I.

ANATOMY OF EAR, PHYSIOLOGY OF HEARING, ASSESSEMENT OF HEARING,

HEARING LOSS VESTIBULAR FUNCTION TESTS

ANATOMY OF EAR
AURICLE OR PINNA

• The entire pinna (except its lobule and outer part of external acoustic canal) is made up of a framework of a
single piece of yellow elastic cartilage
• There is no cartilage between the tragus and crus of the helix – incisura terminalis
• An incision made in this area will not cut through the cartilage – used for endaural approach in surgery of
external auditory canal and mastoid

EXTERNAL ACOUSTIC CANAL

• 24 mm long
• Outer part – directed upwards, backwards and medially
• Inner part – directed downwards, forwards and medially
• To see the tympanic membrane – pinna has to be pulled – upwards, backwards and laterally
• Cartilaginous part

Outer one-third (8mm)

Two deficiencies – fissures of Santorini – through them the parotid and superficial mastoid infections
can appear in the canal or vice versa

Skin is thick and contains ceruminous and pilosebaceous glands which secrete wax

Hair is only confined to the outer canal and therefore furuncles are seen only in the outer third of the
canal
• Bony part

Inner two-thirds (16mm)

Devoid of hair and ceruminous glands

Isthmus – bony projection lateral to TM – foreign bodies lodged medial to isthmus are difficult to
remove

Antero-inferior part of bony canal may present a deficiency – foramen of Hushke - in children up to 4
years – permitting infections to and from the parotid

TYMPANIC MEMBRANE
• Obliquely set so that postero-superior part is more lateral than antero-inferior part
• 9-10mm tall; 8-9mm wide; 0.1mm thick

Pars tensa
• Forms most part of tympanic membrane
• Periphery thickened to form annulus tympanicus
• Central part is tented inwards at the level of tip of malleus and is called the umbo
• Umbo is the most reliable landmark in otoscopy
• A bright cone of light seen radiating from the tip of malleus to the periphery in the anteroinferior quadrant

Pars flaccida (Shrapnel's membrane)

• Situated above the lateral process of malleus between the notch of Rivinus and the anterior and posterior
malleal (earlier called malleolar) folds
NERVE SUPPLY OF EXTERNAL EAR
Pinna
• Greater auricular nerve(C2C3)
• Lesser occipital nerve(C2)
• Auriculotemporal nerve (mandibular branch of 5th nerve)
• Auricular branch of Vagus (Arnold's N)
• Facial nerve

External auditory canal

• Anterior and superior walls – auriculotemporal branch of mandibular nerve
• Posterior and inferior walls – auricular branch of vagus – Arnold's nerve
• Part of posterior wall – sensory branch of facial nerve – Nerve of Wrisberg

Tympanic membrane
• Anterior half of lateral surface- auriculotemporal
• Posterior half of lateral surface- Arnolds nerve
• Medial surface - tympanic branch of 9th nerve (Jacobson's N)

MIDDLE EAR
• Mesotympanum – part of middle ear lying opposite to pars tensa (narrowest part)
• Epitympanum or attic – lying above pars tensa but medial to Shrapnell's membrane
• Hypotympanum – lying below the level of pars tensa
• Protympanum – around the tympanic orifice of Eustachian tube
Boundaries
• Roof (tegmental wall): tegmen tympani; separates middle ear from middle cranial fossa
• Floor (jugular wall): bone which separates middle ear from jugular bulb
• Lateral wall : formed largely by TM; To a lesser extent by bony outer attic wall (scutum)
• Anterior wall: Bone which separates middle ear from internal carotid artery. It has 2 openings

upper- canal for tensor tympani

lower- ET
 • Posterior wall

Pyramid – bony projection where tendon of stapedius arises

Facial nerve runs in the posterior wall just behind the pyramid

Two recesses – Facial recess (suprapyramidal) and Sinus tympani (infrapyramidal)

These recesses are the most common location of cholesteatoma persistence after ear surgery

Sinus tympani is very difficult to access surgically

Facial recess is lateral to facial nerve and its relations are
o Medial – pyramid
o Lateral – posterosuperior meatal wall
o Below - chorda tympani
o Above - fossa incudis
• Medial wall: formed by labyrinth

Promontory- formed by basal turn of cochlea

Oval window- foot plate of stapes fixed

Round window or fenestra cochlea- covered by secondary TM

Canal for facial nerve – above the oval window

Processus cochleariformis - anterior to oval window, marks the genu of facial nerve (landmark of
surgery)
• Prussak's space

medially neck of malleus

laterally pars flaccida

above lateral process of malleus

anteriorly, posteriorly and superiorly by lateral malleal ligament

Contents of middle ear

• Ear ossicles – Malleus, Incus, Stapes (the smallest bone)
• Ligaments of ear ossicles
• Muscles – Tensor tympani and Stapedius
• Vessels of Middle ear
• Nerves – Chorda tympani and tympanic plexus

Arterial supply
• Anterior tympanic branch – from maxillary artery
• Posterior tympanic branch – from posterior auricular artery

MASTOID ANTRUM
• Large air containing space in the upper part of mastoid
• Roof formed by tegmen antri (continuation of tegmen tympani)
• Marked externally on the surface of mastoid by suprameatal or MacEwen's triangle
• Boundaries of suprameatal triangle

Supramastoid crest or temporal line – above (base)

Posterosuperior margin of bony external auditory canal – anteroinferiorly

Tangential line joining supramastoid crest to spine of Henle - posteriorly
• The petrosquamosal suture may persist as a bony plate – Korner's septum
• Korner's septum – surgically important – mastoid antrum cannot be reached unless it is removed

• Middle ear cleft: Middle ear together with Eustachian tube, aditus, antrum and mastoid air cells.
INNER EAR or LABYRINGH
• Bony labyrinth
• Membranous labyrinth –filled with endolymph
• Space between membranous and bony labyrinth filled with – perilymph

BONY LABYRINTH
• Vestibule

In its lateral wall lies the oval window

D Medial wall has two recesses
o Spherical recess - lodges saccule
o Elliptical recess – lodges utricle

Posterosuperior part receives five openings of semicircular canals
• Semicircular canals

Lateral, posterior and superior semicircular canals

Lie in planes at right angles to one another

Responds to angular acceleration and deceleration
• Cochlea

Coiled tube making 2.5 to 2.75 turns round a central pyramid of bone called modiolus

Three compartments – Scala vestibule, Scala tympani and Scala media

MEMBRANOUS LABYRINTH
Cochlear ducts

Also called the membranous cochlea or scala media

Triangular in cross section and the three walls are formed by
o Basilar membrane
o Reissner's membrane
o Stria vascularis
• Utricule and Saccule: Utricle responds to linear acceleration and deceleration or gravitational pull
• Semicircular ducts
• Endolymphatic duct and sac

Composition of inner ear fluids

Endolymph Perilymph CSF
Sodium (mEq/L) 5 140 152
Potassium (mEq/L) 144 10 4
Protein (mg/dL) 126 200-400 20-50
Glucose (mg/dL) 10-40 85 70

EUSTACHIAN TUBE/AUDITORY TUBE/PHARYNGOTYMPANIC TUBE

• 36mm long in adults
• Runs downwards, forwards and medially from tympanic end
• Two parts – Postero lateral bony part (12mm)
• Antero medial fibro cartilaginous part (24mm)
• Two parts meet at the isthmus – narrowest part of ET
• Tympanic end (bony) - anterior wall of middle ear
• Pharyngeal end - lateral wall of nasopharynx, it raises an elevation called torus tubarius 1 cm behind the
posterior end of inferior turbinate
• 3 muscles -
 1. tensor veli palatini(dilator tubae) opens tubal lumen
2. levator veli palatini
3. salpingopharyngeus
• Ostmann's pad of fat- helps the tube closed at pharyngeal end
• Lining- pseudo stratified ciliated columnar, cilia beat in the direction of nasopharynx
• Nerve supply : tympanic branch of 9th cranial nerve supplies sensory as well as secretomotor fibres
• Tensor veli palatine- mandibular branch of 5th nerve
• Levator veli palatine and salpingopharyngeus – pharyngeal plexus
• Blood supply

Ascending pharyngeal artery

Middle meningeal artery

Artery of pterygoid canal

Infant and adult Eustachian tube differences

Infant Adult
13 – 18 mm at birth 36mm
At birth - 10° with horizontal 45° with horizontal
At 7 years - 45° with horizontal
No angulation at isthmus Angulation present at isthmus
Bony part slightly longer than 1/3rd of Bony part 1/3rd ;
the total length Cartilaginous part 2/3rd
Tubal cartilage – flaccid; reflux of Tubal cartilage -
nasopharyngeal secretions can occur comparatively rigid
Ostmann's pad of fat – less in volume More in volume and helps to
keep the tube closed

• Functions

Ventilation & regulation of middle ear pressure

Protection against nasopharyngeal sound pressure and reflux of nasopharyngeal secretions

Clearance of middle ear secretions
• ET function tests: Valsalva test, Politzer test, Toynbee's test, Tympanometry, Sonotubometry

Lymphatic drainage of ear

Area Nodes
Concha, Tragus, Fossa triangularis, Pre auricular and parotid nodes
External cartilaginous canal
Lobule and antitragus Infra-auricular nodes
Helix and anti-helix Post auricular nodes, deep jugular and spinal accessory nodes
Middle ear and Eustachian tube Retropharyngeal nodes – upper jugular chain
Inner ear No lymphatics

KEY POINTS:
• Bill's bar – in the internal acoustic meatus separates facial nerve from superior vestibular nerve
• Glasserial fissure – in the middle ear transmits anterior tympanic branch of maxillary artery, anterior
ligament of malleus and Chorda tympani nerve through canal of Huguier
• Tympanic membrane develops from all the three germinal layers
• Embryology of inner ear

I arch – malleus and incus

II arch – stapes except its foot plate
 • Ear ossicles – ossify by 4th month (first bones to ossify in human body)
• Otic capsule – annular ligament and foot plate of stapes
• Otic capsule (bony labyrinth) ossifies from 14 centres
• Rouviere node – most superior node of lateral group of retropharyngeal nodes
• Cetilli's angle(sinodural angle) is situated between sigmoid sinus and middle fossa dura plate
• Solid angle – where three bony semicircular canals meet
• Hansen cells, Deiter's cells – normal cells near hair cells in inner ear
• Donaldson's line – landmark for endolymphatic sac
• Oort's anastomosis – vestibulocochlear nerve anastomosis
• Electrodes in cochlear implants are inserted in – round window

Trautmann's triangle
• Identifies the location of posterior cranial fossa
• Boundaries

Posterior – sigmoid sinus

Anterior – bony labyrinth

Superior – superior petrosal sinus

Hyrtl's fissure
• Tympanomeningeal hiatus
• Embryonic remnant that connects CSF space to middle ear
• Can be a source of congenital CSF otorrhea

PHYSIOLOGY OF HEARING
Conduction of sound
• Impedance matching mechanism or Transformer action of middle ear: conversion of sound of greater
amplitude with lesser force to that of lesser amplitude but greater force
• It is accomplished by
• Lever action of ossicles
o Handle of malleus is 1.3 times longer than the long process of incur
o Mechanical advantage = 1.3
o Lever ratio = 1.3 : 1
Hydraulic action of TM
o Effective vibratory area of TM = 55 sq.mm.
o Area of Foot Plate of stapes = 3.2 sq.mm.
o Hydraulic ratio = 17: 1

• The product of Lever ratio and Hydraulic ratio (17 x 1.3) gives the Transformer ratio of 22: 1

Natural resonance and efficiency of auditory apparatus

• External auditory canal — 3000 Hz
• Tympanic membrane — 800 to 1600 Hz
• Middle ear — 800 Hz
• Ossicular chain — 500 to 2000 Hz

Intensity of various sound at a distance of 1 m

• Whisper — 30 dB
• Normal conversation — 60 dB
 • Shout — 90 dB
• Discomfort of the ear — 120 dB
• Pain in the ear — 130 dB

 Frequency range in normal hearing — 20 Hz to 20000 Hz

 In routine audiometric testing — 125 to 8000 Hz are evaluated

ASSESSMENT OF HEARING
Conductive hearing loss: caused by any disease process interfering with conduction of sound from the external ear
to the stapedio-vestibular joint

Sensori-neural hearing loss

• Lesions of cochlea – sensory type
• Lesions of VIII nerve and its connections – neural type
• Lesions of VIII nerve – retro-cochlear lesions
• Lesions of central auditory connections – central deafness

TUNING FORK TESTS

• For routine clinical practice – tuning fork of 512 Hz is ideal

Test Normal CHL SNHL

Rinne AC>BC (Rinne +ve) BC>AC (Rinne-ve) AC>BC
Weber Not lateralized Lateralized to poor ear Lateralized to better ear
ABC Same as examiner's Same as examiner's Reduced
Schwabach Equal Lengthened Shortened
Bing Hears louder when ear No change in hearing Hears louder when ear canal is
canal is closed (Positive) (Negative) open (Positive)
Gelle's Positive Negative Positive

Gelle's test
• A test for bone conduction
• Examines the effect of increased air pressure in ear canal on hearing
• When air pressure is increased in the ear canal by Siegel's speculum, it pushes the TM and ossicles inwards,
raises the intra-labyrinthine pressure and causes immobility of basilar membrane and decreased hearing
• But no change in hearing when the ossicular chain is fixed or disconnected
• Previously used to diagnose otosclerosis, but now superceded by tympanometry

AUDIOMETRIC TESTS

PURE TONE AUDIOMETRY (PTA) – uses

• Measures the degree and type of hearing loss
• Essential to prescribe a hearing aid
• To find the degree of handicap for medicolegal purposes
• To predict speech reception threshold

SPEECH AUDIOMETRY
• Speech reception threshold (SRT): The minimum intensity at which 50% of words are repeated correctly by
the patient
 • Speech discrimination score: patients ability to understand speech

Phonetically balanced (PB) words – single syllable words e.g. pin, day, bus are used

Tested at 30 – 40 dB Sensation level (SL)
• Roll over phenomenon:

Seen in retrocochlear hearing loss

With increase in speech intensity above a particular level, the PB word score falls rather than maintain a
plateau as in cochlear type of lesions

Uses of speech audiometry

• To differentiate organic from functional hearing loss
• To find the intensity at which discrimination score is best which is helpful for fitting a hearing aid
• To differentiate cochlear from retrocochlear lesions

IMPEDANCE AUDIOMETRY
• Objective test
• Useful in children

Consists of Tympanometry & Acoustic reflex measurements

Tympanometry
• Principle: when a sound strikes tympanic membrane, some of the sound energy is absorbed while the rest is
reflected
• A stiffer TM would reflect more of sound energy than a compliant one
• Tone is delivered at 220 Hz
• By charting the compliance of tympano-ossicular system against various pressure changes, different
tympanograms are obtained
• Also used to test

