ENT (Viva) – 4th &5TH Year

Mohammad Shariful Alam (Shohan)

Session: 2003-04
Shahabuddin Medical College & Hospital

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 Mohammad Shariful Alam
(Shohan)
EAR

Q. Type of hearing loss in otitis media with effusion (OME). Medical management of
acute otitis media. What is myringtomy?

Ans. OME is the commonest cause of non-suppurative conductive deafness in children.

Causes of effusion:
A. Middle ear:
1. Malfunctioning of Eustachian tube:
(a) Adenoid hyperplasia
(b) Chronic rhinitis and sinusitis
(c) Chronic tonsillitis
(d) Benign and malignant tumours of nasopharynx.
(e) Palatal defects, e.g. cleft palate, palatal paralysis.
2. Allergy:
Allergic oedema of middle ear cleft and subsequent effusion.
3. Unresolved acute otitis media: Inadequate antibiotic therapy stimulates mucosa to
secret more fluid. The number of goblet cells and mucous glands also increase.
4. Viral infections: Various adeno- and rhino- viruses may cause middle ear effusion.
5. Immunological disorder of middle ear mucosa
6. Disturbance in muco-cilliary transport in middle ear
7. Barotraumas

B. Inner ear:
 Otitic labyrinthitis: When inner ear is infected from middle ear infection (diffuse
purulent or serous labyrinthitis).
 Infective labyrinthitis: From meningeal or haematogenous route (e.g., by
Salmonella typhi & Salmonella paratyphi)
 Viral labyrinthitis: Following viral infections, such as measles, mumps, and
influenza. (Severe and permanent seonsori-neural deafness).

The aims of treatment are:

(a) To control infection of the middle ear cleft.
(b) To give symptomatic relief.
(c) To ensure patency of Eustachian tube for drainage and ventilation.
(d) To ensure complete resolution and full return of auditory functions.

Medical treatment of acute otitis media:

1. Bed rest and drink plenty of fluid.
2. Application of dry heat helps to relieve pain.
 Mohammad Shariful Alam
(Shohan)

3. Analgesics to relieve earache e.g., Ibuprofen, Paracetamol or Nimusulide tablet.

4. Systemic antibiotics to control of infection e.g., Amoxycillin, Tetracycline,
Roxythromycin, Cephalexin, Co-trimazole etc.
5. Nasal decongestant to maintain patency of the Eustachian tube by 1% ephedrine in
normal saline or decongestive nasal drop (e.g., Oxymetazoline), and antihistaminic tablet
6. Sedatives.

Myringotomy:
It is incision of the tympanic membrane with the purpose to drain suppurative or
nonsuppurative effusion of the middle ear or to provide aeration in case of malfunctioning
Eustachian tube.

*For curiosity: Antibacterial agents and their dosage in acute otitis media

Drug Trade name Total daily dose Divided dose

Amoxicillin Fimoxyl 40 mg/kg 3
Moxacil
Ampicillin Amblosin 50-100 mg/kg 4
Co-amoxiclav Fimoxiclav 40 mg/kg 2-3
Moxaclav
Erythromycin Eromycin 30-50 mg/kg 4
Etrocin
Cefaclor Ceflon 20mg/kg 2-3
(II generation) Loracef
Cefixime Cef-3 8mg/kg 1 or 2
(III generation) Triocim
Cefpodoxime Starin 10mg/kg (max 400 2
proxetil Taxetil mg/day)
Ceftibuten (?) 9 mg/kg 1
(III generation)
Co-trimoxazol Cotrim 8 mg (TMP) + 40 mg 2
(Trimethoprim + Fisat (SMZ)/kg
Sulphamethoxazole)

Q. 5 pathology of external ear causing conductive deafness.

Ans. External ear pathology causing conductive deafness are-

1. Congenital:
 Atresia
 Microtia
 Treacher-Collins syndrome
2. Impacted wax or cerumen
3. Impacted foreign body
4. Otitis externa:
 Diffuse otitis externa (when the auditory canal is obstructed)
 Otomycosis (when mycotic plug is formed)
5. Neoplasm:
(i) Benign - Osteoma, chondroma, exostosis.
 Mohammad Shariful Alam
(Shohan)

(ii) Malignant - Osteosarcoma, chondrosarcoma.

Q. Sudden pain in the ear of a child after upper respiratory tract infections. What is
your diagnosis? How you diagnosed?

Ans. Child is suffering from acute suppurative otitis media, its clinical features are-

1. Stage of tubal occlusion:

Symptoms:
i) Acute coryza
ii) Mild earache
iii) Fullness in the ear
iv) Mild conductive deafness
Signs:
i) Tympanic membrane retracted & lusterless.

2. Stage of exudation or pre-suppuration:

Symptoms:
i) Severe earache (sharp & stabbing)
ii) Deafness increases
iii) Bubbling sound (due to serous exudates)
iv) General illness: Rise of temperature, Malaise, Vomiting.

Signs:
i) Tympanic membrane: Red & congested, dilated vessels radiating from the
handle of the malleus gives Cart-wheel appearance.

3. Stage of suppuration:
Pre-perforation:
Symptoms:
i) Pain is more acute (throbbing)
ii) Deafness is more marked
iii) High rise of temperature (101˚ - 103˚F)
Signs:
i) Bulged, congested & yellow spot on the tympanic membrane
ii) Mastoid tenderness
Perforation:
Symptoms:
i) Otorrhoea (pus or mucopus or may be blood stained)
ii) Pain diminishes
iii) Temperature comes down
iv) Conductive deafness is more marked
Signs:
i) Perforation on the tympanic membrane
 Mohammad Shariful Alam
(Shohan)

ii) Pulsating discharge reflect light intermittently called “Light-house sign”

iii) Mastoid tenderness disappears

4. Stage of resolution:
i) In early cases or in mild infection: Resolution occurs without perforation
ii) In cases of perforation: Discharge subsides and perforation heals up or dry small
perforation is left behind

5. State of complication:
i) Persistence of otorrhoea & deafness
ii) Vertigo & headache
iii) Increase temperature
iv) Facial paralysis.

Q. Clinical features of otosclerosis. Treatment of otosclerosis.

Ans. Clinical features of otosclerosis:

Symptoms:
1. Painless, progressive and bilateral hearing loss usually begins between the ages of 11-30.
2. Tinnitus due to high vascularity of spongiosum.
3. Paracusis willisii – the ability to hear better in noisy surroundings as people talk louder in
noisy place.
4. Patients have a monotonous, well modulated soft speech.
5. Occasional vertigo or giddiness.

Sign:
1. Otoscopy reveals
- tympanic membrane is quite normal and mobile.
- Flamingo’s tint or positive Schwartze’s sign.
2. Eustachian tube function is normal.
3. Tuning fork test:
(a)Rinne is negative on both sides and Weber will be lateralized to the more deaf ear
(conductive type o deafness)
(b)Gelle’s test is negative.

Treatment: Though there are no medications that have been shown to work, the followings are
the treatment options-
a) Conservative treatment:
1. Regular observation
2. When there is active stage or positive flamingo flash – Na fluoride 50-75 mg/day
for 2 years. Then 25 mg/day for whole life.
3. Hearing aid –when operation is contraindicated or patient is not agreeable to
operation. Hearing aids are effective for conductive hearing loss.
b) Surgical treatment:
1. Stapedectomy under general anaesthesia is the most modern operation.
 Mohammad Shariful Alam
(Shohan)

2. Other surgical procedures-

 Fenestration operation
 Stapes mobilisation
 Small fensetra stapedotomy.
Q. What are the ototoxic drugs? Mention five.
Ans. Ototoxic drugs are-
1) Aminoglycoside antibiotics:
 Streptomycin & gentamycin  mainly vestibulotoxic,
 Neomycin, kanamycin, vancomycin & tobramycin  mainly cochleotoxic.
2) Diuretics: Ethacrynic acid, frusemide, etc.
3) Anti-malarial drug: Quinine, Chloroquine, etc.
4) NSAID: Salicylate, Aspirin, etc.
5) Tobacco and alcohol.

