LARYNX

Active space

ENT
By Dr. Rajiv Dhawan
HOW TO EXAMINE THE LARYNX

1. INDIRECT LARYNGOSCOPY

2. FIBREOPTIC LARYNGOSCOPY

3. RIGID ENDOSCOPY OF LARYNX

CARTILAGES OF LARYNX
LARYNX is made of 6 cartilages

(A) 3 unpaired cartilages

* 1. Thyroid
* 2. Cricoid
* 3. Epiglottis

Thyroid & Cricoid are palpable from outside.

Epiglottis
 It is attached to midpoint of thyroid cartilage.
 To same midpoint, 2 vocal cords are also attached

 It covers vocal cords (= GLOTTIS)--- partially

 It is elastic cartilage & It does not ossify with Age

Thyroid Angle

It is the Angle between two laminae of thyroid cartilage

Prominence of thyroid cartilage in males is called .

B. Three PAIRED CARTILAGES

1. Corniculate - rudimentary cartilage

2. Cuneiform - rudimentary cartilage
3. Arytenoids - make posterior 1/3 of vocal
cord

----------------------------------------------------------------
MEMBRANES OF LARYNX

1. Thyrohyoid membrane: It is pierced by

(i) Internal branch of SLN (Superior
laryngeal Nerve) also called Internal
laryngeal nerve (ILN)
(ii) Superior laryngeal vessels
(iii) Laryngocele

2. Cricothyroid Membrane: It is site of

surgery called

This airway surgery is

rarely done inAcute airway
obstruction

------------------------------------------------------------------
MUCOSA OF LARYNX
Larynx is lined by ciliated columnar epithelium
except vocalcords which are lined by
KERATOSIS LARYNX
In some smokers, vocal cord epithelium
starts shedding faster. This leads to a
disease called Keratosis Larynx.

It is…………………………………….disease

Clinical Picture

Treatment
.
= Decortication of vocal cord
+ Quit smoking
Other Treatment

----------------------------------------------------------------------------------

Three divisions of larynx

1. Supraglottis
2. Subglottis
3. Glottis

A,SUPRAGLOTTIS
It has 5 parts

(i) Epiglottis
(ii) Aryepiglotic folds
SUPRAGLOTTIS
(iii) False Vocal Cords =
(Rudimentary)
(iv) Ventricle – Space between False
vocal cords & true vocal cords

(v) Saccule – small mucosal Out pouching

from ventricle

----------------------------------------------------------------------------------------------------------------------

Supraglottic diseases
1.Dysphonia Plica Ventricularis
If a patient produces sound from ......................................... ,
Then it is a disease called as Dysphonia Plica Ventricularis.

2. Laryngocele
● It is Abnormally
● It is a Disease More Common in People who Play

It Pierces Thyrohyoid Membrane

and Appears as an AirFilled Neck
Swelling.
 EXAMINATION The Sound of Air
Leak heard when Laryngocele is
Pressed)

Investigation - X-ray Soft Tissue Neck With Valsalva.

Treatment- Surgical Excision
---------------------------------------------------------------
B.SUBGLOTTIS This is the empty space in cricoid ring

-----------------------------------------------------------------------------------------------------------------------------------------------------

C. GLOTTIS
Glottis is True vocal cord

length of vocal cord

● male – 18-23 mm
● female – 16 - 17 mm
  TA- THYROARYTENOID MUSCLE
 IA INTERARYTENOID MUSCLE (ONLY UNPAIRED MUSCLE)

Both TA and IA are adductor muscles

if they are weak itis a disease called

Phonaesthenia

Examination shows

due to gap between vocal cords

Vocal cords do not have ...

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-
 VOCAL CORD DISORDERS

REINKE'S EDEMA

Reinke's space is the ............................................................................... ………………..in

vocal cord

Edema of this space called Reinke's edema

CHIEF COMPLAINT

This is Bilateral diffuse swelling of vocal cord

* Cause - 1. Smoking (most common)
1. Vocal abuse
* Treatment ..

VOCAL NODULES
= SINGER’S NODULES /Screamer’s Nodules
= Teacher's Nodules
* Cause 1.vocal abuse 2. Laryngopharyngeal reflux of gastric acid ( LPR)
* N o d u l e s a r e a l w a y s Bilateral

Site of Nodule = .......

Chief Complaint Hoarse voice
* Treatment ...

VOCAL POLYP

Cause
site

Chief Complaints

Treatment Surgery MLS

(micro laryngeal surgery)
This is Surgery of vocal cord under microscope

Focal
Focal length
lengthof
of ENT microscope MCQ

EAR = 200 mm E–2

NOSE = 300 mm N–3
LARYNX = 400 mm T–4
(MLS)
INTUBATION GRANULOMA

- It Is Iatrogenic disease

Cause: Faulty Intubation (eg. after surgery under general

anesthesia) or in ICU patient on ventilator

CHIEF COMPLAINT

Th e y a r e Bilateral
Site = ......

* Treatment MLS (micro laryngeal surgery)

JUVENILE PAPILLOMA OF LARYNX

It is a disease of Young children (3 - 6 yrs)
Cause
(from mother at birth)
Exam--- Viral HPV warts in larynx

They can spread to Trachea

Clinical Presentation 3 - 6 yr Child with
Chronic Hoarseness of voice
± Respiratory difficulty
* Treatment Microlaryngreal Surgery (MLS ) with
Recurrence is very common
**CO2 is most commonly used laser in laryngeal surgery.
Its Wavelength is

Difference between Pediatrics and adult larynx

Pediatrics adult
Position C2 – C3 High C3 – C6 (low)

Narrowest part Glottis

Method of Larynx Examination:

A. Indirect laryngoscopy OPD procedure

Indirect laryngoscopy mirror is a Straight mirror .

The mirror surface is warmed before using

I/L does Not show MCQ

(i) Anterior commisure of VC.

(ii) Laryngeal surface of epiglottis = under surface
(iii) Ventricle
(iv) Saccule
(v) Undersurface of vocal cords
B. Direct Laryngoscopy OT procedure
 STRIDOR
Stridor is Noisy Breathing. Its cause is Airway obstruction

3 Types of stridor
Type level of obstruction
Inspiratory ......
Biphasic Glottis, Sub glottis, Cervical trachea
Expiratory Thoracic Trachea, Bronchi

Function of Larynx
Primary function – Protection of lower airway (lungs)
Phonation which means Sound Production
Sound is produced from True vocal cords inAdduction
in Expiratory phase of respiration

Golden rule

MUSCLES OF LARYNX
1 Abductor 4 Adductors 2 Tensors

Posterior Thyroarytenoid Cricothyroid

Cricoarytenoid (main)

Interarytenoid Vocalis muscle

Lateral  Tensors give us

Cricoarytenoid quality of voice

Cricothyroid
 All muscles lie inside larynx except
MCQ

Motor supply of Larynx

All muscle of larynx are supplied by Recurrent laryngeal Nerve

( RLN) except cricothyroid which is supplied by external Branch

of Superior laryngeal nerve ( SLN) also called external laryngeal

nerve ( ELN)

Sensory supply of Larynx

SUPRAGLOTTIS = Int. Branch of SLN (ILN)
SUBGLOTTIS = RLN
Glottis = Both these Nerves

RLN
Vagus
SLN

VOCAL CORD PALSY

Left side vocal cord palsy is 4
times more common than right
side
This is because of longer
course of Left RLN
Most Common Cause of

Unilateral VC palsy

Bilateral VC palsy Thyroid surgery

ORTNER SYNDROME
( CARDIOVOCAL SYNDROME)

Left Atriomegaly causing left vocal cord palsy

UNILATERAL VOCAL CORD PALSY

BILATERAL VOCAL CORD PALSY --2 TYPES

A. Bilateral Abductor palsy

Cause Bilateral RLN Injury in Thyroid surgery

only cricothyroid left (Adductor muscle)

Vocal cord come in median/Paramedian position

Symptoms:
[Respiratory difficulty with stridor
with Normal voice

Patient Can't Breathe properly

but can speak Normally
MCQ

Immediate Treatment = Tracheostomy

After Wait for 6 months

Definitive Treatment
= lateralization of vocal cord
Other treatment = CO2 laser Cordectomy
B. Bilateral Adductor Palsy

Cause = Bilateral Vagus Palsy = RLN + SLN palsy

(Complete Palsy)

No muscle is working
So,Vocal cord lie in Cadaveric Position = Intermediate Position (OPEN)

* Chief Complaints  Aphonia – loss of voice

 Aspiration – pneumonia

* D e f i n i t i v e Treatment( after 6 months) .....

=
Medialisation of Vocal cord

* Other Treatment TEFLON or FAT Injection in Vocal Cord.

IF SLN is Injured in Thyroid surgery

Cricothyroid muscle is Paralysed

(it is main Tensor muscle)

C/C Poor Quality of voice

Examination shows . MCQ

-------------------------------------------------------
LARYNGOMALACIA
MC Congenital anomaly of larynx.

It is also called congenitallaryngeal stridor.

It is the most common cause of

It is the Weakness of
 Chief complaint is Stridor

1. …………………………………………. Stridor
2. Stridor Starts in Ist week of life
3. Stridor increases after Crying & suckling of milk
4. Stridor decreases in Prone Position
 In Laryngomalacia baby, CRY Sound is Normal because
Vocal cords are Normal

Examination Finding

Treatment of Laryngomalacia This baby has no hypoxia so

– Reassure the parents that it is self limiting condition

Congenital Laryngeal web

 PAEDIATRIC LARYNGEAL INFECTIONS

(A) Acute Epiglottitis

It is bacterial Infection of supraglottis
It is caused by Streptococcus pneumoniae >
Hemophillus Influenza B
Age = 2 - 7 yrs MCQ

Clinical Presentation:
● Respiratory difficulty
● …………………………….. stridor
● High fever
● Drooling of Saliva
● Hot Potato voice
● Child Sits Bending Forward

X-Ray Soft Tissue Neck ( Lateral View)

= Swollen epiglottis.
* Treatment
● First Treatment =

● Steroids
● Antibiotic

What to Avoid in this baby?

