal (IAC).
Course of Facial Nerve
Fig.: Course of Facial Nurve
Intratemporal Segments:
Meatal:
• Segment from meatal foramen of the IAC to the fundus of IAC.
Meatal segment is ensheathed within an extension of the meninges.
Fig.: Internal Acoustic Meatus
Fig.: Internal Acoustic Meatus

• The lateral wall of the IAC is the lamina cribrosa, and the superior fundus is divided
vertically by Bill’s bar, a triangular strut of bone seen only on axial images.
• Facial nerve transverses in the anterior superior quadrant of the IAC separated by the
falciform crest inferiorly and Bill’s bar posteriorly.
1. Other quadrants:
Superior vestibular nerve [superior posterior].
Inferior vestibular nerve [inferior posterior].
The cochlear nerve [inferior anterior]
2. Labyrinthine:
Segment from fundus of IAC to geniculate ganglion.
Narrowest segment of the fallopian canal (0.68 mm diameter).
3. Tympanic (Horizontal segment):
Segment from geniculate ganglion to the second genu (inferior to the horizontal
canal).
Most common site of dehiscence (40–50%).
4. Mastoid (Vertical segment):
Segment from the second genu to the stylomastoid foramen.
The nervus intermedius (of Wrisberg) carries parasympathetic general visceral
efferents to the salivary and lacrimal glands, as well as special visceral afferent
fibers from the chorda and general sensory efferents from the external auditory
canal and postauricular area.
Facial Nerve Components:
Branchial Motor (Special visceral efferent):
• Premotor cortex—motor cortex— corticobulbar tract—bilateral facial nuclei (pons)—
muscles of facial expression.
• Fibers that innervate the forehead receive bilateral innervation from the upper
motor neurons and fibers that innervate the lower face receive contralateral fibers
only from the upper motor neurons.
• Also supplies stapedius (stapedial reflex), stylohyoid, posterior digastric, and
buccinator muscles
Parasympathetic (General visceral efferent):
• Submandibular and sublingual glands.
Sensory (General sensory afferent):
• Supplies sensation to the auricular concha, postauricular skin, wall of the EAC, and
part of the tympanic membrane.
• Cell bodies housed in the geniculate ganglion (also holds the cell bodies of the taste
fibers).
Taste (Special visceral afferent):
• Anterior 2⁄3rd of the tongue and hard and soft palate.
Facial Nerve Markers:
1. Tragal pointer: The facial nerve may be located 1 cm medial, inferior, and deep from
tragal cartilage.
2. Tympanomastoid suture line: The facial nerve is 6–8 mm deep to the inferior end
of the tympanomastoid suture line.
3. Digastric attachment to digastrics ridge: Identifies the plane of the facial nerve.
4. Retrograde dissection from distal branches: May be required in select cases.
5. Styloid foramen: Maidentify the main trunk.
Topodiagnostic Tests:
1. Schirmer’s test - Reduced lacrimation -lesion proximal to geniculate ganglion.
2. Stapedial reflex - Lost in lesions above nerve to Stapedius.
3. Taste test and submandibular salivary flow test - Impairment of taste and reduced
salivation indicate injury above the chorda.
Treatment: Reassurance, analgesics, care of eye, physiotherapy.
Steroids (Prednisolone drug of choice) prevent incidence of synthesizing crocodile
tears and to shorter the recovery time.
Surgical treatment: Decompression of the nerve in vertical and tympanic
segments.
• 85 - 90% of patients recover fully.
Melkersson’s Syndrome:
• Facial paralysis.
• Swelling of lips.
• Fissured tongue.
Treatment: Same as for Bell’s.
Frey’s Syndrome:
Gustatory sweating: There is sweating and flushing of skin over the parotid during
mastication.
Results from Parotid Surgery:
• Crocodile tears: Gustatory lacrimation.
• Unilateral lacrimation with mastication.
• Faulty regeneration of parasymathetic fibers which now supply lacrimal gland instead
of salivary gland.
• Section of Greater superficial petrosal nerve.
• Tympanic neurectomy.
Bell’s Palsy
• The most common form of facial paralysis is Bell’s palsy..
Clinical Manifestations:
• The onset of Bell’s palsy is fairly abrupt, maximal weakness being attained by 48
hours as a general rule.
• Pain behind the ear may precede the paralysis for a day or two.
• Taste sensation may be lost unilaterally, and hyperacusis may be present.
Pathophysiology:
• Bell’s palsy is associated with the presence of Herpes simplex virus (HSV) type 1 DNA
in endoneural fluid and posterior auricular muscle, suggesting that a reactivation of
this virus in the geniculate ganglion may be responsible. However, a causal role for
HSV in Bell’s palsy is unproven.
Laboratory evaluation:
• The diagnosis of Bell’s palsy can usually be made clinically in patients with (1) a
typical presentation, (2) no risk factors or preexisting symptoms for other causes of
facial paralysis, (3) absence of cutaneous lesions of herpes zoster in the external ear
canal, and (4) a normal neurologic examination with the exception of the facial nerve.
Treatment:
• Symptomatic measures include (1) the use of paper tape to depress the upper
eyelid during sleep and prevent corneal drying, and (2) massage of the weakened
muscles.
• A course of glucocorticoids, given as prednisone 60–80 mg daily during the first 5
days and then tapered over the next 5 days, appears to shorten the recovery period
and modestly improve the functional outcome.
• A recently published randomized trial found no added benefit of acyclovir (400 mg
five times daily for 10 days) compared to prednisolone alone for treatment of acute
Bell’s palsy; the value of valacyclovir (usual dose 1000 mg daily for 5–7 days) either
alone or in combination with glucocorticoids is not known.
Concept 4.3: Hearing Rehabilitation
Learning Objective: To Learn the Importance of Hearing Rehabilitation
Time Needed
1st reading 20 mins
2 look
nd
10 mins
Hearing Aids
BTE CIC
ITE BAHA
Bone-Anchored Hearing Aid:

• The device is composed of three main parts: a titanium implant, an external abutment,
and a sound processor.
• The titanium prosthesis is surgically embedded into the skull with a small abutment
exposed outside the skin.
• BAHA- Bone- Anchored Hearing Aid will be given to hearing impaired individuals
where conventional hearing aids can not be given, like in bilateral anotia, EAC atresia,
discharging ear, EAC stenosis. Its is a specialised device which is surgically fitted
partly on to mastoid bone.
Cochlear Implants
• Are electronic devices which convert sound signals into electrical impulses, this in
turn stimulates the cochlear nerve directly by pressing the hair cells of cochlea.
Components:
• Microphone – picks up acoustic signals.
• Speech processor – converts sound signals into electrical energy.
• Electrode – Stimulates the cochlear nerve.
Electrode is placed in Scala Tympani best Candidate is post Lingually Deaf Patient Multiple Channel
Implant is better than Single Channel Implant
Criteria for adults:

(a) Age: 18 years or more.
(b) Bilateral severe to profound hearing loss.
(c) Limited or no benefit from hearing aids.
(d) No medical contraindication to undergo surgery.
Post–lingually deafened adults are good candidates. Results are not so good in
pre-lingually deaf adults unless they had been receiving aural- oral training for
communication.
Criteria for Children:
• Auditory deprivation, i.e. lack of auditory stimulus in the early developmental period
causes degenerative changes in central auditory pathways. An early auditory
stimulation by cochlear implants can prevent it. Now implants can be used at an age
as early as 12 months.
The criteria are:
• Bilateral profound or severe to profound hearing loss.
• Minimal or no benefit from hearing aid.
• No medical contraindication.
• Willingness and support of family to enrol the child for post-implant training
programme.
Intracochlear placement of the electrode(s) into the scala tympani is superior
to extracochlear placement over the promontory or round window.
Brain Stem Implants: Lateral Recess of IV Ventricle

Extra Edge:
• Julius Lempert is the father of modern otology.
• John Shea did the first stapedectomy.
• William House is the father of neurotology.
• Dr Hayes Martin is the father of Head and Neck Surgery.
• Travelling theory of hearing was given by Von Bekesy.
Temporal Bone Fractures

Longitudinal Transverse
Frequency More common
Type of injury Parietal blow Occipital blow
Fracture line Parallel to the long axis of petrous Runs across the petrous pyramid, Start at
pyramid,starts at squamous part of foramen magnum or jugular foramen
temporal bone to end at foramen lacerum.
Bleeding ear Common -
CSF rhinorrhoea Present -
Structure injured Tegmen, ossicles, TM Labyrinth
Hearing loss Conductive SN
Vertigo Less
Facila paralysis. Less
WORKSHEET
MCQ OF “HIGH YIELDING TOPICS OF EAR” FROM DQB

Assessment of Vestibular Functions
Nystagmus
Peripheral Central
Temporal Bone Fractures

Longitudinal Transverse
Frequency
Type of injury
Fracture line
Bleeding ear
CSF rhinorrhoea
Structure injured
Hearing loss
Vertigo
Facila paralysis.
N X
RY
LA
5 Anatomy of Larynx
CONCEPTS
Â Concept 5.1 Clinical Anatomy of Larynx
Concept 5.1: Clinical Anatomy of External Ear
Learning Objective: To Learn the Applied Anatomy of Larynx
Time Needed
1st reading 30 mins
2 look
nd
15 mins
Laryngeal Cartilages:
The larynx is a tubular structure that has 3 paired and 3 unpaired cartilages.
Unpaired: Thyroid, Cricoid and Epiglottis Paired: Arytenoids, Cuneiform (of Wrisberg)
and Corniculate (of Santorini)
• Only complete cartilage in whole trachea- bronchial tree: Cricoid.
• Epiglottis - leaf like yellow elastic cartilage.
• Thyroid - Largest of all the cartilages: Its two alae meet anteriorly forming an angle
of 90° in males and 120° in females
VC are attached to the middle of thyroid angle.
Most of laryngeal foreign bodies are arrested above the vocal cords.
In males In females
Length 44 mm 36 mm
Transverse diameter 43 mm 41 mm
Antero-posterior diameter 36 mm 26 mm
Circumference 136 mm 112 mm

Fig.: Laryngeal joints (cricoarytenoid, cricothyroid) - Synovial joints
Thyrohyoid membrane-is pierced by superior laryngeal vessels and internal laryngeal nerve.
Cricovocal Membrane
Fibroelastic membrane
Upper border forms the vocal ligament
Anteriorly meets with its fellow to form the conus elasticus.
Quadrangular membrane
Anatomy of Larynx | 73
Paraglottic Space
Pre - Epiglottic Space (Space of Boyer):

Superior Border: Hyoepiglottic ligament
Anterior Border: Thyrohyoid membrane and ligament
Posterior Border: anterior surface of the epiglottis and thyroepiglottic ligament
Pre-Epiglottic Space

Structure of Vocal Cord
Larynx- Sagittal section (anterior on the right)
Changes seen in vocal cords with age:
• The superficial layer of the lamina propria becomes oedematous and thicker.
• Elastic fibres in the intermediate layer- atrophy.
• Collagenous fibres of the deep layer become denser.
• Vocalis muscle atrophy.
Glottis (Rima Glottidis):

• Is the elongated space between vocal cords anteriorly and arytenoids posteriorly.
• Antero - posteriorly it is about 24 mm in men and 16 mm in women.
• It is the narrowest part of laryngeal cavity.
• Anterior 2/3rd of VC are membranous and posterior 1/3rd cartilaginous.
• Epithelium is ciliated columnar type except over the VC and upper part of the
vestibule where it is stratified squamous type.
• There are no mucous glands in the vocal folds.
Lymphatic Drainage
Supraglottic larynx Lymphatics which pierce the thyrohyoid membrane and go to upper deep cervical
Infraglottic larynx lymphatics which pierce the cricothyroid membrane and go to prelaryngeal and
pretracheal nodes and then to lower deep cervical and mediastinal nodes
There are NO lymphatics in VC hence carcinoma of this site rarely shows lymphatic metastases.
Reinke’s Space - Under the epithelium of VC is a potential space with scanty subepithelial
connective tissue.
Difference between Adult and Child’s Larynx:
Infant Adult:
• Position High C2-C3 low placed C4-5
• Narrowest part Subglottis Glottis
• Submucosal loose connective tissue Lax and abundant Very less loose
WORKSHEET
MCQ OF “ANATOMY OF LARYNX” FROM DQB

In males In females
Length
Transverse diameter
Antero-posterior diameter
Circumference
Lymphatic Drainage
Supraglottic larynx
Infraglottic larynx
Difference between Adult and Child’s Larynx:

Infant Adult:
• Position
• Narrowest part
• Submucosal loose
connective tissue
6 Disorders of Larynx
CONCEPTS
Â Concept 6.1 Congenital Lesions of Larynx
Â Concept 6.2 Types of Stridor
Â Concept 6.3 Acute and Chronic Inflammation of

Larynx
Â Concept 6.4 Vocal Cord Paralysis

Concept 6.1: Congenital Lesions of Larynx
Learning Objective: To Learn Different Types of Congenital Lesions of Larynx and Their
Management
Time Needed
1 reading
st
15 mins
2 look
nd
5 mins
Laryngomalacia
Intermittent inspiratory stridor that improves in
prone position
Worse with feeding Crying or when placed
on back
Presents within weeks of Normal voice
birth
• Most common laryngeal anomaly.