Functions of Eustachian tube

Patency of grommet placed in the TM in cases of serous otitis media

Acoustic Reflex
• Based on the fact that a loud sound, 70 – 100 dB above the threshold of hearing, causes bilateral
contraction of the stapedius muscles

Uses
• To test hearing in infants and young children
• To find malingerers
• To detect cochlear pathology (presence of stapedial reflex at lower intensities)
• To detect VIII nerve lesion, Facial nerve lesions and brainstem lesions

Acoustic reflex is absent in

• Late stapedial fixation
• Profound cochlear lesion
• Retrocochlear lesion
• Ossicular discontinuity
 Types of Tympanograms

• Type A – normal tympanogram

• Type As – (Low compliance) otosclerosis, malleus fixation
• Type AD (High compliance) ossicular discontinuity or thin and lax tympanic membrane
• Type B – (No change in compliance with pressure changes) middle ear fluid, thick tympanic membrane
• Type C – (Maximum compliance occurs with negative pressure in excess of 100 mm of H20) retracted
tympanic membrane

Special Tests of Hearing

Recruitment
• The ear which does not hear low intensity sound begins to hear greater intensity sounds louder than normal
hearing ear
• Patients with recruitment are poor candidates for hearing aids
• Typically seen in lesions of cochlea – Meniere's disease and Presbycusis

Short Increment Sensitivity Index (SISI)

• Patients with cochlear lesions distinguish smaller changes in intensity of pure tone better than normal
persons and those with conductive or retro-cochlear pathology
• Thus used to differentiate cochlear and retro-cochlear lesions
Threshold tone decay
• Measure of nerve fatigue and used to detect retrocochlear lesions

Evoked response audiometry

• Electrocochleography (EcoG)
• Auditory brain stem response (ABR) or Brainstem evoked response audiometry (BERA)
EcoG
• Useful to find fine threshold of hearing in young infants and children within 5-10 dB
• To differentiate cochlear lesions from VIII nerve lesions
BERA/ABR
• In normal persons 7 waves are produced in the first 10 ms
• The first, third and fifth waves are most stable and used in measurements
• Anatomical site from where the waves arise

Wave I distal part of 8th nerve

Wave II proximal part of 8th nerve

Wave III cochlear nucleus

Wave IV superior olivary complex

Wave V lateral lemniscus

Waves VI & VII inferior colliculus
Uses of BERA
• Screening of infants
• To determine threshold of hearing in infants, children; adults and malingerers who do not cooperate
• To diagnose retrocochlear & brainstem pathology
• To monitor VIII cranial nerve intraoperatively during surgery of acoustic neuroma

Auditory Steady State Response (ASSR)

• ABR cannot test hearing losses above 80 dB and in infants with severe to profound deafness
• ASSR is useful in such situations

OTOACOUSTIC EMISSIONS
• OAEs are low intensity sounds produced by outer hair cells of a normal cochlea.
• Do not disappear in 8th nerve damage as cochlear cells are normal
• Uses:
1. screening test for hearing in neonates and uncooperative, mentally challenged after sedation
2. distinguish cochlear from retrocochlear lesions
3. used to diagnose retrocochlear lesions especially auditory neuropathy

OAEs absent in
• 50% normal individuals
• Cochlear lesions
• Middle ear disorder
• Hearing loss >30 dB

Tests to detect psychogenic HL or malingering or Non organic hearing loss:

• PTA and speech audiometry - inconsistent results on repeat. Normally the results are within ±5DB. Variation
greater than +5dB is diagnostic of NOHL
• Absence of shadow curve while testing bone conduction when the healthy ear is not masked
• Inconsistence in PTA and SRT
• Stenger's test
• Acoustic reflex threshold
• Electric response audiometry

HEARING LOSS
CONDUCTIVE HEARING LOSS
• Negative Rinne test (BC > AC)
• Weber lateralized to poorer ear
• Normal ABC test
• Low frequencies affected more
• Audiometry: BC better than AC with air
bonegap. Greater the air-bone gap, more is the
CHL
• Loss is not more than 60 dB
• Speech discrimination is good
SENSORINEURAL HEARING LOSS
• Positive Rinne test (AC > BC)
• Weber lateralized to better ear
• Bone conduction reduced on ABC and
• Schwabach test
• More often involving high frequencies
• Audiometry: No air-bone gap
• Difficulty in hearing in the presence of
noise
• Loss may exceed 60 dB
• Speech discrimination poor

CONDUCTIVE HEARING LOSS

 Average hearing loss in different lesions of conductive apparatus
Complete obstruction of ear canal 30 dB
Perforation of tympanic membrane 10-40 dB
Ossicular interruption with intact drum 54 dB
Ossicular interruption with perforation 38 dB
Malleus fixation 10-25 dB
Closure of oval window 60 dB

Management of conductive hearing loss

• Myringotomy - incision over TM
• Myringoplasty - repair of TM
• Ossiculoplasty - reconstruction of ossicular chain
• Tympanoplasty - repair of TM and ossicles

Types of Tympanoplasty (Wul!stein's classification)

• Type I ; Myringoplasty (for TM perforation)
• Type II : for TM perforation + erosion of malleus
• Type III : Myringostapedopexy/Columella tympanoplasty
Malleus and incus absent
Graft placed over stapes head (columella effect)
• Type IV : Only foot plate of stapes present
Graft placed between oval window and round window
Foot plate exteriorized over which sound waves act directly (baffle effect)
• Type V : Fenestration operation
• Type VI : Sonoinversion

 Best graft for myringoplasty — temporal fascia

SENSORINEURAL HEARING LOSS

OTOTOXIC DRUGS
Aminoglycosides Vestibulotoxic Antimalarials Diuretics
• Streptomycin • Quinine • Ethacrynic acid
• Gentamycin • Chloroquine • Frusemide
• Tobramycin Cytotoxic drugs Miscellaneous
Cochleotoxic • Nitrogen mustard • Alcohol, tobacco, marijuana
• Neomycin • Cisplatin • Carbon monoxide poisoning
• Kanamycin • Carboplatin • Erythromycin, Ampicillin
• Amikacin Analgesics • Propranolol
• Sisomycin • Salicylates • Propylthiouracil
• Dihydrostreptomycin • Indomethacin, brufen • Desferrioxamine
• Phenylbutazone • Tetanus antitoxin

NOISE TRAUMA
• Acoustic trauma (single brief exposure)
• Noise induced hearing loss (chronic exposure)
Factories Act
• No exposure in excess of 115 dB is to be permitted
• No impulse noise of intensity greater than 140 dB is permitted
• Manufacture sale and use of firecrackers generating sound level > 125 dB (Al) or 145 dB © pk from 4 m
distance from the point of bursting are not permitted (Environmental protection rules 2006)
• The audiogram in NIHL shows a typical notch at 4 KHz, both for air and bone conduction
• Ear protectors should be used when the noise levels exceed 85DB
• They provide protection up to 35 dB

Noise level (dB) 90 92 95 97 100 102 105 110 115

Permitted hours of exposure/day 8 6 4 3 2 1.5 1 0.5 0.25

Damage caused by Noise trauma depends on

• Frequency of 2000 to 3000 Hz causes more damage than lower or higher frequencies
• As the intensity of the noise increases, permissible limits of time decreases
• Continuous noise is more harmful than interrupted noise
• Pre-existing ear disease increases the chances of noise induced trauma

PRESBYCUSIS
• Sensory neural hearing loss associated with physiological aging in ear
• Hear well in quiet surroundings but have difficulty in hearing in the presence of background noise
• Speech heard but not understood
• Test – Recruitment positive

Deafness: hearing loss > 90 dB in the better hear

WHO classification of degree of hearing loss

• Mild : 26 – 40 dB
• Moderate : 41 – 55 dB
• Moderately severe : 56 – 70 dB
• Severe : 71– 90 dB
• Profound : > 90 dB

VESTIBULAR FUNCTION TESTS

Peripheral nystagmus Central nystagmus

Lesion in labyrinth or VIII nerve Lesion in neural pathways (Vestibular nuclei,
brainstem, cerebellum)
Suppressed by optic fixation Not suppressed by optic fixation
Enhanced in darkness or by the use of Frenzel glasses
Latency: 2 – 20 s No latency
Duration < 1 min > 1 min
Direction fixed, towards the undermost ear Direction changing
Fatiguable Non fatiguable
Sever vertigo No or slight vertigo

• Hallpike monoeuvre – differentiates central from peripheral nystagmus

 Type of nystagmus
Latent
Ataxic
Torsional nystagmus
Vertical Downbeat
Vertical Upbeat
Pendular nystagmus
See-Saw
Miner's
Nystagmus retractorius
Disease
Convergent squint
Internuclear ophthalmoplegia
Brainstem/Vestibular lesions (Syringomyelia)
Lesion at craniocervical junction (Arnold-Chiari malformation) or
cerebellar degeneration
Lesion at the junction of pons/medulla or pons/midbrain
Multiple sclerosis
Chiasmal lesions
Coal miners
Perinaud's syndrome

FISTULA TEST
• The basis of this test is to induce nystagmus by creating pressure changes in the external canal which are
then transmitted to the labyrinth by using a Siegel's speculum or intermittent pressure over the tragus.

Negative fistula test Positive fistula test

• Normally the test is negative because
pressure changes in the external canal cannot
be transmitted to the labyrinth
• Cholesteatoma (erosion of horizontal
semicircular canal)
• Fenestration operation (surgically created
window in the Horizontal canal)
• Poststapedectomy fistula (abnormal opening
in the oval window)
• Rupture of round window membrane

False negative Fistula test False positive Fistula test

• When cholesteatoma covers the site of • Congenital syphilis (hyper mobile stapes
fistula footplate)
• Meniere's disease (Hennebert's sign)

• Hennebert's phenomenon – dysequilibrium following nose blowing or lifting heavy objects.

• Seen in perilymph fistula

Fitzgerald-Hallpike test (Bithermal caloric test)

• Tests the integrity of horizontal semicircular canal
• Patient lies supine with head tilted 30° so that horizontal canal is vertical
• Ears are irrigated for 40 seconds alternatively with water at 30°C and 44°C (7° below and above normal body
temperature) and eyes observed for nystagmus
• Cold water induces nystagmus on the opposite side and warm water on the same side

BENIGN PAROXYSMAL POSITIONAL VERTIGO

• Vertigo when the head is placed in a certain critical position
• No hearing loss or other neurological symptoms
• Caused by a disorder of posterior semicircular canal
• Many patients have history of head injury and ear infection
• Diagnosed by: Hallpike manoeuvre
• Treatment: Epley's manoeuvre
 II. DISEASES OF EXTERNAL EAR & MIDDLE EAR

DISEASES OF EXTERNAL EAR

OTOMYCOSIS
• Fungal infection of the ear canal
• Predisposing factors: prolonged usage of antibiotic drops
• Intense itching, discomfort or pain, watery discharge with a musty odor and ear blockage
• A niger – black filamentous growth
• A fumigatus – pale blue or green
• Candida – white or creamy deposit
• Otoscopy: greyish white thick debris like "wet blotting paper"
• Treatment – aural toilet + antifungal + keratolytic agent (2% salicylic acid)

OTITIS EXTERNAL HEMORRHAGICA

• Hemorrhagic bullae on the TM and deep meatus
• Viral origin
• Seen in influenza epidemics

MALIGNANT OTITIS EXTERNA

• Necrotizing otitis externa or skull base osteomyelitis
• Caused by Pseudomonas aeruginosa infection
• Diabetes is the major predisposing factor
• Severe pain worsening at night
• Presence of granulations at bony cartilaginous junction
• Biopsy and radical surgery to be avoided
• Multiple cranial nerve palsies can occur
• Most common nerve palsy – facial nerve
• Gallium-67 scan is useful in diagnosis and follow-up
• Treatment: diabetes control, antibiotics, surgery (drainage of subperiosteal abscess, removal of necrotic
tissue and sequestrated bone)

IMPACTED WAX or CERUMEN

• Ear wax – composed of secretion of sebaceous glands, ceruminous glands, hair, desquamated epithelial
debris, keratin and dirt
• Was has protective function – lubricates the ear canal and entraps the foreign body
• It has acidic pH
• It is bacteriostatic and fungistatic
• Presenting symptoms – impairment of hearing or sense of blocked ear
• Treatment of impacted wax – syringing
• Wax softeners – 5% sodium bicarbonate in glycerine, 2% paradichlorobenzene, hydrogen peroxide, liquid
paraffin, olive oil

KERATOSIS OBTURAN
• Normally epithelium from surface of TM migrates onto the posterior meatal wall
• Failure of this migration or obstruction to migration due to wax leads to collection of pearly white mass of
desquamated epithelial cells in deep meatus
• By pressure effect cause bone absorption leading to widening of meatus
• Commonly seen between 5 – 20 yrs
 • Associated with bronchiectasis and sinusitis
• Symptoms – pain, deafness, tinnitus, discharge
• Treatment – keratotic mass removed by syringing or instrumentation
• Recurrence checked by keratolytic agents like 2% salicylic acid in alcohol

RETRACTED TYMPANIC MEMBRANE

• Dull and lusterless
• Cone of light – absent or interrupted
• Handle of malleus – foreshortened
• Lateral process of malleus – more prominent
• Anterior and posterior malleal folds – sickle shaped
• Results from negative intratympanic pressure when ET is blocked

Retraction of pars tensa – Sade's classification
• Grade 1: mild retraction not touching the long
process of incus
• Grade 2: retracted drum touching the long
process of incus
• Grade 3: retracted drum touching the
promontory
• Grade 4:drum plastered to promontory
Retraction of pars flaccida – Tos's classification
• Grade 1: mild attic retraction, not touching
neck or malleus
• Grade 2: attic retraction touching neck or
malleus
• Grade 3: limited outer attic wall erosion
• Grade 4: severe outer attic wall erosion

KEY POINTS:
• Bat ear/ Prominent ear/ Protruding ear

Most common congenital anomaly of pinna

Concha is large with poorly developed anti-helix and scapha

Surgically corrected after 6 years if cosmetic appearance so demands

• Cryptotia (Pocket ear) - Upper third of auricle is embedded under scalp skin
• Darwin's tubercle – pointed tubercle on the upper part of helix
• Stahl's ear – flat helix, upper crus of antihelix duplicated and reaches the rim of helix
• Cauliflower ear – hematoma of the auricle
• Wildermuth's ear – antihelix is more prominent than helix
• Myringitis bullosa – mycoplasma pneumoniae
• Acute necrotizing otitis media –β-hemolytic streptococci
• Mouse nibbled appearance of pinna – Leprosy
• Mouse nibbled appearance of larynx –TB
• Preauricular sinus – faulty union of the first and second branchial arches
• Most common cancer of pinna – basal cell carcinoma

DISORDERS OF MIDDLE EAR

ACUTE SUPPURATIVE OTITIS MEDIA
• Purulent inflammation of the muco-periosteum of the middle ear cleft
• Predisposing factors: poor nutrition, feeding in supine position, cleft palate
• Commonly occurs in children (because ET is shorter, straighter and wider)
• The most common organism – Streptococcus pneumoniae followed by H. influenzae
Clinical stages
• Stage of congestion

Hyperemia of mucosa

Ear ache, fever, mild hearing defect

Otoscopy: Injection of TM – initially along the handle of malleus, later spreading to the periphery
(cartwheel sign)
• Stage of exudation

Severe pain, high fever, marked deafness, mastoid tenderness

TM thickened and bulge out with loss of landmarks
• Stage of suppuration

TM may rupture, releasing pus and relieving pain

Ear discharge is the main symptom

A small central perforation in the pars tensa through which pulsatile discharge is seen (light house sign)
• Stage of resolution – with increased host resistance and adequate antibiotics
• Stage of complications

Medical treatment: systemic antibiotics, decongestants, analgesics

Surgical: Myringotomy indications
• Bulging drum - Imminent rupture
• Incomplete resolution due to inadequate or resistance to antibiotics
• Persistent effusion beyond 12 weeks

OTITIS MEDIA WITH EFFUSION

• Synonyms: Serous Otitis Media / Secretory Otitis Media / Mucoid Otitis Media/ Glue Ear
• Non purulent sterile effusion accumulates in the middle ear cavity
• MCC of conductive deafness in school-going children

• Etiology

Malfunctioning of Eustachian tube (adenoid hyperplasia, chronic rhinitis, sinusitis & tonsillitis, tumors of
nasopharynx, cleft palate)

Allergy

Unresolved otitis media

Viral infection - adeno and rhinoviruses

• Symptoms:

Hearing loss (<40DB)

Delayed and defective speech

Mild ear ache.