B) Acute Laryngotracheal bronchitis ( ALTB) -CROUP

It is viral Infection of complete Airway But ………………………..is

the most affected Part
It is caused by Para influenza virus
Age = 3 month - 3years
* Clinical Presentation:
● Respiratory difficulty
● Biphasic stridor ( mostly inspirartory)
● Low Fever
● Barking cough
* X-Ray Soft Tissue Neck AP View
= Narrowing of subglottis

* Treatment:
● Humidified oxygen
● Bronchodilator
● Steroids

● Antibiotics to prevent Secondary

Infection
LARYNGEAL FOREIGN BODY

A person while having lunch suddenly get choking & aphonia

MCQ

This is due to food particle stuck as laryngeal foreign Body

Immediate Treatment

Pressure is given on epigastrium in upward and backward

direction
In a child

Bronchial foreign body

VOICE DISORDERS

PITCH DISORDER OF VOICE

Normal voice features in adults-

Males Dull voice

Females Sharp voice

PITCH DISORDERS

1. PUBERPHONIA

 High pitch voice in adult male (Feminine voice)

 Patient is Shy introvert young male

Treatment

Speech Therapy & Psychotherapy

, patient is asked to pull thyroid cartilage downwards and press it

backwards (so that VC loosens) and then speak (speech therapy). This is
done for 3 to 6 months. Psychotherapy is also needed.
 If speech therapy fails, then we do

It is surgicalshorteningorlooseningofvocalcord.
2. ANDROPHONIA

Low pitch voice in female (masculine voice)

Surgical Treatment

= Surgical lengthening or tightening of vocal cord

Functional Aphonia / Hysterical Aphonia

Patient is pretending the symptom of sudden loss of voice

(actuallythe voice is normal)

More common in (20- 30 year old)
How to prove the diagnosis =
MCQ

* Treatment Psychotherapy
OR
Psychiatrist Consultation
CANCER LARYNX

 Risk factor smoking, alcohol

 MORE COMMON IN MALES

 This cancer has three types

(A) GLOTTIS CANCER

It is the cancer of true vocal cord

It is the Most common site of laryngeal cancer
* Chief Complaints . MCQ

There are NO Neck Node Metastasis in glottic cancer

good prognosis
B) SupraGlottic Cancer
Most common site is epiglottis
* C/F (i) Throat pain Refereed to Ear
(ii) Feeling of lump in throat
(iii) Dysphagia
(iv) ………………………………………………………. voice
C) Subglottic Cancer
* Rare
* C/F Stridor MCQ

Tumor Staging of Laryngeal Cancer

T1 one named structure Involved

T2 more than one named structure

T3 VC is fixed (= immobile)

T4 Invasion of thyroid cartilage

Treatment of cancer larynx

T1
T2

T3
Total laryngectomy followed
T4 By Radiotherapy

After total laryngectomy patient has Permanent tracheotomy

Now a days, treatment of choice for T1 No Mo glottic cancer is

Laser Surgery > RT
Voice production after laryngectomy
(1) Esophageal voice = Poor Method

(2) Electro larynx/artificial larynx =

It is battery operated external vibrator

(3) Tracheoesophageal Puncture Device(TEP)

example
TEP Is Unidirectional valve. It is Internal device Surgically fitted between
trachea & Esophagus
RADICAL NECK DISSECTION
It is a surgery done in Metastasic (Secondary) Neck Nodes in
Head Neck Cancer.

List of Structures Removed in RND

1. Level I To Level V Neck Nodes.

2.
3. Internal Jugular Vein
4. Accessory Spinal Nerve.
5. MCQ

6. Tail of Parotid Gland.

7. Submandibular salivary Gland.
TRACHEOSTOMY

Indications of tracheostomy

1. Respiratory obstruction above the level of trachea for airway

management

2. For prolonged mechanical ventilation (intubation) >7days.

3. For bronchial toilet. Eg –COPD pt in coma.

4. To prevent aspiration (the cuff of tube helps to prevent asipration)

5. In oropharyngeal surgery to prevent aspiration and maintain airway.

6. In maxillofacial trauma to prevent aspiration and maintain airwa

 MC site of Tracheostomy is 2nd & 3rd tracheal Ring

This is called Mid Tracheotomy

we leave First Ring to prevent damage to larynx.

What is High Tracheostomy?

MCQ

 Tracheostomy reduces dead space by

 Tracheostomy is temporary procedure except after

total laryngectomy

Tracheostomy can lead to Apneoa due to

Tracheostomy can lead to surgical emphysema

Tracheostomy Tubes

(A) PVC Tracheostomy Tube

uncuffed cuffed

● Cuff decreases aspiration

 B) Metallic Tracheostomy Tube
eg - Chevalier Jackson Tracheostomy Tube.
It has an outer and Inner Tube.
Innertube is longer

If Tracheostomy tube is blocked due to improper suction

Pharynx

ENT
BY
Dr. Rajiv Dhawan
ANATOMY OF PHARYNX
Pharynx is a Fibromuscular Tube from Skull Base to C6 vertebrae

It has 3 constrictor muscles.

1. Superior constrictor muscle (SC)
2. Middle constrictor muscle (MC)
3. Inferior constrictor (IC) muscle — it has 2 parts
A. Oblique fibers- Thyropharyngeus (TP)
B. Circular fibers- Cricopharyngeus (CP)

MCQ

KILLIAN’S DEHISCENCE
It is a triangular area in Inferior constrictor muscle between
fibres of ........................................................................... This area lacks
muscular support. Therefore it is a weak area of pharynx. Therefore
1. It is the site of the formation of ........................................
...........................................................
2. It is a possible site of perforation during rigid endoscopy.
SINUS OF MORGAGNI (SOM)

It is the space between the skull base and upper border of

superior constrictor muscle.
● Eustachian tube & Tensor veli palatini muscle
passes through sinus of morgagni.

Q. Which is the most common site of impaction of foreign

body in digestive tract?
Disc Battery as Oesophageal Foreign Body

PHARYNX It has 3 parts

(1) Nasopharynx
(2) Oropharynx
(3) Laryngopharynx

LARYNGOPHARYNX (HYPOPHARYNX)
It has 3 Parts:
(i) Pyriform Sinus (Right & left) (PS)
(ii) Post Cricoid Area (PCA)
(iii) Posterior Pharyngeal Wall (PPW)

● MOST COMMON site of Hypo pharyngeal Malignancy

i s -Pyriform sinus
 Internal Branch of SLN (Internal laryngeal Nerve)

gives sensory supply to

Supra glottis Pyriform sinus

A patient presents in emergency with throat pain due
to accidental swallowing of fish bone. Surgeon removed
the foreign body but while removing foreign body, the
surgeon injured the internal laryngeal nerve Where was
the foreign body stuck?
a. Base of tongue
b. tonsillar area
c. Pyriform sinus
d. Esophagus

Laryngeal crepitus

Clicking sensation felt when larynx is moved over cervical

vertebrae

This is absent in ........................................................................

Absence of laryngeal crepitus is called ...................................... .
NASOPHARYNX
● To put it simply, the empty space behind the nose is
Nasopharynx.
● It has 2 important landmarks.
1. Eustachian tube opening (ET)
2. Adenoid tissue (more prominent in children).

● Eustachian tube connects the middle ear to nasopharynx;

therefore nasopharyngeal diseases can lead to middleear
diseases for example GLUE EAR (serous otitis media)
which leads to conductive hearing loss (CHL)

THREE TOPICS IN NASOPHARYNX-

1. ADENOID
2. ANGIOFIBROMA
3. NASOPHARYNGEAL CARCINOMA.
ADENOID
Also called nasopharyngeal Tonsil
- Adenoid is a Collection of Lymphoid tissue in NPX
- Adenoid has No capsule, No crypts and it has No definite Blood
supply.
- it is Present at Birth
- increases in size upto 6 yr of Age
- start decreasing in size at puberty
and disappear by 20 years of age

Adenoid Hypertrophy

It is a disease of ..............................................................
– It is more than physiological enlargement of adenoid
– It is Due to Recurrent upper respiratory infection
* Clinical Picture (1) Mouth breathing child
(2) Adenoid face
(a) ........................................
(b) ........................................
(c) ........................................
(d) ........................................
(3) Rhinolalia Clausa
(4) ± glue ear (. ............................................ )
(5) Failure to thrive
(6) Obstructive sleep apnoea ( OSA)
Treatment Surgery called Adenoidectomy

Position of patient during surgery

................................ Neck extension

Same position is used for
Tonsillectomy.
Over Neck extension can lead to atlanto-axial subluxation (C1–C2)

Method of surgery = Curettage

Name of Instrument = St. Clair Thomson adenoid curette

ANGIOFIBROMA
( Juvenile Nasopharyngeal Angiofibroma)
● Most common benign tumor of Nasopharynx
● Site of origin is sphenopalatine foramen
● It is a highly vascular tumor
● It is seen in .............................................
The tumor can extend into
(1) Nose
(2) Cheek
 Pharynx ▶ 55
(3) Orbit Proptosis .............................................. MCQ

(4) Brain
* Clinical Picture 12-16 yr old Boy with Nasal mass with
profuse epistaxis MCQ

* Investigations (1) Biopsy is contraindicated

(2) CECT shows Hollmann Miller Sign
MCQ

Ant. Bowing of Post. wall of Maxilla (Antrum = maxilla)

(3)Angiography
* Treatment Surgery

NASOPHARYNGEAL CARCINOMA
● More common in china
● Etiology = .................................... MCQ