• Most common cause of stridor in neonate and chronic pediatric stridor.
• Approximately 15% associated with secondary airway lesions.
Pathophysiology: Immature cartilage, abnormal calcium metabolism.
Symptoms
• Usually self-limiting as cartilage stiffens with growth.
• If severe symptoms : Supraglottoplasty
Congenital Webs
Disorders of Larynx | 81
Most commonly anteriorly based

Types: supraglottic (2%), glottic (75%), subglottic (7%)
Incomplete recanalization at 8th week of embryological development
• Symptoms: weak cry at birth, aphonia, and variable degrees of respiratory obstruction
(inspiratory stridor).
• Diagnosis: flexible nasopharyngoscopy, direct laryngoscopy.
• Treatment: endoscopic lysis if >50% (laser excision), consider keel or open procedure
for extensive involvement, may require tracheostomy.
Congenital Subglottic Stenosis

• <4 mm in newborn.
• Pathophysiology: Incomplete recanalization, small diameter cricoid cartilage, or
trapped first tracheal ring.
Types:
• Membranous: Circumferential, thickened mucous glands or fibrous tissue
• Cartilaginous: Abnormal shelf on cricoid or a trapped 1st tracheal ring
• Mixed:
Grades: I. <50% obstruction, II. 51–70%, III. 71–99%, IV. Complete obstruction
Features: Biphasic stridor in first few months of life, may mimic croup or recurrent
URI, failure to thrive.
Diagnosis: Endoscopy, chest X-ray, neck plain films, flexible nasopharyngoscopy
to assess vocal fold motion.
Management:
Secure Airway: May require tracheotomy (decannulation by 2–3 years of age).
Medical Management: Reflux regimen, may consider corticosteroids.
Grade I–II:
• Consider endoscopic management (CO2 or KTP laser excision with dilation).
• Contraindications to endoscopic procedure include significant cartilage loss,
concurrent laryngotracheal stenosis, posterior commissure involvement,
circumferential cicatricial scar or thick scar (>1 cm), and infected tissue (chondritis).
Grade III–IV:
Open procedures: Indicated for Grade III–IV or when endoscopic management is
contraindicated.
Concept 6.2: Types of Stridor
Learning Objective: To Learn Site of Obstruction by Description of Upper Airway Sound
Time Needed
1st reading 10 mins
2 look
nd
5 mins
Description of Upper Airway Sound by Site of Obstruction

• Nasopharyngeal: Snoring, no cough.
• Oropharynx: Gurgly.
• Supraglottic: Inspiratory stridor, throaty voice, feeding problems.
• Glottic: Inspiratory or biphasic stridor, hoarseness.
• Subglottic: Husky voice, biphasic stridor, barking cough.
• Tracheobronchial: Expiratory stridor, wheezing, suprasternal retraction indicate obstruction above
thoracic inlet.
Types of Stridor and Probable Site of Obstruction
Extra Edge
Laryngo Tracheal Trauma:
• The supraglottis is less dependent on external support and contains abundant soft
tissue and redundant mucosa.
• The subglottis is supported by the only circular cartilage in the larynx, the cricoid,
which is the narrowest point of the neonatal and infant airways.
• Laryngeal fractures are common after 40 years of age (because of calcification of
laryngeal frame work).
Concept 6.3: Acute and Chronic Inflammation of Larynx
Learning Objective: To Learn Etiology of Laryngeal Infections
Time Needed
1st reading 20 mins
2 look
nd
10 mins
Acute Laryngotracheobronchitis Acute Epiglottitis
Pathogen Parainfluenza virus 1 Streptococcus

Age <5 years old 2-6 years old
Location Subglottic Suppraglottic
Onset Gradual (days) Sudden onset (hours)
Cough barky normal
Posture supine upright
Drooling no yes
Fever low grade high fever
Radiographs steeple sign thumb printing
Treatment supportive airway management and antibiotics
Laryngeal Diphtheria
• Children below 10 years of age.
• Laryngeal Symptoms: Hoarse voice, croupy cough, inspiratory stridor, increasing
dyspnoea with marked upper airway obstruction.
• Cervical lymphadenopathy: Characteristic “bull - neck” may be seen.
Tuberculosis of Larynx
C/F:
• Weakness of voice is the earliest symptom followed by hoarseness.
• Ulceration in larynx gives rise to severe pain (may radiate to ear).
• Hyperemia of VC with impairment of adduction is the first sign.
• Ulceration of VC - mouse nibbled appearance.
• Pseudoedema of epiglottis (red and swollen) - Turban epiglottis
Lupus of Larynx
• Indolent tubercular infection.
• Affects anterior part of larynx.
• Painless and often asymptomatic.
Syphilis of Larynx
• Only gumma of tertiary stage is sometimes seen.
REINKE’S EDEMA
Concept 6.4: Vocal Cord Paralysis
Learning Objective: To Learn The Concept Of Vocal Cord Paralysis And It’s Management
Time Needed
1st reading 30 mins
2 look
nd
15 mins
Laryngeal Innervation
• Right recurrent laryngeal nerve arises from the vagus at the level of subclavian artery.
• Left recurrent laryngeal nerve arises at the level of arch of aorta.
• Left recurrent laryngeal nerve is more prone to paralysis.
• Superior laryngeal nerve: Arises from inferior ganglion of the vagus.Divides into
external and internal branches at the level of greater cornua of hyoid bone.
About 30% of cases are idiopathic.

Vocal Cord Paralysis:
Semon’s law:
• This theory was proposed by Rosenbach and Semon in 1881.
• Law is stated as “In the course of a gradually progressing organic lesion involving
the recurrent laryngeal nerve three stages can be observed. In the first stage, only
the abductor fibers are damaged, the vocal folds approximate in the midline and
adduction is still possible. In the second stage, the additional contracture of adductors
occur so that the vocal folds are immobilized in the median position. In the third stage,
the adductors become paralysed and the vocal folds assume a cadaveric position”.
Wagner and Grossman Theory:
• This is the most popular and widely accepted theory which could account for the
varying positions assumed by a paralysed vocal cord. This theory was first proposed
by Wagner and Grossman (1897). This theory states that in complete paralysis of
recurrent laryngeal nerve, the cord lies in the paramedian position because the
intact cricothyroid muscle adducts the cord. (Because the superior laryngeal nerve is
intact).
PPP Rule (Posterior Commissure Points to Paralyzed Side in Unilateral

Superior Laryngeal Nerve Paralysis)
Position of cords Location of V.C. Healthy Diseased
from midline
Median Midline Phonation RLN palsy
Paramedian 1.5 mm Strong whisper RLN palsy
Intermediate 3.5 mm RLN and SLN
Gentle abduction 7 mm Quiet respiration Paralysis of adductors
Full abduction 9.5 mm Deep inspiration Paralysis of adductors
Palsy Symptoms Treatment

URLNP Mild voice change NO
BRLNP Dyspnoea and stridor Tracheostomy or lateralization
USLNP Low pitch voice (Cricothyroid) Depending on symptoms
Anaesthesia of one side
BSLNP Aspiration Tracheostomy or epiglottopexy
UCP Hoarseness, aspiration Medialisation
BCP Aphonia, aspiration, inability to cough Tracheostomy or epiglottopexy
Lateralisation • Arytenoidectomy
• Lateralisation via endoscope
• Thyroplasty Type II
• Cordectomy
• Nerve Muscle Implant (Sternohyoid)
Medialisation • Injection of Teflon
• Thyroplasty Type I
• Muscle or cartilage implant
• Arthrodesis of cricoarytenoid joint
Thyroplasty:
Type I:
• Indicated for membranous vocal fold defects resulting in breathy dysphonia or
aspiration.
• Medializes vocal fold by inward lateral compression with an implant (silastic, gortex,
hydroxyapatite) placed via a window in the thyroid cartilage.
Type II:
• Lateral expansion (thyroid cartilage split with graft placed to widen anteriorly by
lateralizing the vocal folds).
Type III:
• Indicated to lower vocal pitch or address adductor spasmodic dysphonia by shortening
and relaxing vocal folds.
Type IV:
• Indicated to increase vocal pitch by lengthening and tensing vocal folds.
Reinnervation Procedures
Indications: UNILATERAL permanent vocal fold paralysis.
Advantages: Maintains muscle tone, no foreign body reaction, best preservation of
mucosal wave, most physiologic.
Disadvantage: Does not result in active ADduction and ABduction, long operative time,
delayed results (up to 6 months), high technical skill, may require a Gelfoam injection
until reinnervation becomes effective.
ANSA CERVICALIS nerve has similar fiber composition (myelinated versus
unmyelinated) to the RLN making it compatible for RLN grafting.
Voice Abnormalities
1. Dysphonia plica ventricularis (Ventricular dysphonia): Voice is produced by
false cord (Ventricular folds).
2. Functional aphonia (Hysterical aphonia): Females emotionally labile, 15 – 30
years.
3. Puberphonia (Mutational falsetto voice): Gutzmann’s pressure test - Pressing the
thyroid prominence in backward and downward direction relaxes the overstretched
cords and low tone voice can be produced.
4. Phonasthenia: Weakness of voice due to fatigue of phonatory muscle.
I/L shows three characteristic findings:
• Elliptical space between the cords (weakness of thyroarytenoid).
• Triangular gap near posterior commissure (weakness of inter arytenoid).
• Key hole appearance of glottis (when both are involved).
WORKSHEET
MCQ OF “DISORDERS OF LARYNX” FROM DQB

Description of Upper Airway Sound by Site of Obstruction
Nasopharyngeal
Oropharynx
Supraglottic
Glottic
Subglottic
Tracheobronchial
Acute Laryngotra- cheobronchitis (CROUP) Acute Epiglottitis

Pathogen
Age
Location
Onset
Cough
Posture
Drooling
Fever
Radiographs
Treatment
Position of cords Location of V.C. Healthy Diseased

from midline
Median
Paramedian
Intermediate
Gentle abduction
Full abduction
Palsy Symptoms Treatment

URLNP
BRLNP
USLNP
BSLNP
UCP
BCP
7 Tumors of Larynx and
Their Management
CONCEPTS
Â Concept 7.1 Benign Lesions
Â Concept 7.2 Carcinoma Larynx

Concept 7.1: Benign Lesions
Learning Objective: To Learn Different types of Benign Lesions and their Management
Time Needed
1st reading 15 mins
2 look
nd
5 mins
Non-neoplastic Neoplastic
Solid Squamous papilloma
▫ Vocal nodules ▫ Juvenile type
▫ Vocal polyp ▫ Adult-onset type
▫ Reinke’s oedema Chondroma
▫ Contact ulcer/granuloma Haemangioma
▫ Intubation granuloma Granular cell tumours
▫ Leukoplakia Glandular tumours, e.g.
▫ Amyloid tumours ▫ Pleomorphic adenoma
Cystic ▫ Oncocytoma
▫ Ductal cysts Neurilemmoma
▫ Saccular cysts Neurilemmoma
▫ Laryngocele Rhabdomyoma
Lipoma
Solid Non neoplastic lesions

1. Vocal nodules (Singer’s or Screamer’s nodes): Appear symmetrically or free edge of
VC.
2. Vocal Polyp: Usually unilateral, same position as vocal nodule, Surgery
Tumors of Larynx and Their Management | 93
3. Contact Ulcer: Due to faulty voice production.
4. Intubation granuloma:
Cystic Lesions
They are of 3 types:
• Ductal cysts: Most often they are retention cysts (seromucinous duct).
Asymptomatic if small.
If large, causes hoarseness, cough, throat pain and dyspnea.
• Saccular cyst: Obstruction to the orifice of saccule.
Presents as cyst in ventricle.
• Laryngocele:
An air filled cystic swelling due to dilatation of saccule.
Lined by columnar ciliated epithelium whereas simple laryngeal cysts are lined by
squamous epithelium.
Internal laryngocele is confined within the larynx
External laryngocele (30%)-saccule herniates through thyrohyoid membrane
External laryngocele presents as a reducible swelling which increases in size on
coughing or performing Valsalva.
Trumpet players, glass blowers, weight lifters (#transglottic pressure).
Hoarseness, cough, stridor, dysphagia, sore throat, pain snoring.
• Treatment: Surgical excision.
A laryngocele in an adult may be associated with carcinoma or papilloma larynx.
Recurrent Respiratory Papillomatosis