Q. Treatment of furunculosis in ear.

Ans. Treatment:

1. The meatus is packed with wick soaked in 10% icthammol in glycerin or smeared with
neomycin-steroid ointment.
- Wick acts as a splint and prevents movement of cartilaginous part. It also
relieves the tension of the furuncle into the canal by counter pressure and
thereby relieves pain.
- Icthammol is bacteriostatic and irritant.
- Glycerin is hygroscopic and reduces oedema.
The ribbon-gauze wick should be removed after 48 hours. Repacking may be necessary,
if tenderness persists.
2. If furunculosis burst, canal should be cleaned and packed with gauze soaked in antibiotics
and kept for 24 hours.
3. Analgesic is administered to reduce the pain.
4. Use of heat in the form of fomentation is soothing.
5. Systemic antibiotic e.g., Erythromycin, roxythromycin, cephalexin, or Trimethoprim-
Sulphonamide group of drug, is administered in severe case or when there is spreading
cullulitis.
6. Incision of furuncle is necessary if large boil and pus pointing.
7. In recurrent furunculosis, diabetes should be excluded and treatment should be done
accordingly, if present.
8. If the patient is non-diabetic (with recurrent furunculosis), then ear swab culture is
performed and a course of autovaccine should be considered.
9. Any other causative factor or focal sepsis should be looked into.

Q. 5 pathologies of middle ear causing conductive deafness.

 Mohammad Shariful Alam
(Shohan)

Ans. Middle ear pathology causing conductive deafness are-

1. Congenital:
o Ossicular chain deformity
o Fused ossicles
o Incudo-stapedial joint separation
o Congenital otosclerosis

2. Traumatic
o Haematomas
o Ossicular dislocation

3. Inflammatory
o Acute : ASOM
o Chronic:
- Non-specific: CSOM, Adhesive otitis media, secondary otitis media
- Specific: Tubercular and syphilitic.

4. Neoplastic
o Glomus jugularae
o Carcinoma.

Q. What are the causes of discharging ear?

Ans. Causes of discharging ear are-

A. Causes in the external ear:

(a) Inflammatory:
i. Bacterial inection- mainly by Staph. Aureus, Streptococcus, Haemophillus,
Pseudomonas, Proteus
 Localized otitis externa due to burst of furuncle (purulent discharge)
 Diffuse otitis externa due to diseases like DM & the condition is called
Otitis Externa Malignance characterized by perichondritis and formation
of pus.
ii. Fungal disease (Otomycosis)- Caused by
 Aspergillus nigra → black discharge
 Candida albicans → white discharge
iii. Viral inflammation- Caused by Herpetic virus
 Myringitis bullosa blood stained discharge
 Herpes zoster oticus (due to blood vessel rupture)

(b) Neoplastic:
 Benign – osteoma, exostosis.
 Malignant - squamous cell carcinoma, basal cell carcinoma.
- (malignant)
(c) Impacted wax or foreign body in the ear.

B. Causes in the middle ear:

(i) Acute suppurative otitis media with perforation
 Mohammad Shariful Alam
(Shohan)

(ii) Chronic suppurative otitis media

- Discharge is thin mucoid or mucopurulent in safe variety
- Discharge is purulent in unsafe variety & CSOM with complication
- Discharge is blood stained in CSOM with infected polyp or granulation tissue
- Characteristics of discharge:
 Foul smelling: in conditions like cholesteatoma, infection with gram negative
organism (e.g., Pseudomonas, Proteus) → fishy smell.
 Non foul smelling
(iii) Tympanic membrane perforation
(iv) Middle ear malignancy (e.g., carcinoma, glomus tumours, haemangioma etc.)
(v) Following RTA, in secondary infection → blood stained discharge.

C. Middle cranial fossa: C.S.F. otorrhoea-

Head injury with temporal bone fracture
Congenital defect
Cholesteatoma
Malignancy.

Q. Intratemporal complications o CSOM. Intracranial complications of CSOM.

Ans. Complications of otitis media are classified into two main groups:

Extra-cranial / Intratemporal Intracranial

1. Mastoiditis (*) 1. Extradural abscess
2. Petrositis, (*) and Gradenigo’s syndrome 2. Subdural abscess
3. Facial paralysis (*) 3. Meningitis (*)
4. Labyrinthitis (*) 4. Brain abscess
5. Subperiosteal abscess: (a) Temporal lobe
(a) Post-auricular (b) Cerebellar abscess (*)
(b) Zygomatic & Luc’s 5. Lateral sinus thrombophlebitis (*)
(c) Bezold’s abscess 6. Otitic hydrocephalus
(d) Pharyngeal abscess 7. Peri-sinus abscess
(e) Citelli’s abscess 8. Encephalitis (*).
6. Osteomyelitis of the temporal bone
7. Blood stream infection: Septicemia and
pyemia
8. Otogenic tetanus

Q. Types of mastoidectomy. Indication of cortical mastoidectomy.

Ans. Types of mastoidectomy:

I. Cortical mastoidectomy*
II. Radical mastoidectomy*
III. Modified radical mastoidectomy*
IV. Mastoidectomy with cavity obliteration
V. Canal-down & Canal-up technique in mastoidectomy.

Indication of cortical mastoidectomy:

1. Acute mastoiditis where there is coalescence of the mastoid air-cells.
 Mohammad Shariful Alam
(Shohan)

2. Masked mastoiditis.
3. Unresolved acute otitis media with persistent otorrhoea.
4. In some cases of persistent or recurrent secretory otitis media.
5. As an imitial step to perform:
(a) Endolymphatic sac surgery
(b) Decompression of facial nerve
(c) Translabyrinthine or retro-labyrinthine procedures for acuostic neuroma.

Q. 5 causes of sensory-neural deafness.

Ans. Causes of sensory neural deafness are-

Congenital or prenatal deafness Acquired or post-natal deafness

(a) Hereditary group (Genetic): I. Cause in cochlea or inner ear:
 Pendred syndrome i. Traumatic:
 Waardenburg’s syndrome  Fracture temporal bone (*)
 Klippel Fiel syndrome  Head injury
 Blast injury (*)
(b) Pregnancy group: ii. Operative:
 Rubella  Post-stapedectomy (*)
 Rh-factor  Labyrynthectomy
 Congenital syphilis iii. Infective:
 Severe viral infection of the mother  Bacterial: Labyrinthitis (*)
 Viral: Measles, mumps, influenza,
(c) Birth group or prenatal group: pox, etc.
 Prolonged labour iv. Vascular:
 Anoxia or hypoxia  Spasm
 Premature birth  Thrombosis
 Birth trauma v. Toxic:
 Phenylketonuria  Streptomycin, quinine, gentamycin,
and other ototoxic drugs. (*)
vi. Degenerative:
 Senile deafness or presbyacusis
vii. Noise induced:
 Acute noise trauma
 Chronic noise trauma
viii. Miscellaneous:
 Diabetes
 Meniere’s disease (*)
 Ramsay Hunt syndrome

II. Causes in internal auditory canal and C.P.

angle:
i. Acuostic neuroma (*)
ii. Meningioma
iii. Cholesteatoma
iv. Tuberculoma
v. Basal meningitis
 Mohammad Shariful Alam
(Shohan)

III. Cause in central nervous system:

 Dessiminated sclerosis
 Vascular accidents
 Tumours

Q. What is prebyacusis? Treatment of presbyacusis.

Ans. Presbyacusis (senile deafness):

The term presbycusis refers to sensorineural hearing impairment associated
with physiological aging process in the ear particularly after 60 years is called presbyacusis.
Characteristically, presbycusis involves bilateral high-frequency hearing loss
associated with difficulty in speech discrimination and central auditory processing of information.
Here degenerative process usually affects organ of Corti, spiral ganglion or stria vascularis.