● Site of origin = Fossa of Rossenmuller

This fossa lies just above ET

unilateral ET Blockage

unilateral .................... = Serous otitis media

MCQ

Conductive hearing loss

56 ENT for FMG : Workbook – Dr. Rajiv Dhawan

 NPC is a Hidden cancer = Occult primary . so

 Most common manifestation of nasopharyngeal
carcinoma is
.......................................................................................................
MCQ

(itparalysis
This tumor also causes is a Hidden
of cancer
cranial =nerves
Occult primary)

Trotter's Triad in NPC MCQ

 Neuralgia In Temporoparietal area due to 5th nerve

 Palatal palsy due to 10th nerve
 CHL
* Treatment Chemo Radiation > Radiotherapy MCQ

OROPHARYNX
It has following parts:
(1) Soft palate
(2) Uvula
(3) Anterior and posterior Tonsillar Pillars
(4) Tonsil = Palatine Tonsil
(5) Posterior 1/3 = Base of Tongue
(6) Lingual Tonsil
(7) Posterior pharyngeal wall
(8) ........................................ MCQ
Bed of Tonsil

It is made By Superior constrictor muscle

Styloid Process & Glossopharyngeal nerve lie in Bed of Tonsil

Eagle Syndrome

Styloid Process

long styloid process touching IX CN

This will lead to Throat Pain Referred to EAR

This is called ............................................... = Styalgia

TONSIL

Tonsil has capsule, crypts, and it has definite

blood supply
Deepest crypt is called as Crypta Magna
● Main source of blood supply of tonsil – ....................................
........................................................ . MCQ

● Venous drainage of tonsil – Paratonsillar vein

This vein is the main source of bleeding during Tonsillectomy

58 ENT for FMG : Workbook – Dr. Rajiv Dhawan

Haemorrhage in Tonsillectomy (3 Types)

(i) Primary – during surgery

(ii) Reactionary – within 24 hrs of surgery

It is due to slippage of ligature

it is an emergency

Treatment .............................................
MCQ

(iii)Secondary –after 24 hours ( mostly after 5th day of surgery)

Cause infection of Tonsillar fossa

(mild bleeding)
MCQ
Treatment .............................................
 Pharynx ▶ 59

QUINSY (PERITONSILLAR ABSCESS)

● Collection of pus between Tonsil and its Bed.
● More common in adults
● Mostly unilateral
● Examination
1. Tonsil is pushed medially
2. Uvula is pushed to other side MCQ
 60 ENT for FMG : Workbook – Dr. Rajiv Dhawan

* Chief Complaints (i) TRISMUS difficulty in mouth opening

due to spasm of ............................ MCQ

(ii) HOT POTATO VOICE (plummy voice)

* Treatment Per oral I & D and Remove Tonsil after 6 weeks

It is called ...................................................................

old concept
MCQ

Some surgeons remove tonsil at time of abscess drainageHOT = ABSCESS

TONSILLECTOMY

If same history and examination finding as of quinsy are

given in question + outer neck swelling close to angle of
mandible MCQ

Answer will be PARA PHARYNGEAL ABSCESS

Quiencke's Disease idiopathic edema of uvula.

RETROPHARYNGEAL SPACE
Space is divided into 2 halves by mid line band
Band. These 2 Halves are called

These spaces have Retro pharyngeal Lymph Nodes also called

MCQ

as .................................................................. MCQ

Infection of these Lymph Nodes will lead to

Acute Retropharyngeal abscess

* Clinical Presentation 2 yr Child Presenting with

- Inspiratory stridor
- Respiratory distress
- drooling of saliva,
- Hot Potato voice
X- Ray Neck show – widening
of Pre-vertebral shadow MCQ

* Treatment 1. Airway management

2. Incision & drainage.
LUDWIG'S ANGINA

It is Infection of floor of mouth =

● Floor of mouth is made by ................................................

● Source of Infection ..................................................
● Bacteria = ....................................................................
* Chief Complaints After dental infection patient
develops
1. Chin swelling
2. Trismus
3. +\- Respiratory Distress
* Treatment External I & D
Miscellaneous

● Pre - Malignant lesions of oral cavity

- leukoplakia

- erythroplakia

- oral submucous fibrosis

● Fordyce Spot – ectopic sebaceous gland in mucosa

● Reverse smoking Risk factor for Hard palate cancer

● MC Site of oral cavity cancer lateral Border of tongue

● MC Head and Neck cancer in India

● MC site of oral cavity cancer in India

● Commando operation oral cavity cancer (Combined oro

mandibular resection with reconstruction)

 Nose and
Paranasal
Sinuses

ENT by
Dr. Rajiv Dhawan
DESIGN OF EXTERNAL NOSE
The External nose is made of 4 paired structures
(1) Nasal Bones
(2) upper lateral cartilages

(3) lower lateral cartilages = ...............

they form external nasal opening

(4) LESSER ALAR cartilages
these are Small cartilage between upper lateral and lower
lateral cartilages

NASAL VALVE
It is Junction of upper lateral and lower lateral cartilage

 Cottle's Test ..............................................................................

..........
SADDLE NOSE: DEPRESSED NOSE
* Causes Trauma (MC Cause)
Leprosy
Syphilis (Tertiary)
Septal surgery
Tuberculosis
Wegner;’s granulomatosis

* Treatment Augmentation Rhinoplasty By using Iliac

crest graft.

RHINOPHYMA (POTATO NOSE)

Hypertrophy of ......................................... of skin
of external Nose
It is more common in Males

Most common malignancy of skin of external Nose is
MCQ
Basal cell carcinoma = Rodent Ulcer

RHINOLITH
* It is formation of stone in nasal cavity
*

FOREIGN BODY IN NOSE

More common in School age Children

* Clinical Picture
7 yr old Child presenting with unilateral foul smelling Nasal
discharge and epistaxis Foreign Body in Nose MCQ

* Treatment Endoscopic Removal

If there is Disc Battery in Nose, Ear, Esophagus
* Treatment ........................................................................

Because battery will Release alkali

which can cause Necrosis

NASAL MYIASIS

It is Presence of maggots in Nose

Maggot are larvae of Housefly MCQ

Foul smelling condition lead to myiasis

* Treatment Maggot oil nasal drops to kill them [. ....... ]
MCQ

& use mosquito Net.

NASAL BONE FRACTURE

It is most commonly fractured Bone of face.
 * Treatment Immediate closed Reduction Before
edema starts Using Forceps MCQ

If Edema is already there, then wait for 7 days and then

reduce fracture

NASAL SEPTUM FRACTURE

It is of two types
(i) if force is from (ii)if force is from
HORIZONTAL FRACTURE VERTICAL FRACTURE

OR OR
JARJAWAY FRACTURE CHEVALLET # MCQ

* Treatment Fracture Reduction using ................................

 ZYGOMATIC FRACTURE/TRIPOD FRACTURE

2nd most commonly Fractured Bone of Face

Injury to Infra-orbital nerve is seen in

Zygomatic # .......................................
Maxilla # due to injury to
Carcinoma of Maxillary Sinus Infra-orbital Nerve
MCQ

MC fractured Part of mandible

= Condyle of mandible ( = Subcondylar fracture)

MID FACE FRACTURE ( Le Fort Fractures)

It is FRACTURE OF MAXILLA.

There are of 3 types of Le Fort fractures:

1. LE FORT I - Transverse fracture :

It passes along the palate.
This leads to a. floating palate.
B. Ecchymosis on palate
this is called ...................................... .
 * 2. LE FORT II - also called PYRAMIDAL fracture.

* 3. LE FORT III - also called CRANIOFACIAL

DISJUNCTION.

LE FORT II & III passing through the base of the skull so

there is a possibility of ......................................... .
This is called traumatic CSF leak which is blood mixed
CSF

----------------------------------------------------------
LATERAL WALL OF NOSE
 TURBINATE: It is a projection on lateral wall of Nose.
There are Three Turbinates
1. Inferior Turbinate (IT)
2. Middle Turbinate (MT)
3. Superior Turbinate (ST)
 CONCHA: is the Bony part of Turbinate
There are three concha.
1. Inferior Concha ..............................................................
MCQ
 2. Middle Concha
Part of ethmoid Bone
3. Superior Concha

 MEATUS: Space Below Turbinate

There three Meatus:
1. Inferior Meatus (IM)
2. Middle Meatus (MM)
3. Superior Meatus (SM)

 SPHENO ETHMOIDAL RECESS (SER)

It is the area above Superior Turbinate.

 CHOANA: Posterior opening of Nasal cavity

Choanal Atresia
It is a congenital disease due to persistence of bucconasal
membrane. Bilateral complete choanal atresia is a neonatal
airway emergency.
Why?
.................................................................................................................
 Pediatrician is unable to pass
suction catheter through nose

C/P; blue baby turns pink on crying

Immediate treatment -
Put wide bore nipple in child's mouth

PARA NASAL SINUSES

- Mucosa lined Air Filled Hollow Cavities in Skull Bones
- They are ventilated during expiration MCQ

- They secrete mucus which is drained into Nose.

There are 4 Pair of sinuses.

* (1) Maxillary sinus

also called .............................................................. .
- Largest sinus, volume – ................................. .
* (2) Frontal Sinus
* (3) Spheroid Sinus
* (4) Ethmoid Sinus = Ethmoid air cells
 Ethmoid air cells (has 2 groups)

Anterior Posterior

Number 2–8 1–8

Two Anterior ethmoid air cells are constant they are named
as following:

BULLA ETHMOIDALIS AGGER NASI

largest anterior most
ant. ethmoid cell ant. ethmoid cell
 In some people ethmoid air cells can grow at 3 unusual areas
MCQ

in orbital Floor Close to optic Nerve Inside middle Turbinate

........................ ........................ ..................................