• Second most common cause of hoarseness in children.
• 2/3rd present before the age of 15, usually regresses by puberty.
• Higher risk in adults and with HPV types16 and 18.
Papillomatosis
Juvenile Senile
Multiple sites of involvement Single site
Recurrent, may resolve spontaneously Recurrence less common
First presents with hoarseness, then inspiratory or biphasic stridor, dyspnea,

dysphagia.
Management:
• Microlaryngoscopy with Laser Excision: Frequent conservative endoscopic CO2 laser
ablation (biopsy to evaluate for malignancy).
• Avoid Tracheotomy, may seed lower airway or stoma.
Chondromas
• More common in men.
• Most commonly arise from internal posterior cricoid cartilage (hyaline cartilage),
may also arise from thyroid, arytenoid,epiglottic cartilage (fibroelastic).
• Insidious hoarseness from vocal fold restriction, dyspnea for subglottic lesions,
dysphagia for posterior cricoid lesions, globus sensation.
• Diagnosis: endoscopic wedge biopsy,
• CT of neck (calcification).
• Treatment: complete excision via an endoscopic or external approach (depending
on the size of lesion).
Granular Cell Tumor

• 3% risk of malignant degeneration.
• Arise from Schwann cells in the posterior aspect of true vocal fold or arytenoids.
• C/F: Insidious hoarseness.
• Lesion: Small, sessile, gray mass.
• Diagnosis: Endoscopy with biopsy.
• Treatment: Complete excision via an endoscopic or external approach
Hemangioma
• Most Common Head and Neck neoplasm in children.
• Typically presents by 6 months old, then involutes by 2 years of age.
• Most common laryngeal site: Left posterior lateral quadrant of subglottis
(although may appear anywhere in upper respiratory tract).
• 50% of subglottic hemangiomas are associated with cutaneous involvement.
Sarcoidosis
• Laryngeal features: Supraglottic submucosal mass (epiglottis most common),
dysphonia, globus sensation, dyspnea.
• Treatment: Endoscopic removal for symptomatic lesions (hoarseness or airway
obstruction), may consider corticosteroids for significant exacerbations.
Wegener’s Granulomatosis
• Most commonly involves the subglottis.
• Laryngeal features: Subglottic mass, dyspnea, biphasic stridor.
• Treatment: Endoscopic removal for symptomatic lesions, medical management.
Amyloidosis
• Laryngeal features: Anterior subglottic mass (polypoidal covered with smooth
mucosa).
• Treatment: Endoscopic removal for symptomatic lesions (hoarseness or airway
obstruction).
Concept 7.2: Carcinoma Larynx
Learning Objective: To learn different types of Carcinoma Larynx and their Management
Time Needed
1st reading 20 mins
2 look
nd
10 mins
Regions of the Larynx

Supraglottis - Epiglottis, Aryepiglottic folds, arytenoids, ventricular bands, ventricles
and saccule.
Subglottis - Walls of subglottis upto the lower border of cricoid cartilage.
Glottis - True VC, Anterior and Posterior commissures.
Glottis extends from the horizontal plane passing through apex of ventricle to 1 cm
below it.
Appearance of lesion
1. Lesions of suprahyoid epiglottis are usually exophytic.
2. Lesions of infrahyoid epiglottis are usually ulcerative.
3. Lesions of VC - raised nodule, ulcer or thickening.
4. Lesions of anterior commissure - granulation tissue.
5. Lesions of subglottic region - raised submucosal nodule (mostly involving anterior
half).
TNM Classification
1TX Primary tumor cannot be assessed.
T0 No evidence of primary tumor.
Tis Carcinoma in situ.
Supraglottis
T1 Tumor limited to one subsite of supraglottis with normal vocal cord mobility.
T2 Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside
the supraglottis (e.g. mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without
fixation of the larynx.
T3 Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid
area, pre-epiglottic space, paraglottic space, and/or inner cortex of thyroid cartilage.
T4a Moderately advanced local disease.
Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea,
soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or
esophagus).
T4b Very advanced local disease.
Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
Glottis
T1 Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal
mobility.
T1a Tumor limited to one vocal cord.
T1b Tumor involves both vocal cords.
T2 Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility.
T3 Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or
inner cortex of the thyroid cartilage.
Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond
the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap
muscles, thyroid, or esophagus).
Tumor invades prevertebral space, encases carotid artery or invades mediastinal structures.
Subglottis
T1 Tumor limited to the subglottis.
T2 Tumor extends to vocal cord(s) with normal or impaired mobility.
T3 Tumor limited to larynx with vocal cord fixation.
Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea,
soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or
esophagus).
Tumor invades prevertebral space, encases carotid artery or invades mediastinal structures.
Treatment
• Radiotherapy
• Surgery
(a) Conservation laryngeal surgery
(b) Total laryngectomy
• Combined therapy.
• Endoscopic CO2 laser excision
Radiotherapy.
• Cancer of the vocal cord.
• Superficial exophytic lesions, especially of the tip of epiglottis, and aryepiglottic folds.
Total laryngectomy is indicated in the following conditions:
• T3 lesions (i.e. with cord fixed)
• All T4 lesions
• Invasion of thyroid or cricoid cartilage
• Bilateral arytenoid cartilage involvement
• Lesions of posterior commissure
• Failure after radiotherapy or conservation surgery
• Transglottic cancers, i.e. tumours involving supraglottis and glottis across the
ventricle, causing fixation of the vocal cord.
Total Laryngectomy is Contraindicated in PTS with distant metastasis.
Vocal Rehabilitation after total Laryngectomy

• Oesophageal speech.
• Electrolarynx.
• Tracheo-oesophageal speech.
Tracheostomy
• The term tracheotomy refers to the formation of a surgical opening in the trachea. It
refers strictly to a temporary procedure.
• Tracheostomy on the other hand refers to the creation of a permanent stoma
between the trachea and the cervical skin.
Indications of Tracheostomy:
The indications fall into five broad categories, with some overlap between
them:
• Mechanical obstruction of the upper airways.
• Protection of tracheobronchial tree in patients at risk of aspiration.
• Respiratory failure.
• Retention of bronchial secretions.
• Elective tracheostomy e.g. during a major head and neck surgery, a tracheostomy
can provide/improve surgical access and facilitate ventilation.
Significant Benefits:
• The advantages of a tracheostomy tube are that they reduce the upper airway dead
space by up to 150 ml (50%). This means that there is a significantly reduced effort
in breathing compared to the naso- or oropharyngeal route.
Types of Tracheostomy:
Emergency tracheostomy:
• Airway obstruction is complete or almost complete.
• Usually vertical incision is given.
Elective tracheostomy:
• Transverse incision, 5 cm long, given 2 fingers above the sternal notch (cosmetically
better scar).
Endotracheal intubation:
• Securing an airway by passing an endotracheal (ET) tube via the oro- or nasotracheal
route is the most commonly used method.
• The ET tubes cause trauma to the upper airways and larynx.
• However, in prolonged intubation (2–3weeks), there may be serious complications,
with long-term laryngeal injuries.
Transtracheal needle ventilation:
• This method is used to rapidly obtain a surgical airway after failed mask ventilation
and endotracheal intubation.
• A 12 to 14-gauge (16 to 18-gauge in children), plastic sheathed intravenous cannula
is pushed into the tracheal lumen via the cricothyroid ligament.
• In the midline, the cricothyroid ligament is a very safe route to the airway as there
are usually no structures between the skin and the ligament.
• This area is therefore referred to as a bloodless field.
• This method of ventilation can be used for up to 45 minutes, buying sufficient time to
convert to a more definitive surgical airway.
• This technique is hazardous for patients with total upper airway obstruction as the
lack of air exit may result in a pneumothorax.
Cricothyroidotomy (Minitracheostomy, Laryngotomy):
• In this procedure, a scalpel blade is used to incise the cricothyroid ligament
and the blade is then turned through 90 degrees to hold the wound open while a small
endotracheal or minitracheostomy tube is inserted into the trachea.
• This is extremely effective in the emergency situation and the patient can be ventilated
for up to 24–48 hrs with this tube in situ.
• If ventilation is needed for longer, then the cricothyroidotomy should be converted
to a formal tracheostomy as there is an increased risk of subglottic laryngeal stenosis
and voice problems.
• The procedure is contraindicated in children under 12 years because of the
risk of damage to the cricoid cartilage in younger children.
Tracheostomy:
• This is the definitive surgical airway.
• First tracheotomy change may be considered after 3–5 days to allow the tract to form.
WORKSHEET
MCQ OF “TUMORS OF LARYNX AND THEIR MANAGEMENT” FROM DQB

Papillomatosis
Juvenile Senile
TNM Classification
1TX Primary tumor cannot be assessed.
T0
Tis
Supraglottis
T1
T2
T3
T4a
T4b
Glottis
T1
T1a
T1b
T2
T3
T4a
T4b
Subglottis
T1
T2
T3
T4a
T4b
G Y
L O
NO
H I
R
8 Applied Clinical Anatomy
in Rhinology
CONCEPTS
Â Concept 8.1 Clinical Anatomy of Nose
Â Concept 8.2 Clinical Anatomy of Paranasal

Sinuses
Concept 8.1: Clinical Anatomy of Nose
Learning Objective: To Learn the Clinical Applied Anatomy of Nose
Time Needed
1st reading 20 mins
2 look
nd
10 mins
(Nose and Paranasal Sinuses)

Anatomical Aspects:
External Nose:
This is pyramidal in shape and is made up of:
2 nasal bones+2 nasal processes of frontal bones+2 frontal processes of maxilla
Fig.: Nasal Anatomy
Cartilaginous part: Nasal Septum:

• Upper lateral cartilages Parts:
• Lower lateral cartilages
(Alar Cartilages)
Two parts:
• Lateral: nasal ala
• Medical crura: columella
• Lower Alar (Sesamoid) Cartilages
Fig.: Nasal Septum

Applied Clinical Anatomy in Rhinology | 109
Major contributions to septum:
• Septal cartilage.
• Vomer.
• Perpendicular plate of ethmoid.
Minor contributions to septum:
• Nasal spine of frontal bone.
• Maxillary spine.
• Rostrum of sphenoid.
• Crests of maxillary and palatine bones.
Blood Supply of The Nasal Septum:
• The arterial supply to the nasal cavity is from the branches of the maxillary artery,
one of the terminal branches of the external carotid artery.
• The most important branch is the sphenopalatine artery.
• The sphenopalatine artery anastomoses with the septal branch of the superior labial
branch of the facial artery in the region of the vestibule.
• The submucous venous plexus is drained by veins that accompany the arteries.
Lateral Nasal Wall:
• Each half of the nasal cavity has a floor, a roof, a lateral wall, and a medial or septal
wall.
• The floor is formed by palatine process of the maxilla and the horizontal plate of the
palatine bone.
• The roof is narrow and is formed anteriorly beneath the bridge of the nose by the
nasal and frontal bones.
• In the middle, by the cribriform plate of the ethmoid, located beneath the anterior
cranial fossa.
• Posteriorly, by the downward sloping body of the sphenoid.
• The lateral wall has three projections of bone called the superior, middle, and inferior
nasal conchae.
• The space below each concha is called a meatus.
Inferior meatus Naso-Lacrimal duct.
Middle meatus Maxillary,Frontal,Few ethmoidal air cells.
Superior Meatus It receives the openings of the posterior ethmoid sinuses.
Sphenoethmoidal recess It receives the opening of the sphenoid air sinus.
Nerve Supply of Nasal Cavity:

• Olfactory Nerves.
• Autonomic nerves (secretomotor), vidian nerve (of pterygoid canal).
Nerves of common sensation: anterior ethmoidal, sphenopalatine ganglion branches,
infraorbital nerve branches.
Nerve Supply of Nasal Cavity
Nasal Valves:
External Nasal Valve (Nasal vestibule):
• Anterior nostril (nasal alar cartilage, columella, and nasal sill).
• Internal Nasal Valve (Limen nasi):
• Bordered by septum, anterior edge of the inferior turbinate and caudal edge of upper
lateral cartilage.
• Narrowest segment (50% of total nasal resistance).
Concept 8.2: Clinical Anatomy of Paranasal Sinuses
Learning Objective: To Learn the Clinical Applied Anatomy of Paranasal Sinuses
Time Needed
1st reading 20 mins
2 look
nd
10 mins
Lateral Nasal Wall
Uncinate process The uncinate process is a wing or boomerang shaped piece of bone. It forms
the first layer or lamella of the middle meatus. It attaches anteriorly to the
posterior edge of the lacrimal bone, and inferiorly to the superior edge
of the inferior turbinate. Superior attachment of the uncinate process is
highly variable, may be attached to the lamina papyracea, or the roof of the
ethmoidal sinus, or sometimes to the middle turbinate
Bulla ethmoidalis The ethmoid bulla, also known as bulla ethmoidalis, is the largest and most
consistent air cell of the anterior ethmoid air cells.
Hiatus semilunaris The ethmoid bulla, also known as bulla ethmoidalis, is the largest and most
consistent air cell of the anterior ethmoid air cells.
Ethmoidal infundibulum 3-D structure in deep part of hiatus semilunaris, frontal sinus, maxillary and
the anterior ethmoids drain into it.
Haller cell Is a variation of anterior ethmoid air cells and they lie in relation to orbital
floor.
Onodi cell Is a variation of posterior ethmoid and lies in relation to optic nerve. When
present they can increase the chance of complications.
Aggar nasi Anterior most anterior ethmoidal air cell.
Concha Bullosa Pneumatized middle turbinate.
Osteomeatal complex (Picadli’s circle):