Treatment:
Presbycusis is not curable, but the effects of the disease on patients’ lives can be mitigated.
 General nutrition should be improved including administration of Vit. B 1, B6, and B12.
 Amplification devices: Properly fitted hearing aids may contribute to the rehabilitation
of a patient with presbycusis.
 Lip reading and auditory training
 Cochlear implants
 Curtailment of smoking and stimulants like tea and coffee may help to decrease tinnitus.

Q. What is deafness? What are the types of deafness?

Ans. Deafness:
Partial or complete loss of hearing is called deafness.

Types:
1. Conductive deafness
2. Sensory-neural deafness
3. Mixed
4. Psychogenic deafness.

Q. What is cholesteatoma? Clinical presentation of cholesteatoma.

Ans. Cholesteatoma:
The term cholesteatoma is a misnomer, because it neither contains
cholesterol crystals nor is it a tumour to merit the suffix “oma”.

*This is a sack or a pocket in the middle ear cleft lined by keratinized

squamous epithelium and contains desquamated concentric sheets of keratin (and cholesterol
crystals), usually associated with infections.
In other words cholesteatoma is a “skin in the wrong place”.

Essentially choesteatoma consists of two parts,

 Mohammad Shariful Alam
(Shohan)

(i) The matrix, which is made up of keratinizing squamous epithelium resting on a thin
stroma of fibrous tissues and
(ii) A central white mass, consisting of keratin debris produced by the matrix.

Formation:
1.Congenital cholesteatoma: It arises from the embryonic epidermal cell and rests in th middle
ear cleft or temporal bone.

2.Primary acquired cholesteatoma:

 Retraction pocket theory (most accepted theory):
Auditory tube dysfunction/obstruction
↓
Hypoventilation of middle ear cleft & epitympanum
↓
Negative pressure of middle ear cavity produces pocket like depression in pars flaccid or postero-
superior region of pars tensa
↓
The pocket turns into pouch
↓
Self cleansing property of squamous epithelium is lost
↓
So, there is collection of sheets of squamous epithelium in concentric layers in the sac with
formation of a tumour like mass called cholesteatoma.
3. Secondary acquired cholesteatoma:
a. Migration theory: After perforation squamous cells migrate to the middle ear cavity &
break into crystal keratin materials.
b. Metaplastic theory:
Chronic tonsillitis, adenoid
↓
Infection passes into middle ear cavity & break into crystal materials
↓
Inadequate treatment causes persistence of infection for years
↓
So, squamous cell metaplasia & shedding of cells are broken down to form cholesteatoma
c. Implantation theory: Implantation of squamous epithelium from skin pedicle or remnant
under the graft may lead to cholesteatoma formation.

Q. What is tympanoplasty?

Ans. Tympanoplasty:
A tympanoplasty is a surgical procedure that repairs or reconstructs the eardrum
(tympanic membrane) to help restore normal hearing. This procedure may also involve repair or
reconstruction of the small bones behind the tympanic membrane (ossiculoplasty) if needed.
 Mohammad Shariful Alam
(Shohan)

This procedure is usually not performed (or needed) in children under four years
of age. A tympanoplasty is recommended when the eardrum is torn (perforated), sunken in
(atelectatic), or otherwise abnormal and associated with hearing loss. Abnormalities of the ear
drum and middle ear bones can occur through injury, otitis media, congenital (at birth)
deformities, or chronic ear conditions such as a cholesteatoma.

Q. Causes of pain in ear (otalgia).

Ans.
Local causes Referred causes
A. External ear 1. Via Vth cranial nerve
 Furuncle (a) Dental:
 Perichondritis  Caries tooth
 Otitis externa  Apical abscess
 Impacted wax & FB  Impacted molar
 Herpetic lesions including bullous  Malocclusion
myringitis (b) Oral cavity:
 Traumatic rupture of TM &  Benign or malignant ulcerative lesions
myringitis of oral cavity or tongue
 Malignant growth (c) Temperomandibular joint disorder:
B. Middle ear  Bruxism
 Acute otitis media  Osteoarthritis
 Acute salpingitis  Recurrent dislocation
 Acute mastoiditis  Ill-fitting denture
 Barotraumatic otitis media (d) Sphenopalatine neuralgia.
 Haemotympanum
 Unsafe variety of CSOM with 2. Via IXth cranial nerve
threatening complications (a) Oropharynx:
 Malignant growth  Acute tonsillitis
 Peritonsillar abscess
 Tonsillectomy
 Benign or malignant ulcer of soft palate,
tonsil and its pillars
(b) Base of tongue:
 Tuberculosis or malignancy
(c) Elongated styloid process.

3. Via Xth cranial nerve

 Malignancy or ulcerative lesion of-
- Vallecula
- Epiglottis
- Larynx or laryngopharynx
- Oesophagus

4. Via C2 and C3 spinal nerves

 Mohammad Shariful Alam
(Shohan)

 Cervical spondylosis
 Injuries to cervical spine
 Caries spine

Q. Treatment of traumatic perforation of ear drums.

Ans. Treatment:
1. Immediate treatment: Should be conservative & preventive. Majority cases heal with this
treatment alone:
 Sterile cotton wool is applied at the external meatus. It is to be changed if soaked.
 No ear drop should be given & syringing of the ear should be avoided.
 Swimming & bathing in ponds or pools should be avoided.
 If there is chance of infection in traumatic perforation, then administer systemic
antibiotic, either orally or perenterally in proper dose and duration.
 If associated with cold, then nasal decongestant and antihistaminic tablets are to
be used.
 Application of trichlor-acetic acid or silver nitrate at the margin of perforation
may help the healing process.
In majority of cases, healing of the TM occurs by epithelialization.
2. If patient attends late with purulent discharge following a perforation, then the case is to
be treated like a case of ASOM with perforation.
3. If no healing within 3 to 6 months, myringoplasty operation is to be performed. In this
operation, TM is repaired with temporal fascia.

Q. Name qualitative hearing test (clinical test).

Ans. Qualitative hearing tests are-

1) Tuning fork test-

 Rinne test
 Weber test
 Absolute Bone-Conduction
2) Impedance audiometry/Tympanometry
3) Stapedeal reflex test (SRT)
4) Vestbulo-cochleography.

Q. Causes of tympanic membrane perforation.

Ans. Causes of tympanic membrane perforation are-

1. While picking the ear with matchstick, pencil, hair-pins, etc.

2. Foreign body trauma or trauma during removal of F.B.
3. Sudden fluid compression or water jet: Syringing, water polo game, diving, etc.
4. Air compression: Slapping, blast, barotraumas.
5. Forceful inflation of Eustachian tube
 Mohammad Shariful Alam
(Shohan)

6. Indirect way: By head injury and fracture of the petrous temporal bone.

NOSE

Q. Nasal septoplasty/SMR – which one is functionally better? Complications of nasal

septal surgery.

Ans. Septoplasty is functionally better because-

 Conservation form of surgery to correct deviation with minimum resection of cartilage
and repositioning in midline.
 Most suitable in children and adolescence as it does not interfere with growth of the nose.
 It is also preferred in females to avoid cosmetic deformity of nose.
 Flappy Septum – never occurs.
 Haematoma septum – does not occur.

Complications of nasal septal surgery are-

1. Septal perforation and crusting due to injury and tearing of the

muco-periosteal flap of the intact side.
2. Haemorrhage
3. Septal haematoma
4. Septal abscess
5. Depression of the bridge of the nose
6. Retraction of columella
7. Persistance of deviation
8. Synechia between septum and turbinates
9. Flapping of the septum
10. Meningitis
11. Toxic shock syndrome

Q. Symptom and management of allergic rhinitis.

Ans. Symptoms:
 Mohammad Shariful Alam
(Shohan)

(1) Paroxysmal sneezing followed by watery nasal discharge

(2) Nasal obstruction
(3) Nasal irritation
(4) Anosmia
(5) Heaviness of head & headache
(6) Irritation and congestion of eyes, respiratory distress, and broncho-spasm.
Management:
A. Prophylactic:
(a) Avoidance of allergen
(b) A course of desensitizing vaccine based on result of skin sensitivity test.
(c) Hyposensitisation by vaccine
(d) Immuno-therapy by gamma-globulin or immunoglobulin injection.