• Otoscopy :

Dull and opaque tympanic membrane

Loss of light reflex

Thin leash of blood vessels seen along the handle of malleus (less marked than ASOM)

Retracted TM

Bulging of the posterior part of TM

Fluid level and air bubbles seen

Mobility restricted

• Tuning fork tests — Conductive deafness

• Impedance Audiometry: decreased compliance, flat curve, shift to negative side
• X-ray Mastoid: Clouding of air cells.
• Treatment ; Medical — Decongestant , Anti allergic, Antibiotics , Middle ear aeration (Valsalva maneuver)
• Surgical:
 1. Myringotomy and fluid aspiration: 2 incisions one in the antero inferior and other antero superior
quadrant of the TM to aspirate thick glue like secretions.(Beer can principle)
2. Grommet insertion: left in place till spontaneously extruded
3. Tympanotomy (or) cortical mastoidectomy.
• Sequelae of SOM

Atrophic tympanic membrane and atelectasis of middle ear

Ossicular necrosis

Tympanosclerosis

Retraction pockets and cholesteatoma

Cholesterol granuloma

ERO-OTITIS MEDIA or BAROTRAUMA

• Results from failure of ET to maintain middle ear pressure at ambient atmospheric level
• Usual cause — rapid descent during air flight, underwater diving or compression in pressure chamber
• When the atmospheric pressure is higher than that of middle ear by a critical level of 90 mmHg, ET gets
locked (soft tissues of pharyngeal end are forced into the lumen of the ET)
• Sudden negative pressure in the middle ear causes retraction of TM, hyperemia and engorgement of vessels
• Severe earache, hearing loss and tinnitus are common

PATULOUS EUSTACHIAN TUBE

• Abnormally patent ET
• Mostly idiopathic
• Other causes

Rapid weight loss

3rd trimester pregnancy

Multiple sclerosis
• Chief complaint — autophony (hearing his own voice), even breath sounds
• Pressure changes in the nasopharynx are easily transmitted to middle ear — movements of TM can be seen
with inspiration and expiration

CHRONIC SUPPURATIVE OTITIS MEDIA

Tubotympanic or safe or benign type
Profuse mucoid, odorless discharge
Central perforation (Pars tensa)
Granulations and Osteitis uncommon
Ossicular necrosis uncommon
Pale polyp
Cholesteatoma absent
Complications rare
Mild to moderate conductive deafness
Atticoantral or unsafe or dangerous type
Scanty, purulent, foul smelling discharge
Marginal or attic (Pars flaccida) perforation
Granulations and Osteitis common
Ossicular necrosis common
Red and fleshy polyp
Present
Common
Conductive or mixed deafness

Tubo-tympanic type
• Ossicular necrosis — particularly long process of incus because of its precarious blood supply
• Round window shielding effect — patient hears better in the presence of discharge than when the ear is
dry.
• Treatment—Aural toilet, antibiotic ear drops, systemic antibiotics, surgical removal of aural polyp and
granulations

Attico- antral type

• Surgery is the mainstay of treatment
 Canal wall up procedure
Intact canal wall mastoidectomy
Cortical mastoidectomy + Posterior
tympanotomy
Meatus – normal appearance
Does not require routine cleaning
High rate of recurrent or residual
cholesteatoma
Requires second look surgery after 6
months of so to rule out cholesteatoma
Patient can swim
Easy to wear a hearing aid if needed
Canal wall down procedure
Atticotomy
Modified radical mastoidectomy
Radical mastoidectomy
Widely open meatus – communicating with
mastoid
Dependence on doctor for cleaning mastoid
cavity once or twice a year
Low rate of recurrence
Not required
Swimming can lead to infection of mastoid
Not easy to fit hearing aid

CHOLESTEATOMA
• Cholesteatoma a misnomer – it neither contains cholesterol nor it is a tumor
• Lining of middle ear cleft

Anterior and inferior part – ciliated columnar epithelium

Middle part – cuboidal epithelium

Attic – pavement like epithelium
• Presence of keratinizing squamous epithelium in the middle ear or mastoid – cholesteatoma
• Cholesteatoma is skin in wrong place
• Most common site of origin – posterior epitympanum
• Theories of Cholesteatoma

Presence of congenital cell rests

Wittmaack's theory – invagination of TM from the attic or posterior-superior par tof pars tensa in the
form of retraction pockets

Ruedi's theory – basal cell hyperplasia

Habermann's theory – epithelial invasion

Sade's theory – metaplasia

TUBERCULOUS OTITIS MEDIA

• Mostly secondary to pulmonary infection
• Painless ear discharge (ear ache characteristically absent)
• Painless necrosis of tympanic membrane
• Multiple perforations of pars tensa which may coalesce to form a single one
• Hearing loss out of proportion to symptoms
• Facial paralysis is a common complication

COMPLICATIONS OF CSOM
ACUTE MASTOIDITIS
• Pain and tenderness over mastoid
• Pulsatile ear discharge – light house effect
• Sagging of posterosuperior meatal wall
• Treatment – antibiotics, cortical mastoidectomy
Abscesses in relation to mastoid infection
• Bezold abscess – pus breaks through the thin medial side of the tip of the mastoid and presents as a swelling
in the upper part of neck
• Luc abscess – meatal abscess
• Citelli's abscess – abscess behind the mastoid towards the occipital bone

PETROSITIS
Gradenigo's syndrome
• Ear discharge
• Diplopia (CN VI paralysis)
• Retroorbital pain (CN V)

LABYRINTHITIS
Circumscribed labyrinthitis
• Thinning or erosion of bony capsule of labyrinth, usually of the horizontal semicircular canal
• CSOM is the most common cause
• Transient vertigo induced by pressure on tragus, cleaning the ear or Valsalva manoeuvre

Diffuse serous labyrinthitis

• Diffuse intralabyrinthine inflammation without pus formation
• Reversible if treated early
• Circumscribed labyrinthitis is the most common cause
• Spontaneous nystagmus with quick component towards affected ear

Diffuse suppurative labyrinthitis

• Diffuse pyogenic inflammation with permanent loss of vestibular and cochlear function
• Usually follows serous labyrinthitis
• Spontaneous nystagmus with quick component towards healthy side

LATERAL/SIGMOID SINUS THROMBOPHLEBITIS

• Hectic Picket-fence type of fever with rigors
• Griesinger's sign- due to thrombosis of mastoid emissary vein, edema over posterior part of mastoid
• Papilledema
• Tobey-Ayer test :
Compression of jugular vein on thrombosed side – no effect on CSF pressure
Compression of jugular vein on the normal side – rapid rise in CSF pressure
• Crowe-Beck test: pressure on the jug. vein on healthy side – engorgement of retinal & supra orbital veins
• Tenderness along Jugular vein
• Contrast CT/MRI: delta sign

OTOSCLEROSIS or OTOSPONGIOSIS
• Disease of bony labyrinth where spongy bone replaces normal enchondral layer of bony otic capsule
• Most often the otosclerotic focus involves stapes leading to stapes fixation and CHL

Etiology
• Family history present, Autosomal dominant
• Common in Indians
• Females affected twice more than males.
• But in India males are more affected
 • Age 20-30 yrs
• May be initiated or made worse by pregnancy, menopause, after an accident or a major operation
• Van der hoeve syndrome- triad of Osteogenesis imperfecta, Blue sclera and Otosclerosis

Types
• Stapedial otosclerosis causing stapes fixation and CHL is the most common variety
• Fistula ante fenestrum - in front of oval window is the site of predilection (anterior focus)
• Cochlear otosclerosis – causes SNHL

Microscopic
• Immature focus – vascular spaces, osteoclasts, osteoblasts & fibrous tissue – stains blue on HE staining (Blue
mantles of Manasse)
• Mature focus – less vascular with lot of fibrous tissue and few osteoblasts – stains red on HE staining

Symptoms and Signs

• Hearing loss – painless progressive bilateral CHL
• Paracusis willisi – hears better in noisy surroundings
• Tinnitus, Vertigo, Monotonous soft speech
• TM – normal and mobile
• Schwartz sign – reddish hue seen on the promontory through TM, which indicates active focus
• TFTs- negative Rinne, Weber lateralized to the ear with greater hearing loss
• In some cases a dip in the bone conduction curve appear at 2000Hz which disappears after successful
stapedectomy (Carhart's notch)
• Bezold's triad – absolute negative Rinne's, raised lower tone limit, prolonged bone conduction

Treatment
• Medical- Sodium fluoride
• Surgical: Stapedectomy/ Stapedotomy with a placement of prosthesis - treatment of choice

Selection of patients for Stapes surgery

• Hearing threshold for air conduction should be > 30 DB
• Average air-bone gap should be atleast 15 DB
• Rinne negative for 256 and 512 Hz
• Speech discrimination score > 60%

Contraindications for stapedectomy

• Only hearing ear
• Associated Meniere's disease
• Young children
• Professional athletes, high construction workers, drivers, frequent air travelers
• Those who work in noisy surroundings
• Relative Cls: otitis externa, TM perforation, exostosis

Complications of stapedectomy
• Floating foot plate (mostly iatrogenic)
• Perilymph leak
• Sensorineural hearing loss
• Injury to facial nerve or Chorda tympani
 • Labyrinthitis
• Conductive hearing loss due to dislocation of prosthesis

GLOMUS TUMOUR
• Most common benign neoplasm of middle ear
• Rule of 10: 10% familial; 10% multicentric; 10% functional (secrete catecholamines)
• Middle age (40-50 years)
• Females affected 5 times more
• Benign encapsulated, extremely vascular, very slow growing, locally invasive
• Abundant thin walled blood sinusoids with no contractile muscle coat – profuse bleeding
• Types:

Glomus jugulare (from jugular bulb)

Glomus tympanicum (from promontory)

Glomus vagale (from vagus)

Symptoms
• Conductive deafness
• Pulsatile tinnitus, swishing character, temporarily stopped by carotid pressure

Otoscopy
• Red reflex through intact TM
• Rising sun appearance when the tumor arises from the floor of middle ear
• Brown's sign (pulsation sign) when ear canal pressure is increased, the tumor pulsates vigorously
• CT: Phelp's sign – erosion of jugular plate
• MR: salt and pepper lesions
 III. FACIAL NERVE, DISEASE OF INNER EAR

FACIAL NERVE

Surgical landmarks
• Processus cochleariformis – geniculate ganglion lies anterior to it
• Oval window and horizontal canal –facial N. runs above oval window and below horizontal canal
• Short process of incus –facial nerve lies medial to it
• Pyramid –facial nerve runs behind it
• Tympanomastoid suture –facial nerve runs behind it

For parotid surgery

• Cartilaginous pointer (a sharp triangular piece of cartilage of pinna that points to the nerve) –facial nerve
lies 1 cm deep and slightly anterior and inferior to the pointer
• Tympanomastoid suture – nerve lies 6-8mm deep to the suture
• Styloid process – nerve crosses lateral to the styloid process
• Posterior belly of digastric – if this muscle is traced backwards along its upper border to its attachment to
the digastric groove, nerve is found between it and styloid process

Severity of nerve injury

• Neurapraxia – conduction block
• Axonotemesis –_injury to axons
• Neurotemesis –_injury to nerve

PALSY
• Most common cause of facial paralysis
• Idiopathic LMN facial paralysis
• Both sexes affected with equal frequency
• All ages affected; incidence increases with increasing age
• Positive family history in 10% patients
• Increased risk in diabetics and pregnant women
• Etiology – viral, ischemia, hereditary, autoimmunity

Clinical features
• Sudden onset
• Patient is unable to close his eye
• On attempting to close the eye – eyeball turns up and out – Bell phenomenon
• Salivary dribbling from the angle of mouth
• Asymmetrical face
• Epiphora
• Noise intolerance (stapedial paralysis)
• Loss of taste (chorda tympani involvement)
• Diagnosis is by exclusion

Treatment
• Medical - Prednisone is the drug of choice
• Surgery – nerve decompression
Prognosis
• 90% patients recover fully
• Good prognosis in incomplete Bell palsy & if clinical recovery starts within 3 weeks of onset
• Recurrence can occur

MELKERSSON SYNDROME – triad of

• Swelling of lips
• Fissured tongue
• Fissured

RAMSAY HUNT SYNDROME

• Herpes Zoster Oticus
• Cause – Varicella Zoster virus
• Facial paralysis
• Vesicular rash in the external auditory canal and pinna
• Anesthesia of face, giddiness, hearing impairment

BILATERAL FACIAL PALSY

• Guillain Barre syndrome
• Lyme's disease
• Sarcoidosis
• HIV seroconversion phase
• Acute lymphoblastic leukemia
• Leprosy
• Sickle cell disease
• Chronic inflammatory demyelinating polyneuropathy
• Bulbar palsy