Is a site for the common drainage pathway of the anterior group of sinuses (frontal /anterior / maxillary).
Structures contributing to its formation are:
Maxillary sinus ostium.
Hiatus semilunaris.
Ethmoidal infundibulum.
Middle meatus.
Frontal recess.
Ethmoidal bulla.
Uncinate process.
Status at Birth Adult size 1st Radiological

evidence
Maxillary sinus Present 15 years 4–5 month
Ethmoid sinus Present 12 1 year
Frontal sinus Not present Until teens 6 years
Sphenoid sinus Not present 15 to Adult 4 years
WORKSHEET
MCQ OF “ALLPLIED CLINICAL ANATOMY IN RHINOLOGY” FROM DQB

Opening In Lateral Wall
Inferior meatus
Middle meatus
Superior Meatus
Sphenoethmoidal recess
Uncinate process
Bulla ethmoidalis
Hiatus semilunaris
Ethmoidal infundibulum
Haller cell
Onodi cell
Aggar nasi
Concha Bullosa
9 Clinical Disorders in Rhinology
CONCEPTS
Â Concept 9.1 Infection of Nose and Paranasal
Sinuses
Â Concept 9.2 Granulomatous Disease of the Nose
Â Concept 9.3 Rhinosinustis
Â Concept 9.4 Nasal Polyps and Underlying Causes
Â Concept 9.5 Epistaxis and It’s Management
Â Concept 9.6 Fractures of the Facial Skeleton

Concept 9.1: Infection of Nose and Paranasal Sinuses
Learning Objective: To learn Infection of Nose /Paranasal sinuses and their Management
Time Needed
1st reading 15 mins
2 look
nd
10 mins
Sinusitis
Acute sinusitis:
Sinuses involved in order of frequency: Maxillary > Frontal > Ethmoid > Sphenoid
Major Factor Minor Factor
Facial pain or pressure Headache
Facial congestion or fullness Fever (in chronic sinusitis)
Nasal obstruction or blockage Halitosis
Nasal discharge, purulence, or discolored postnasal drainage Fatigue
Hyposmia or anosmia Dental pain
Purulence in nasal cavity Cough
Fever (in acute rhinosinustis only) Ear Pain, pressure or fullness
Frontal sinusitis:
• Frontal headache, oedema of upper eyelid.
Maxillary sinusitis:
• Pain referred to gums, odema of lower eye lid.
Sphenoid sinusitis:
• Headache, usually localised to the occiput or vertex.
• Postnasal discharge.
Ethmoid sinusitis:
• Pain over bridge of the nose, oedema of both the lids.
Complication of Sinusitis:
Most common organism known to produce complication of sinusitis: Staphylococcus
aureus.
1. Orbital.
2. Osteomyelitis.
3. Intracranial.
Orbital Complication:
Chandler classification:
• Group I – Preseptal cellulitis.
Clinical Disorders in Rhinology | 117
• Group II – Orbital cellulitis.
• Group III – Subperiosteal abscess.
• Group IV – Orbital abscess.
• Group V – Cavernous sinus thrombosis.
Superior orbital FISSURE syndrome:
• Cranial Nerves VI, III and IV paralysis (in that order).
Orbital Apex Syndrome: Optic nerve paralysis.
Pott’s Puffy Tumour:
• Subperiosteal abcess subsequent to frontal sinustis.
• Organisms: Staphylococcus, Streptococcus, Anaerobes
Chronic Complications:
• Mucocele / Pyoceles.
Concept 9.2: Granulomatous disease of the Nose
Learning Objective: To learn Granulomatous disease of the Nose and their Management
Time Needed
1st reading 20 mins
2 look
nd
10 mins
Granulomatous Disease of the Nose

Bacterial Fungal Tertiary
Syphilis Rhinosporidiosis Wegener’s
Tuberculosis Aspergillosis Granulomatosis
Lupus Mucormycosis Non – healing midline granuloma
Rhinoscleroma Candidiasis Sarcoidosis
Leprosy Histoplasmosis
Blastomycosis
Tuberculosis of Nose:
• Cartilaginous portion of the nasal septum and the anterior end of the inferior turbinate.
Lupus Vulgaris:
• Sites affected: Most common site is the mucocutaneous junction of the nasal septum.
Rhinoscleroma:
Organism: Klebsiella rhinoscleromatis
In India, Northern parts are more affected.
• Atrophic Stage.
• Granulomatous Stage.
• Cicatrical Stage.
Mikulicz Cells:
Large foam cells with a central nucleus and vacuolated cytoplasm (contain the bacilli).
Russell Bodies:
Eccentric nucleus and a pink- staining cytoplasm- Look like plasma cells.
Treatment:
• Streptomycin (2 gm/day).
• Tetracycline (2 gm/day). minimum: 4-6 wks (till 2 consecutive samples negative).
• Rifampicin: 450 mg daily 6 wks.
Leprosy:
• Anterior part of the nasal septum and the anterior end of the inferior turbinate.
• Perforation of the nasal septum.
Fungal Infections:
Rhinosporidiosis:
Organism: Rhinosporidium seeberi. Distribution: India (Southern parts), Sri lanka.
Sites of Affection:
Most commonly: Nose and Nasopharynx Mulberry shaped polypoidal mass studded
with white dots or sporangia on its under surface.
Site: Vestibule (septal area).
Treatment:
Complete excision of the mass with a cutting diathermy and cauterization of its base.
Medical management: Local injection of corticosteroids and courses of dapsone and
amphotericin.
Aspergillosis Mucormycosis (Rhinocerebral Phycomycosis)
Aspergillosis: is the commonest fungal • Remarkable a ffinity for blood vessels - arteries.
infection of the nose and sinuses. • M.R.I. detects early vascular and intracranial invasion.
Frequency: A. fumigatus (90%) > A. Treatment:
niger and A. flavus. Local debridement and systemic amphotericin-B.
Wegener’s Granulomatosis:
• Systemic disorder, with upper and lower airway involvement and skin and kidney
involvement.
• Treatment: steroids, cytotoxics.
Non-healing Midline Granuloma – A Type of Lymphoma:
• Destructive disease of nose and midface.
• No lung/kidney involvement.
• Is a malignant lymphoma.
• Diagnosis: many repeated biopsies may be needed to diagnose.
• Treatment: radiotherapy, followed by debridement and nasal prosthesis.
• Steroids and cytotoxics contraindicated since they reduce the immune response.
Concept 9.3: Rhinosinustis
Learning Objective: To learn Concepts of Rhinosinusitis
Time Needed
1st reading 15 mins
2 look
nd
5 mins
Chronic Rhinosinustis
When symptoms of sinusitis persist for more than 12 weeks, chronic state develops.
Commonest cause is incomplete resolution of acute episode.
• Organism: Mixed aerobic and anerobic.
• Treatment: Medical.
Vasomotor Rhinitis
• Non allergic
• Sneezing is less
• Usually persists throughout the year
Complications: Long standing cases develop nasal polyp, hypertrophic rhinitis and sinusitis.
Treatment:
• Medical - Avoidance of physical factors, antihistaminics, oral nasal decongestants, topical and systemic
steroids.
• Surgical - Nasal obstruction - reduce size of nasal turbinates (Polyp, DNS).
• Excessive rhinorrhoea - Vidian neurectomy.
Drug induced Rhinitis:

• Antihypertensives - Reserpines, guanethidine, methyl dopa, propranolol.
• Anticholinesterase drugs - neostigmine (Myasthenia gravis) Contraceptive pills.
Rhinitis medicarmentosa:
• Topical decongestant nasal drops excessive use causes rhinitis.
• Treatment: Withdrawal of drugs, short course of systemic steroid and Turbinectomy
(Some).
Rhinitis due to Hypothyroidism:
• Leads to hypoactivity of sympathetic system with predominance of parasympathetic
activity.
Chronic Specific Rhinitis
Atrophic rhinitis (OZAENA):
• Progressive atrophy of the nasal mucosa and the underlying bone of the turbinate and
the presence of viscid secretions which from foul smelling crusts.
• Klebsiella ozaenae (Perez bacillus), Diphtheriods and Bacillus mucosus.
• Usually starts in females.
• Around puberty.
Treatment:
Medical:
• Alkaline douching
(Alkaline solution: - 280 ml warm water + a teaspoonful of the following powder: *
Sodium bicarbonate (28.4g) + Sodium biborate (28.4g) + Sodium chloride (56.7g).
• Glucose in glycerine.
• Kemicetine antiozaena solution.
• Chloramphenicol.
• Estradiol dipropionate.
• Vitamin D2.
• Human placental extract: tissue therapy with systemic human placenta extract
Surgical Treatment:
Young’s operation:
• Closure of the nostril following elevation of the nasal vestibular folds.
Modified Young’s operation:
• Partial closure of the nostril leaving behind a 3mm hole.
• This remains for a period of 2 years.
Lautenslager’s operation:
• Surgical procedures aimed at medializing the lateral nasal wall.
Concept 9.4: Nasal Polyps and Underlying Causes
Learning Objective: To learn Pathophysiology of Nasal Polyps and their Management
Time Needed
1st reading 15 mins
2 look
nd
5 mins
Nasal Polyps:
Definition:
• Non-neoplastic hypertrophied, edema- tous, prolapsed mucosa.
• Insensitive to pain and do not shrink with the use of vasoconstrictors.
P.S - Polyps seen before 2 years of age: Suspect meningococele or encephalocele, hence
CT scan should be done.
If seen between 2-10 yrs of age: Suspect cystic fibrosis .
Respiratory diseases which predispose the patient to nasal polyps are:
1. Kartagener’s syndrome: Primary ciliary dyskinesia.
2. Young Syndrome: Hyperviscidosis (bronchiectasis, sinusitis and azoospermia).
Antrochoanal polyp:
Antrochoanal polyp
Differences between antrochoanal polyp and ethmoidal polyp:

Ethmoidal polyp Antrochoanal polyp
Seen in adults Seen in children and adolescents
Males: Females =2:1 to 4:1 Males> Female
Allergy is the commonest cause Infection is the commonest cause
Multiple (bunch of grapes) Unilateral