B. Curative management:
1. Oral antihistamines: e.g., Pheniramine maleate, Promethazine, Cetrizine,
Terfanadine, Loratidine, Fexofenadine etc.
2. Symapthomimetic drugs: Topical use of sympathomymetic drugs cause nasal
decongestion e.g., Phenylephrine, Oxymetazoline, Xylometazoline etc.
3. Steroid: Can be used as spray (e.g., Beclomethasone, Fluticasone) or as submucosal
injection.
4. Sodium chromoglycate as nasal spray.
5. General body nutrition is to be improved. Vitamin C and B-complex is to be
administered. Bowel is to be kept regular.
C. Surgical management:
(a) Minor surgery: Reduction of nasal turbinate’s (inferior):
(i) Surface electro-cautery
(ii) Submucosal diathermy (S.M.D)
(b) Other nasal surgery:
(i) Submucosal resection (S.M.R)
(ii) Fiber-optic endoscopic sinus surgery (FESS).

Q. Epistaxis in a child of 3/4 years - cause and management.

Ans. Cause: In children commonest cause is epistaxis from Little’s area either spontaneous or
due to-

1. Picking of the nose

2. Injury to the nose
3. Exanthematous fever (e.g., measles, pox)
4. Foreign body nose
5. Diphtheric rhinitis
6. Enlarged adenoids, etc.
 Mohammad Shariful Alam
(Shohan)

Management:

1. Pinching of nose for 10-15 minutes, as pressure on nostril from outside compresses the
vessels on the Little’s area and stops bleeding.
2. Traumatic bleeding is often controlled by application of ice on bridge of the nose which
causes reflex vaso-constriction.
3. In cases of persistent bleeding, the blood is sucked out including clots with suction
machine under direct vision and spraying the nose with 4% xylocane.
- If the actual bleeding point is found out, may be cauterized by chemical or electro-
cautery under G/A.
- If bleeding point cannot be seen, then thick cotton wool pledget soaked in 4% Xylocaine
solution should be inserted into the nasal cavity and it is removed after several minutes.

Q. Causes of nasal obstruction with epistaxis.

Ans. Causes of nasal obstruction with epistaxis are-

Infected antro-choanal polyp

Foreign body nose and rhinolith
Rhinosporidiosis
Diphtheric rhinitis
DNS with acute rhino-sinusitis
Back pressure from enlarged adenoid
Juvenile nasopharyngeal angiofibroma
Haemangioma
Papilloma
Carcinoma of nose, paranasal sinuses and nasopharynx
Malignant garnuloma

Q. Procedure of antral wash out.

Ans. Procedure of antral wash out/proof puncture/antral irrigation:

 Instruments & reagents:
1.Thudicum’s nasal speculam
2.Lichtwitz antrum-punture trocar and cannula
3.Higgison’s syringe or 50 cc syringe
4.A collecting kidney tray
5.Sterile normal saline or sterile water (at body temperature)
6.Tille’s forceps or nasal dressing forceps
7.Cotton balls
8.Head light with mirror
 Informed written consent of the patient
 Steps of operation:
 Mohammad Shariful Alam
(Shohan)

1. Anaesthesia
- In adult local anaesthesia is preferred
- In children & frightened patient general anaesthesia is required
2. Area of middle meatus should be decongested to open the maxillary ostium for easy
return of fluid.
3. Position
- Sitting position is preferred in all adults, when using local anaesthesia
- When using general anaesthesia, patient is placed in tonsillectomy position
4. With the help of the nasal speculum, the Lichwitz trocar and cannula is introduced
into the lateral wall of the inferior meatus at a point 1.5 – 2.0 cm from anterior end
of inferior turbinate and near the attachment of concha with lateral wall.
5. The trocar is directed towards the outer canthus or rather zygoma with butt of the
trocar in the palm of the hand.
6. The medial wall of the sinus is punctured and sense of entering cavity is felt by the
surgeon.
7. The index finger acts as a guard to prevent double puncture.
8. The trocar is removed and cannula is advanced till it reaches the opposite antral
wall and then withdrawn a little.
9. Now saline or sterile water is passed to the antrum by Higgison’s syringe.
10. Syringing is continued until the return is clear.
11. The remaining water in the antrum is cleared out by withdrawing the syringe from
saline and pumping-out air.
12. After the puncture is over, cannula is removed and a pack kept in the inferior
turbinate to control bleeding.
13. Swab from antral pus may be taken for culture and sensitivity.

Q.Types of nasal ployp. Difference between 2 types.

Ans. Nasal polyps are non-neoplastic pedunculated masses of hypertrophied oedematous nasal
or sinus mucosa composed of loose fibro-oedematous tissue lined by ciliated columner
epithelium.

Types of nasal polyp:

Nasal polyps are classified into 3 categories-
1. Simple mucous polyp: (commonest variety)
(i) Antro-choanal polyp
(ii) Bilateral ethmoidal polypi.
2. Fungal polyps
3. Neoplastic polyps:
(i) Benign tumors such as papilloma, hemangioma, fibroma, inverted papilloma etc.
may present as a polyp.
(ii) Malignant tumours may present as solid polypoid mass, either of ethmoid or
maxillary sinus origin or inverted papilloma with malignant change.

Difference between Antrochoanal polypi and Ethmoidal polypi:

 Mohammad Shariful Alam
(Shohan)

Traits Antrochoanal Polyp Ethmoidal Polyp

1. Age Common in children and adolescents. Common in adults.
2. Aetiology Mainly allergic in origin; may be Allergy or multifactorial
infective also.
3. Number Solitary Multiple
4. Laterality Unilateral Bilateral
5. Origin Maxillary antrum near the ostium. Arise from anterior, middle and
posterior group of ethmoid cells.
6. Growth Grows backwards to the choana and Grows forwards and best seen in
best seen in P.N.S. by posterior A.N.S. by anterior rhinoscopy.
rhinoscopy.
7. Extension May extend into the nasopharynx and No.
oropharynx.
8. Size & shape Trilobed with antral, nasal and Usually small and grape-like
choanal parts. masses.
9. X-ray of the sinuses Shows unilateral opacity of the Shows bilateral antral haziness and
maxillary antrum. ethmoid cells are also hazy.
10. Treatment Polypectomy; endoscopic removal or Endoscopic surgery or
Caldwell-Luc operation if recurrent. ethmoidectomy.
11. Recurrence Uncommon, if removed completely. Common.

Q. Treatment of chronic maxillary sinusitis.

Ans. Treatment:
a. Conservative treatment:
1.Aggravating factors such as dust, smoke, alcohol and tobacco should be avoided.
2.Nutritious diet & Vit. C is helpful.
3.Dental sepsis is to be controlled.
4.Nasal decongestants and antihistamines to control allergy.
5.Steam inhalation helps to loosen mucoid secretion.
6.Broad spectrum antibiotic therapy e.g., with Cephalexin, amoxycillin with
clavulanic acid, azythromycin, doxycycline.
7.Steroid nasal spray is helpful to reduce oedematous turbinate’s and clearing ostio-
metal complex.

b. Surgical treatment:
1.Eradication of sinus:
a) Bilateral antral wash out
b) Intra-nasal antrostomy or endoscopic maxillary antrostomy
c) Caldwell-Luc operation
d) Trephnine of frontal sinuses
2.Functional endoscopic sinus surgery (FESS)
3.Removal of associated cause e.g. DNS, polyp, HIT etc.
 Mohammad Shariful Alam
(Shohan)

Q. What is FESS?
Ans. FESS:
Functional Endoscopic Sinus Surgery (FESS) is a term coined by an American ENT
Surgeon, Dr David Kennedy in 1985 to describe the diagnosis and treatment of diseases of the
nose and paranasal sinuses using endoscopes and CT scans.
*FESS helps to maintain normal physiology, cilliary activity and drainage of the
sinuses, thereby clears sinus pathology.ostio-meatal complex area is cleared of all obstructive
pathology – mainly polypoid mucosa. Anterior end of polypoid middle turbinate is excised,
uncinate process is trimmed, osteii of paranasal sinuses are freed from obstruction and helping
proper drainage of sinuses.
FESS is not one operation, but rather a range of diagnostic and treatment procedures
carried out with the help of rigid nasal endoscopes.