STRUCTURE DRAINING IN NASAL CAVITY

1. Nasolacrimal Duct IM
2. Maxillary Sinus
3. Frontal Sinus MM
4. Anterior Ethmoidal cells

5. Posterior " " SM

6. Sphenoid Sinus SER
in chronic Dacryocystitis Surgery done called DCR (Dacryocystorhinostomy)
DCR opening is made in MM MCQ

Middle Meatus
It is the most Imp area of Sinus drainge
It has (1) Bulla ethmoidalis (BE)
(2) Uncinate process (UP)

it is sickle shaped Bone which covers BE

(3) Ethmoidal Infundifulum
Space between BE & UP
 3 sinuses drain into ethmoidal infundibulum
(area of middle meatus)

This whole unit is called ..............................................................

if OMC is Block due to mucosal edema

Blockage of Sinus drainage

Sinusitis

if > 3 months

CHRONIC RHINOSINUSITIS

Chief Complaints

 Nasal blockage
 Purulent Nasal discharge
 Post Nasal drip
 Decreased sense of Smell
 ................................................ – Frontal Sinusitis
MCQ
Investigations

(1) Nasal endoscopy (Best Investigation)

It has 3 passes
1st pass along IT
2nd pass above MT
3rd pass inside MM
(2) X-Ray Best xray view for
sinuses ..................................... It
shows all sinuses except

Best X-Ray view for Sinus

Maxillary Water's view
Frontal
Caldwell's view
Etmoidal
Spheroid X-Ray Skull lateral view
(3) CT Scan Best Radiological Investigation for sinuses.

Treatment Antibiotics + Decongestant ] × 3 weeks

if it fails

Surgery FESS
Functional endoscopic sinus surgery

Complicatiions of sinusitis

(i) ORBITAL INFECTION MC with ....................................

.. MCQ

(ii) MUCOCELE FORMATION Sinus expansion due

to mucus collection

MC in ........................................
.
(iii) Osteomyelitis of frontal bone itleadtosubperiosteal
frontal abscess, It
is called as.

..............................................
......
MCQ
DEVELOPMENT OF SINUSES
 Radiologically Sinuses appear in sequence
First to develop M
E
S
last to develop F MCQ

● M, E are present at Birth

● E Most developed at birth.
● S appear at .................................
● F appear at .................................

General Points

most common Benign tumor of sinuses Osteoma MCQ

Osteomas are most common in Frontal Sinus

MC Fungus to cause sinusitis ASPERGILLUS FUMIGATUS

most common site of

aspergilloma

Maxillary Sinus
NASAL POLYP
It is prolapsed pedunculated edematous mucosa of sinuses.
Etiology Chronic Infection or allergy

Chronic Inflammation

Edema

Polyp
Polyp

(A) ANTROCHOANAL (B) ETHMOIDAL POLYP =

= KILLIAN'S POLYP NASAL POLYP
 Arise from maxillary  Arise from ethmoid
sinuses & grows posteriorly air cell
toward Choana
 Can Be seen on Posterior
Rhinoscopy  More common in adult

 More common in Children allergy is the cause

due to chronic Infection  Multiple
 single, unilateral  Bilateral
Treatment Surgery FESS >
Endoscopic polypetomy Treatment T. O. C Topical
Corticosteroid Nasal spray
eg FLUTICASONE
 * SAMPTER'S TRIAD
● .......................................................................................................
● .......................................................................................................
● .......................................................................................................

SINUS MALIGNANCY
 Most common sinus involved = Maxillary sinus
Risk Factor :Occupational Exposure to
(i) Nickel sq. cell carcinoma
(ii) Wood dust adenocarcinoma. (....................................)

Ohngren's Line

It is from ..............................................................................................
It is used for prognosis assesment of cancer of maxillary sinus
Tumor above this line has poor prognosis due to early orbital Involvement.

Treatment Total maxillectomy

followed By Radio therapy MCQ
RINGERTZ TUMOR
● It is also called Inverted papilloma of Nose.
● Site of origin = lateral wall of Nose MCQ

● more common in males

● The tumour grows Inward So called
Inverted.
● It is locally invasive tumor
* Treatment - Surgery.

MUCORMYCOSIS
It is seen in
● HIV patient
● young diabetic patient
● COVID 19 patients
It is caused by Mucor fungi
Mucor is Angio Invasive fungus, hence
grows from nose into orbit and brain

Clinical picture

Blackish Nasal mass

Blackish discoloration around eye
D.O.C...........................................................................................
(Debridement is done first)
VASOMOTOR RHINITIS
Parasympathetic overactivity in Nasal mucosa
* Clinical Presentation on Change of Temperature, patient
gets excessive Watery Rhinorrhea and itching in nose
* Treatment of VMR Surgery Vidian Neurectomy
Vidian Nerve = Nerve of Pterygoid
canal.

This Nerve Gives ................................................................................

RHINITIS MEDICAMENTOSA
Prolonged use of Decongestant nasal drops
eg Xylometazoline or Oxymetazoline

...............................................................
Treatment

Stop these drops

Start steroid nasal spray

OLFACTION
(Sense of smell)
Olfactory epithelium lines upper 1/3rd of Nasal cavity.
Olfactory Neurons Pass through ....................................................
* Anosmia Total loss of smell
* Hyposmia decreased sense of smell
* Causes
A Obstructive eg. Nasal polyp
B Neurological cause eg.

- Head injury
- COVID 19
- Parkinsonism
- Alzhimer's disease

Kallman Syndrome =
.............................................................

A patient of anosmia can still sense

It is Not a Smell. it is an Irritant. it is sense through
...............................................

NASAL SEPTUM & ITS DISORDERS

 Nasal septum made of 7 parts (3 Major, 4 Minor)

(1) Septal = quadrangular cartilage

(2) Perpendicular plate of ethmoid 3 major parts
(3) Vomer

(4) Spine of maxilla 4 minor parts

(5) Spine of Frontal Bone
(6) Rostrum of sphenoid
(7) Crests of palatine & Maxillary Bone

Deviated Nasal Septum (DNS)

(i) Can lead to nasal Blockage on deviated side
(ii) Crust formation on patent side
Crust = dried mucus due to increased airflow
(iii) Compensatory IT hypertrophy on patent
side (ITH)
ITH gives ........................................ of Nasal mucosa
(iv) Hyposmia
(v) Sinusitis
(vi) Epistaxis
(vii) Ext. Nasal deformity
(viii) Headache = ...................................................
= Ant. ethmoidal neuralgia MCQ

It is due to contact between DNS & Middle

turbinate
  Treatment: of DNS is surgery called Septoplasty

MC long term Complication of FESS/Septoplasty ..................

Treatment–local application of
...................................................
Reduces Synechaie formation

Septal Haemotoma

Due to Trauma
Bilateral

* Chief Complaints Nasal swelling and Bilateral Nasal

Blockage
* Treatment ............................... MCQ

Other wise it will convert to septal abscess septal

perforation
Septal Perforation

Causes (i) Trauma

(ii) Septal surgery
(iii) Cocaine snorting Vaso constrictor
(iv) TB
Lupus Perforation of cartilaginous Part.
Leprosy
(v) ............................ Perforation of Bony Part
MCQ

* Chief Complaints Whistling sound

* Treatment Surgical Closure of perforation using septal
Buttons

ATROPHIC RHINITIS (OZEANA)

It is Atrophy of turbinates (mucosa, submucosa & underlying
bones) . It is more common in females
* Cause:
● Autoimmunity
● Vit D deficiency
● Estrogen deficiency
● Infection By ................................................. MCQ

Exam Shrunken Turbinates

Roomy Nasal Cavities

Crust formation in nose which leads to 2 complaints

1. Nasal Blockage
2. Bad smell From patient
But
Pt. has anosmia

MCQ
This is called …………………………………………………….

* Treatment
alkaline Nasal douching

Powder 1. ........................................
2. .....................................
3. .....................................
* Surgery: (1) Young's operation MCQ

(2) ...................................................................
Permanent partial closure of both nostrils
(3) Lautenslager operation
RHINOSCLEROMA (WOODY NOSE)
Chronic granulomatous infection of Nose By Klebsella
Rhinosclesomatis (= Frisch Bacillus)
More common in (UP, Rajasthan)

It has 3 stages

(1) Atrophic - like atrophic Rhinitis

(2) Granulomatus lead to Hard external Nose.
(3) Fibrosis stage

* Biopsy ................................................................... MCQ

* Treatment D. O. C ........................ + ............................ MCQ

RHINOSPORIDIOSIS
Infection of Nose by Rhinosporidium seeberi
This is an Aquatic Protozoan found in Ponds
Infection is acquired by bathing in ponds
It is more common in ...................................................

Sites Involved

Nose (MC)
Oral Cavity
Conjuctiva
Genital mucosa

C/P ........................................................ with epistaxis

* Treatment Surgery Excision of mass with
electrocautery of Base Followed By
..................... to prevent Recurrence MCQ

CSF RHINORRHEA
Leakage of CSF from Nose
* Most common site of leak ..................................................
* Causes
1. Surgery FESS
2. Head injury Traumatic CSF leak (Blood mixed CSF).

on Filter paper it gives

........................................ MCQ

Tests/points to differentiate CSF from nasal discharge

1. CSF is non stcky (Handkerchief test)

2. Patient can not sniff back CSF
3. Biochemical analysis
4. Most confirmatory Test for CSF leak is =
....................................

Tests to find the site of leak

1. Nasal endoscopy
With Flourescien dye intrathecal injection
 2. CT Cisternography
3. MRI (T2) images
4. Best Radiological Investigation to find the site of leak =
.................... ....................................................................................
Treatment = Conservative treatment for 7-10 dayswith
bed rest and antibiotics
BLOOD SUPPLY OF NOSE
Blood Supply of Nose

UPTO MT Above MT
ECA
ICA

Maxillary Facial Opthalmic Artery

Anterior Post
Sphenopalatine Greater Superior ethmoidal ethmoidal
(SP) Palatine labial Artery Artery
(GP) (SL) (AE) (PE)

Artery of Epistaxis = ....................................................