Seen easily on anterior rhinoscopy Seen commonly on postnasal examination
X ray PNS may show hazy ethmoids and normal X ray PNS shows hazy maxillary antrum
maxillary sinuses
Mostly bilateral Usually unilateral
Recurrence is common Recurrence is uncommon
Polypectomy Caldwel luc surgery in recurrent cases
Ethmoidal polyps:
Treatment:
• Medical treatment: lntranasal corticosteroids for 4-6 weeks (steroid drops/ sprays):
effective in 50% of the cases
• Surgical: FESS (Functional Endoscopic sinus surgery).
Antrochoanal Polyp (Killian’s Polyp):
Parts: dumbbell shaped
a. Antral.
b. Nasal.
c. Choanal.
Treatment:
• No medical treatment.
• Surgical Management:
FESS is treatment of choice.
Aulsion/ Intranasal polypectomy.
Caldwell-Luc operation is done for recurrent AC polyp.
FESS:
Indications:
1. Chronic bacterial sinusitis unresponsive to adequate medical treatment.
2. Recurrent acute bacterial sinusitis.
3. Polypoid rhinosinusitis (diffuse nasal polyposis).
4. Fungal sinusitis with fungal ball or nasal polypi.
5. Antrochnanal polyp.
6. Mucocele of frontoethmoid or sphenoid sinus.
7. Control of epistaxis is by endoscopic cautery.
8. Removal of foreign body from the nose or sinus.
9. Endoscopic septoplasty.
Advanced Nasal Endoscopic Techniques:
1. Removal of benign tumours e.g. inverted papillomas or angiofibromas.
2. Orbital abscess or cellulitis management.
3. Dacryocystorhinostomy.
4. Repair of CSF leak.
5. Pituitary surgery.
6. Optic nerve decompression.
7. Orbital decompression for Graves disease.
8. Control of posterior epistaxis (endoscopic clipping of sphenopalatine artery).
9. Choanal atresia.
Synechia Most common complication of endoscopic sinus surgery
Nasal Septum
• DNS.
• Crooked nose.
• Saddle nose.
• Hump nose.
• Perforation.
Small and medium sized perforation (< 2 cm in diameter): Closure surgically.
Large perforation (> 2 cm in diameter): Obturators or silastic septal buttons.
Concept 9.5: Epistaxis and It’s Management
Learning Objective: To Learn Clinical Importance of Epistaxis and their Management
Time Needed
1st reading 15 mins
2 look
nd
5 mins
Epistaxis:
Anatomy:
• Epistaxis is normally classified into anterior or posterior, but it can also be classified
as superior or inferior depending on the carotid supply.
• Broadly, the internal carotid (via the ethmoidal arteries) supplies the region above
the middle turbinate while the remaining areas are supplied by branches of the
external carotid artery. This includes the sphenopalatine artery, which supplies most
of the septum and turbinates on the lateral wall. The interface between the two
carotid systems varies in position according to the pressure in each one. There
is also crossover between the right and left arterial systems, which can result in
persistent nasal bleeding despite unilateral arterial ligation.
• Anterior bleeds are responsible for about 80% of epistaxis. They occur at an
anastomosis called Kiesselbach’s plexus on the lower part of the anterior septum
known as Little’s area. Posterior bleeding is derived primarily from the posterior
septal nasal artery (a branch of the sphenopalatine artery), which forms part of the
Woodruff plexus.
Aetiology:
• The aetiology of epistaxis can be divided into local and general causes, however most
(80%–90%) are actually idiopathic.
Local:
• Idiopathic
• Trauma
Nose picking
Facial injury
Foreign body
• Inflammation
Infection
Allergic rhinosinusitis
Nasal polyps
• Neoplasia
Benign (for example, juvenile angiofibroma)
Malignant (for example, squamous cell carcinoma)
• Vascular
Congenital (for example, hereditary haemorrhagic telangiectasia)
Acquired (for example, Wegener’s granulomatosis)
• Iatrogenic
Surgery (for example, ENT/ maxillofacial/ophthalmic)
Nasal apparatus (for example, nasogastric tube)
• Structural
Septal spurs or deviation
Septal perforations
• Drugs
Nasal sprays (for example, topical decongestants)
Abuse (for example, cocaine)
General
• Haematological
Coagulopathies (for example, haemophilia)
Thrombocytopenia (for example, leukaemia)
Platelet dysfunction (for example, Von Willebrand’s disease)
• Environmental
Temperature
Humidity
Altitude
• Drugs
Anticoagulants (for example, heparin, warfarin)
Antiplatelet (for example, aspirin, clopidogrel)
• Organ failure
Uraemia
Liver (for example, cirrhosis)
• Other
Atherosclerosis/hypertension
Alcohol
Management of Epistaxis
Concept 9.6: Fractures of the Facial Skeleton
Learning Objective: To Learn Concepts of the Facial Fractures and their Management
Time Needed
1 reading
st
20 mins
2 look
nd
10 mins
Nose:
Fracture of the Nose:
(Classification):
1. Class 1 Fracture [Chevallet]:
Depressed nasal fracture.
Force required 25-75 lb/inch.
Fracture line runs parallel to the dorsum and the nasomaxillary suture line.
NASAL SEPTUM is NOT involved in this injury (In a severe variant it is involved).
Features: DO NOT cause gross lateral displacement.
Treatment: Fracture reduction done either immediately or after 5-7 days once
oedema settles.
2. Class 2 Fracture [Jarajavay]:
Involves the nasal bone, the frontal process of the maxilla and the SEPTAL
STRUCTURES.
Ethmoidal labyrinth and the orbit are spared.
Here the quadrilateral cartilage gets dislocated from the maxillary crest.
Treatment: Closed reduction of the nasal bone fracture with open reduction of
the septum.
3. Class 3 Fracture:
Caused by high velocity trauma.
Naso-orbitio-ethmoid fracture.
Treatment:
• Open reduction and internal fixation.
• Distal part of the nasal bone is half the thickness of the proximal part. Therefore
more susceptible to injury.
• Untreated nasal bone fractures lasting for more than 21 days require Open Reduction.
• Caudal dislocation is a type of class 2 fracture or at times class 1 fracture.
• Any CSF leak persisting for more than 2 weeks have to be considered for repair.
Mandible:
• Most common site of fracture: Subcondylar region.
• Fracture sites: Condyle > angle > body > symphysis
Le Fort Type Fractures
Zygomatic Fractures = Tripod fracture

Commonly called Tripod fracture since the bone breaks at three places:
1. FRONTOZYGOMATIC SUTURE.
2. INFRAORBITAL RIM.
3. ZYGOMAT1CO-TEMPORAL SUTURE (posterior to it).
Orbital Fracture:
• Orbital fracture predominantly involves the floor since it is the thinnest wall (0.5-1
mm).
• It is commonly found in association with Le fort type - 2 and zygomatic fractures.
C.S.F Rhinorrhoea: Common Cause is Traumatic Fracture of Cribri form

Plate:
Features CSF fluid Nasal secretion
History Nasal or sinus surgery, head injury or Sneezing, nasal stuffiness, itching in
intracranial tumour the nose or lacrimation.
Flow of discharge A few drops or a stream of fluid Continous, No. effect of bending
gushes down when bending forwards forward or straining. Can be sniffed
or straining: cannot be sniffed. No back.
stiffening
Character of discharge Thin, watery and clear Slimy (mucus) or clear (tears)
taste sweet salty
Sugar content More than 30 mg/dl Less than 10 mg/dl
Presence of β2 transferrin Always present. It is specific for CSF Always absent.
Double Ring Sign is Helpful in Traumatic CSF Leak (Blood Surrounded by CSF).
Management: Wait and watch, I.V. Antibiotics.
Extra Edge:
Choanal Atresia:
• Obliteration of the posterior choana is the result of a failure of the nasobuccal membrane
to rupture during the fourth week of embryonic life.
• Unilateral.
• Occurs on the right side.
• Unilateral nasal obstruction often presents later in infancy or childhood as rhinorrhea and
congestion.
• Diagnosis is made by the inability to pass catheters through the nose or by nasal endoscopy
(flexible or rigid).
• CT scan is always obtained to confirm the physical findings.
• Bilateral atresia must be addressed during first weeks of life.
• McGovern’s nipple may be required for feeding initially for bilateral choanal atresia. If
possible, surgical repair is delayed until the child is older than 2 years.
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
Sinusitis
Sinuses involved in order of frequency:
Major Factor Minor Factor
Differences between antrochoanal polyp and ethmoidal polyp:

Ethmoidal polyp Antrochoanal polyp
Features CSF fluid Nasal secretion

History
Flow of
discharge
Character of
discharge taste
Sugar content
Presence of β2
transferrin
10 Malignancy in Rhinology
CONCEPTS
Â Concept 10.1 Tumors of Nasal Cavity
Â Concept 10.2 Tumors of Paranasal Sinuses

Concept 10.1: Tumors of Nasal Cavity
Learning Objective: To Learn Tumors of Nasal Cavity and their Management
Time Needed
1st reading 15 mins
2 look
nd
10 mins
• Capillary haemangioma: Bleeding polypus: Litter’s area

• Cavernous haemangioma: Turbinate
Keratotic Papilloma (Benign Squamous Papilloma,Vestibular Wart)
• Pathophysiology: benign lesions arise from squamous epithelium (associated
most commonly with Human Papilloma Virus 6 and 11)
• Low malignant potential
• SSx: verrucous lesion, commonly on nasal vestibule, painless
• Rx: simple excision or laser ablation.
Inverted Papilloma
• Pathophysiology: arise from proliferation of reserve cells in squamous mucosa
(associated with human papilloma virus):More common in males
• Often misdiagnosed as a nasal polyp (polyps are more translucent, bilateral, and
bleed less)
• unilateral obstruction, sinusitis, epistaxis, rhinorrhea, diplopia, typically
presents on the lateral nasal wall (rarely on the nasal septum), may be associated
with a benign nasal polyp
• Complications: 10% malignant degeneration from lateral wall lesions (rare from
nasal septum), extension into sinuses, orbit (blindness, diplopia, proptosis), or
intracranial and skull base
• Adequate en bloc excision typically requires a medial maxillectomy, may require
an ethmoidectomy or craniofacial resection, endoscopic excision may be considered
for select lesions
• (recurrence rate up to 20%)
Malignancy
• Most common tumour: squamous cell carcinoma
• Most common site of squamous cell carcinoma: Lateral wall
• Most common site of malignant melanoma:
1st Anterior part of septum.
2nd Middle turbinate.
3rd Inferior turbinate
Radiotherapy and chemotherapy has to be avoided
Malignancy in Rhinology | 137
Concept 10.2: Malignancy of Paranasal Sinuses
Learning Objective: To Learn Malignancy of Paranasal Sinuses and Management
Time Needed
1st reading 15 mins
2 look
nd
10 mins
Malignancy of Paranasal Sinuses

Malignancy is most commonly seen in the maxillary sinus.
Histology: Most common PNS carcinoma is squamous cell carcinoma (Nickel
exposure) but people working in wood/furniture factories have adenocarcinoma more
commonly.
Classification:
1. Ohngren’s classification: using an imaginary line between medial canthus to the
angle of mandible. Growth above this line have poor prognosis and growth below this
line have good prognosis.
2. Lederman’s classification: Using two line of sebileav, one passing through floor of
antrum, the other through roof of antrum, dividing the area into:
a) Supra structure
b) Meso structure and
c) Intra structure.
Treatment: In most cases a combination of surgery (Total maxillectomy) and radio
therapy is required.
Carcinoma Maxillary Sinus
• Arises from the lining of maxillary sinus.
• Middle aged males (40-60 years).
• Remains silent for a long time or shows only symptoms of sinusitis.
• Destroys bony walls and invades the surrounding structures.
Clinical Features
Nasal stuffiness -
Blood-stained nasal discharge. These are early C/F
Facial paraesthesia or pain. Often misdiagnosed and treated as Sinusitis
Epiphora. -
Lederman’s Classification
• Ethmoid, sphenoid, frontal sinuses and olfactory area of nose.
• Maxillary and respiratory part of nose.
• Alveolar process
Lederman’s Classification
Tnm Classification and Staging.

Tumour (T)
• T1 - Tumour limited to maxillary sinus mucosa with no erosion.
• T2 - Bony ersion, extension hard palate, nasal meatus, except the posterior wall.
• T3 - Invading posterior wall, subcuta- neous tissue, floor/medial wall of orbit,
pterygoid fossa, ethmoid sinus.
• T4a - ant. Orbit, skin of cheek, pterygoid plates, cribriform plates, sphenoid, frontal
sinus.
• T4b - orbital apex, dura, brain, middle cranial fossa, nasopharynx, cramil nerves
other than maxillary division of Trigeminal (V2).
Treatment
• Stage 1 & 2 SCC → Surgery or Radiation.
• Stage 3 & 4 SCC → Combined modalities.
• Inoperable tumors → Chemoradiation
• Intra arterial infusion of 5-Fluorouracil or Cisplatin.
Malignancy in Rhinology | 139
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
Malignancy of Nose
• Most common benign tumor:
• Most common malignant tumor:
• Most common site of squamous cell carcinoma:
• Most common site of malignant melanoma:
Malignancy of PNS
• Most common benign tumor:
• Most common malignant tumor