Q. Causes of nasal septum perforation.

Ans. Causes of nasal septum perforation are-

1. Traumatic perforation:
 Following septal surgery
 Repeated cautery
 Habitual nose picking
 To put ornaments
2. Pathological perforation:
(a) Delayed drainage of septal abscess
(b) Nasal myiasis
(c) Rhinolith or neglected foreign body causing pressure necrosis
(d) Chronic grnaulomatous condition
 Catilagenous part – lupus, tuberculosis, leprosy
 Bony part – syphilis
(e) Wegener’s granuloma
3. Chrome perforation (chemical): is an occupational hazard.
4. Idiopathic: No definite cause found.

Q. Causes of unilateral nasal obstruction.

Ans. Causes of unilateral nasal obstruction are-

Vestibule
Furuncle
Vestibulitis
Stenosis of nares
Atresia
 Mohammad Shariful Alam
(Shohan)

Nasoalveolar cyst
Papilloma
Squamous cell carcinoma

Nasal cavity
Foreign body
DNS
Hypertrophic inferior turbinate
Concha bullosa
Antro-choanal polyp
Synechia
Rhinolith
Bleeding polypus of septum
Benign and malignant tumours of nose and paranasal sinuses
Sinusitis, unilateral

Nasopharynx
Unilateral choanal atresia

Q. What are complications of sinusitis?

Ans. Complications of sinusitis:
a. Local spread of infection:
1.Cellulitis over sinuses
2.Abscess formation
3.Orbital cellulitis
4.Cellulitis of eyelid
5.Osteomyelitis.

b. Distant spread of infection:

1.Pharyngeal infection
2.Laryngeal infection
3.Chronic suppurative otitis media (CSOM)
4.Dental sepsis
5.Intracranial :
 Meningitis
 Cavernous sinus thrombosis
 Brain abscess
 Extradural abscess.

THROAT
 Mohammad Shariful Alam
(Shohan)

Q. Sign symptom and management of peritonsillar abscess.

Ans. Clinical features:

Symptoms:
 Local:
i. Severe pain in the throat (usually unilateral)
ii. Odynophagia
iii. Muffled and thick speech
iv. Foul breath
v. Ipsilateral earache
vi. Dribbling of saliva and mild trismus
 General:
i. Patient looks ill and anxious
ii. High rise of temperature (103˚ - 104˚)
iii. General malaise
iv. Body aches
v. Headache
vi. Nausea
vii. Constipation
Signs:
1. Buccal mucosa is dirty and foetor may be present.
2. There is marked congestion, bulging and oedema of the tonsilar, peritonsilar and palatal
region on the affected site.
3. A diffuse swelling of the soft palate just superior to the involved tonsil is seen displacing
the uvula medially.
4. In more advanced cases, there may be an area of pus pointing underneath the thin
mucosa.
5. Tonsillar glands are enlarged and tender on the affected side.
6. If untreated, abscess may burst into pharynx, often through crypta magna.

Treatment:
a. Hospitalization
b. Conservative treatment: In the early stages when no distinct abscess is pointing-
I. Intravenous fluids to combat dehydration
II. Intravenous broad-spectrum antibiotics
III. Analgesics like paracetamol, pethidine.
IV. Maintenance of oral hygiene by hydrogen per-oxide or saline mouth washes.

c. Surgical treatment: If there is frank abscess formation-

I. Incision and drainage of abscess under local anaesthesia, pt. in upright sitting
position. Abscess is opened at the point of maximum bulge above the upper pole
of tonsil or just lateral to the point of junction of anterior pillar with a line drawn
through base of the uvula.
 Mohammad Shariful Alam
(Shohan)

II. Interval tonsillectomy: The tonsils are removed four to six weeks following an
attack of quinsy.
Abscess or hot tonsillectomy: It has the risk of rupture of the abscess during anaesthesia, and
excessive bleeding at the time of operation.

Q. Post-operative care immediately after tonsillectomy.

Ans. Postoperative care:

 Normal unaided respiration should be established before the patient leaves the operation
theatre.
 The patient is placed in tonsil position until fully recovered from anesthesia which allows
free respiration and permits any blood and secretions, which may collect, to run out of the
nose and mouth.
 A strict watch should be kept on the pulse, respiration and blood pressure of the patient. A
rising pulse indicates hemorrhage.
 Nothing is given orally for first 3/4 hours, and then liquid feed is allowed.
 Cold drinks (e.g. cold milk, ice cream or ice cubes) and soft diets are prescribed for the
initial few days. Diet is gradually built from soft to solid food. Plenty of fluid should be
encouraged.
 Analgesics are given for pain.
 Antiseptic mouth washes to keep the mouth clean.
 A suitable antibiotic can be given orally or by injection for a week.

Q. Causes of dysphagia.

Ans. Causes of dysphagia are-

A. Mechanical causes:
1. Oral causes:
 Lock-jaw
 Stomatitis, glossitis and angular stomatitis
 Submandibular sialo-adenitis
 Impacted molar, and other dental lesions
 Inflammation of the floor of the mouth
 Malignant growth of the tongue, ulcer tongue, etc.
 Tumors of oral cavity, odontogenic tumours, palatal tumours, etc.
2. Pharyngeal and laryngeal causes:
 Acute follicular tonsillitis
 Peritonsillar abscess
 Retro-pharyngeal and para-pharyngeal abscess
 Cancer of the pharynx
 Oedema larynx
 Advanced laryngeal cancer
 Foreign body pharynx
 Pharyngeal diverticulum
 Specific lesion e.g., koch’s, syphilis etc.
 Mohammad Shariful Alam
(Shohan)

 Palatal and pharyngeal paralysis

 Agranulocytic angina
 Paterson-Brown Kelly syndrome
3. Oesophageal causes: (*)
(a)Causes in the lumen:
 Foreign bodies such as coins in the children
 Meat bones or dentures in adult
(b)Causes in the wall:
 Congenital atresia and other abnormalities
 Corrosive oesophagitis
 Peptic oesophagitis (reflux)
 Traumatic oesophagitis (operative)
 Acquired strictures
 Spasm and diverticulum
 Cardio-spasm or Achalasia
 Benign tumours : e.g., Adenoma or myoma, etc.
 Cancer oesophagus
 Tracheo-oesophageal fistula
 Oesophageal varix
 Scleroderma
(c)Causes outside the wall:
 Retro-sternal goiter and enlarged thymus in infants and young children
 Pressure by mediastinal mass
 Enlarged heart and aneurysm of the aorta
 Bronchogenic carcinoma
 Dysphagia lusoria
4. Cervical causes:
o Enlarged thyroid and malignant thyroid
o Metastatic, Hodgkin’s or other neck node mass
o Ludwig’s angina
o Parotitis
o Temporo-mandibular arthritis
B. Neuro-muscular causes:
i. Central lesions causing vagal paralysis
ii. Motor neuron disease
iii. Peripheral neuritis
iv. Jugular-foramen syndrome
v. Myasthenia
C. Psychological: Globus hystericus

Q. 5 common causes of hoarseness of voice.

Ans. Causes of hoarseness of voice:

1. Inflammations
 Acute: Acute laryngitis, laryngo-tracheo-bronchitis, laryngeal diphtheria
 Chronic:
 Mohammad Shariful Alam
(Shohan)

 Specific: Tuberculosis, syphilis, scleroma, fungal infections

 Non-specific: Chronic laryngitis, atrophic laryngitis.
2. Tumors
 Benign: Papilloma, haemangioma, chondroma, fibroma, leukoplakia.
 Malignant: Carcinoma.