Congenital facial palsy

• Melkersson Rosenthal syndrome
• Mobius syndrome

TEMPORAL BONE FRACTURES

Longitudinal fracture Transverse fracture

More common Less common
Caused by parietal blow Caused by occipital blow
Bleeding from the ear - common Bleeding from the ear – absent
CSF otorrhoea - present Absent
Conductive hearing loss Sensorineural hearing loss
Vertigo – less often Sever vertigo due to labyrinth or VIII N injury
Facial paralysis Facial paralysis
• Less common • More common
• Delayed onset • Immediate onset
• Nerve injured in tympanic segment, • Nerve injured in meatal or labyrinthine segment
distal to geniculate ganglion proximal to geniculate ganglion
Localization of facial lesion
Central facial paralysis
• Paralysis of lower half of face on the
• contralateral side
• Retained functions

Forehead movements (bilateral
innervation of frontalis muscle)

Involuntary emotional movements

Tone of facial muscles
Peripheral facial paralysis
• All muscles of the face on the involved side are
• paralyzed
• Unable to frown, close eye, purse lips or whistle
• Lesion at the level of nucleus – associated paralysis
of V nerve
• Lesion at cerebellopontine angle – involvement of
• CN V, IX, X, XI
• Lesion in bony canal – topodiagnostic tests
• Lesion outside the temporal bone – affects only the
motor functions of the nerve

Complications of facial paralysis

• Exposure keratitis
• Synkinesis (mass movement) – when the patient wishes to close the eye, corner of mouth also twitches or
vice versa
• Tics and spasms
• Crocodile tears (gustatory lacrimation)

Unilateral lacrimation with mastication

Due to faulty regeneration of parasympathetic fibres which now supply lacrimal glands instead of
salivary glands

Treatment – section of greater superficial petrosal nerve or tympanic neurectomy
• Frey's syndrome (gustatory sweating)

Flushing and sweating of skin over the parotid during mastication

Results from parotid surgery

Parasympathetic fibres supplying parotid are misdirected and supply sweat glands over parotid

Treatment – Jacobson's neurectomy
 Level of lesion
Pons
Cerebellopontine angle
Internal acoustic meatus
Geniculate ganglion
Above the origin of nerve to
stapedius
Horizontal tympanic canal
Clinical features
Facial palsy+ Strabismus + Contralateral hemiplegia + Facial sensory loss
VIII Nerve paralysis + loss of taste in anterior 2/3 of tongue + loss of
lacrimation + Facial palsy
Loss of taste in anterior 2/3 of tongue + loss of lacrimation + Facial palsy
Herpetic vesicles at external ear + loss of taste in anterior 2/3 of tongue +
loss of lacrimation + Facial palsy
Hyperacusis + Loss of taste in anterior 2/3 of tongue + intact lacrimation
+ Facial palsy
Loss of taste in anterior 2/3 of tongue + intact lacrimation + Facial palsy

Stylomastoid foramen Facial palsy

Topodiagnostic tests for lesions of Facial nerve in infratemporal part

• Schirmer test
• Stapedial reflex
• Taste test
• Submandibular salivary flow test

Treatment options
• Nerve repair or nerve grafts: Facial nerve regeneration occurs at a rate of one millimetre per day. If a nerve
has been cut or removed, direct microscopic repair is the best option.
• Nerve transposition: Often the tongue nerve (hypoglossal nerve) or the other facial nerve can be connected
to the existing facial nerve.
• Muscle transposition or sling procedures: The temporalis muscle or masseter muscle (some of the only
muscles on the face not supplied by the facial nerve) can be moved down and connected to the corner of the
mouth to provide movement of the face.
• Muscle transfers: Free muscles from the leg (gracilis) used to provide both muscle bulk and function
• Ancillary eyelid or oral procedures: In addition to one of the above, it is necessary to include a brow lift or
facelift, partial lip resection, eyelid repositioning, lower eyelid shortening, or upper eyelid weights

 Most common anomaly of facial nerve – dehiscence (absence of bony cover – most commonly in tympanic
segment over the oval window)

MENIERE'S DISEASE/ENDOLYMPHATIC HYDROPS

• Disorder of endolymphatic system which is distended due to increased volume of endolymph
• Associated with allergy, hypothyroidism, Na and water retention
• Male predilection
• Age group 35 – 60 years
• Studies have demonstrated that the disease is attributable to a mutation in chromosome 6

3 Cardinal symptoms
• Episodic vertigo
• Roaring tinnitus
• Fluctuating hearing loss

Other features
• Tullio phenomenon – loud sounds produce vertigo
• Diplacusis –tone of a particular frequency may be heard normal in one ear and higher pitch in the other ear
• Intolerance to loud sounds – poor candidates for hearing aids
 • Lermoyez syndrome – variant of Meniere's disease
• Drop attacks (Tumarkin's otolithic crisis) sudden drop attack without loss of consciousness, no vertigo and
no fluctuation in hearing loss
• Nystagmus – seen only during acute attack, quick component towards healthy ear

Investigations
• Otoscopy - no abnormality
• SISI >70 % (normal 15%)
• Recruitment positive
• Electrocochleography – diagnostic of Meniere's disease

Normal ratio of Summating potential (SP) to Action potential (AP) is 30%

In Meniere's disease > 30%
• Glycerol (dehydrating agent)test: When given orally, it reduces endolymphatic pressure and thus improves
symptoms

Management of acute attack

• Vestibular sedatives
• Inhalation of carbogen (5% CO2 and 95% 02) – good cerebral vasodilator
• Histamine drip

Medical management
• Chemical labyrinthectomy: gentamycin injected into the middle ear causes destruction of vestibular
labyrinth
• Microwick (1mm x 9mm) – made of polyvinyl acetate, delivers drugs from external canal to the
• inner ear and thus avoids repeated intratympanic injections

Surgery:
• Decompression of endolymphatic sac
• Endolymphatic shunt
• Sacculotomy(Fick's operation)
• Cody tack's procedure
• Section of vestibular nerve
• Labyrinthectomy
• Intermittent low pressure pulse therapy (Meniett device therapy)

Test Normal Cochlear lesion Retrocochlear lesion

Pure tone audiogram Normal SNHL SNHL
Speech discrimination 90-100% < 90% Very poor
Roll over phenomenon Absent Absent Present
Recruitment Absent Present Absent
SISI score 0-15% >70% 0-20%
Threshold tone decay 0-15DB <25DB >25DB
Stapedial reflex Present Present Absent
Stapedial reflex decay Normal Normal Abnormal
BERA Normal interval Normal interval Wave V delayed or
between wave I and V between wave I and V absent

ACOUSTIC NEUROMA
• Syn: Vestibular Schwannoma or Neurilemmoma or 8th Nerve tumor
 • 80% of all Cerebello-pontine angle tumors
• 10% of all brain tumors
• Benign encapsulated, extremely slow growing tumors
• Bilateral tumors seen in neurofibromatosis
• Tumors almost always arise from the Schwann cells of the vestibular division of VIII nerve
• Classification based on size

Intracanalicular (confined to internal auditory canal)

Small size (< 1.5 cm)

Medium size (1.5 — 4 cm)

Large size (> 4 cm)
• Age group: 40-60 years
• No sex predilection
• Cochleovestibular symptoms

Earliest symptoms

Progressive unilateral SNHL associated with tinnitus — most common presenting symptom

Difficulty in understanding speech out of proportion of pure tone hearing loss (characteristic of AN)
• Cranial nerves

5th nerve earliest to be involved

Reduced corneal sensitivity, numbness and paresthesia of face
• Facial nerve involvement

Hitzelberger's sign (hypoaesthesia of posterior meatal wall)

Loss of taste

Decreased lacrimation
• Investigations

Pure tone audiometry — SNHL more marked in higher frequencies

Speech audiometry - Poor speech discrimination and Roll over phenomenon

Recruitment absent

Short Increment Sensitivity Index (SISI) shows a score of 0-20%

Threshold tone decay — retrocochlear type of lesion

Diminished or no response to calorie tests.

Gold standard for diagnosis: MRI with gadolinium enhancement
• Treatment- surgical removal, gamma knife or Cyber knife surgery

Fluctuating hearing loss

• Serous otitis media
• Meniere's disease
• Perilymph fistula
• Malingering

Common drugs causing tinnitus

• Aspirin
• Quinine
• Salicylate
• Streptomycin
• Neomycin
• Gentamycin

Blue drum
• Hemotympanum
 • Glue ear
• Glomus tumor
• Hemangioma of middle ear

Habenula perforate
• Area where the branches of cochlear nerve enter the cochlea
• Openings may be wide leading to perilymph gusher in stapes surgery
• Enlarged internal acoustic meatus and congenital stapes fixation
• X- linked

Dandy syndrome/Oscillopsia
• Difficulty to read boards or hoardings while walking
• Seen in B/L loss of vestibular function
• E.g: after systemic streptomycin therapy

Elastic fibro cartilage (no calcification) Hyaline cartilage (undergoes calcification)

• Pinna • Thyroid
• Epiglottis • Cricoid
• Corniculate • Greater part of arytenoid
• Cuneiform
• Apex of arytenoids

DEAFNESS ASSOCIATED SYNDROMES

Syndrome /Inheritance
Waardenberg's syndrome
(AD)
Jervell and Lange-Neilson's
syndrome (AR)
Pendred syndrome (AR)
Alport syndrome
AD or X-linked
Treacher-Collins syndrome
(mandibulofacial dysostosis)
(AD)
Crouzon's syndrome(AD)
(craniofacial dysostosis)
Apert's syndrome(AD)
Features Onset/Type HL
• White forelock, Vitiligo Congenital
• Heterochromia iridis SNHL
• Dystopia canthorum
• Repeated syncopal attacks Congenital
• Prolonged QT interval SNHL
• Goiter evident before puberty Congenital
• Perchlorate discharge test shows defect in SNHL
organic binding of iodine
• Hereditary progressive GN Delayed
• Corneal dystrophy Progressive SNHL
• Antimongoloid palpebral fissures Congenital
• Coloboma of lower lid Conductive
• Hypoplasia of mandible and malar bones
• Malformed pinna and meatal atresia
• Malformed malleus & incus (stapes
normal)
• Frog eyes, Hypertelorism Congenital
• Parrot beak nose Conductive or mixed
• Mandibular prognathism
• Mental retardation
• Syndactyly Congenital,
• Features of Crouzon's syndrome Conductive (stapes
fixation)
Usher syndrome(AR)
Klippel – Feil syndrome(AR)
Stickler's syndrome(AD)
Van der Hoeve's syndrome
Pierre –Robin sequence
Goldenhar's syndrome (facio-
auriculo-vertebral dysplasia or
oculo-auriculo-vertebral
[OAV]syndrome)
• Retinitis pigmentosa Delayed
• Night blindness SNHL
• Short neck Congenital
• Fused cervical vertebrae, Spina bifida SNHL or mixed
• Atresia of ear canal
• Small jaw, Cleft palate Delayed
• Myopia, Cataract Conductive or SNHL
• Juvenile onset arthritis
• Osteogenesis imperfecta (h/o fractures) Delayed
• Blue sclera CHL, SNHL or mixed
• Micrognathia, Glossoptosis, Cleft palate SNHL or conductive
• Facial asymmetry Mixed or conductive
• Low set ears, Preauricular tags, Atresia of
ear canal
• Cardiac abnormalities
• Hemivertebrae in cervical region
• Epibulbar dermoid
• Coloboma or upper lid
 IV. ANATOMY OF NOSE, DISEASES OF EXTERNAL NOSE, NASAL CAVITY & NASAL
SEPTUM

ANATOMY
EXTERNAL NOSE
Bony part
• Upper one third
• Two nasal bones which meet in the midline and rest on the upper part of the nasal processes of the frontal
bones

Cartilaginous part
• Upper lateral cartilages

Lower free edge — seen intranasally as limen vestibule or nasal valve
• Lower lateral (alar) cartilages
• Lesser alar (sesamoid) cartilages
• Septal Cartilage

INTERNAL NOSE
• Each nasal cavity communicates with exterior through naris and
• With the nasopharynx through posterior nasal aperture or choana
• Skin lined portion — vestibule
• Mucosa lined portion — nasal cavity proper

Roof of nasal cavity

• Anterior sloping part — nasal bones
• Posterior sloping part — sphenoid bone
• Middle horizontal part — cribriform plate of ethmoid
• Floor — palatine process of maxilla

Lateral wall of nose

• 3 or occasionally 4 turbinates or concha
• Space below turbinate — meatus
• Inferior turbinate — separate bone
• Middle turbinate — part of ethmoid bone
• Superior turbinate — part of ethmoid bone

Important structures in middle meatus

• Uncinate process — thin, sickle like, bony leaflet arising from the ethmoid
• Bulla ethmoidalis — bulge produced by the anterior most ethmoidal cell
• Gap between these two — hiatus seminularis
• Space above and below bulla - Suprabullar and infrabullar recesses which together form the lateral sinus
(sinus lateralis of Grunwald)
• Atrium is a shallow depression in front of middle turbinate
• Agar nasi – anterior most ethmoidal cell
• Antral Puncture (Proof Puncture) is done through middle meatus.
 Inferior meatus
Middle meatus
Superior meatus
Sphenoethmoidal recess
Nasolacrimal duct – guarded at its terminal end by Hasner's valve
Middle ethmoidal air cells (forms a bulge-Bulla Ethmoidalis)
Frontal sinus opens into the infundibulum
Maxillary sinus and anterior ethmoidal sinus opens posterior to infundibulurn
Posterior ethmoidal sinus
Sphenoid sinus

Osteomeatal complex
• An area in the middle meatus where there are openings of anterior group of paranasal sinuses
• Landmarks in the OM complex (Picadli's circle)

Uncinated process

Bulla ethmoidalis

Hiatus semilunaris

Ethmoidal infundibulum

Nerves of common sensation

• Anterior ethmoidal nerve
• Branches of sphenopalatine ganglion
• Branches of infra-orbital nerve – supply vestibule of nose

VIDIAN NERVE
• Parasympathetic nerves that supply nasal glands come from greater superficial petrosal nerve, travel in the
nerve of pterygoid canal (vidian nerve) and reach sphenopalatine ganglion where they relay before
reaching nasal cavity
• They also supply blood vessels of nose and cause vasodilatation
• Sympathetic fibres come from T1 and T2 segments of spinal cord, pass through superior cervical ganglion,
travel in deep petrosal nerve and join parasympathetic fibres of greater superficial petrosal nerve to form
the nerve of pterygoid canal
• They reach the nasal cavity without relay in sphenopalatine ganglion and cause vasoconstriction
• Excessive rhinorrhea in vasomotor and allergic rhinitis can be controlled by section of vidian nerve

 Nasal cycle – 2.5 to 4 hours

DISEASES OF EXTERNAL NOSE

Saddle nose
 Depressed nasal dorsum
 Nasal trauma causing depressed fractures — MCC
 Corrected by augmentation rhinoplasty

Hump nose
• Corrected by reduction rhinoplasty

Crooked nose
• Midline dorsum from frontonasal angle to the tip is curved in a C or S shaped manner
• Usually traumatic
• Corrected by rhinoplasty or septorhinoplasty