N X
RY
A
PH
11 Anatomy of Pharynx
CONCEPTS
Â Concept 11.1 Clinical Anatomy Of Pharynx
Concept 11.1: Clinical Anatomy of Pharynx
Learning Objective: To Learn the Clinical Applied Anatomy of Pharynx
Time Needed
1st reading 20 mins
2 look
nd
10 mins
Pharynx
Mucosa:
• Nasopharynx: Pseudostratified columnar epithelium.
• Orpharynx and Hypopharynx: Non-keratinizing stratified squamous epithelium.
Pharynx
Nerves:
• The Constrictors and salpingopharyngeus are supplied by branches from
the pharyngeal plexus, the Constrictor inferior by additional branches from
the external laryngeal and recurrent nerves, and the Stylopharyngeus by the
glossopharyngeal nerve.
Anatomy of Pharynx | 145
Sinus of Morgagni:
• Killian’s dehiscence: Lies between the oblique (thyropharyngeus) and transverse
(cricopharyngeus) parts of the inferior constrictor muscle. Syn. Gateway of Tears.
• Laimer- Hackeman’s area (in the upper posterior part of the oesophagus, just
below the cricopharynx where the longitudnal fibres do not cover the circular fibres).
• Tornwaldt’s disease is an inflammation or abscess of the embryonic remnant cyst
of the pharyngeal bursa appearing at the posterior median wall of the nasopharynx.
All muscles of Supplied By Which is supplied by
Pharynx Pharyngeal plexus (IX,X Stylopharyngeus Glossopharyngeal nerve

and sympathetic)
Palate Pharyngeal plexus (IX,X Tensor veli palatini Medial pterygoid nerve
and sympathetic)
Tongue Hypoglossal.(XIIth ) Palatoglossus. Pharyngeal plexus (IX,X

and sympathetic
Facial expression, Facial (VIIth) Levator palpebrae Occulomotor

Buccinator superioris
Mastication Mandibular division of Buccinator Facial (VIIth)

trigerminal.
Structures Entering the Pharynx

Above the superior constrictor Between the middle and superior constrictor
• Cartilaginous part of eustachian tube • Stylopharyngeus
• Tensor palati. • Glossopharyngeal nerve
• Levator palati.
• Palatine branch of ascending pharyngeal artery.
Between the middle and inferior constrictor Below the inferior constrictor
• Internal laryngeal nerves • Recurrent laryngeal nerves
• Superior laryngeal vessels • Inferior laryngeal artery
Lymphatic Drainage of the Pharynx

The lymph vessels of the pharynx either directly or indirectly drain into the deep cervical
group of lymph nodes.
Palatine Tonsil = Tonsil:
Palatopharyngeal and palatoglossal folds (Anterior and posterior pillars).
Plica Triangularis: Plica Semilunaris:
Triangle fold of mucous covers the lower part of the Is a semilunar fold of mucous membrane.
tonsil. Covers the upper pole of the tonsil.
Features:
Each tonsil has 15-20 crypts.
Blood supply Branch of
1. Tonsillar artery Facial artery
2. Ascending palatine Facial artery
3. Dorsal lingual Lingual artery
4. Descending palatine Maxillary artery
5. Tonsilar branch Ascending pharyngeal artery
• Veins from tonsils drain into peritonsillar vein which joins the common facial vein.
• Lymphatics from tonsils mainly drain into jugulodigastric nodes.
Anatomy of Pharynx | 147
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
All muscles of Supplied By Which is supplied by
Pharynx
Palate
Tongue
Facial expression,
Buccinator
Mastication
Structures Entering the Pharynx

Above the superior constrictor Between the middle and superior constrictor
Between the middle and inferior constrictor Below the inferior constrictor
12 Clinical Disorders of Pharynx
CONCEPTS
Â Concept 12.1 Infection of Pharynx
Â Concept 12.2 Abscess of Head and Neck

Concept 12.1: Infection of Pharynx
Learning Objective: To Learn Infection of Pharynxand their Management
Time Needed
1st reading 20 mins
2 look
nd
10 mins
Acute Tonsillitis
Types:
Acute catarrhal or superficial tonsillitis
• Acute follicular tonsillitis – Purulent material seen in crypts as yellowish spots.
• Acute parenchymatous – Tonsillar substance is affected causing uniform
enlargement and redness.
• Acute membrane tonsillitis – Exudation coalesce to form a membrane.
Complications
Chronic tonsillitis Acute otitis media
Peritonsillar abscess Rheumatic fever
Parapharyngeal abscess Acute glomerulonephritis
Subacute bacterial endocarditis
Most common organism: β Hemolytic Streptococci:

Differential Diagnosis of Membrane over the Tonsils
Membranous tonsillitis Vincent’s angina Infectious mononucleosis
Agranulocytosis Leukaemia Aphthous ulcer
Malignancy of tonsil Traumatic ulcer
DIPHTHERIA: MEMBRANE IS DIRTY GREY, REMOVAL CAUSES BLEEDING
Clinical Disorders of Pharynx | 151
Tonsillectomy
Cold Knife (Steel) Dissection:
• However, monopolar cautery (Electrocautery) is the preferred method of choice
because it causes less bleeding than the scapel method.
Electrocautery:
• Electrocautery burns the tonsillar tissue and assists in reducing blood loss through
cauterization.
• Research has shown that the heat of electrocautery (400 degrees Celsius)
results in thermal injury to surrounding tissue.
• This may result in more discomfort during the postoperative period.
Harmonic Scalpel:
• This medical device uses ultrasonic energy to vibrate its blade at 55,000 cycles per
second.
• Invisible to the naked eye, the vibration transfers energy to the tissue, providing
simultaneous cutting and coagulation.
• The temperature of the surrounding tissue reaches 80 degree celsius. Proponents
of this procedure assert that the end result is precise cutting with minimal thermal
damage.
Radiofrequency Ablation (Somnoplasty):
Monopolar radiofrequency thermal ablation transfers radiofrequency energy to the
tonsil tissue through probes inserted in the tonsil.
• The procedure can be performed in an office setting under light sedation or local
anaesthesia. After the treatment is performed, scarring occurs within the tonsil
causing it to decrease in size over a period of several weeks.
• The treatment can be performed several times. The advantages of this technique are
minimal discomfort, ease of operations, and immediate return to work or school.
• Tonsillar tissue remains after the procedure but is less prominent. This procedure
is recommended for treating enlarged tonsils and not chronic or recurrent
tonsillitis.
Carbon Dioxide Laser:
• Laser Tonsil Ablation (LTA) finds the otolaryngologist employing a hand-held CO2 or
KTP laser to vaporize and remove tonsil tissue. This technique reduces tonsil volume
and eliminates recesses in the tonsils that collect chronic and recurrent infections.
This procedure is recommended for chronic recurrent tonsillitis, chronic sore throats,
severe halitosis or airway obstruction caused by enlarged tonsils.
• The LTA is performed in 15 to 20 minutes in an office setting under local anaesthesia.
The patient leaves the office with minimal discomfort and returns to school or work the
next day. Post-tonsillectomy bleeding may occur in two to five percent of patients.
Previous research studies state that laser technology provides significantly less pain
during the post-operative recovery of children, resulting in less sleep disturbance,
decreased morbidity, and less need for medications. On the other hand, some believe
that children are adverse to outpatient procedures without sedation.
Microdebrider:
• What is a “microdebrider?” The microdebrider is a powered rotary shaving device
with continuous suction often used during sinus surgery.
• It is made up of a cannula or tube, connected to a handpiece, which in turn is
connected to a motor with foot control and a suction device.
• The endoscopic microdebrider is used in performing a partial tonsillectomy, by
partially shaving the tonsils. This procedure entails eliminating the obstructive
portion of the tonsil while preserving the tonsillar capsule.
• A natural biologic dressing is left in place over the pharyngeal muscles, preventing
injury, inflammation, and infection. The procedure results in less post-operative
pain, a more rapid recovery, and perhaps fewer delayed complications. However,
the partial tonsillectomy is suggested for enlarged tonsils – not those that incur
repeated infections.
Bipolar Radiofrequency Ablation (Coblation):
• This procedure produces an ionized saline layer that disrupts molecular bonds
without using heat. As the energy is transferred to the tissue, ionic dissociation occurs.
• This mechanism can be used to remove all or only part of the tonsil. It is done under
general anaesthesia in the operating room and can be used for enlarged tonsils and
chronic or recurrent infections.
• This causes removal of tissue with a thermal effect of 45-85°C. The advantages
of this technique are less pain, faster healing, and less post operative care.
Indication:
Absolute Relative As part of an operative
procedure
Large tonsils causing sleep apnea Diphtheria carriers not responding As part of uvulopalato
to antibiotics. pharyngoplasty (UPPP) done for
OSA.
Recurrent tonsillitis (3-4 docu- Rheumatic fever where As an approach to IX nerve and
mented attacks of acute tonsillitis antistreptococcal prophylaxis styloid process.
for a period of 2-3 years). cannot be maintained.
U/L enlarged tonsil (suspicion of malignancy).
-
-
Recurrent quinsy (recurrence: - -
20%).
Contraindications:
• Hb<10g%.
• Age< 3 yrs.
• Acute infection.
• In epidemics of polio.
• Bleeding disorders (laser tonsillectomy).
• Uncontrollable systemic disease (diabetes, hypertension).
Laser Tonsillectomy:
Is performed with KTP-532, decreased blood loss.
Complications of Tonsillectomy:
• Peroperative bleeding: Primary haemorrhage.
• Reactionary haemorrhage (venous bleed).
• Secondary haemorrhage (bleeding after 24 hours postoperatively (not as severe as
primary haemorrhage).
• Occurs at: 6-8 days
Adenoids V/S Tonsil

Tonsil Adenoid
1. Encapsulated 1. Unencapsulated
2. Two in number 2. One
3. Has crypts 3. Has furrows
4. Present in oropharynx 4. Present in nasopharynx
5. Lined by squamous epithelium 5. Lined by ciliated columnar epithelium
6. Has no efferent lymphatics 6. Has both afferent and efferent lymphatics
Extra Edge:
Thornwaidt’s Cyst (Pharyngeal Bursitis)
Interior of the pharyngeal bursa (A median recess representing attachment of notochord to
endoderm of the primitive pharynx).
Features Treatment
Is a cystic nasopharyngeal swelling. Antibiotics: Infection.
Persistent post-nasal discharge. Marsupialization.
Nasal obstruction.
Concept 12.2: Abscess of Head and Neck
Learning Objective: To Learn Abscess of Head and Neck and their Management
Time Needed
1st reading 20 mins
2 look
nd
10 mins
Peritonsillar Abscess (QUINSY)

Definition:
Is a collection of pus between the fibrous capsule and the superior constrictor muscle
(tonsillar bed).
Commonest site: Upper pole of tonsils, usually unilateral.
1. Occurs as a complication of acute tonsillitis.
2. May arise de novo without a preceeding history of tonsillitis.
Organisms: Mixed flora (anaerobes and aerobes).
Clinical features:
Fever (104°F) with chills and rigors General body ache Earache.
Trismus (spasm of pterygoid muscles) Halitosis Hot potato voice
Treatment:
• Incision and drainage (Peroral).
• I.V. fluids, antibiotics, analgesics. (Abscess requires drainage, but peritonsillitis may
respond to conservative measures).
• Interval tonsillectomy - Patient to undergo tonsillectomy at 6 weeks if recurrent
quinsy.
• Hot Tonsillectomy / Abscess Tonsillectomy
• Tonsillectomy performed in the acute stage of quinsy: not advocated.
Odema of the Uvula (Quinke’s Disease):

Quinke’s disease is acute oedema of the uvula.
Acute Retropharyngeal abscess
Retropharyngeal Space
• Extent: from the skull base to the bifurcation of trachea.
Boundaries:
Anteriorly:
• Buccopharyngeal fascia covering the constrictors.
Posterioly:
• Prevertebral fascia.
Laterally:
• Carotid shealth.
Features:
It is a potential space.
a. It is divided into two lateral compartments called space of Gillete; therefore abscess
causes U/L bulge.
b. The space is filled with loose areolar tissue and retropharyngeal lymph nodes which
disappear by 3-4 years of age (Nodes of Rouviere).
Acute:
• Children.
• Cause: Suppuration of retropharyngeal lymph nodes due to infection at its drainage
sites.
Features:
• Dysphagia.
• Fever.
• Difficulty in breathing with stridor.
• Bulge in the posterior pharyngeal wall.
Treatment:
• Incision and drainage peroral.
• Antibiotics.
• Tracheostomy: If large, causing mechanical obstruction to the airway.
Prevertebral Space: Between vertebral bodies and their ligaments posteriorly and the
prevertebral fascia anteriorly.
• Infection is usually due to caries of spine.
• Prevertebral abscess causes midline bulge (Treatment is aspiration perorally, ZN
staining for tubercle bacilli and ATT).
Parapharyngeal Space:
• Extent: Skull base to the hyoid bone.
Boundaries:
1. Shape: Inverted 5- sided pyramid.
2. Base: Greater wing of sphenoid.
3. Laterally: Rami of the mandible and deep lobe of the parotid.
4. Medially:
Eustachian tube.
Pharynx.
Palatine tonsil.
5. Posterioly: Vertebral and prevertebral muscles.
6. Anteriorly: Pterygoid muscles and interpterygoid fascia.
Contents: Styloid process and its muscles divide the space into 2 compartments:
1. Pre-styloid compartment:
a. Pterygoids.
b. Tensor veli palatini.
2. Post-styloid:
a. Neurovascular bundle.
b. Internal carotid artery.
c. Internal jugular vein.
d. IX, X, XI, XII cranial nerves.
e. Sympathetic chain.
Other Contents:
Loose areolar tissue and lymph nodes.
Features:
The parapharyngeal space communicates with the retropharyngeal, parotid,
submandibular, carotid and visceral spaces.
Parapharyngeal Abscess:
Etiology: Pharynx: Tonsillitis, Adenoiditis, Peritonsillar abscess.
• Teeth: Dental infections.
• External trauma: Penetrating injuries of the neck.
Clinical Symptoms and Signs:
1. Anterior Compartment:
Prolapse of the tonsil and tonsillar fossa.
Trismus.
External swelling behind the angle of the jaw.
Marked odynophagia.
2. Posterior Compartment:
Bulge in pharyngeal wall posterior to the posterior pillar.
IX, X, XI, XII palsy.
Sympathetic chain involvement.
Parotid bulge.
Minimal trismus.
Treatment:
Abscess drainage: Through a collar incision in the neck at the level of Hyoid-bone, IV
antibiotics.
WORKSHEET
MCQ OF “CLINICAL DISORDERS OF PHARYNX” FROM DQB