 Tumour-like masses: Vocal nodule, vocal polyp, angiofibroma, amyloid tumour,

contact ulcer, cysts, laryngocele.
3. Trauma:
 External: Strangulation, injury neck, etc.
 Internal: Instrumentation, fumes, operative.
4. Paralysis: Paralysis of recurrent, superior laryngeal or both nerves.
5. Fixation of cords: Arthritis or fixation of cricoarytenoid joints.
6. Congenital:

 Laryngeal web, stenosis and atresia

 Laryngeal malacia
 Laryngeal arrhythmia
7. Miscellenious: Dysphonia plica ventricularis, myxoedema, gout
8. Functional: Hysterical aphonia

Q. Causes and management of reactionary hemorrhage after tonsillectomy.

Ans. Reactionary hemorrhage occurs within 24 hours of the operation, but commonly within first
5/6 hours. Bleeding results from –
(a) Failure to ligate all bleeding points;
(b) Slipping of a loosely tied knot or clot following rise of B.P. after operation;
(c) Collapsed vessels opening up in the post-operative period;
(d) Bleeding from vessels after relaxation of the stretched faucial tissue and muscle on
removal of the mouth gag;
(e) Failure of a vessel to contract and retract following crushing; and
(f) In cases of local anesthesia, as the effect of adrenaline wears off, the vessels dilate.

Management:
After tonsillectomy operation in post-operative period when the patient is placed in
tonsillar position if blood continuously accumulates in the mouth or dribbles through the mouth
or repeated gulping specially in the children indicates reactionary hemorrhage.
 I/V channel should be opened and saline infusion should be started.
 Patient’s blood is to be drawn and sent for grouping and cross matching.
 A strict watch should be kept on the pulse, respiration and blood pressure of the
patient. If features of shock develops than treatment of shock.
 Airway is cleaned by giving suction and it is to be ensured that there is no obstruction
or hypoxia.
 Mohammad Shariful Alam
(Shohan)

 Mouth is opened and tonsillar fossa is inspected. If a bleeding clot is seen, then it has
to be removed with a Luc forceps and a piece of gauze soaked in hydrogen-per-oxide
or adrenaline is held firmly against the fossa for 10-15 minutes. Usually in many
cases bleeding stops by this measure.
 If the bleeding persists
- call the immediate senior consultant and anesthesiologist and make sure the
operation theatre is ready
- the patient is to be taken to operation theatre immediately and under G/A, the
bleeding is controlled by ligation or electro-cauterization of bleeding vessel
- a nasogastric tube is to be introduced before anesthesia and swallowed blood is to
be sucked out to prevent aspiration
 Blood transfusion is necessary in severe cases.
 The patient is then kept under watch and follow-up is given accordingly.

Q. Complication after adenoidectomy.

Ans. Complications of adenoidectomy are-

1. Haemorrhage : Primary, reactionary, & secondary.

2. Eustachian tube injury and stenosis.
3. Injury to pharyngeal musculature and vertebrae.
4. Otitis media :
i. Secretory otitis media
ii. Acute otitis media.
5. Velopharyngeal insufficiency.
6. Nasopharyngeal stenosis due to scarring.
7. Incomplete removal and recurrence.

Q. What you know about achalasia cardia?

Ans. Achalasia cardia:

Achalasia Cardia is a primary oesophageal motility disorder,
characterized by a hypertensive lower oesophageal sphincter (LOS) which fails to relax on
swallowing, and by aperistalsis of the body of the oesophagus.

Incidence:
The incidence of the disease is 1-2 per 200,000 per year, with both sexes equally affected.
Onset of the disease is typically between the ages of 20 and 50.

Aetiology:
Exact aetiology is unknown. Some theories are-
1.Loss of ganglionic cells in the myenteric (Auerbach’s) plexus
2.Abnormal pinch-cock action of right crus of diaphragm
3.Vagal disturbance
 Mohammad Shariful Alam
(Shohan)

4.Aerophagy
5.Primary dilatation
6. Lack of integrated parasympathetic stimulation and non-propulsive motility in
the body of the oesophagus.

Pathology:
 Marked dilatation of the lower two- third of the oesophagus
 Lumen (diameter) 7.5 cm.
 Muscular walls are hypertrophied
 No hypertrophy of the cardiac sphincter
 Histopathology of muscle specimens generally shows a reduction in the number of
ganglion cells (and mainly inhibitory neurons) with a variable degree of chronic
inflammation.

Clinical features:
Age- Young person of both sexes.
Onset of disease is insidious.
Symptoms:
1.Dysphagia – more liquid then solid.
2.Regurgitation of undigested food.
3.Discomfort or pain in the retrosternal or epigastric region.
4.Loss of weight.
5.Fullness after meal in retrosternal or epigastric area.
6.Night time cough.

Differential diagnosis:
1.Carcinoma of oesophagus
2.Stricture
3.Hiatus hernia.

Investigations:
1. Endoscopic examination shows a tight cardia and food residue in the oesophagus.
2. Barium swallow X-ray of the oesophagus shows
- It usually shows a "bird’s beak" narrowing at the GO junction and oesophageal
dilatation proximal to the narrowing.
- Gastric gas bubble is usually absent
3. Oesophagoscopy shows the dilated oesophagus with smooth narrowing of cardiac end
containing undigested food.
4. Oesophageal Manometry :( In this test, a thin tube is passed into the esophagus to measure the
pressure exerted by the esophageal sphincter.)
Typical manometrical findings are the absence of oesophageal peristalsis and a
hypertensive LOS which fails to relax completely in response to swallowing.

Treatment:
1. Medical treatment: Before meal- Nifedipine
2. Botulinum toxin injection. Injected into the sphincter, botulinum toxin paralyzes the
muscle and allows it to relax.
 Mohammad Shariful Alam
(Shohan)

3. Forceful dilatation of cardia under general anaesthesia: Oesophagoscopy & dilatation by-
 Plastic balloons
 Hydrostatic bag
4. Surgical treatments:
 Hellar’s myotomy under general anaesthesia
 Anastomic operation – anastomosis between stomach & oesophagus.

Q. Causes of white lesion in throat.

Ans. Causes of white lesions in throat are-

1. Acute follicular tonsillitis

2. Faucial diphtheria
3. Vincent’s angina
4. Agranulocytosis
5. Infectious mononucleosis (Glandular fever)
6. Oral thrush (cadidiasis)
7. Leukaemia

Q. Causes of ulcer in the margin of the tongue.

Ans. Causes of ulcers of the oral cavity:

1. Infections
 Viral: Herpengina; primary and secondary herpes simplex; hand, foot and
mouth disease
 Bacterial: Vincent’s infection, TB, syphilis
 Fungal: Candidiasis
2. Immune disorders:
 Aphthous ulcer
 Bechet’s syndrome

3. Trauma
 Physical: Cheek bite, jagged tooth, ill-fitting denture
 Chemical: Silver nitrate, phenol, aspirin burn
 Thermal: Hot food or fluid, reverse smoking
4. Neoplasms
5. Skin disorders:
 Erythema multiforme
 Llichen planus
 BMMP
 Bullous pemphigoid
 Lupus erythometosus

6. Blood disorders:
 Leukaemia
 Agranulocytosis
 Pancytopenia
 Mohammad Shariful Alam
(Shohan)

 Cyclic neutropenia
 Sickle cell anaemia
7. Drug allergy: Mouth washes, tooth paste, etc
8. Vitamin deficiencies
9. Miscellaneous:
 Radiation mucositis
 Cancer chemotherapy
 Ddiabetes mellitus
 Uraemia

Q. Management of hemorrhage after adenoidectomy.

Ans. Management of hemorrhage after adenoidectomy-

Hemorrhage usually seen in immediate post-operative period.