EPISTAXIS
Little's area

It is most common area of epistaxis

This area is on Anteroinferior part of septum

Little’s area has .................................................... of 4
arteries[SP + GP + SL + AE] MCQ

Posterior ethmoidal artery is not a part of Keisselbach's plexus

Causes of Epistaxis

1. Most common cause of epistaxis = Finger Nail Trauma

(Nose Picking)
2. Hypertension (causes posterior epistaxis)
3. Accidental Trauma
4. Bleeding disorder eg. Haemophilia
5. Anticoagulant drugs eg. Aspirin, Warfarin
6. Haemorrhagic fever eg DENGUE

Treatment

* Pinch the Nose (2-3 min)

* Chemical Cauterization of Little's area with .........................
...................
* Anterior nasal packing

* Posterior Nasal packing

If posterior and anterior nasal packing fails to

control bleeding

ESPAL (Endoscopic Sphenopalatine artery

ligation )

if fails
Maxillary artery ligation
if fails
ECA ligation
if fails
................................................ MCQ
 EAR

ENT
By
Dr. Rajiv Dhawan
EMBRYOLOGICAL DEVELOPMENT OF EAR

DEVELOPMENT OF PINNA

● Tragus of pinna develops from 1st branchial arch

● Rest of pinna develops from 2nd branchial arch.

● …………………………………….. is the junction of 1st arch and 2nd arch.

● There is no cartilage in incisura terminalis.

HILLOCKS OF HIS

During embryological development of pinna, 6 elevations

form on the head and neck are of embryo from 1st and 2nd
arches which eventually fuse to form pinna.
These 6 elevations are called ............................................. .
MCQ

Pinna development completes by the 20th week of

embryological life
CONGENITAL DISORDERS OF PINNA

 PREAURICULAR SINUS

 If the union of 1st and 2nd arch is

incomplete, it will lead to a congenital
disorder called preauricular sinus
 If asymptomatic, it needs no treatment
 If recurrent infection is there in pre-
auricular sinus, surgical resection of
tract is done

Development Defects Of Pinna

ANOTIA MICROTIA
It is total absence of pinna It is small pinna.
 What is Bat Ear ?

● Normal pinna has 2 curvatures called

HELIX (C) and ANTIHELIX(c).
● If anti helix is absent, it is called
................. .
● Cosmetic surgery of pinna called
Otoplasty.
● It is done at ................... of age. (ideal age) as pinna attains
adult size by this time MCQ

Development Of Other Structures

STRUCTURE DERIVED FROM

TYMPANIC MEMBRANE From all 3 layers : ectoderm,
endoderm, mesoderm

Development Of Ossicles

 Malleus and Incus develop from the ........................... .

 Stapes- ............................. . MCQ

 Cochlea
 Cochlea is derived from
 Cochlea development completes by ............................ .
.

MIDDELE EAR OSSICLES

 Names:
- Malleus (hammer)(M)
- Incus (anvil) (I)
- Stapes (stirrup) (S)

- Size- Malleus >Incus >Stapes

- Stapes is the smallest bone in the body (S for stapes,
S is small)
 Malleus:
 It has a hammer like shape.
 Parts:
1. Head of malleus,
2. Lateral process,
(outward), close to TM
3. Handle of malleus
4. Umbo (Tip of handle)

 Incus:
 Parts:
1. Body
2. Short process of Incus
3. long process of Incus
4. Lenticular process
(end of long process)

 Stapes:
 Parts:
1. Headorsuperstructure
of stapes,
2. Footplate of stapes.-it
is attached at oval
window of cochlea
 Stapes acts like a .................. If stapes is fixed, it will
lead to disease called ........................... .
 MIDDE EAR MECHANICS

● Tympanic membrane and ossicles work as one unit.

● This assembly conducts sound energy to the inner ear.

● Middle ear also amplifies sound energy This amplification

factor is called Middle ear Transformer ratio
● MIDDLE EAR TRANSFORMER RATIO = ...................
● Main function of the middle ear is IMPEDANCE MATCHING
MECHANISM
PINNA

● Pinna is made of YELLOW ELASTIC

CARTILAGE covered by skin.

NERVE SUPPLY OF PINNA

................................................................................
- It is the main nerve supply of pinna;
- It also supplies lobule of pinna.

DISORDERS OF PINNA

 1. PINNA HAEMATOMA:
 It is due to trauma
 It is a sub-perichondrial hemorrhage.
 Treatment is aspiration or
drainage + pressure bandage.
 Otherwise it will lead to necrosis ◀ BOXER
of cartilage, which leads to post EAR
traumatic pinna deformity called
as ........................................................
........... . MCQ

 2. KELOID PINNA:
 Pinna can be a site of keloid
 It is most commonly found on helix.

◀ KE
 DARWIN'S TUBERCLE:
 It is anatomical variation. It is
not a disease.
 It is conical elevation on ............................ .

◀ DARWIN'S TUBERCLE

EXTERNAL AUDITORY CANAL (EXTERNAL

AUDITORY MEATUS)

(EAC / EAM)

● EAC is 24mm in length, outer 8mm is cartilaginous and

inner 16mm is BONY.
● The bony EAC is made by atympanic part of the temporal
bone.
● EAC is lined by skin. Outer
part skin has hair follicles and
CERUMINOUS = WAX glands
which are modified APOCRINE
GLANDS.
● Some people produce more
wax which leads to EAC
occlusion by wax collection.
This will lead to conductive
hearing loss (30 dB approx.)

◀ WAX in EAC
● Treatment is SYRINGING- direction of water is ................
................. MCQ

● Use water at body temperature. In syringing avoid cold

water because it can lead to ...................... .
 Direction of EAC

In adults, direction is TORTUOUS. It is inward, downward and forward.

Therefore during ear examination/Otoscopy, pinna is pulled
................................................................................
in adults

Fissure of Santorini MCQ

● These are natural defects the cartilaginous part of EAC.

Live Insect in the EAC

Treatment
 SENSORY NERVE SUPPLY OF EAC

There are three nerves

NERVE SUPPLY TO
Auriculotemporal nerve Anterior wall and roof of
EAC

Auricular branch of the Posterior wall and floor of

Vagus EAC

Stimulation of this nerveleads

It is also called
to .
.. ..

.
MC
Q
Sensory division of the facialnerve Posterosuperior part ofEAC.

MALIGNANT OTITIS EXTERNA:

 It is infection of the underlying bone of EAC.

  It is also called as skull base osteomyelitis.
 It is a life threatening infection, therefore called
malignant otitis externa.
 It is seen in.............................................................
(60-70 years)
 It is caused by ........................................ . MCQ

Clinical Picture:
 Severe ear ache.
 Blood stained ear discharge.
 +/- facial nerve palsy (it is the most commonly involved
nerve).
Active space

* Treatment:
 DOC- ......................................................................
 4. OTOMYCOSIS- (= SINGAPORE EAR)
 It is the fungal infection of EAC.
 The most common fungus to
cause this is ...........................
.......,
 Examination - .............................................................. . MCQ

* Treatment-
 Aural toilet-
 Antifungal ear drops. Eg- Clotrimazole,

 5. EXOSTEOSIS
 It is also called SURFER'S EAR.
 It is hyperplasia of bony EAC.
 It is more common in water sports persons so,it is called
............................................ .
TYMPANIC MEMBRANE (TM)

 It is also called MYRING.

 It is …………………………….. IN
COLOUR, oval in shaped.
 Diameter of tympanic
membrane is ..........................
.......... .
 Surface area is .................... .

 TM shows movement on
Seigelization.
Seigelization means putting air
pressure on a tympanic membrane.
It is done with the help of Siegel
speculum.

TM Has 4 landmarks

a) Handle of Malleus.
b) Lateral process of Malleus.
c) UMBO.
d) Cone of light.
Cone of Light

It is formed by reflection of light from handle of the Malleus.

(light of otoscope) Cone of light position
● Right ear it is .....................................
● Left ear it is .......................................

Tympanic membrane has 2 parts -

1. PARS TENSA (PT) LOWER, MAJOR, STRONGER PART

- It has three layers.
A. outer- skin.
B. inner - mucosa.
C. middle - fibrous layer.

2. PARS FLACCIDA ( PF) UPPER, MINOR, WEAKER PART

It is also called SHRAPNELL'S MEMBRANE. Middle
fibrous layer is almost absent in pars flaccida.
MCQ
Next Concept

● Main function of the Eustachian tube is middle ear

ventilation.
● If ET gets blocked it will lead to negative pressure in the
middle ear, this lead to retracted TM.
Features of retracted tympanic membrane

It is dull in appearance

◀ RETRACTED TM

RETRACTION POCKET
If there is too much retraction

it will lead to formation ofretraction pockets

The retraction pocket is most commonly seen in .................
..................
Retraction pocket is lined by skin and filled by keratin.

If the retraction pocket is allowed to

progress

there will be small perforation at the tip of the Fundus of

retractionpocket.
Through this perforation, skin starts growing into the
middle ear.
Presence of skin in the middle ear is called ..........................
............... .
(It is pearly white in colour).

Traumatic perforation

DR RAJIV DHAWAN ENT 48

 EUSTACHIAN TUBE

 It connects the middle ear to the nasopharynx.

 It is ........... in length, outer 12mm is bony inner 24mm is
cartilaginous
 At birth, it is nearly horizontal, but in adults it has
.............................. with the horizontal.
 Main function of the Eustachian tube is ................................
................. .
 ………………………………………………………………. muscle opens the tube
during swallowing. MCQ
 GLUE EAR(OME)
Glue ear is also called
SEROUS OTITIS
MEDIA or
SECRETORY OTITIS
MEDIA. (SOM) also
called Otitis Media
with Effusion (OME)

It is collection of sterile thick glue like fluid in middle ear.