RHINOPHYMA (POTATO TUMOR)

• Benign tumor due to hypertrophy of sebaceous glands of the tip of the nose
 • Often seen in cases of long standing acne rosacea
• Pink lobulated mass over the nose with superficial vascular dilation
• Treatment: paring down the bulk of tumor with CO2 laser

 Basal cell carcinoma — most common malignant tumor of skin of nose

NASAL SEPTUM & ITS DISEASES

3 Parts of nasal septum
• Columellar septum
• Membranous septum
• Septum proper

Perpendicular plate of ethmoid

Vomer

Septal (quadrilateral) cartilage

Minor contributions from
o Crest of nasal bones
o Nasal spine of frontal bone
o Rostrum of sphenoid
o Crest of palatine bones
o Crest of maxilla
o Anterior nasal spine of maxilla

Fractures of nasal septum

• Jarjaway fracture — blows from the front
• Chevallet fracture — blows from below
• Walsham's forceps — for disimpacting and reducing fractures of nasal bone
• Asch's septum forceps — for reducing fractures of nasal septum
• Tilleys's Hartmann's and Wilde's forceps — nasal packing, foreign body removal

DEVIATED NASAL SEPTUM

• Cottle test — on pulling the cheek away from the midline, nasal valve opens, increasing the airflow from that
side (indicates abnormality of vestibular component of nasal valve)
• Treatment: Submucous resection (SMR) — done in adults under local anesthesia

Sluder's neuralgia or Anterior ethmoidal neuralgia

Pressure on the anterior ethmoidal nerve by a spur

Pain in the lower half of face

Nasal congestion

Rhinorrhea

Increased lacrimation
• Septal surgery is usually done after 17 years
• For a child with severe DNS — Septoplasty

SEPTOPLASTY
• Tissue sparing procedure where septa' deviation is corrected by minimal resection of cartilage and bone
• Freer's hemitransfixation incision on the concave side of the cartilage
• Mucoperichondrial elevation is done on the side of incision and 3 tunnels are created

Anterior tunnel — exposure of quadrangular septal cartilage on the concave side

Inferior tunnel —anterior nasal spine and maxillary crest on both sides are exposed

Posterior tunnel — perpendicular plate of ethmoid and vomer are exposed
SEPTAL HEMATOMA
• Collection of blood under the perichondrium of periosteum of nasal septum
• Bilateral nasal obstruction is the me presenting symptom
• Frontal head ache may be seen
• Small hematomas — aspiration with wide bore needle
• Large hematomas — incision and drainage

SEPTAL ABSCESS
• MCC — secondary infection of septal hematoma
• May follow acute infections like typhoid or measles
• Severe b/I nasal obstruction with pain and tenderness over bridge of nose
• Should be drained as early as possible
• Complications: necrosis of septal cartilage — depression of dorsum in supratip area
• Serious complications — meningitis, cavernous sinus thrombosis

PERFORATION OF NASAL SEPTUM

• Trauma is the most common cause
• Septal abscess
• Nasal myiasis
• Rhinolith
• Chronic granulomatous conditions

Lupus, TB, Leprosy – perforation of cartilaginous part

Syphilis – perforation of bony part
• Wegener's granuloma
• Drugs and chemicals – steroid spray, cocaine addicts

ATROPHIC RHINITIS or OZAENA

• Atrophy of nasal mucosa and turbinates
• Nasal cavities are roomy and full of foul-smelling crusts
• Ciliated columnar epithelium is replaced by stratified squamous type
• Commonly seen in females and starts around puberty
• There is foul smell from the nose of which the patient is unaware (merciful anosmia)
• Nasal obstruction inspite of wide nasal chambers (due to large crusts filling the nose)
• Removal of crusts may cause bleeding
• Medical treatment – nasal irrigation and removal of crusts, local antibiotics, oestradiol spray, submucosal
placental extract injection
• Surgery – Young's operation

RHINITIS SICCA
• Seen in patients who work in hot, dry and dusty surroundings (bakers, iron and gold smiths)
• Confined to anterior third of nose – particularly nasal septum
• Ciliated columnar epithelium undergoes squamous metaplasia
• Dirty black crusts
• Absence of - foul smell and atrophy of turbinates (differentiates from atrophic rhinitis)

RHINITIS CASEOSA (NASAL CHOLESTEATOMA)

• Usually unilateral
• Mostly affects males
 • Nose filled with offensive purulent discharge and cheesy material
• Probably arises from chronic sinusitis

RHINITIS MEDICAMENTOSA
• Prolonged use of local nasal decongestants

VASOMOTOR RHINITIS
• Non allergic rhinitis
• Overactivity of parasympathetic system – excessive secretion from the nasal glands, vasodilation and
engorgement of nasal mucosa
• Nasal mucosa is hyper-reactive and responds to non-specific stimuli like change in temperature, dust, smoke
etc
• Symptoms:

Paroxysmal sneezing – bouts of sneezing just after getting out of bed in the morning

Excessive rhinorrhea – profuse, watery

Nasal obstruction – more marked at night, alternates from side to side

Post nasal drip
• Signs: nasal mucosa is congested and hypertrophic
• Complications: nasal polypi, hypertrophic rhinitis, sinusitis
• Medical treatment: antihistaminic, oral nasal decongestants
• Surgical: vidian neurectomy

RHINOSCLEROMA
• Chronic granulomatous disease caused by Klebsiella rhinoscleromatis (Frisch bacillus)
• Subdermal infiltration of the lower part of external nose and upper lip giving a woody feel
• Miculicz' cells (plasma cells) and Russel bodies (also seen in multiple myeloma)
• Corin cells, morula cells, mott cells are also seen
• Gothic sign
• Potato nose, hebra nose, elephantiasis of nose
• Tapir nose (also in leishmaniasis)
• Treatment: streptomycin + tetracycline for 4-6 weeks

RHINOSPORIDIOSIS
• Caused by the fungi – Rhinosporidium seeberi
• In India, most cases are seen in southern states
• Disease acquired through contaminated water
• Presents as leafy polypoidal mass, pink to purple in color in the nose
• The mass is very vascular and bleeds easily on touch
• Surface is studded with white dots
• Other presenting features – epistaxis, nasal discharge, nasal stuffiness
• Treatment – complete excision with diathermy knife

MUCORMYCOSIS
• A fungal infection of the nose and PNS which may prove rapidly fatal
• Seen in uncontrolled diabetics and those taking immunosuppressive drugs
• The rapid destruction of tissues is due to the affinity of the fungus to invade the arteries and cause
endothelial damage and thrombosis
• Typical finding: black necrotic mass filling the nasal cavity and eroding the septum and hard palate
• Treatment: amphotericin B and surgical debridement
FOREIGN BODIES IN THE NOSE
• If a child presents with unilateral, foul smelling nasal discharge (sometimes blood stained), foreign body
must be suspected
• Other important causes of unilateral blood stained nasal discharge

Rhinolith

Nasal diphtheria

Nasal myiasis

RHINOLITH
• It is stone formation in the nasal cavity
• A Rhinolith usually forms around the nucleus of a small exogenous foreign body, blood clot or inspissated
secretion by deposition of calcium and magnesium salts
• Common in adults
• Presents with unilateral nasal obstruction and foul smelling nasal discharge (often blood stained)

CHOANAL ATRESIA
• Persistence of bucconasal membrane
• Bony – 90%; membranous - 10%
• Unilateral atresia is more common
• Bilateral atresia presents with respiratory obstruction (new born – a natural nose breather, does not breath
from mouth)
• Diagnostic features

Mucoid discharge in the nose

Absence of air bubbles in the nasal discharge

Failure to pass a catheter from nose to pharynx
• McGovern's technique – feeding nipple with a large hole
• Definitive treatment – surgical correction at one and half years

CSF RHINORRHEA
• Discharge is clear, watery, appears suddenly in a gush of drops when bending forward (tea pot sign) or
straining
• Uncontrollable and cannot be sniffed back
• No associated sneezing, nasal congestion or lacrimation
• When collected in a test tube and allowed to stand, it remains clear (nasal discharge leaves a sediment)
• Glucose content > 30mg/dI (nasal discharge - < 10 mg/dl)
• β2 transferrin is specific for CSF (absent in nasal discharge)
• In traumatic CSF leak, CSF and blood are mixed – double ring sign or target sign

Localization of CSF leak

• Intrathecal injection of a dye or a radioisotope and placing pledges of cotton in the olfactory slit, middle
meatus, Sphenoethmoidal recess and near the Eustachian tube and examine the pledges for radioactivity

Olfactory slit – cribriform plate (most common site)

Middle meatus – frontal or ethmoidal sinus

Sphenoethmoidal recess – sphenoid sinus

Eustachian tube – temporal bone

ETHMOIDAL POLYP
• Site of origin – usually from the middle meatus
• Diseases associated

Chronic rhino sinusitis

Asthma

Aspirin intolerance

Cystic fibrosis

Allergic fungal sinusitis

Nasal mastocytosis
• Syndromes associated with ethmoidal polyp

Kartagener's syndrome Young syndrome Churg-Strauss syndrome

Bronchiectasis Sinopulmonary disease Asthma, Fever
Situs inversus Azoospermia Eosinophilia
Ciliary dyskinesia Vasculitis
Granuloma

Antrochoanal polyp Ethmoidal polyp

Children Adults
Infection Allergy
Solitary Multiple, grape like clusters
Unilateral Bilateral
Arise from maxillary sinus Ethmoidal sinus
Grows backwards to choana Grows anteriorly
Recurrence uncommon Common

Samter's triad
• Nasal polypi
• Bronchial asthma
• Aspirin sensitivity

EPISTAXIS

BLOOD SUPPLY OF NOSE

Nasal septum Lateral wall of nose
Internal carotid system
Branches of ophthalmic artery
• Anterior ethmoidal artery
• Posterior ethmoidal artery
External carotid system
• Posterior medial nasal artery (Sphenopalatine • Posterior lateral nasal branches
artery) (Sphenopalatine artery)
• Nasopalatine artery (Sphenopalatine artery) • Greater palatine artery (Maxillary artery)
• Septal branch of greater palatine artery (branch • Nasal branch of anterior superior dental
of maxillary artery) (infraorbital branch of maxillary artery)
• Septal branch of superior labial artery (branch • Branches of facial artery to nasal vestibule
• of facial artery)

Little's area or Kiesselbach's plexus

• Situated in the anteroinferior part of nasal septum, just above the vestibule
• Most common site of epistaxis in children
• Site of origin of bleeding polypus (hemangioma) of nasal septum
 • Four arteries anastamose here

Anterior ethmoidal artery

Septal branch of sphenopalatine artery

Septal branch of greater palatine artery

Septal branch of superior labial artery

 Retrocolumellar vein — common site of venous bleeding in young people

Woodruff's plexus
• Site of epistaxis in elderly
• Located posterior to middle turbinate
• 3 arteries anastamose here

Sphenopalatine artery

Ascending pharyngeal artery

Posterior nasal artery

Anterior epistaxis Posterior epistaxis

• More common
• Mostly from Little's area
• Usually in children or young adults
• Usually due to trauma
• Bleeding is usually mild, can be controlled by
local pressure or anterior pack
• Less common
• Mostly from Woodruff's area
• Usually > 40 years
• Usually spontaneous, due to hypertension or
arteriosclerosis
• Bleeding is severe, requires hospitalization,
postnasal pack often required

Treatment of epistaxis
• Bleeding from Little's area can be easily controlled by pinching the nose with thumb and index finger for
about 5 mins
• Trotter's method: patient made to sit, leaning a little forward over a basin to spit any blood and breathe
quietly from the mouth
• Cauterization — in anterior epistaxis, when bleeding point has been located
• Anterior nasal packing
• Posterior nasal packing
• SMR for persistent or recurrent bleeds
• Endoscopic cautery — if posterior bleeding point is located
• Ligation of vessels

External carotid — when conservative measures have failed, external carotid artery is ligated above the
origin of superior thyroid artery. Avoided these days in favor of embolization or ligation of more
peripheral branches

Maxillary artery — in uncontrolled posterior epistaxis

Ethmoidal arteries — in anterosuperior bleeding above middle turbinate

Transnasal Endoscopic Sphenopalatine artery ligation (TESPAL)

TRAUMA TO THE FACE

• Tripod fracture —fractures of zygoma
• Fractures of mandible — condylar fractures — most common
• Fractures of maxilla

Le Fort I (transverse fracture) — runs above and parallel to the palate

Le Fort II (pyramidal fracture) — runs through the root of nose, lacrimal bone, floor oforbit and
infraorbital margin

Le Fort III (craniofacial dysjunction) – starts from the root of nose, and runs along the nasofrontal,
maxillofrontal, zygomaticofrontal and ethmoidofrontal suture lines

Le Fort fractures

ORO-ANTRAL FISTULA
• Pathological communication between the maxillary sinus and oral cavity
Etiology
• Dental extraction – most common cause. Roots of upper second premolar and molars (usually first and
sometimes 2nd and 3rd molars) are closely related to the antrum
• Failure of sublabial incision to heal after Caldwell-Luc operation
• Maxillary carcinoma
• Trauma – fracture and penetrating injuries of maxilla
• Osteitis of maxilla
• Syphilis

Clinical features
• Regurgitation of food into the antrum
• Foul smelling discharge from nose and fistulous opening
• Inability to build pressure in mouth – inability to blow wind instruments, drink through a straw
• Valsalvin test - This test is performed by asking the patient to blow air through the nose after pinching the
nose closed. The patient must keep the mouth open. The air could be heard hissing out of the fistula

Rhinomanometry
• Done by calculating the nasal resistance to airflow by two measurements

Nasal airflow

Transnasal pressure

Costen syndrome
• Otherwise called Myofacial pain dysfunction syndrome
• Abnormality of temporomandibular joint
V. ANATOMY OF PARANASAL SINUSES, ACUTE & CHRONIC SINUSITIS,NEOPLASMS
OF NASAL CAVITY & PNS

DEVELOPMENT & ANATOMY OF PARANASAL SINUSES

Anterior group (All open in middle meatus) Posterior group

• Maxillary sinus • Posterior ethmoidal sinus (opens in superior
• Frontal sinus meatus)
• Anterior ethmoidal sinus • Sphenoid sinus (opens in sphenoethmoidal
recess)

MAXILLARY SINUS
• Antrum of Highmore
• Largest PNS
• Pyramidal in shape; base towards the lateral wall of nose
• Capacity 15 mL in adult
• Anterior wall — facial surface of maxilla
• Posterior wall — infratemporal and pterygopalatine fossae
• Medial wall — middle and inferior meatuses
• Floor — alveolar and palatine processes of maxilla
• Floor is related to the roots of second premolar and first molar teeth
• Ostium — situated high up in the medial wall (unfavorable for natural drainage)
• Accessory ostium is seen in 30% cases