 Nose and mouth may be full of blood
 Vomitus of dark coloured blood which the patient had been swallowing gradually in
post-operative period.
 Rising pulse rate.

 Primary hemorrhage always brisk and stops quickly.

 Reactionary hemorrhage is common within 24 hours of operation. It is often due to remnant
of adenoids.
 Packing the area for sometimes
 Conservative treatment:
- Decongestive nasal drops
- Coagulants and
- Sedatives
 Persistent bleeders are electro-coagulated under vision.
 If bleeding still not controlled a postnasal pack is left for 24 hours under general
anaesthsia.
 If remnant of the adenoid tissue is present, then it should be removed.
 Secondary hemorrhage is uncommon.

Q. What is adenoid facies?

Ans. Chronic nasal obstruction and mouth breathing due to enlarged adenoid lead to
characteristic facial appearance of a child called adenoid facies. Features of adenoid facies are-

1. Elongated face with dull expression

2. Open mouth
3. Dribbling of saliva from angle of the mouth
4. Prominent and crowded upper teeth
5. Hitched up upper lip
6. Pinched nose
7. Highly arched hard palate
8. Rounded shoulder
 Mohammad Shariful Alam
(Shohan)

9. Flat chest
10. Abdomen is protuberant

Q. A woman of 45 years of age with anaemia complains dysphagia. What is your D x?

Ans. The woman is probably suffering from Plummer-Vinson syndrome (Paterson-Brown Kelly
syndrome).
This is a precancerous lesion, commonly seen in woman whom there is chronic superficial
pharyngo-oesophagitis.

Aetiology:
 Iron deficiency anaemia
 Vitamin deficiency
 Auto-immune disease.

Clinical features:
1. Dysphagia – more to solids
2. Feeling of lump in the throat
3. Features of iron deficiency anaemia
4. Angular stomatitis, glossitis, and koilonychias.
5. Web formation or cicatrisation in post-carotid region.

Diagnosis:
(1) By clinical features, signs of vitamin deficiency
(2) Hypochromic microcytic anaemia
(3) Barium swallow X-ray shows a web at the post-cricoid region.
(4) Hypopharyngoscopy and oesophagoscopy to confirm.
(5) Serum iron and iron binding capacity to see prognosis after treatment.

Treatment:
1. Iron and vitamins are given in large doses.
2. Endoscopic examination and dilatation relieves dysphagia.
3. Follow-up.

Q. Causes and management of primary hemorrhage after tonsillectomy.

Ans. Causes of primary haemorrhage: Occurs at the time of operation

1. Faulty selection of the patient i.e. pt. with high blood pressure, DM, any bleeding
disorders.
2. Injury to the surrounding structures
3. Tonsillar fibrosis.

Management:
It can be controlled by pressure, ligation or electrocoagulation of the bleeding vessels.

Q. Types of hemorrhage after tonsillectomy.

 Mohammad Shariful Alam
(Shohan)

Ans. The most common complication of tonsillectomy operation is haemorrhage which is of

three types-
(i) Primary haemorrhage – occurs at the operation table.
(ii) Reactionary haemorrhage – is due to rise of blood pressure in the post-operative
period.
(iii)Secondary haemorrhage – is due to infection.

Q. What are the indications of tonsillectomy?

Ans. Indications of tonsillectomy are divided into:

Absolute Relative As a part of another operation

1.Recurrent infections of throat- 1. Diphtheria carriers, who do 1. Palatopharyngoplasty
(a) Seven or more episodes in not respond to antibiotics. 2. Glossopharyngeal neurectomy
one year, or 2. Streptococcal carriers, who 3. Removal of styloid process.
(b) Five episodes per year for 2 may be the source of
years, or infection to others.
(c) Three episodes per year for
3 years, or 3. Chronic tonsillitis with bad
(d) Two weeks or more of lost taste or halitosis which is
school or work in one year. unresponsive to medical
treatment.
2.Peritonsillar abscess –
tonsillectomy is done 4-6 4. Recurrent streptococcal
weeks after abscess has been tonsillitis in a patient with
treated. valvular heart disease.
3.Tonsillitis causing febrile
seizures.
4.Hypertrophy of tonsils
causing
 Airway obstruction (sleep
apnoea)
 Difficulty in diglutation
 Interference with speech.
5.Suspicion of malignancy :
 Lymphoma – in children
 Epidermoid carcinoma – in
adults.

Q. Tell 5 contraindications of tonsillectomy operation.

Ans. Contraindications for tonsillectomy:

1. Acute tonsillitis or acute upper respiratory tract infection.
2. Blood dyscrasia and bleeding diathesis.
3. Overt or submucous cleft palate.
4. During epidemic of polio.
5. Systemic infection and chronic debilitating disease (e.g. severe DM, gross HTN,
severe asthma).
6. Children under 3 years of age. (They are at poor surgical risks)
 Mohammad Shariful Alam
(Shohan)

HEAD-NECK

Q. Name parotid salivary gland tumor. Name surgical procedure of parotid.

Ans. Classification/Name of salivary gland tumors:

Type Sub-group Common examples

i. Adenoma Pleomorphic Pleomorphic adenoma (most common benign)
Monomorphic Adenolymphoma (Warthin’s tumor)
ii. Carcinoma Low grade Acinic cell carcinoma
Adenoid cystic carcinoma
Low-grade muco-epidermoid carcinoma
High grade Adenocarcinoma
Squamous cell carcinoma
High-grade muco-epidermoid carcinoma
iii. Non-epithelial tumors Haemangioma
Lymphangioma
iv. Lymphomas Primary lymphomas Non-Hodgekin’s lymphomas
Secondary lymphomas Lymphomas in SjÖgren’s syndrome

v. Secondary tumors Local Tumors of head and neck specially

vi. Unclassified tumors
vii. Tumor like lesions
Distant Skin and bronchus
Solid lesions Benign lymphoepithelial lesion
Adenomatoid hyperplasia
Cystic lesions Salivary gland cysts

Surgical procedure of parotid:

1. Superficial parotidectomy
- Incision and development of a skin flap
(Incision is the ‘lazy S’ pre-auricular-mastoid-cervical)
- Mobilisation of the gland
- Location of the facial nerve trunk
- Dissection of the gland off the facial nerve
- Closure
2. Radical parotidectomy

Q. What is Ludwig’s angina?

Ans. Ludwig’s angina:
This is a rare, virulent and often fatal septic inflammation of the soft tissue of the
sublingual space with subsequent extension to the submandibular space and tissues of the neck.
 Mohammad Shariful Alam
(Shohan)

Q. Symptoms of hyperthyroidism and hypothyroidism.

Ans. Symptoms of hyperthyroidism and hypothyroidism are-

Hypothyroidism Hyperthyroidism
 Tiredness  Tiredness
 Mental lethargy  Emotional lability
 Cold intolerance  Heat intolerance
 Weight gain  Weight loss
 Constipation  Excessive appetite
 Menstrual disturbance  Palpitations
 Carpal tunnel syndrome

Q. Indication of tracheostomy.

Ans. Indications of tracheostomy are-

A. Respiratory obstruction
1. Infections
- Acute laryngo-tracheo-brochitis, acute epiglottitis, diphtheria
- Ludwig’s angina, peritonsillar, retropharyngeal or parapharyngeal abscess,
tongue abscess
2. Trauma
- External injury of larynx and trachea
- Trauma due to endoscopies, especially in infants and children
- Fracture of mandible or maxillofacial injuries
3. Neoplasms
- Benign and malignant neoplasms of larynx, pharynx, upper trachea, tongue
and thyroid
4. Foreign body larynx
5. Oedema larynx due to steam, irritant fumes or gases, allergy, radiation
6. Bilateral abductor paralysis
7. Congenital anomalies
- Laryngeal web, cysts, tracheo-oesophageal fistula
- Bilateral choanal atresia
B. Retained secretions
1. Inability to cough
- Coma of any cause, e.g. head injuries, cerebrovascular accidents, narcotic
overdose
- Paralysis of respiratory muscles, e.g. spinal injuries, polio, Guillain-Barre
syndrome, myasthenia gravis
- Spasm of respiratory muscles, tetanus, eclampsia, strychnine poisoning
2. Painful cough
- Chest injuries, multiple rib fractures, pneumonia
3. Aspiration of pharyngeal secretions
 Mohammad Shariful Alam
(Shohan)

- Bulbar polio, polyneuritis, bilateral laryngeal paralysis

C. Respiratory insufficiency
- Chronic lung conditions, viz. emphysema, chronic bronchitis, bronchiectasis,
atelectasis
- Conditions listed in A and B*
* In viva voce this point should not be told. Conditions listed in A and B means the points mentioned under the heading
of respiratory obstruction and retained secretions.