Differential Diagnosis of Membrane over the Tonsils
DIPHTHERIA:
Indication:
Absolute Relative As part of an operative
procedure
13 Malignancy of Pharynx
CONCEPTS
Â Concept 13.1 Tumors of Pharynx
Concept 13.1: Malignancy of Pharynx
Learning Objective: To Learn Malignancy of Pharynx and their Management
Time Needed
1 reading
st
20 mins
2nd look 10 mins
Nasopharyngeal Carcinoma
Commonest site of origin: Fossa of Rosenmuller.
Site: Above and behind the medial end of the eustachian tube.
Epidemiology of Nasopharyngeal Carcinoma

Geographical Distribution Cantonese race in China
Environmental Factors
Genetic Chinese have a higher genetic susceptibility. (HLA - A2 and A8).
Viral Epstein Barr Virus (raised antibody, viral genome in tumor cells).
Seroimmunological Index in NPC:

• IgA VCA : Viral capsid antigen
• IgA EA : Early antigen
The two titres can be used for follow-up of the patient for recurrence and for occult
tumors
• IgA VCA: For serological screening of nasopharyngeal carcinoma.
• Genetic markers in nasopharyngeal carcinoma: HLA–A, B, DR: Short arm of
chromosome 6.
Prognosis: HLA-A2: Best prognosis (survival: 40% 5 yrs survival).
HLA-B46: Highest frequency in China. HLA-A33-B58: worst prognosis (mostly
young, onset < 30 yrs).
Histopathology- Commonest type: Squamous epithelium
Clinical Features:
Painless cervical lymphadenopathy: 60%. (commonest → Jugulodigastric)
Epistaxis and nasorespiratory symptoms: 40%
Audiological symptoms (Tinnitus, otalgia, deafness): 30%
Neurological symptoms: 20%. All cranial nerves except 1,2 and 7,8 can be involved.(Most commonly:
V, VI, IX, X)
Malignancy of Pharynx | 161
Trotter’s Triad
• U/L middle ear effusion and so conductive hearing loss.
• Pain in that ear.
• Paralysis of the soft palate (X nerve).
Tolosa- Hunt Syndrome

• U/L orbital pain. [relapsing/ Remitting pain (III, IV and VI cranial nerve)].
• Paraesthesia of the forehead.
Treatment
• Radiotherapy: Definitive treatment for nasopharyngeal carcinoma and its regional
node metastasis, recurrence following radiotherapy is due to parapharyngeal space
involvement.
• No neck lymphadenopathy; Not irradiated.
Brachytherapy:
• Transnasal intracavity brachytherapy: lr-192.
Lhermitte’s Sign (lightening pains):
• Uncommon complication.
• Causes: Due to radiation injury to the cervical spinal cord.
Angiofibroma
Definition: Locally invasive vasoformative neoplasm occurring only / exclusively in
adolescent males.
Site of Origin: Sphenoplatine foramen.
Antral Sign (Holman Miller Sign)
• Angiofibroma is the most common benign tumour of nasopharynx seen in
adolescent males.
• It originates from sphenopalatine foramen.
• It’s a highly vascular tumour.
• CECT scan shows Hollman Miller ( =Antral) sign. Surgery is treatment of choice.
• Pre-op embolisation will reduce blood loss.
• Pre-op Estrogen, Flutamide ( androgen antagonist) are helpful in reducing blood loss.
• Debulking or biopsy of this tumour is never done as it is a highly vascular tumour.
• Tumours confined to nasopharynx can be approached through Wilson’s transpalatal
approach. But tumours extending to cheek would need trans- maxillary approach
using weber fergusson incision.
Approaches to the Tumour:

Transpalatal approach Confined to the nasopharynx.
Transpalatal with gingivobuccal Additional access to pterygopalatine fossa incision

(Sardana’s approach)
Transnasal approach with transantral approach Infratemporal fossa

Lateral rhinotomy with maxillectomy Tumor in the nasal fossa spilling over to the
pterygopalatine fossa
Middle cranial fossa approach For extension to the middle cranial fossa
Anterior cranial fossa For anterior cranial fossa extension
Tumors of Hypopharynx:
• Most common type of tumor: Squamous cell type
• Most common site of hypopharyngeal malignancy: Pyriform sinus
Post-cricoid Carcinoma:
• Plummer Vinson syndrome is a premalignant condition for post cricoid carcinoma.
Extra Edge
Keratosis Pharyngis
Features:
1. Benign condition.
2. Horny excrescences on the tonsillar surface, pharyngeal wall of lingual tonsils; appear
as white/ yellow dots and cannot be wiped off.
3. No constitutional symptoms.
Malignancy of Pharynx | 163
WORKSHEET
MCQ OF “MALIGNANCY OF PHARYNX” FROM DQB

Epidemiology of Nasopharyngeal Carcinoma
Geographical Distribution
Environmental Factors
Genetic
Viral
Approaches to the Tumour:

Transpalatal approach
Transpalatal with gingivobuccal
Transnasal approach with transantral approach
Lateral rhinotomy with maxillectomy
Middle cranial fossa approach
Anterior cranial fossa

T Y
VI
C A
A L
OR
Applied Anatomy of
14 Oral Cavity & Misc Topics
CONCEPTS
Â Concept 14.1 Clinical Anatomy of Oral Cavity
Â Concept 14.2 Submucous Fibrosis
Â Concept 14.3 Tumors of Oral Cavity
Â Concept 14.4 Obstructive Sleep Apnoea (OSA)
Â Concept 14.5 Lasers in Otlaryngeology

Concept 14.1: Clinical Anatomy of Oral Cavity
Learning Objective: To Learn the Clinical Applied Anatomy of Oral Cavity
Time Needed
1st reading 20 mins
2 look
nd
10 mins
• Mouth / oral cavity extends from the lip to the oropharyngeal isthmus i.e. anterior
pillar of tonsillar fossa, posterior margin of hard palate and junction of anterior 2/3rd
and posterior 1/3rd of tongue.
• Parotid ducts open through a small papilla opposite the upper 2nd molar tooth.
• Submandibular and sublingual ducts open into the floor of the mouth beneath
the tongue.
• Myelohyoid is the main muscle which makes the floor of the mouth.
• Oral stage of deglutition is voluntary.
• Pharyngeal and oesophageal stages are involuntary.
Nerves of Taste:
• IXth CN - Posterior 1/3rd of tongue (bitter).
• Chorda tympani (VII) - Ant 2/3rd of tongue (Sweet, sour and salt).
Lymphatic Drainage:
1. Lips:
Lower lip: Medial portion drains into submental lymph nodes. Lateral portion
drains into submandibular lymph nodes.
Upper lip - Preauricular, infraparotid and submandibular nodes
2. Lymphatics from anterior portion of floor of mouth drain into submandibular nodes
and also cross the midline.
3. Tongue:
Tip - Submental and jugulo omohyoid nodes
Lateral portion - Ipsilateral submandibular and deep cervical nodes
Central portion and base – Deep cervical nodes of both sides
Applied Anatomy of Oral Cavity & Misc Topics | 169
Concept 14.2: Submucous Fibrosis
Learning Objective: To Learn the Concepts of Submucous Fibrosis
Time Needed
1st reading 15 mins
2 look
nd
10 mins
Submucous Fibrosis
Etiology
• Prolonged Local Irritation: Due to mechanical and chemical irritation caused by
chewing betel nut.
• Dietary deficiency : VA; VB complex
• Localized collagen disease
• Racial : Mainly affects Indians
Pathology
Epithelial atrophy & sub mucosal fibro elastic transformation.
↓
Progressive trismus and difficulty to protrude the tongue.
Clinical Features
• Age → 20 – 40 years
• Sex → F > M
• Is PREMALIGNANT
Treatment
Medical
Steroids – Topical injection of steroids combined with hyalase
Concept 14.3: Tumors of Oral Cavity
Learning Objective: To Learn the Tumors of Oral Cavity and Management
Time Needed
1st reading 30 mins
2 look
nd
15 mins
Tumors of Oral Cavity: Malignant Tumors: Etiology:

• Smoking.
• Tobacco chewing.
• Spices.
• Sharp tooth.
• Sepsis (dental).
• Dietary deficiency.
Iron deficiency – Paterson.
Brown – Kelly syndrome.
• Leucoplakia.
• Syphilis.
• Lichen planus.
• Submucous fibrosis.
• Chronic hyperplasic candidiasis.
Carcinoma Lip– Most common cancer of oral cavity.

Sex M>F
Age 40 – 70 years
Site Lower lip, between commissure and midline of lip
Lymph nodes involvement Submental and submandibular involved first followed by deep cervical
nodes,
Pathology 98% are squamous cell carcinoma which can be endophytic, verrucous and
ulcerative.
Treatment → <2cm diameter: Interstitial radiotherapy
OR
Surgery → Larger lesions – Resection with reconstruction
Basal Cell Carcinoma:

Lips:
• Most common location of oral cancer.
• 90% on lower lip, 90% 5-year survival if <2 cm, 90% squamous cell carcinoma (Rule
of 90).
• Basal cell carcinoma is more common on upper lip.
• Lower lip has bilateral and ipsilateral lymphatic drainage into level I–III nodal groups
and upper lip has ipsilateral lymphatic drainage into level I–III nodal groups (no
contralateral drainage due to embryological fusion plates).
• Poorer prognosis is associated with upper lip and commissure involvement.
Carcinoma Buccal Mucosa:
• Squamous cell carcinoma is most common.
• Commonest site of origin is buccal sulcus.
• Submandibular and upper deep cervical nodes involved.
Treatment:
• < 2 cm – Surgical removal with safe margin.
• Larger lesions with no encroachment on bone – Interstitial radiotherapy or Surgery
• Involvement of bone also: Wide resection with neck dissection with postoperative
radiotherapy.
Carcinoma Oral Tongue:

Age 50 – 70 years
Sex M>F
Site Lateral border most common
LN Lateral border – submandibular and upper deep cervical

Tip – submandibular and submental and lower deep jugular
Treatment < 2 cm – Surgical excision Or interstitial radiotherapy > 2cm – Hemiglossectomy with or
without neck dissection
Neoplasms of Salivary Glands

• 75% salivary gland tumors arise in parotid.
• 80% of these are benign and 80% of benign tumors in parotid are pleomorphic
adenomas.
• Adenolymphoma (benign tumor) is seen in 5th – 7th decades with M>F; also known
as Warthin’s tumor. Hot spot is seen with Tc99 scan.
• MC malignant tumor of parotid is muco- epidermoid carcinoma.
• MC malignant tumor of minor salivary gland is adenoid cystic carcinoma, shows
perineural spread.
• MC benign tumor of parotid in children is hemangioma.
Caldwell-Luc procedure:
• Intraoral approach to anterior maxillary wall from canine fossa above gum line, the
diseased mucosa is removed from the maxillary sinus, also allows for a middle meatal
antrostomy, and ethmoidectomy (transantral ethmoidectomy).
• The incision is made in the gingivobuccal sulcus, above the canine fossa.
Indications: Sinus disease not obtainable by endoscopic sinus surgery, inspissated
secretions, neo-ossification, cystic fibrosis.
Caldwell-Luc procedure
Advantages: allows adequate exposure of inside of maxillary sinus, favorable intraoral

incision.
Disadvantages
• Nonfunctional.
• Damages mucosa (decreased cilia count, increased fibrosis and bone growth).
• Risk of infraorbital nerve and dental injury (hypoesthesia to teeth and lip).
Concept 14.4: Obstructive Sleep Apnoea (OSA)
Learning Objective: To Learn the Concepts of Obstructive Sleep Apnoea (OSA)
Time Needed
1st reading 20 mins
2 look
nd
10 mins
Obstructive Sleep Apnoea (OSA)