FRONTAL SINUS
• Each frontal sinus is situated between the inner and outer tables of frontal bone
• Varies in shape and often loculated by incomplete septa

Kuhn classification of frontal cells

Cell type Anatomical location
I Single frontal cell above agger nasi cell, but not extending above frontal beak
II Tier of cells in frontal recess above agger nasi cell, but not extending above frontal beak
III Single massive cell pneumatizing cephalid into frontal sinus
IV Isolated cell in the frontal sinus

ETHMOIDAL SINUS
• Number varies from 3 – 18
• Occupy the space between upper third of lateral nasal wall and medial wall of orbit
• Clinically divided by a basal lamina into anterior and posterior ethmoidal cells
• Anterior group

Agger nasi cells

Ethmoid bulla

Supraorbital cells

Frontoethmoid cells

Haller cells – situated in the floor of orbit
• Posterior group

Onodi cell – posterior most cell

Optic nerve and sometimes carotid artery are related to it laterally
SPHENOID SINUS
• Lateral wall – optic nerve and internal carotid artery
• Lower part of lateral wall – maxillary nerve
• Floor – vidian nerve
• Anterior part of roof – olfactory tract, optic chiasma and frontal lobe
• Posterior part of roof – pituitary gland, cavernous sinus

Sinus Number Development At Birth First Radiological Fully develops at

Evidence
Maxillary 2 2-3 months IUL Present 4-5 months 15 Years
Ethmoid 3 – 18 3-4 months IUL Present 1 Year 12 Years
Frontal 2 4th month IUL Absent 6 Years Teen age
Sphenoid 2 4th month IUL Absent 4 Years 15 Years

Ventilation of sinuses
• During inspiration, air current causes negative pressure in the nose
• During expiration, positive pressure is created in the nose and this sets up eddies which ventilate the sinuses
• Thus the ventilation of PNS is paradoxical
• Emptied of air during inspiration and filled with air during expiration

ACUTE SINUSITIS

Exciting causes Predisposing causes

• Nasal infections • Obstruction to sinus ventilation and drainage
• Swimming and diving — nasal packing, DNS, hypertrophic turbinates,
• Trauma — penetrating injuries or compound vasomotor rhinitis, nasal polypi, neoplasm
fractures of sinuses • Stasis of secretions in nasal cavity
• Dental infections (in maxillary sinusitis only) • Previous attacks of sinusitis

Clinical features of acute sinusitis

Maxillary sinusitis
• Head ache
• Pain over upper jaw, gums, teeth
• Tenderness on pressure over
anterior wall of antrum
• Nasal discharge
• Edema of lower eyelid
• Anterior rhinoscopy shows pus in
middle meatus
Frontal sinusitis
• Frontal head ache — shows
periodicity. Starts on waking
up, gradually increases and
reaches peak by midday and
then subsides (office head
ache)
• Tenderness over frontal
• sinus, just above medial
canthus
• Edema of upper eyelid
Ethmoid sinusitis
• Pain over bridge of nose,
medial and deep to the
eye
• Retroorbital pain -
aggravated by
movements of eye ball
• Edema of both eyelids
• Swelling of middle
turbinate

Postural test
• A piece cotton soaked in vasoconstrictor is placed around middle meatus
• The patient is made to sit with affected sinus turned up for 10-15 minutes
• Appearance of discharge in middle meatus indicates acute maxillary sinusitis.
Surgery for chronic sinusitis
Chronic maxillary sinusitis
• Antral puncture and
irrigation
• Intranasal antrostomy
• Caldwell-Luc operation
Chronic frontal sinusitis
• Trephination of frontal sinus
• External frontoethmoidectomy
(Howarth's or Lynch operation)
• Osteoplastic flap creation
Chronic ethmoid sinusitis
• Intranasal ethmoidectomy
• External ethmoidectomy

MUCOCELE OF FRONTAL SINUS

• Usually presents in the superomedial quadrant of the orbit
• Displaces the eyeball forward, downward and laterally
• Swelling is cystic, non-tender; egg shell crackling may be elicited
• X-rays show clouding of sinus with loss of scalloped outline which is so typical of normal frontal sinus

Treatment: frontoethmoidectomy with free drainage of frontal sinus into the middle meatus

FUNCTIONAL ENDOSCOPIC SINUS SURGERY

• Minimally invasive surgery and does not require skin incisions or removal of intervening bone to access the
disease
• In the sinuses, ventilation and drainage of the sinuses is re-established preserving the nasal and sinus
mucosa and its function of mucociliary clearance
• It is called functional because the aim is to restore the function of the sinuses by providing drainage and
aeration, by relieving the obstruction at the natural ostia of the sinuses
• Soft tissue shavers (microdebriders) – to remove nasal polyps, soft tissue masses and mucosa

Indications for FESS Contraindications

• Chronic bacterial sinusitis unresponsive to medical
treatment
• Recurrent acute bacterial sinusitis
• Diffuse nasal polyposis
• Fungal sinusitis with fungal ball
• Antrochoanal polyp
• Mucocele of frontoethmoid or sphenoid sinus
• Control of epistaxis by endoscopic cautery
• Removal of foreign body from nose or sinus
• Endoscopic septoplasty
• Inexperience and lack of proper
instrumentation
• Disease inaccessible by endoscopic
procedures (lateral frontal sinus & stenosis
of internal opening of frontal sinus)
• Osteomyelitis
• Threatened intracranial or intraorbital
complications

NEOPLASMS OF NASAL CAVITY

BENIGN TUMORS
INVERTED PAPILLOMA
• Also called as Transitional cell papilloma or Ringertz tumor or Schneiderian papilloma
• Tumor of the nonolfactory mucosa of nose and paranasal sinuses
• Most common site of origin – lateral wall of nose in the middle meatus
• Human Papilloma virus is thought to be an etiologic factor
• More common in men in the age group 40 – 70 years
• Almost always unilateral
• Medial maxillectomy – is the treatment of choice
MALIGNANT TUMORS
ESTHESIONEUROBLASTOMA
• Olfactory neuroblastoma or Olfactory placode tumor
• Arise from the olfactory epithelium in the upper third of nose
• Bimodal peaks (10-20 & 50-60)
• Endoscopic examination – friable, cherry red, polypoidal mass in the upper third of nasal cavity

SQUAMOUS CELL CARCINOMA

• Most common type
• Men > 50 years
• Squamous cell ca of septum – nose pickers cancer

 Schneiderian membrane – other name for respiratory mucosa

 Capillary hemangioma – bleeding polypus of septum
 Malignant Melanoma – most common site anterior part of nasal septum

NEOPLASMS OF PARANASAL SINUSES

Benign neoplasms
• Most common benign tumor osteoma
• Osteomas – most common in frontal sinus
• Fibrous dysplasia – most common in maxillary sinus
• Fibrous dysplasia – ground glass appearance of sinus

Malignant neoplasms
• Maxillary sinus is most commonly involved
• Workers of furniture industry – adenocarcinoma of ethmoids and upper nasal cavity
• Nickel refining – squamous cell and anaplastic carcinoma
• 80% tumors are squamous cell carcinomas

MAXILLARY SINUS CARCINOMA

• Mostly in males
• 40 – 60 years
• CT scan – best non-invasive method to find the extent of the disease

Ohngren's classification
• An imaginary plane from medial canthus of eye to angle of mandible
• Growths situated above this plane (suprastructural) have a poorer prognosis than those below it
(infrastructural)

Lederman's classification
• Uses two horizontal lines of Sibileau.
• One passing through the floors of orbit and the other through the floors of maxillary antrum.
• Suprastructure: ethmoid, sphenoid and frontal sinuses and olfactory area of nose
• Mesostructure: maxillary sinus and respiratory area of nose
• Infrastructure: containing alveolar process

Surgeries
• Total maxillectomy for operable tumor involving maxilla
• Extended maxillectomy – if the growth involves orbit, skin, face or soft tissues in the infratemporal fossa
Prognosis – usually poor
RADIOLOGY OF SINUSES
View
Occipito-mental or Water's
Occipito-frontal or Caldwell
Submento-vertical or Basal or
Jug Handle
Decubitus Water's and
Supine (Brow up) view
Bucket handle
Best seen structure
Maxillary sinus
Frontal & Ethmoid sinus
Structures in the base of skull
Fluid level in sinus
Fracture of zygomatic arch
Other structures visualized
Floor of the orbit, frontal sinuses,
anterior ethmoidal cells
Nasal floor
Posterior wall of frontal sinus,
maxillary and sphenoid sinuses
 VI. DISEASES OF ORAL CAVITY & PHARYNX

ORAL CAVITY
APHTHOUS ULCERS
• Recurrent, superficial, involving movable mucosa – inner surfaces of lips, buccal mucosa, tongue, floor of
mouth and soft palate
• Spares mucosa of hard palate and gingivae
• Etiology unknown
• Treatment: topical steroids and cauterization with 10% silver nitrate

VINCENT'S ANGINA / TRENCH MOUTH

• Ulcerative lesion of pharynx
• Causative organism: fusiform bacillus and Borrelia vincenti
• Starts at the interdental papillae and then spreads to the free margins of the gingivae which gets covered
with necrotic slough

LUDWIG'S ANGINA
• Cellulitis involving the submandibular space extending to the flora of mouth
• This space is subdivided by the mylohyoid muscle

Sublingual space (above mylohyoid)

Submaxillary space (below mylohyoid)
• 80% cases are due to dental infections
• Usually a polymicrobial infection
• Clinical features - Odynophagia and trimus
• Important complication – airway obstruction

Premalignant lesions

LEUKOPLAKIA
• A clinical white patch that cannot be characterized clinically or pathologically as any other disease
• Etiology – smoking, tobacco chewing, alcohol, chronic trauma due to ill-fitting dentures
• Buccal mucosa and oral commisures are the most common sites
• Males affected 3 times more than females
• Types

Homogenous – less often associated with malignancy

Nodular (speckled) – higher incidence of malignant transformation

Erosive (erythroleukoplakia) – higher incidence of malignant transformation
• On an average 5% become malignant

ERYTHROPLAKIA
• Red patch or plaque on mucosal surface
• No sex predilection
• Most common sites – lower alveolar mucosa, gingivobuccal sulcus and floor of the mouth
• Malignant potential is 17 times higher than in leukoplakia

Oral manifestations in AIDS

• Thrush – candida infection
• Hairy leukoplakia – EBV infection
 • Aphthous ulcers
• Mucocutaneous Herpes simplex

PHARYNX

Anatomy
• 12– 14 cm long
• Extends from base of skull to the lower border of cricoid cartilage
• Width 3.5cm at its base and 1.5 cm at pharyngo-esophageal junction (narrowest part of digestive tract apart
from the appendix)
• Four layers of pharyngeal wall

Mucous membrane

Pharyngeal aponeurosis (pharyngobasilar fasci)

Muscular coat
o External layer
 Superior constrictor
 Middle constrictor
 Inferior constrictor
o Internal layer
 Stylopharyngeus
 Palatopharyngeus
 Buccopharyngeal fascia

Killian's dehiscence
• Inferior constrictor has two parts

Thyropharyngeus with oblique fibres

Cricopharyngeus with transverse fibres
• Potential gap between these two parts is called Killian's dehiscence
• Perforation can occur during esophagoscopy – also called gateway of tears
• Site of herniation in cases of pharyngeal pouch

WALDEYER'S RING
• A collection of sub epithelial lymphoid tissue around the entrance to the pharynx

Inner ring Outer ring

• Adenoids • Retro pharyngeal node
• Tubal tonsils • Jugulodigastric node (tonsillar node)
• Lingual tonsils • Submandibular node
• Palatine tonsils • Submental node

Divisions of pharynx
NASOPHARYNX or EPIPHARYNX
• Extends from base of skull to the soft palate or the level of the horizontal plane passing through the hard
palate
• Roof — basisphenoid and basiocciput
• Posterior wall — arch of atlas vertebrae (roof and posterior wall merge with each other)
• Anterior wall — choanae
• Lateral wall

Opening of ET 1.25cm behind the posterior end of inferior turbinate

Torus tubarius — elevation above and behind the tube

Fossa of Rosenmuller — recess present above and behind torus tubaris, which is the commonest site of
origin of carcinoma

Contents of nasopharynx
• Adenoids (Nasopharyngeal tonsils)
• Nasopharyngeal bursa — found within the adenoid mass; abscess formation — Thornwaldt's disease
• Rathke's pouch — dimple above the adenoids
• Tubal tonsil (Eustachian or Gerlach tonsil)
• Sinus of Morgagni: Space between the base of skull and upper free border of superior constrictor muscle.
Structures passing through it

Eustachian tube

Levator veli palatini

Tensor veli palatine

Ascending pharyngeal artery
• Passavant's ridge: Mucosal ridge raised by fibres of palatopharyngeus

OROPHARYNX
• Extends from the plane of hard palate above and hyoid bone below
• Posterior wall — retropharyngeal space; lies opposite to 2' and 3' cervical vertebrae
• Anterior wall — deficient above; below — base of tongue, lingual tonsils and valleculae
• Lateral wall — palatine tonsils, anterior pillar (palatoglossal arch) posterior pillar (palatopharyngeal arch)

HYPOPHARYNX or LARYNGOPHARYNX
• Extends from hyoid bone above and lower border of cricoid cartilage below
• Lies opposite to 3rd , 4th 5th and 6th cervical vertebrae
Clinically divided into three regions
• Pyriform sinus

Lies on either side of larynx

Extends from pharyngoepiglottic fold to the upper end of esophagus

Laterally – thyro-hyoid membrane and thyroid cartilage

Medially – aryepiglottic fold, arytenoid and cricoid cartilages

Foreign bodies may lodge here

Internal laryngeal nerve runs submucosally
• Post-cricoid region – common site of carcinoma in Plummer-Vinson syndrome
• Posterior pharyngeal wall

ADENOID/NASOPHARYNGEAL TONSIL/LUSCHKA'S TONSIL

Anatomy
• Sub epithelial collection of lymphoid tissue at the junction of posterior wall and roof of nasopharynx
• Increases in size up to 6 yrs, tends to atrophy after that, completely disappears at the age of 20yrs
• No crypts, no capsule (present in palatine tonsil)
• Blood supply

Ascending palatine branch of facial artery

Ascending pharyngeal branch of external carotid artery

Pharyngeal branch of third part of maxillary artery

Ascending cervical branch of inferior thyroid artery
Clinical features of adenoid enlargement
• Nasal obstruction is the commonest symptom
• Nasal discharge, sinusitis, epistaxis, voice change
• ET obstruction: CHL, CSOM, SOM
• Adenoid facies: elongated face with dull expression, open mouth, prominent and crowded upper teeth,
hitched up upper lip, high arched palate
• Pulmonary hypertension and Cor pulmonale
• Aprosexia – lack of concentration