Basic aetiology of glue ear is ET blockage
Most common age is .....................................................................

Causes of ET blockage

 Most common cause is adenoid hypertrophy causing ET

blockage (mostly .........................) seen in ............................
.................. .
 Rare cause- NASOPHARYNGEAL CARCINOMA causing
ET blockage (mostly .........................), seen in .........................
.
Clinical Picture

School age child complaining of

- Heaviness in the ear (it is not painful disease).
- Conductive hearing loss (CHL).
(Poor school performance.
- +/- Adenoid face ( see image)

Examination

a) Glue like fluid behind TM.

b) Air bubbles trapped within glue.

Treatment

- Surgery – Myringotomy in (..............................................) +

Grommet insertion (also called as middle ear ventilation
tube) +/- adenoidectomy MCQ

◀ Myringotomy ◀ Grommet

----------------------------------------------------------------------------------------

MIDDLE EAR
 It is also called TYMPANUM.
 Middle ear is a hollow cavity in the temporal bone.
 It has three parts--

MESOTYMPANUM It is covered by TM. It is the middle

(M) part of middle ear
EPITYMPANUM (E) Also called as ATTIC, it is covered
by bone called ............................. .
HYPOTYMPANUM It is covered by bone (unnamed
(H) bone).
● Depth of middle
ear
* E - 6mm
* M - 2mm
* H - 4mm

Sensory supply of the middle ear

It is by tympanic branch of Glossophrayngeal nerve

(JACOBSON'S NERVE).

REFERRED OTALGIA

Tonsillectomy, tonsillitis, lead to earache via ........

Stylalgia ( eagle syndorme) .........................

Supraglottic cancer lead to earache via

Pyriform sinus cancer ............... ................
SIX WALLS OF MIDDLE EAR

ROOF Above it lies the dura of temporal

lobe of the brain.’

FLOOR Below the floor lies JUGULAR BULB.

ANTERIORWALL This wall has 2 openings,
* Lower opening- for Eustachian tube
* Upper opening for Tensor tympani muscle which
attaches to Malleus).
This muscle supplied by Mandibular
division of Trigeminal nerve.
POSTERIORWALL It has a projection called .......................... .
From pyramid, Stapedius muscle arises and attaches
to stapes
, this muscle is supplied by the facial nerve.
LATERAL It is made by Tympanic membrane
WALL
MEDIALWALL Behind this wall lies the inner ear
A. Medial wall has Two projections ofinner ear
a) ...............................- projection of
basal turn of cochlea.
b) Lateral semicircular canal bulge .
B. Medial wall has 2 windows for inner ear
a) Oval window- which is covered bya footplate
of stapes.
b) Round window- it is covered byround
window membrane. Also
called as ............................ .
Concept

Above the ear

Below the ear
Behind the ear

MIDDLE EAR CLEFT

Middle ear cleft is a combination of all hollow cavities in
temporal bone.
It has 5 parts
a) Eustachian tube.
b) Middle ear.
c) Aditus.
d) Antrum.
e) Rest of air cells.
Antrum- it is the largest and most constant mastoid
air cell. Antrum is connected to the middle ear through
...................... .
All these hollow spaces are mucosa lined and are
interconnected
Spread of Disease

NPx to middle ear OTITIS MEDIA

ME to mastoid Mastoiditis
ME to petrous apex Petrositis

DISEASES OF MIDDLE EAR CLEFT

1.ASOM – ACUTE SUPPURATIVE OTITIS MEDIA

● It is an infection of the middle

ear mucosa by pyogenic
organisms.
● Most common organism to cause
this is .............................................. .
Infection reaches from
nasopharynx to the middle ear
via theeustachian tube.
● C/C- earache.
● Examination- red tympanic membrane with dilated
capillaries
This is called ................................................... .
● Treatment- medical management. MCQ

Q. ASOM patient with red bulging tympanic membrane.

What is the treatment?
Ans. Treatment is
 If no management is done in a patient of ASOM
with red bulging TM, it will lead to perforation of
tympanicmembrane
  If no treatment is taken for next 3months- it will
lead to permanent perforation. This disease is called
safe CSOM.

2. SAFE CSOM ( Tubotympanic CSOM)

It is also called TUBOTYMPANIC CSOM.
It is characterized by the presence of permanent central
perforation in Pars Tensa of TM.
Chief complaint

a) Ear discharge- Discharge is not foul smelling and not blood

stained.

b) Hearing loss ( Conductive)

 Ossicle Erosion
 In long standing cases there can be ossicular erosion.
 First ossicle to be eroded is ...................... .
 WHY INCUS? –

  Ossicle erosion will increase CHL.

 Treatment is surgery

SURGICAL OPTIONS :

 1. MYRINGOPLASTY
 It is the repair of tympanic membrane perforation using
a graft.
Most commonly used graft is ............................................. .
 It's a microscopic ear surgery.We use MOLLISON'S
self retaining mastoid retractorto expose the area.

◀
 2. Type III TYMPANOPLASTY- MOLLISON
RETRACTOR
 This is done when disease has eroded Malleus and Incus
M(-) I(-) S(+) situation
 TM graft is placed in contact with stapes.
 This surgery is also called COLUMELLA
TYMPANOPLASTY

3.MASTOIDITIS

 It is an infection of the mastoid air cells. It is a

complication of ASOM and CSOM.
 Chief Complaint

a) pain behind the pinna,

b) profuse ear discharge

On Examination

1. Mastoid surface is found to be smooth, red and shiny.This is called the

......................................................................
. It is the first sign of Mastoiditis.
 2. Mastoid tenderness is positive

3. LIGHT HOUSE SIGN on Otoscopy

The pus is continuously flowing from mastoid to middle
ear. This gives ................................................ .
4. Reservior sign
This patient complains of profuse ear discharge. On
cleaning ,the discharge fills immediately again this is
called ....................................................................
MCQ

Treatment -

- Surgery is CORTICAL
MASTOIDECTOMY it is also
called as ........................................
.......... . MCQ

- First cell to be located during

mastoid surgery is .....................................................since
it is the most constant and largest cell of mastoid.
How to find Mastoid antrum ?

Landmark for mastoid antrum is McEwen's Trianglealso

called as Suprameatal triangle.

KORNER SEPTUM

 It’s an embryological error (anatomical variation).

 It is due to persistence of ...................................................
.........
 It leads to difficulty in finding antrum for surgery.

ABSCESS FORMATION IN MASTOIDITIS

◀ Post Auricular ◀ Bezold's Abscess.

 CAUSE - untreated Mastoiditis can lead to abscess
formation at 3 sites
 These Sites are
a) Most common site is mastoid abscess, which is post
auricular abscess.
b) Along Sternocleidomastoid is ......................................... .
c) Along Digastric muscle is called .................................... .

4.PETROSITIS – GRADINEGO SYNDROME

● It is an infection of Petrous apex air cells.
● It's a complication of ASOM or CSOM.
● Petrous apex has relation with .......................... cranial nerves

It has 3 features – (Mnemonic GERD) MCQ

Gradinego syndrome (G)

a) Ear discharge.(E)
b) Retro orbital pain due to 5th nerve involvement.(R)
c) Diplopia due to 6th nerve involvement.(D)

* Treatment- Surgical Exploration.

5.UNSAFE CSOM – ATTICOANTRAL CSOM

 Hallmark of this disease is the presence of .......................... .

WHAT IS CHOLESTEATOMA ?

Cholesteatoma is the ectopic presence of skin in the middle

ear cleft. It is ..................................... in colour

Most common site of cholesteatoma

................................. in Epitympanum. It is the space between

the pars flaccida and the neck of Malleus.

Origin of cholesteatoma (Three Types)

* 1. primary acquired cholesteatoma ( most common type)

It is due to Retraction Pocket

 2. Secondary Acquired Cholesteatoma is due to marginal perforation
* 3. Congenital cholesteatoma

It presents as PEARLY WHITE MASS behind .............

...................................................... . MCQ

Why is cholesteatoma unsafe ?

Answer -It is due to bone erosion.

It leads to Complications, so it is called unsafe CSOM.

Chief complaints

 Ear discharge- .................................................................

 Hearing loss is mostly conductive
 * Treatment
Surgeryis calledMRM (ModifiedRadicalMastoidectomy)
also called as Tympanomastoid Exploration.
Main aim of MRM is to ............................................. . MCQ

COMPLICATIONS OF UNSAFE CSOM

1.LABYRINTHINE FISTULA

This is the Erosion of bony cover of ............................................

which lies on the medial wall of middle ear. It isdue to bone
eroding properties of cholesteatoma.
 Chief complaint- vertigo in a patient of chronic foul
smelling ear discahrge
* Examination- Positive fistula sign.
Fistula sign is best seen with ..................................
(putting air pressure on TM with Seigel speculum) .This
stimulates inner ear and patient experiences vertigo
and nystagmus).

FALSE POSITIVE FALSE NEGATIVE FISTULA

FISTULA SIGN SIGN
(.............................................)
* Congenital syphilis. * Fistula in a dead labyrinth.
* Fistula covered by
cholesteatoma.
2.BRAIN ABSCESS due to unsafe CSOM

 Most common site of otogenic brain abscess is the

...........................and the second site is cerebellum.
 Chief Complaint ........................................................................
..................
 Investigation- CECT brain.
* Treatment is Neurosurgery.

3.SIGMOID SINUS THROMBOSIS / LATERAL SINUS THROMBOSIS

 It is an intracranial complication of unsafe CSOM.