Q. Post operative care after tracheostomy.

Ans. Post-operative management/after cares after tracheostomy:

1. Constant supervision:
 Constant supervision for bleeding, displacement or blocking of tube and removal of
secretions is essential.
 A nurse or patient’s relative should be attendance.
 Patient is kept in propped up position.
 Patient is given a bell or a paper pad and a pencil to communicate.
2. Suction:
 Depending on the amount of secretion, suction may be required every half an hour or
so.
 Use sterile catheters with a Y-connector to break suction force.
3. Prevention of crusting and tracheitis: This is achieved by-
(a) Proper humidification by following methods-
i. Humidifier
ii. Steam-tent in children
iii.Ultrasonic nebulizer or
iv. Steam-kettle.
(b) If crusting occurs,
- A few drops of normal or hypotonic saline or Ringer’s lactate are instilled into
the trachea every 2-3 hours to loosen crusts.
- A mucolytic agent such as acetylcysteine solution can be instilled to liquefy
tenacious secretions or to loosen the crusts.

4. Care of tracheostomy tube:

 Inner cannula should be removed and cleaned as and when indicated for the first 3
days.
 Outer tube, unless blocked or displaced, should not be removed for 3-4 days to allow
a track to be formed when the tube placement will become easy.
 After 3-4 days, outer tube can be removed and cleaned every day.
5. Feeding:
 Mohammad Shariful Alam
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Proper nourishment is essential for recovery of the patient. If the patient is unable to
eat, then naso-gastric feeding is to be started.

6. Physiotherapy and change of posture:

 In ambulatory patient: Coughing out is encouraged and various breathing exercise to
be taught.
 In non-ambulant patient: Posture is to be changed frequently and lung care is to be
taken to prevent lower respiratory tract infection.
7. Dressing:
Water proof dressing should be applied to prevent maceration of surrounding skin.
8. Decannulation:
 Tracheostomy tube is plugged and the patient closely observed. If the patient can
tolerate it for 24 hours, tube can be safely removed.

Q. Causes of midline neck swelling.

Ans. Causes of midline neck swelling are-
Solid Cystic
 Swelling of the thyroid isthmus and  Ranula
pyramidal lobe  Ludwig’s angina
 Enlarged lymph nodes (submental,  Sublingual dermoid
prelaryngeal, pretracheal)  Lipoma in the submental region
 Thyroglossal cyst
 Subhyoid bursitis
 Cold abscess in the space of Burns

Q. Causes of lymph node enlargement in neck.

Ans. Causes of cervical lymph adenopathy:

Inflammatory
 Reactive hyperplasia
Infective
 Viral
For example, infectious mononucleosis, HIV
 Bacterial
Streptococcus, Staphylococcus
Actinomycosis
Tuberculosis
Brucellosis
 Protozoan
Toxoplasmosis
Neoplastic
 Malignant
Primary, e.g. lymphoma
Secondary, e.g. squamous cell carcinoma
Known primary
Occult primary
 Mohammad Shariful Alam
(Shohan)

Q. Causes of thyroid swelling. Name the investigations of thyroid enlargement.

Ans. Classification of thyroid swelling:
 Simple goiter (euthyroid)
Diffuse hyperplastic
Physiological
Pubertal
Pregnancy
Multinodular goiter

 Toxic
Diffuse
Graves’ disease
Multinodular
Toxic adenoma

 Neoplastic

Benign
Follicular adenoma

Malignant
Primary
Follicular epithelium – differentiated
Follicular
Papillary
Follicular epithelium – undifferentiated
Anaplastic
Parafollicular cells
Medullary
Lymphoid cells
Lymphoma
Secondary
Metastatic
Local infiltration

 Inflammatory
Autoimmune
Chronic lymphocytic thyroiditis
Hashimoto’s disease
Granulomatous
De Quervain’s thyroiditis
Fibrosing
Riedels thyroiditis
Infective
Acute (bacterial thyroiditis, viral thyroiditis, ‘subacute thyroiditis’)
Chronic (tuberculous, syphilitic)
Other
Amyloid
Investigation:

1. Thyroid function

Thyroid functional state TSH (0.3-3.3 mU l-1) Free T4 (10-30nmol l-1) Free T3 (3.5-7.5 μmol l-1)
 Mohammad Shariful Alam
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Euthyroid Normal Normal Normal

Thyrotoxic Undetectable High High
Myxoedema High Low Low
Suppressive T4 therapy Undetectable High High (may be normal)
T3 toxicity Low/undetectable Normal High

2. Autoantibody titres
Serum level of antibodies against thyroid peroxidase (TPO) and thyroglobulin are
useful in determining the cause of thyroid dysfunction and swelling. Levels above 25 units’ ml-1 for TPO
antibody and titres of greater than 1:100 for anti-thyroglobulin are considered significant.

3. Isotope scan
The uptake by the thyroid of a low dose of either radiolabelled iodine (132I) or the cheaper
99m
technetium ( Tc) will demonstrate the distribution of activity in the whole gland. In hyperthyroidism both
the proportion of the tracer dose taken up and the rate at which this takes place are increased.

4. Ultrasonography
Ultrasongrapphy is used in determining the physical characteristics of thyroid swellings
and to demonstrate subclinical nodularity and cyst formation.

5. Fine-needle aspiration cytology

FNAC is the choice of investigation in discrete thyroid swellings.
Thyroid conditions that can be diagnosed by FNAC include colloid nodules, thyroiditis, papillary
carcinoma, medullary carcinoma, anaplastic carcinoma and lymphoma.

6. Radiology
Chest and thoracic inlet radiograph may confirm the presence of significant retrosternal goitre
and tracheal deviation, compression or retrosternal extension and are required when either clinical suspicion
or FNAC indicates malignancy.

7. Ultrasound scan
High-frequency ultrasound gives good anatomical images of the thyroid and surrounding structures.

8. Other scans
Computed topography (CT), magnetic resonance imaging (MRI) and positron emission
topography (PET) are used for the assessment of known malignancy and to assess the extent of retrosternal
and, occasionally, recurrent goitres.

9. Laryngoscopy
Flexible laryngoscopy is used preoperatively to determine the mobility of the vocal cord.

10. Core biopsy

Core biopsy gives a strip of tissue for histological assessment. It is applied in assessment of
locally advanced, surgically unresectable malignancy.

Q. Causes of unilateral neck swelling.

Ans. Causes of unilateral neck swelling are-

 Mohammad Shariful Alam
(Shohan)

Site Solid Cystic

Submandibular Tumor of submandibular gland Plunging ranula
triangle Sialolithiasis Sublingual dermoid
Enlargement of lymph nodes
Carotid triangle Carotid body tumor Carotid aneurysm
Sternomastoid tumor Branchial cyst
Solidication of lymph nodes Laryngoceal
Cyst adenoma of thyroid (lateral lobe)
Cold abscess of lymph nodes (e.g., TB
lymphnodes)
Posterior triangle Enlarged supraclavicular lymph nodes Cystic hygroma
Laryngoceal
Pharyngeal pouch
Subclavian aneurysm