ADENOIDECTOMY
• St Clair Thompson's adenoid curette is used

Indications
• Adenoid hypertrophy causing snoring, mouth breathing, sleep apnea or speech abnormalities
• Recurrent rhinosinusitis
• Chronic otitis media with effusion
• Dental malocclusion
• Recurrent ear discharge

Contraindications
• Cleft palate or submucous palate
• Hemorrhagic diathesis
• Acute upper respiratory tract infection

TONSILS
Anatomy
• Develops from the endoderm of second pharyngeal pouch
• Each tonsil is located in the lateral wall of oropharynx between anterior and posterior pillars
• Capsulated, capsule deficient on medial surface
• 12 —15 crypts seen on the medial surface
• Central large crypt: crypta magna/ intratonsillar crypt (represents ventral part of rd pharyngeal pouch
• Bed of the tonsil formed by superior constrictor and styloglossus muscles
• Outside the superior constrictor tonsil is related to facial artery, submandibular salivary gland, posterior belly
of digastric, medial pterygoid, angle of mandible
• Blood supply

Tonsillar branch of facial artery(main supply)

Ascending pharyngeal from external carotid artery

Ascending palatine from facial artery

Dorsal linguae branches of lingual artery

Descending palatine branch of maxillary artery

ACUTE TONSILLITIS
• Acute catarrhal or superficial tonsillitis — part of generalized pharyngitis; in viral infections
• Acute follicular tonsillitis — crypts filled with purulent material, presenting as yellowish spots on surface of
tonsil
• Acute parenchymatous tonsillitis — tonsil uniformly red and enlarged
• Acute membranous tonsillitis — exudates from the crypts, coalesces to form a membrane
• Hemolytic streptococcus is the most common organism
 • Clinical features: sore throat, dysphagia, fever, otalgia
• Treatment: Systemic antibiotics for 7 — 10 days
• Complications: chronic tonsillitis,
peritonsillar abscess, parapharyngeal abscess,
cervical abscess, ASOM, Rheumatic fever, Acute glomerulonephritis, Subacute bacterial endocarditis

CHRONIC TONSILLITIS
• Enlargement of tonsils. In chronic parenchymatous tonsillitis — enlarged tonsils may meet in the midline
(kissing tonsils)
• Small tonsils; pressure on anterior pillar expresses frank pus — chronic fibroid tonsillitis
• Yellowish beads of pus on medial surface — chronic follicular tonsillitis
• Flushing of anterior pillar compared to rest of pharyngeal mucosa
• Enlargement of jugulodigastric lymph nodes

TONSILLECTOMY
Position – Rose's position

Most common method employed – Dissection and Snare method

Absolute Indications
• Recurrent throat infection > 7 in lyr or 5 per yr for 2 yrs or 3 per yr for 3yrs
• Peritonsillar abscess – 4-6 wks after abscess is treated
• Hypertrophy of tonsils causing airway obstruction(sleep apnea), dysphagia or speech interference
• Tonsillitis causing febrile seizures
• Suspected malignancy

Relative indications
• Diphtheria carriers, streptococcal carriers
• Chronic tonsillitis

As a part of another operation

• Palatopharyngoplasty for sleep apnea syndrome
• Glossopharyngeal neurectomy
• Removal of styloid process
S

Contraindications
• Acute infection of upper respiratory tract, even Acute tonsillitis
• Children < 3 yrs
• Submucous cleft palate
• At the time of polio epidemic
• Bleeding disorders

Complications
• Hemorrhage is the most common complication
• Primary hemorrhage – at the time of surgery (trauma to aberrant vessel or paratonsillar vein)
• Reactionary hemorrhage – with in 24 hrs (presence of clots or slipping of ligature)
• Secondary hemorrhage – 5th to 10th post-op day(sepsis)
PERITONSILLAR ABSCESS (QUINSY)
• Collection of pus in the peritonsillar space (between capsule of tonsil and superior constrictor)
• Usually follows acute tonsillitis
• Severe unilateral pain in the throat

Symptoms
• Odynophagia
• Hot potato voice – muffed and thick speech
• Ipsilateral earache

Signs
• Tonsil, pillars and soft palate on the involved site are congested and swollen
• Uvula is swollen, edematous and pushed to the opposite side
• Bulging of soft palate and anterior pillar above the tonsil

Treatment
• Incision and drainage
• Interval tonsillectomy: tonsillectomy 4-6 weeks following an attack of quinsy

RETROPHARYNGEAL ABSCESS
Anatomy
• Lies behind the pharynx, between the bucco-pharyngeal fascia covering the pharyngeal constrictor muscles
and the pre-vertebral fascia
• Extends from the base of skull to the bifurcation of trachea
• The space is divided into two lateral compartments (spaces of Gillette) by a fibrous raphe
• Each lateral space contains retropharyngeal nodes which usually disappear at 3 – 4 years
• Infection of retropharyngeal space can pass down behind the esophagus into the mediastinum
• Source of infection

Extension of infection from parapharyngeal space, masticator or parotid space

Esophageal perforation

Suppuration of retropharyngeal nodes

Clinical features
• Seen in children < 3 years
• Dysphagia and difficulty in breathing are prominent symptoms
• Other features – stridor, torticollis, unilateral swelling in the posterior pharyngeal wall
• X-ray lateral view – widening of prevertebral shadow and sometimes presence of gas

PARAPHARYNGEAL SPACE
Anatomy
• Pyramidal in shape, base – base of skull; apex – hyoid bone
• Medial: buccopharyngeal fascia covering the constrictor muscles
• Posterior: prevertebral fascia
• Lateral: medial pterygoid muscle, mandible and deep surface of parotid gland
• Styloid process and the muscles attached to it divide the space into anterior and posterior compartments
• Source of infection

Peritonsillar abscess

Parotid abscess

Submandibular gland infection

Masticator space infection

Clinical features
• Anterior compartment infections: triad of

Prolapse of tonsil and tonsillar fossa

Trismus (due to spasm of medial pterygoid muscle)

External swelling behind the angle of jaw
• Posterior compartment infections

Bulge of pharynx behind the posterior pillar

Paralysis of CN IX, X, XI, XII & Sympathetic chain

Swelling of parotid region

Minimal trismus or tonsillar prolapse

JUVENILE NASOPHARYNGEAL ANGIOFIBROMA or NASOPHARYNGEAL FIBROMA

• Most common benign tumor of nasopharynx
• Commonly seen in adolescent males in II decade
• Arises from posterior part of nasal cavity close to sphenoparietal foramen
• Vessels in the tumor are just endothelium lined spaces with no muscular coat
• Profuse recurrent epistaxis is the most common symptom
• Progressive nasal obstruction, CHL, serous otitis media are other common symptoms
• Tumor can extend into the nasal cavity, paranasal sinus, pterygomaxillary fossa, infratemporal fossa, orbits
and cranial cavity
• Broadening of nasal bridge, frog face deformity may be seen
• CT scan is the investigation of choice
• CT scan shows anterior bowing of posterior wall of maxillary sinus (Antral sign or Holman-Miller sign)
• Surgical excision is the treatment of choice

Transpalatine approach – for tumors confined to nasopharynx

Lateral rhinotomy approach – for extended tumor

Trans palatine + sublabial approach ( Sardana's approach)

Extended Denker's approach
• To decrease vascularity –Stilbesterol 2.5mg tds for 3 weeks, pre-op radiotherapy, Cryotherapy and
embolization

NASOPHARYNGEAL CARCINOMA
Etiology
• Genetic – most common in China particularly in southern states and Taiwan
• Uncommon in India except in Northeast region
• Virus - EBV
• Environmental – air pollution, tobacco smoking, opium smoking, nitrosamines from dry salted fish, smoke
from burning incense and wood, vitamin C deficiency

Pathology
• Squamous cell carcinoma is the most common type
• Most common site of origin – fossa of Rosenmuller in the lateral wall of nasopharynx

Clinical features
• Age: 5th to 7th decades
• Males affected 3 times more
 • Enlargement of cervical lymph nodes – most common symptom (60-90%)
• Presence of unilateral serous otitis media in an adult should rise the suspicion of nasopharyngeal growth
• Jugular foramen syndrome – involvement of CN IX, X, XI
• Horner's syndrome
• Trotter's triad

Conductive deafness (ET block)

Ipsilateral temporoparietal neuralgia (involvement of CN V)

Palatal paralysis (CN X)
• Jaccods's triad – ipsilateral ophthalmoplegia, amaurosis, ipsilateral neuralgia
• Treatment – Irradiation is the treatment of choice
• Chemo therapy for stage III and IV cancers

STYALGIA (EAGLE'S SYNDROME)

• Styloid process is normally 2.5cm long
• Due to elongated styloid process or calcification of stylohyoid ligament
• Pain in tonsillar fossa and upper neck which radiates to the ipsilateral ear
• Aggravated on swallowing

PATERSON BROWN KELLY SYNDROME/ PLUMMER VINSON SYNDROME

• Also called Sideropenic dysphagia
• Females between > 40yrs
• Progressive dysphagia
• Hypochromic microcytic anemia
• Koilonychia, Glossitis and angular stomatitis
• Atrophy of mucous membrane of alimentary tract
• Barium swallow – post cricoid web
• Bocca's sign: absence of laryngeal crepitation (post cricoid malignancy, perichondritis, foreign body
cricopharynx)
• About 10% (5 – 15%) cases develop Post cricoid carcinoma
• Also predisposes to the development of ca tongue, buccal mucosa, pharynx, esophagus and stomach
• Poor prognosis

ZENKER'S DIVERTICULUM
• Hypopharyngeal diverticulum or Hypopharyngeal pouch
• Pulsion diverticulum where pharyngeal mucosa herniates through Killian's dehiscence
• Gurgling sound on swallowing
• Boyce's sign — swelling is found on the left side, lower part of anterior triangle, soft, gurgles on palpation
• Treatment

Excision of pouch and cricopharyngeal myotomy

Doh!man's procedure

DYSPHAGIA LUSORIA
• Abnormal large vessel pressing on the esophagus and causing dysphagia

Right aortic arch

Double aortic arch

Abnormal right subclavian artery

Abnormal innominate artery
 VII. DISEASES OF LARYNX

ANATOMY OF LARYNX

Laryngeal cartilages

Paired Unpaired
• Arytenoid • Thyroid (largest)
• Corniculate (cartilage of Santorinii) • Cricoid
• Cuneiform (cartilage of Wrisberg) • Epiglottis

• Cricoid is the only cartilage forming complete ring

• VISOR angle – angle between cricoids and thyroid cartilage
• Hyaline cartilage: thyroid, cricoids and most of arytenoids
• Fibroelastic cartilage: epiglottis, corniculate, cuneiform and tip of arytenoids

Laryngeal membranes
Extrinsic membranes Intrinsic membranes
• Thyrohyoid membrane • Cricovocal membrane
• Crithyriod membrane • Quadrangular membrane
• Cricotracheal membrane

Intrinsic muscles of larynx

Action
Abductor of the Vocal Cords
Adductor of the Vocal Cords
Tensor of Vocal Cord
Openers of laryngeal inlet
Closers of laryngeal inlet
Intrinsic Muscle
Posterior Crico Arytenoid
Thyro - arytenoids (external part)
Inter - arytenoids (Transverse arytenoid)
Lateral Crico – arytenoid.
Crico – Thyroid
Thyro - arytenoid (internal part) [VOCALIS]
Thyro - epiglottic (part of thyroarytenoid)
Inter - arytenoids (oblique part);
Inter - arytenoids (ary - epiglottic part)

EXTRINSIC MUSCLES OF LARYNX

Elevators Depressors
Primary elevators Secondary elevators • Sternohyoid
(attached to thyroid cartilage) (attached to hyoid bone) • Sternothyroid
• Stylopharyngeus • Mylohyoid • Omohyoid
• Salpingopharyngeus • Digastrics
• Palatopharyngeus • Stylohyoid
• Thyrohyoid • Geniohyoid

Nerve Supply
Motor
All intrinsic muscles are supplied by Recurrent
laryngeal nerve except for Cricothyroid which is
supplied by External laryngeal nerve
Sensory
Upto the level of Vocal Cords: Internal laryngeal N
Below the level of Vocal Cords: Recurrent laryngeal N
Glottis (Rima glottidis)
• Elongated space between vocal cords anteriorly &
• Vocal processes and base of arytenoids posteriorly
• Antero posteriorly glottis measures 24mm in men and 16mm in women
• Epithelium of vocal cords - stratified squamous

Lymphatics
• Supraglottic larynx – upper deep cervical nodes
• Infraglottic larynx – lower deep cervical nodes
• Glottis – no lymphatics

Adult & Pediatric larynx

Pediatric larynx Adult larynx
Position High in the neck Opposite to C6
Opposite to C3 or C4
Epiglottis Omega shaped Leaf shaped
Narrowest part Sub glottis Glottis
Shape of larynx Conical Cylindrical
Vocal cord length Male –8 mm Male – 24mm
Female-6 mm Female – 16mm

Surgical anatomy of larynx

Site Subsite
Supraglottis • Suprahyoid epiglottis (both lingual and laryngeal surfaces)
• Infrahyoid epiglottis
• Aryepiglottic folds(lateral aspect only)
• Arytenoids
• Ventricular bands(false cords)

Glottis True vocal cords including anterior and posterior commissure

Subglottis Upto the lower border of cricoid cartilage

In Europe, especially especially in France, larynx is described as

Epilarynx (marginal zone) Endolarynx
• Free border and posterior surface of suprahyoid • Infrahyoid epiglottis
epiglottis (anterior epilarynx) • False cords
• Aryepiglottic fold (lateral epilarynx) • Ventricles
• Arytenoids and interarytenoid incisures • Glottis
(posterior epilarynx) • Subglottis

Spaces of larynx
• Pre-epiglottic space of Boyer
• Paraglottic space
• Reinke's space

Under the epithelium of vocal cords

Scanty subepithelial tissue

Edema of this space causes fusiform swelling of the membranous cords (Reinke's edema)
Functions of Larynx
• Airway protection
• Respiration
• Phonation
• Chest fixation

Normal vocal folds produce three typical vibratory patterns:

• Falsetto or (light voice) - glottic closure is not complete, and only the upper edge of the vocal fold vibrates.
• Modal voice - complete glottic closure occurs. This is the basic frequency at which a person phonates. The
modal frequency in adult males is 120 Hz while in adult females it is 200 Hz.
• Glottal fry or low frequency phonation - closed phase is long when compared to the open phase. The vocal
cord mucosa and vocalis muscle vibrate in unison.