* Clinical Picture
A) Headache.
B) Spiky fever. This fever is called .....................................
............. .
C) Pitting edema on a mastoid. This is called ....................
.............................................. . MCQ
 D) There is No change in CSF pressure on pressing IJV.
it can be seen in two ways:
i) On lumbar puncture- it is called TOBEY AYER
TEST
ii) On Fundus (retina) examination- it is called CROWE
BECK TEST MCQ

◀ SIGMOID SINUS THROMBOSIS

.

ONE LINERS TO MEMORISE

● Most common complication of unsafe CSOM is Mastoiditis.

● Most common intracranial complication of unsafe CSOM is
Meningitis.
 INNER EAR
It is also called LABYRINTH.
It has two parts-
- Membranous labyrinth- it is
the true inner ear.
- Bony labyrinth is the bony
cover of inner ear

Cochlea is connected to saccule through a channel called as

PARTS OF INNER FUNCTION SENSORY END

EAR ORGAN
Cochlea Hearing ..................................
Utricle & Saccule Linear balance. ..................................
Semicircular canals Angular balance .................................

FLUIDS OF INNER EAR

Inner ear is filled with endolymph and surrounded by

perilymph.
 A. ENDOLYMPH- It is produced by stria vascularis
of cochlea and it is absorbed by the endolymphatic sac.

- If the endolymphatic sac does not absorb it properly it

leads to MENIERE'S DISEASE.
- In Meniere’s disease - There will be gradual cochlear
damage due to high endolymph pressure.
  B.PERILYMPH- it is nothing but CSF.
 Perilymph is found in inner ear
 CSF is found in subarachnoid space
- CSF and Perilymph are connected by .............................
.................................................. MCQ

- This is the pathway that can lead to post meningitis

deafness.

Endolymph high K+, low Na+.

Perilymph high Na+, low K+.

COCHLEA

 It has 2 ¾ turns.
 Cochlea

BASAL TURN Senses ................... freq

sounds.
APEX senses ................... freq
HELICOTREMA sounds

CUT SECTION OF COCHLEA

● Cochlea is a rolled tube. It’s a fleshy tube in a bony tube.

● Scala vestibuli and Scala Media are separated by ..........
............................................ .
Organ of Corti is lying on the ......................................................and
covered by the ...................................... .

● SOUND ENERGY- it moves basilar membrane which

stimulates the organ of Corti.
● Organ of corti has outerhair cells and inner hair cells

. MCQ

UTRICLE AND SACCULE

 Utricle and Saccule are also called otolithic organs.

MCQ
 Function .................................................. .
 MACULA is the sensory end organ of utricle and saccule.
It is covered by a gelatinous layer. This layer has calcium
carbonate crystals called .................................................. .
 If Otoconia turn free and reach semicircular canals, it
leads to a disease called BPPV

BPPV (BENIGN PAROXYSMAL POSITIONAL VERTIGO)

● BPPV is the most common cause of peripheral vertigo.

● Cause--Otoconia gets displaced and reaches the
semicircular canal (the most commonly involved canal is .....
.................................................).
● Chief complaint- vertigo for few seconds on changing head
position.
● Diagnostic test of BPPV- .........................................................
MCQ

● Treatment of BPPV- ................................................ MCQ

DIX HALLPIKE MANEUVER. EPLEYS MANEUVER
VISUAL QUESTION

3.SEMICIRCULAR CANAL (SCC)

There are three SCC.

1. LATERAL SCC/ HORIZONTAL.
2. POSTERIOR SCC.
3. SUPERIOR SCC.

Function of canal- ANGULAR BALANCE.

 CRISTA- is the sensory end organ of a semicircular canal,
it lies in the dilated end of semicircular canal which is
called ........................
 Crista is covered by a gelatinous layer called .......................
.
MCQ

BITHERMAL CALORIC TEST

 This is a Test for ................................

 Steps-
1. Patient is lying supine with head lifted
30°
2. EAC is irrigated with Warm (44°C) and
Cold (30°C) water.
3. This will produce nystagmus
4. With cold water stimulation, eyes move towards the
.........................,
5. With warm water stimulation, eyes move towards the
..........................

(COWS). MCQ

VESTIBULOCOCHLEAR NERVE – (8th NERVE)

 It has 3 divisions-
1. Cochlear division.
2. Superior vestibular division. (SV)
3. Inferior vestibular division. (IV)
INTERNAL AUDITORY CANAL

7th & 8th nerves enter the ear via the Internal Auditory
Canalalso called internal auditory meatus.

◀ Internal Auditory Canal

CUT SECTION OF INTERNAL AUDITORY CANAL -

.................................- it is vertical bony septum in the upper

part of the internal auditory canal. MCQ

● SV -SUPERIOR VESTIBULAR DIVISION OF

8TH NERVE
● IV- INFERIOR VESTIBULAR DIVISION OF
8TH NERVE
AUDITORY PATHWAY

 It mainly lies in the brainstem area.

1. E- Eighth nerve.
2. C- Cochlear nucleus.
3. O- olivary complex (superior)
4. L- Lateral lemniscus
5. I - Inferior colliculus
6. M- Medial geniculate body
7. A - Auditory cortex.
(Mnemonic - ECOLI-MA)

AUDIOLOGY
Hearing loss is of 2 types

1. Conductive hearing loss(CHL)

2. Sensorineural hearing loss (SNHL).
 Conductive hearing loss Sensorineural hearing loss
problems in the external ear A problem in cochlea e.g.
and middle ear cause CHL. Meniere's disease.
Causes A problem with the 8th
nerve.
wax, glue ear, CSOM, Eg- Acoustic neuroma.
otosclerosis, Ossicular
dislocation.

Sound can be heard in 2 ways

1) Air conduction (AC)- its natural way of hearing, It is

complete test of hearing.
2) Bone conduction (BC)- it is a test,
Bone conduction directly reaches cochlea. Therefore
bone conduction is a test of cochlea and 8th nerve only.
If bone conduction is poor, patient has SNHL.

TUNING FORK TEST

Most commonly used tuning fork 512Hz

Teminology in tuning fork test-
Poor ear means Ear with hearing loss.
Better ear means Ear with normal hearing.
 1. RINNE TEST:
It is a comparison of air conduction and bone conduction.

In normal people AC>BC [RINNE (+)

In CHL BC>AC [RINNE (-)
In SNHL AC> BC [RINNE(+)

 2. WEBER TEST:
Place the tuning fork center of the head and ask the patient
where sound is heard.

Normal people center of forehead

CHL sound is HEARD in POOR ear.
SNHL sound is HEARD in BETTER ear.

 3. ABSOLUTE BONE CONDUCTION-

This test is done with occluded EAC.

In normal people is equal to examiner.

In CHL is equal to examiner
In SNHL it is decreased.
POINTS TO REMEMBER FOR TUNING FORK TEST

* RINNE (-) means conductive hearing loss.

* WEBER heard in poor ear means CHL.
* Bone conduction poor means SNHL (ABC).

SUMMARY OF TUNING FORK TESTS

NORMAL CHL SNHL

RINNE
AC> BC ( +) BC> AC (-) AC>BC ( +)
WEBER
HEARD IN HEARD IN HEARD IN
CENTER OF POOR EAR BETTER EAR
FOREHEAD

ABC EQUAL TO EQUAL TO DECREASED

EXAMINER EXAMINER

GELLES TEST

It's a special tuning fork test used to diagnose ........................

. MCQ

PURE TONE AUDIOMETRY (PTA) AUDIOGRAM

1. It is a subjective test of hearing in air conduction and

bone conduction.
2. Frequencies tested are- 250 TO 8000 Hz

250 500 1000 2000 4000 6000 8000

low low High High high
3. Hearing level up to 25dB is normal hearing.

SYMBOLS USED IN AUDIOGRAM

Interpretation of Audiogram:

1. Normal- both AC & BC are within 25dB range.

2. CHL - AC is poor, BC is normal. AB gap (+)
3. SNHL - both AC, BC poor.
◀ NORMAL AUDIOGRAM ◀ CHL AUDIOGRM

◀ SNHL AUDIOGRAM
 OTOSCLEROSIS NOICE INDUCED HEARING
LOSS
CHL SNHL
.................................................... ....................................................
..... .....
DIP AT 2000 HZ IN BC DIP AT 4000 HZ IN AC
AND BC

TWO SPECIAL AUDIOGRAMS

MENIERE'S DISEASE PRESBYCUSIS

(Age related hearing loss)

. .
* Low frequency SNHL * High frequency SNHL
Therefore it shows .......... Therefore, it shows ........
............................................. ................................................
BRAINSTEM EVOKED RESPONSE AUDIOMETRY (BERA)

BERA is an objective test of hearing.

Principle- We stimulate the ear with sound and record
electrical activity from the auditory pathway (it lies mainly
in brainstem area).
BERA has 7 waves. ( I to VII)
The most important wave of BERA is ......................... which is
produced by ....................................... .
* Uses of BERA-
1. Pediatric patients.
2. Malingerers (MLC)
OTOACOUSTIC EMISSIONS (OAE)

 Emission means ECHOES.

 Principal- We give sound to ear and then we record
echoes from ......................................... of cochlea.
 These echoes are called OTOACOUSTIC EMISSIONS.
 If echoes are recorded it means cochlea is working
normally.

Ideal hearing screening investigation in MCQ

a. NEONATAL HEARING SCREENING - OAE.

b. Meningitis baby or NICU baby (high risk baby) - BERA.

Tympanometry
This test records freedom of movement of TM & Ossicles.

Type A Normal
Type B
Flat curve seen in ......................... . MCQ
Type C Seen in ET Dysfunction
Type As
seen in ......................... MCQ
Type Ad seen in Ossicular dislocation.

Stapedial reflex

Principle-On hearing loud sound, Stapedial muscle contracts

to pull the stapes out of oval window so as to protect

Afferent of this reflex ............................

Efferent of this reflex ……………………………………….