• Obstructive Sleep Apnoea (OSA) is a common feature in middle aged, overweight
men. The prevalence is thought to be approximately 4% in men and 2% in women.
OSA can range from being very mild to severe.
• Sleep apnoea is usually defined as cessation of air flow into the lungs which lasts for
more than 10 seconds. This definition however is rather artificial as some apnoeas
which last for more than 10 seconds during sleep are perfectly normal.
• It is quite common for intervals between breaths to last for 10-20 seconds without
there being any underlying sleep or respiratory disorder.
• The apnoea index (AI) (the number of apnoeas occuring per hour), and the apnoea/
hypopnoea index (AHI) (significant drop in oxygen saturation of 4% or more per hour
due to the cessation of breathing). An AHI of less than 10 is not likely to be associated
with clinical problems.
Respiratory Disturbance Index (RDI):

• Number of apnoea and hypopnea events per hour during sleep.
• RDI upto 5 per hour is considered normal.
• Based on the the value of RDI, sleep aponea can be classified:
Sleep Apnoea RDI
Mild 5–14
Moderate 15–30
Severe >30
The Ultimate Investigation is Polysomnography which will Include:

• Electro-encephalography (EEG) – brain wave monitoring.
• Electromyography (EMG) - muscle tone monitoring.
• Recording thoracic-abdominal move- ments – chest and abdomen move- ments.
• Recording oro-nasal flow - mouth and nose air flow.
• Pulse oximetry - heart rate and blood oxygen level monitoring.
• Electrocardiography (ECG) - heart monitoring.
Obstructive Sleep Apnoea (OSA) is the most common form of sleep apnoea,
this is when the airway is blocked but the respiratory effort continues.
But there is also a condition called Central Sleep Apnoea (CSA). This is a
condition when the brain does not send the right signals to tell you to breathe
when you are asleep causing a lack of respiratory activity.
CSA is less common than OSA, and needs to be investigated by a specialist.
There is also a condition called Mixed Sleep Apnoea which is a combination of both
OSA and CSA.
For those Suffering from OSAS, Treatment Options Generally Include:
• Weight Loss.
• Positional Changes while sleeping. Continuous Positive Airway Pressure (CPAP).
• Uvulopalatopharyngoplasty (UPPP or UP3) (Somnoplasty, Coblation, or other Radio
frequency procedures are generally not effective for treatment of Sleep Apnea,
and are used only for snorers who are thought not to have OSA).
CPAP:
• CPAP is the first line of defense in the treatment of OSAS. In CPAP, pressurized air
is administered by way of a face mask which is worn during sleep. The pressure
of the air is adjusted in order to maintain adequate pressure to overcome airway
obstruction. In this way, most of the apneic episodes are eliminated.
• CPAP, however, remains the best non- surgical treatment for OSAS.
Laup - Laser Assisted Uvuloplasty:
• LAUP is a surgical method used to treat mild-to-heroic snorers and those with very
mild OSAS. This procedure utilizes a laser beam to, in effect, “tighten” floppy tissue
in the back of the mouth, thereby reducing the amount that these tissues contribute
to snoring.
Somnoplasty:
• Somnoplasty and Coblation are both radiofrequency treatments aimed at mild-
to-severe snorers with little or no apnea. This technology utilizes radio frequency
techniques to accomplish the same result as in a LAUP, with much less post-operative
discomfort.
Uppp-Uvulopalatopharyngoplasty:
• UPPP for over a decade has been the mainstay in the surgical treatment of OSAS and
severe snoring.
• It does, though, significantly reduce the degree of OSAS in well over 50 - 60% of
patients, and typically eliminates or significantly reduces snoring.
Concept 14.5: Lasers in Otlaryngeology
Learning Objective: To Learn the Concepts Lasers in Otlaryngeology
Time Needed
1st reading 20 mins
2 look
nd
10 mins
LASERS
CO2 Laser:
• 10,600 nm wavelength.
• Highest power continuous-wave laser.
No current optical fiber to carry beam.
Uses:
Laryngology:
• Laryngology is one of the speciality areas in which lasers are most often used. The
CO2 laser is by far the laser of choice. Because of the precise cutting and superficial
well delineated effect of the CO2 laser, it is widely used in laryngology for delicate
phonatory surgery, precise excision of carcinoma in situ or early (T1) tumors, and
vaporization of bulky obstructing carcinoma of the upper airway.
Rhinology:
• Most of the lasers now available to the otolaryngologist have applications in nasal
surgery.
• The CO2 laser, which mainly cuts and ablates tissue, is used most often for vaporization
of hypertrophied turbinates and occasionally for coagulation of small blood vessels in
the milder forms of hereditary hemorrhagic telangiectasia (Kluger et al, 1987).
• In the noncontact mode, the Nd: YAG laser is a good coagulator. It has been used
successfully for coagulation of vascular lesions of the nose, such as low-flow venous
malformations and hereditary hemorrhagic telangiectasia.
Otology:
• The argon, CO2, and KTP/532 lasers have been useful for ossicular surgery and
particularly stapedotomy.
• The CO2 laser is especially easy to use because of its articulating arm delivery system
that can be connected to the operating microscope and because of its small spot size
(0.2 to 0.3 mm at a focal length of 250 mm).
• The surgeon can operate using a no- touch technique, with good visualization and
precise ablation of the ossicles.
Oral Cavity:
• In the oral cavity, the laser is mainly used as a hemostatic cutting knife, and for this
purpose the CO2 is the laser of choice.
• It is used with a handpiece or with a micromanipulator to delineate and resect small
tumors of the tongue, the floor of the mouth, and the mucosa of the cheek.
• The KTP/532 laser, with its flexible fiberoptic delivery system, may also be used for
the excision of benign and malignant lesions of the oral cavity; however, its soft tissue
interaction is not as precise as that of the CO2 laser.
KTP Laser:
• 532 nm wavelength (potassium-titanyl-phosphate).
• Frequency doubling.
• Nd: YAG laser passes through a KTP crystal – emission is ½ its wavelength.
• Oxyhemoglobin is primary chromophore.
• Applications:
Granuloma excision of the respiratory tract.
Subglottic/tracheal stenosis.
Subglottic/supraglottic cyst excision.
Inferior turbinate reduction.
Nasal papilloma excision.
Nasopharyngeal stenosis.
Supraglottoplasty.
Laryngeal papilloma excision.
Middle ear surgery (Cholesteatoma excision, stapes surgery).
Argon Laser:
• 488 - 514 nm wavelength (Ion laser):
Oxyhemoglobin is target chromophore.
Small spot size (0.1 – 1 mm) – variable in size and intensity.
Flexible delivery system.
Applications:
• Retina or middle ear surgery.
• Facial spider veins.
• Junctional nevi.
• Cherry hemangioma.
• Vascular birthmarks.
• Limitations:
Also absorbed by epidermal and dermal tissues due to melanin.
Continuous mode of operation.
Higher prevalence of postoperative pigmentary alteration and fibrosis.
Nd: YAG Laser:
• 1064 nm wavelength (neodymium-doped yttrium aluminum garnet).
Aiming helium-neon (HeNe) beam.
• Applications:
Deeper penetration (up to 4 mm) for ablative therapy and hemostasis.
Preferentially absorbed by pigmented tissues.
Vascular malformations amenable to treatment.
Used in a multitude of pulmonary, urology and gastroenterology procedures.
Minimally invasive percutaneous laser disk decompression.
• Limitations:
Greater scatter than CO2
Deep thermal injury
Risk for transmural injury
Cryosurgery (also called cryotherapy) is the use of extreme cold produced by liquid
nitrogen (or argon gas) to destroy abnormal tissue. Cryosurgery is used to treat external
tumors, such as those on the skin. For external tumors, liquid nitrogen is applied directly
to the cancer cells with a cotton swab or spraying device.
Cryosurgery is also used to treat tumors inside the body (internal tumors and tumors
in the bone). For internal tumors, liquid nitrogen or argon gas is circulated through a
hollow instrument called a cryoprobe, which is placed in contact with the tumor.
Cryosurgery is used to treat several types of cancers, and some precancerous or
noncancerous conditions. In addition to prostate and liver tumors, cryosurgery can be
an effective treatment for the following:
• Retinoblastoma (a childhood cancer that affects the retina of the eye).
• Early-stage skin cancers (both basal cell and squamous cell carcinomas).
• Precancerous skin growths known as actinic keratosis.
• Precancerous conditions of the cervix known as cervical intraepithelial neoplasia
(abnormal cell changes in the cervix that can develop into cervical cancer).
• Cryosurgery is also used to treat some types of low-grade cancerous and noncancerous
tumors of the bone. It may reduce the risk of joint damage when compared with
more extensive surgery, and help lessen the need for amputation. The treatment is
also used to treat AIDS-related Kaposi sarcoma when the skin lesions are small and
localized.
• Cryosurgery can be used to treat men who have early-stage prostate cancer that is
confined to the prostate gland. It is less well established than standard prostatectomy
and various types of radiation therapy.
• Cryosurgery offers advantages over other methods of cancer treatment. It is less
invasive than surgery, involving only a small incision or insertion of the cryoprobe
through the skin. Consequently, pain, bleeding, and other complications of surgery
are minimized. Cryosurgery is less expensive than other treatments and requires
shorter recovery time and a shorter hospital stay, or no hospital stay at all. Sometimes
cryosurgery can be done using only local anaesthesia.
• The major disadvantage of cryosurgery is the uncertainty surrounding its long- term
effectiveness. While cryosurgery may be effective in treating tumors the physician
can see by using imaging tests (tests that produce pictures of areas inside the body),
it can miss microscopic cancer spread. Furthermore, because the effectiveness of the
technique is still being assessed, insurance coverage issues may arise.
WORKSHEET
MCQ OF “ORAL CAVITY & MISC TOPICS” FROM DQB

Carcinoma Lip– Most common cancer of oral cavity.
Sex
Age
Site
Lymph nodes involvement
Pathology
Treatment
Carcinoma Oral Tongue:

Age
Sex
Site
LN
Treatment

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Concept Based Learning

Video Companion on Each Chapter

Comprehensive Review Series

“EAR NOSE AND

Active Recall Based

First Published 1999, Delhi Academy of Medical Sciences

© 2021 DAMS Publication

Â Concept 1.2 Middle Ear and Mastoid Anatomy

Â Concept 1.3 Clinical Anatomy of Inner Ear

Pinna Develops from 1st and 2nd Branchial Arch

From 1st Arch Tragus From 2nd Arch Rest of Pinna

Cleft pinna Congenital fissure of the pinna

Coloboma lobuli Congenital fissure of the earlobe

Macrotia Congenital excessive enlargement of the auricle

Microtia Congenital small pinna

Melotia Congenital displacement of the pinna

Low-set-ears Congenitally displaced pinna

Polyotia Additional pinna on one or both sides

Preauricular tags Small appendage anterior to pinna

Scroll ear Rim (helix) of pinna is rolled forward and inward

Sensory Innervation of the Auricle

Lesser occipital Cervical plexus C2 Superior portion of medial surface

Auricular Vagus Concha and antihelix

Facial Supplies root of concha

Common Auricular Defects

Bat Ear Antihelix poorly formed

Wildermuth Ear Helix underdeveloped, antihelix is prominent

Mozart’s Ear Helix and antihelix are found fused

External Auditory Canal (EAC)

• Develops from: dorsal end of the 1st Branchial cleft.

Tympanic Membrane (TM):

Tympanic membrane (left).

Arterial Supply of Tympanic Membrane

Fig.: Middle ear

Middle Ear Spaces:

Fig.: Middle ear space

Fig.: The Ossicular Chain, medial Aspect

Middle Ear Muscles:

ROSENTHAL’S CANAL: housing spiral ganglia

Utricle and Saccule.

Characteristic Outer hair cell Inner hair cell

EXTRA POINTS FROM DQB

Common Auricular Defects

Characteristic Feature Outer Hair Cells Inner Hair Cells

Â Concept 2.2 Pure Tone Audiometry

Â Concept 2.3 Tuning Fork Tests

Â Concept 2.4 Speech Audiometry

Â Concept 2.5 Impedance Audiometry

Â Concept 2.6 Electrocochleography & Bera

Pure Tone Testing

High Frequency hearing loss

Tuning Fork Tests:

High Frequency Audiometry: Ototoxic Drugs

Speech Reception Threshold:

Speech Discrimination (SD):

ELECTROCOCHLEOGRAPHY is a procedure to record the potentials generated

Auditory Brainstem Response (ABR) Audiometry

EXTRA POINTS FROM DQB

ABR Peaks: Each peak may correlate to an anatomical location

Â Concept 3.2 Diseases of Middle Ear

Â Concept 3.3 Diseases of Inner Ear

Â Concept 3.4 Otosclerosis.

Â Concept 3.5 Meniere’s Disease

Â Concept 3.6 Tumors in Otology

Â Concept 6.3 Acute and Chronic Inflammation of