PACHYDERMA LARYNGIS
• Chronic hypertrophic laryngitis affecting posterior part of larynx
• Mostly in men who indulge in excessive alcohol and smoking
• Other factors – forceful talking, GERD
• Patient presents with hoarseness of voice
• Indirect laryngoscopy – heaping up of red or grey granulation tissue in the region of interarytenoids and
posterior part of vocal cords
• Contact ulcer may be seen in the vocal cords
• Bilateral and symmetrical
• Does not undergo malignant change

ATROPHIC LARYNGITIS (LARYNGITIS SICCA)

• Atrophy of laryngeal mucosa and crust formation
• More common in women
• Associated with atrophic rhinitis and pharyngitis
• Hoarseness of voice which temporarily improves on coughing and removal of crusts

ACUTE EPIGLOTTIS
• Tripod sign – in acute epiglottitis, child sitting up and leaning forwards, unable to lie supine

ACUTE LARYNGO TRACHEA BRONCHITIS (CROUP)

• Starts as URI with hoarseness & croupy cough, followed by difficulty in breathing & inspiratory stridor

Acute epiglottitis Acute laryngo-tracheo-bronchitis

Hemophilus influenzae type B Parainfluenza type I and II
2 – 7 years 3 months to 3 years
Supraglottic larynx Subglottic area
Sudden onset Slow
High fever Low grade or no fever
Toxic look of patient Non-toxic
Cough absent Barking seal like cough
Marked stridor Present
Odynophagia present Absent
X-ray thumb sign on lateral view Steeple sign on AP view
TUBERCULOSIS OF LARYNX
• Affects posterior part more than the anterior part
• Almost always secondary to PT
• Most commonly affected part is the interarytenoid fold
• Submucosal tubercles
• Pseudoedema (swollen laryngeal mucosa due to cellular infiltration)
• Weakness of voice – earliest symptom
• Impairment of adduction – first sign
• Mamillated appearance – swelling in the interarytenoid region
• Mouse nibbled appearance – ulceration of vocal cord
• Turban epiglottis – pseudoedema of glottis

LUPUS LARYNX
• Involves anterior parts of larynx
• Epiglottis is involved first
• Painless and asymptomatic condition
• Good prognosis

LARYNGOMALACIA
• Most common congenital anomaly of larynx
• Most common congenital anomaly of larynx to cause stridor in infants
• Excessive flaccidity of supra glottis larynx which is sucked in during inspiration producing stridor
• Stridor increases on crying but subsides when the child is put in prone position
• Cry is normal
• Condition manifests at birth but usually disappears at 2 yrs
• Direct laryngoscopy shows elongated epiglottis (omega shaped) aryepiglottic folds and prominent
arytenoids
• Treatment- conservative, for severe cases tracheostomy

CONGENITAL SUBGLOTTIC STENOSIS

• Due to abnormal thickening of cricoid cartilage or fibrous tissue seen below vocal cords
• Cry is normal as in laryngomalacia
• Diagnosis is made when subglottic diameter is < 4 mm in full term neonate (normal 4.5 – 5.5 mm )or < 3 mm
in a preterm neonate (normal 3.5 mm)
• Many cases improve as larynx grow

STRIDOR
• Inspiratory stridor – obstructive lesions of supraglottis or pharynx
• Expiratory stridor – obstructive lesions of thoracic trachea, primary and secondary bronchi
• Biphasic stridor – lesions of glottis, subglottis and cervical trachea

RECURRENT LARYNGEAL NERVE (ABDUCTOR) PARALYSIS

Unilateral RLN Paralysis
• Ipsilateral paralysis of all muscles except Cricothyroid
• Vocal cord assumes median or paramedian position does not move laterally during inspiration
• Semon's law: in all organic lesions abductor fibers are more susceptible and paralyzed earlier than the
adductors
 • Wagner and Grossman hypothesis: Cricothyroid receives innervations from SLN, keeps the vocal cord in
paramedian position
• One third patients asymptomatic
• Small change in voice
• Voice gradually improves due to compensation by healthy cord which crosses midline to meet the paralyzed
one
• No aspiration, airway obstruction, no treatment required

Bilateral RLN Paralysis

• Neuritis or Trauma due to thyroidectomy are the most common causes
• All intrinsic muscles paralyzed, vocal cord in median or paramedian position due to unopposed action of
Cricothyroid
• Airway obstruction – dyspnea, stridor
• Voice is normal
• Treatment — most cases require tracheostomy as emergency procedure
• Lateralization of cord — done by various procedures

Arytenoidectomy

Endoscopic lateralization

Type II thyroplasty

Cordectomy

CAUSES OF RECURRENT LARYNGEAL NERVE PARALYSIS

Right Left Both
• Neck trauma • Trauma • Thyroid surgery
• Aneurysm of subclavian • Bronchogenic cancer • Thyroid carcinoma
artery • Ca thoracic esophagus • Ca cervical esophagus
• Carcinoma right lung apex • Aortic aneurysm • Cervical
• Tuberculosis of cervical • Mediastinal lymphadenopathy • lymphadenopathy
pleura • Enlarged left auricle • Idiopathic
• Intrathoracic surgery

PARALYSIS OF SUPERIOR LARYNGEAL NERVE

Unilateral paralysis
• Paralysis of cricothyroid muscle and ipsilateral anesthesia of larynx above the vocal cord
• Voice is weak and pitch cannot be raised
• Askew position of glottis as anterior commissure is rotated to the healthy side
• Shortening of cord with loss of tension.
• Paralyzed cord appears wavy due to lack of tension
• Flapping of paralyzed cord — sags down during inspiration and bulges up during expiration

Bilateral paralysis
• Both cricothyroid muscles are paralyzed along with anesthesia of upper larynx
• Paralysis and anesthesia causes inhalation of food and pharyngeal secretions giving rise to cough and
choking fits
• Voice is weak and husky
• Epiglottopexy — reversible procedure to close laryngeal inlet to protect lungs from repeated aspiration
 Position of cord Location from midline Healthy Diseased
Median Midline Phonation RLN paralysis
Paramedian 1.5mm Strong whisper RLN paralysis
Intermediate 3.5mm.neutral position Paralysis of both RLN and
(cadaveric) of Cricoarytenoid joint. SLN
Gentle abduction 7mm Quiet respiration Abductor paralysis
Full abduction 9.5mm Deep respiration

COMBINED PARALYSIS OF RLN & SLN

Unilateral
• Paralysis of all muscles on one side except interarytenoid as it receives supply from the opposite side also
• Thyroid surgery is the most common cause
• Vocal cord lies in cadaveric position, 3.5mm from midline
• Healthy cord is unable to approximate the paralyzed cord
• Hoarseness, aspiration, ineffective cough due to air waste
• Treatment: Type I thyroplasty, injection of Teflon paste to paralyzed cord, arthrodesis of cricoarytenoid joint

Bilateral
• All laryngeal muscles are paralyzed and there is total anesthesia of larynx
• Both cords lie in cadaveric position
• Aphonia, aspiration and inability to cough
• Treatment: Tracheostomy, epiglottopexy, vocal cord plication, total laryngectomy

BENIGN TUMORS OF LARYNX

VOCAL NODULES
• Singer's or Screamer's nodes
• Appear symmetrically on the free edges of vocal cords, at the junction of anterior one-third and posterior
two-thirds
• Results of vocal trauma when a person speaks in unnatural low tones for prolonged periods or at high
intensities
• Mostly affects teachers, actors, vendors and pop singers
• Also in school going children who are too talkative
• Symptoms – hoarseness of voice, vocal fatigue and pain in the neck on prolonged phonation
• Small nodules – conservative management
• Large nodules – surgical excision

VOCAL POLYP
• Result of vocal abuse or misuse
• Other factors – allergy and smoking
• Men in the age group 30-50 are mostly affected
• Unilateral, at the junction of anterior one-third and posterior two-thirds of vocal cord
• Hoarseness is the me symptom
• Diplophonia (double voice) – different vibratory frequencies of two vocal cords

LARYNGOCELE
• Air filled cystic swelling due to dilation of saccule
• Types

Internal – confined within the larynx

External – distended saccule herniates through thyrohyoid membrane

Combined
• Supposed to arise from raised transglottic air pressure in trumpet players, glass blowers or weight lifters
• Presents with hoarseness, cough and obstruction of airway
LARYNGEAL CARCINOMA
• Etiology - Tobacco, Alcohol, Genetic, Asbestos, Mustard gas, previous radiation
• More common in males in the age group 40-70 years
• 90% are squamous cell carcinoma
Supraglottic cancer
• Early nodal metastasis to upper and middle jugular nodes
• Bilateral nodes seen in epiglottic cancer
• Supra glottis growths are often silent
• Hoarseness is a late symptom
Glottis cancer
• Most common type
• Free edge and upper surface of vocal cord in its anterior and middle third – most frequent site
• Only local spread
• No nodal metastases
• Hoarseness is an early symptom; hence detected early
• Fixation of cord indicates spread to thyroarytenoid muscle (bad prognosis)
Subglottic cancer
• Earliest symptom – stridor or laryngeal obstruction
• Hoarseness is a late symptom
• Nodal metastases to prelaryngeal, pretracheal and lower jugular nodes

Indirect laryngoscopy
• Lesions of suprahyoid epiglottis – exophytic
• Lesions of infrahyoid epiglottis – ulcerative
• Lesion of subglottic region – raised submucosal nodule
Supravital staining and biopsy
• Toluidine blue is applied to laryngeal lesion and then washed with saline and examined under operating
microscope
• Ca-in-situ & superficial carcinoma – take up dye
• Leukoplakia – does not stain
Surgery
Conservation surgery Total laryngectomy
• Excision of vocal cord after splitting Entire larynx including hyoid bone, pre-epiglottic space,
the larynx (cordectomy via strap muscles and one or more rings of trachea are
laryngofissure) removed
• Excision of vocal cord and anterior • T3 lesions(with cords fixed)
commissure (partial fronto-lateral • All T4 lesions
laryngectomy) • Invasion of thyroid or cricoid cartilage
• Excision of supraglottis (partial • Bilateral arytenoid cartilage involvement
horizontal laryngectomy) • Lesions of posterior commissure
• Failure of RT or conservative surgery
• Transglottic cancers
Treatment of glottic carcinoma
Carcinoma in situ
T1 (limited to vocal cords)
T1 (extension to anterior
commissure or arytenoids)
T2 NO (Supraglottic or
subglottic involvement)
T3 and T4 lesions
• Best treated by transoral endoscopic CO2 laser
• If laser not available, stripping of vocal cords and tissues sent for
biopsy
• If biopsy shows invasive carcinoma, give radiotherapy
• If biopsy confirms only carcinoma in situ — regular follow-up
Radiotherapy is the treatment of choice
• Radiotherapy is the best choice
• If RT not available, frontolateral partial laryngectomy
• If it fails total laryngectomy
Cord mobile — radiotherapy  conservation laryngectomy  TL
Cord mobility impairment  conservation laryngectomy  TL
Total laryngectomy (TL)

Treatment of subglottic cancer

• T1 and T2 lesions: radiotherapy
• T3 and T4 lesions: total laryngectomy and post-operative radiation

Treatment of supraglottic cancer

• T1 lesions: radiotherapy or CO2 laser excision
• T2 lesions: supraglottic laryngectomy with or without neck dissection
• T3 and T4 lesions: total laryngectomy with neck dissection and post-operative RT

DYSPHONIA PLICA VENTRICULARIS

• Ventricular dysphonia
• Voice is produced by ventricular folds (false cords)
• Voice is rough, low pitched and unpleasant
• Functional ventricular dysphonia occurs due to psychogenic causes
• Diagnosed by indirect laryngoscopy–false cords seen to approximate partially or completely and obscure the
view of rue cords on phonation

FUNCTIONAL APHONIA or HYSTERICAL APHONIA

• Seen in emotionally labile females in the age group 15 – 30
• Usually sudden
• Patient communicates with whisper
• O/E – vocal cords are seen in abducted position and fail to adduct on phonation
• Adduction of cords are seen on coughing, which indicates normal adductor function
• Sound of cough is good
• Treatment – reassurance and psychotherapy

PUBERPHONIA or MUTATIONAL FALSETTO VOICE

• Childhood voice has a higher pitch
• When the larynx matures at puberty, vocal cords lengthen and voice changes to lower pitch in males
• Failure of this change is called puberphonia
• Seen in boys who are emotionally immature, feel insecure and show excessive fixation to their mother
• Physical and sexual development are normal
• Gutzmann's pressure test – pressing the thyroid prominence in a backward and downward direction relaxes
the overstretched cords and low pitch voice can be produced
PHONASTHENIA
• Weakness of voice due to fatigue of phonatory muscles
• Thyroarytenoid and interarytenoids are affected
• Seen in voice abuse or misuse
• Indirect laryngoscopy shows

Elliptical space between the cords in weakness of thyroarytenoid

Triangular gap near the posterior commissure in weakness of interarytenoid

Key-hole appearance of glottis when both are involved

HYPONASALITY or RHINOLALIA CLAUSA HYPERNASALITY or RHINOLALIA APERTA

• Due to blockage of the nose or nasopharynx • Failure of nasopharynx to cut off from
oropharynx or abnormal communication
between oral and nasal cavities
• Common cold • Velopharyngeal insufficiency
• Nasal allergy • Congenitally short soft palate
• Nasal polypi • Submucous palate
• Nasal growth • Large nasopharynx'
• Adenoids • Cleft on soft palate
• Nasopharyngeal mass • Paralysis of soft palate
• Familial speech pattern • Post-adenoidectomy
• Habitual • Oro-nasal fistula
• Familial/habitual

THYROPLASTY
Isshiki's classification
Type Procedure Indication
I Medialization of cord Unilateral vocal cord paralysis
Vocal fold atrophy
Sulcus vocalis
II Lateralization of cord Spasmodic dysphonia
Bilateral abductor paralysis
III Shortening(relax) of cord, To treat puberphonia; In those who have undergone
To decrease pitch gender transformation from female to male
IV Lengthening (tighten) of cord, To treat androphonia;
To increase pitch Converts male character of voice to female

TRACH EOSTOMY
High tracheostomy
• Above the level of thyroid isthmus (isthmus lies against II, Ill, IV tracheal rings)
• It violates the I tracheal ring
• Can cause perichondritis of the cricoid cartilage and subglottic stenosis
• Always avoided
• Only indication: carcinoma larynx

Mid tracheostomy
• Preferred one
• Through II or III rings (isthmus either divided or retracted)
Low tracheostomy
• Below the level of isthmus

KEY POINTS:
• Galen's anastomosis — anastomosis between superior and recurrent laryngeal nerves
• Lyre sign — splaying apart of internal and external carotid arteries on angiogram in cases of carotid body
tumor
• Ortner's syndrome — recurrent laryngeal nerve paralysis + cardiomegaly
• Jackson's sign — pooling of saliva in pyriform fossa, seen in pyriform fossa cancer and foreign body in
cervical esophagus
• V shaped epiglottis — lupus
• Hook or knob like epiglottis — leprosy larynx
• Wash leather appearance of larynx — syphilis

*****END*****