This reflex is absent in

1. Deaf patients (8th nerve is gone).
2. Bell's palsy (7th nerve problem).
3. Otosclerosis.
TEMPORAL BONE FEACTURES

 Cause – trauma

BATTLE SIGN - it is ecchymosis in the mastoid region. It

is seen in skull base fractures (temporal bone fractures).

Facial Palsy in Temporal bone fracture is two types:

Delayed Onset facial Palsy Immediate Onset Facial

Palsy
* It is due to edema of * It is due to direct injury
nerve. to nerve by fracture line.
* Treatment is * Treatment is
.............................. MC ............................... MC
Q Q

OSSICULAR DISLOCATION & CHL

 There can be 2 possibilities in ossicular dislocation leading

to conductive hearing loss---
(A) Ossicular dislocation with normal tympanic
membrane- ...................
(B) Ossicular dislocation with Perforated tympanic
membrane - ......................................................... MCQ
 General points to remember

CHL due to Wax - 30dB CHL.

CHL in Glue ear - 10 to 40 dB CHL.

*---------------------------------------------------------
NOISE INDUCED HEARING LOSS

Permissible level of noise in industry is 85dB, 8 hours a

day, 5days a week. (. .....................................................................)
Acoustic dip, is seen in audiogram in noise induced hearing
loss. It is seen in both AC & BC at ............................ .

------------------------------------------------------------------------------------
OTOTOXICITY

It is Drug induced hearing loss. The list of ototoxic drugs:

1. Aminoglycoside- eg- Amikacin, Streptomycin,
Gentamicin.
2. Loop diuretics- eg- Furosemide
3. Antimalarials- eg- Chloroquine, Quinine.
4. NSAIDs- eg- Aspirin, Ibuprofen, Indomethacin.
 5. Anticancer drugs- eg- Cisplatin, Carboplatin.
6. Desferroxamine.
7. Vancomycin.
8. Erythromycin.

● Ototoxicity shows High frequency SNHL in early

stages,.

-------------------------------------
OTOSCLEROSIS / OTOSPONGIOSIS
 It is a fixation of the footplate of stapes. (piston like
movement is slowed)

Disease Profile

 It is more common in young females (2-3rd decade)

 Mostly Bilateral.
 Genetic disease- Autosomal dominant.
 It is gradually progressive disease, but .............................
....... aggravates it. MCQ
 Most common site of origin is a point anterior
to the oval window.
Initial stage of disease is ............... in color.
It graduallyturns..(otosclerosis).
 In the next few years the disease will surround
the footplate from all-around.

Clinical Picture

A young female with bilateral gradually progressive CHL

Patients hear better in noisy areas, this is called ...........

................................................. . MCQ

Examination

 90% of patients show normal Tympanic Membrane.

 10% of patients show ............................................ .
Schwartz sign is seen in .............................. It is Flamingo
pink appearance behind tympanic membrane. MCQ
TREATMENT

 Treatment of choice is surgery called Stapedotomy

>STAPEDECTOMY
In this surgery,
1. Tymapnotomy
2. fixed stapes is replaced with artificial
stapes piston prosthesis

Other treatment

1. Hearing aid- is given for patients unwilling for surgery.

2. Sodium fluoride (NaF) oral therapy.
It is treatment ofchoice for Schwartz sign (+) patient.
(early stage of disease). NaF leads to stablisation of
disease.

 VANDER HOEVE SYNDROME

● OSTEOGENESIS IMPERFECTA.
● OTOSCLEROSIS.
● BLUE SCLERA.
 ACOUSTIC NEUROMA / VESTIBULAR SCHWANNOMA

● It's a benign slow growing tumor of the 8th nerve.

● Most common site of origin is inferior vestibular division
of 8th nerve.
● It is mostly unilateral except in ...............................................
......... .
● It's a brain tumor.
● It is the most common type of Cerebellopontine angle
tumour.
● Ear examination …………………………………..

● Clinical Picture

1. Unilateral, Gradually Progressive SNHL

2. Tinnitus.
3. Imbalance.

ROLL OVER PHENOMENON

This Patient has poor understanding of words and the

understanding capability decreases further when the other
person raises the intensity of sound. This is called
...............................
 Cranial nerve involvement

It occurs in this sequence

1. 8th nerve
2. TRIGEMINAL NERVE (5th nerve) - ................................. .
MCQ

3. SENSORY DIVISION OF FACIAL NERVE --This will

lead to ..................................................
(it is loss of sensation in posterosuperior PART of EAC.) MCQ

Best radiological investigation is Gadolinium enhanced MRI.

* Treatment- Surgery
*********************************************************************
GLOMUS JUGULARE

 It is benign locally invasive highly vasculartumour.

 It is more common in ............................. .
 Site of origin- it arises from glomus cells lying around the
jugular bulb.

The red vascular tumor erodes the floor of the middle ear
and grows into hypotympanum. This is called the .................
....................... . MCQ

The tumor now erodes the tympanic membrane and grows

into external auditory canal leading to bleeding red ear
mass .
This Red ear mass blanches on seigelisation. This is called

CHIEF COMPLAINT

1. Female patient with ...................................................... MCQ

2. Bleeding red ear mass.

* Investigations
1. Biopsy is contraindicated.
2. CECT scan.
3. Angiography

* Treatment- Rx Of choice is surgery.

Glomus Tympanicum
............................................................................................................
............................................................................................................
Promontory is the projection of basal turn of cochlea on the
medial wall of middle ear...

------------------------------------------------

MENIERE’ DISEASE

 Endolymph is produced by stria vascularis of cochlea and it

is absorbed by the endolymphatic sac
 In Meniere’s disease, there is a rise in endolymph volume
due to poor absorption by endolymphatic sac. It is also
called Endolymphatic Hydrops.
 It is mostly ................................................. .
 Etiology is unknown.
 It is an episodic disease.
During Episode
● Episode has 3 features
1. ............................................... .
2. ............................................... .
3. ............................................... . MCQ

● Episode finishes within 24hrs.

● During episodes some people fall down without turning
unconscious, this is called .................................................. .

In Between Episodes

1. Patient hears loud sounds as more loud. This is called ...

................................................................... . MCQ

2. Patients can get vertigo on hearing loud sounds.Thisiscalled

.................................................................... . MCQ

3. Patients have a dislike for noisy areas.

4. Patients hear the same sound in 2 frequencies.Thisiscalled
............................................ . MCQ

Few Years Later

Cochlear damage starts due to high endolymphatic pressure

(glaucoma of ear). This leads to hearing loss in between
episodes also. This will lead to fluctuating hearing loss. It
leads to low frequency SNHL in early stages
 * Investigations MCQ

............................................................. is a special
investigation used to diagnose Meniere’s disease

Treatment

A. During episode- anti vertigo medications

B. In between episode-Acetazolamide (diuretic)

If episodes of vertigo become more frequent and disabling

Further treatment options
1. ENDOLYMPHATIC SAC SURGERY
....................................... is surgical landmark for
Endolymphatic sac.
2. TRANSTYMPANIC GENTAMICIN INJECTION
This injection will lead to Chemical labyrinthectomy.

3.MENIETT DEVICE
It is intermittent pulse therapy for innerear.
 SUPERIOR SEMICIRCULAR CANAL DEHISCENCE SYNDROME

Cause -

1. Congenital.
2. Traumatic or head injury.

Clinical picture

This patient will have conductive hearing loss due to leakage

of sound energy from this dehiscence. This is called THIRD
WINDOW PHENOMENON.
This patient will complain of vertigo on hearing loud sounds.
This phenomenon is called TULLIO’S PHENOMENON.

----------------------------------------------------------------------------

FACIAL NERVE
It enters the temporal bone via internal auditory canal
(internal auditory meatus) and it comes out through
stylomastoid foramen,
In the ear it travels through a bony canal called ..................
................. also called facial nerve canal.

Facial nerve canal has got following 3 segments

1. LABYRINTHINE SEGMENT-
It is the narrowest segment; therefore it is also called
...............................................................................
2. TYMPANIC SEGMENT or HORIZONTAL SEGMENT

3. MASTOID OR VERTICAL SEGMENT

THREE BRANCHES OF FACIAL NERVE in ear

 1. Greater superficial Petrosal nerve

● It arises from the 1st genu.
● this gives supply to the lacrimal gland
● Test for this nerve is ........................................... .
 2. Nerve to Stapedius-
● It arises from 2nd genu.
● Test for this nerve is ........................................... .
 3. Chorda tympani Nerve-
● It arises from the vertical segment of the facial nerve.
3 2 rd
● It supplies Taste sensation to anterior — of tongue.
Active space

● Test for this nerve is ........................................... .

 BELL'S PALSY
● It is idiopathic sudden onset lower motor neuron facial
palsy.
 It is mostly unilateral.
 There is edema in the ..........................................
of the facial nerve canal of this edema leads
to compression of nerve.
 Recent studies show some role of Herpes
simplex virus(HSV1).( Not proven)
* Clinical features:
1. Forehead muscles ............................. paralysed in Bell’s
palsy. This is because it is LMN facial palsy.( Forehead
muscles are not paralysed in UMN palsies)
2. Angle of mouth is deviated to the ............................. .
3. This patient complains of ............................. . This is
due to loss of stapedial reflex. MCQ

4. There is loss of nasolabial fold

5. This patient can develop exposure keratitis
 Treatment - Drug of choice is ............................. for 3 weeks.

Other Treatment
1. Acyclovir (if patient comes .............................. of onset)
MCQ

Artificial tear drops.

2. Physiotherapy.
● The recovery in Bell's palsy is seen in ............................... .
MCQ

● If there is no recovery after 3 weeks of steroid

therapy, then next management is to do
ELECTROPHYSIOLOGICAL NERVE TESTING to
check for extent for nerve degeneration.

MCQ

IATROGENIC INJURY TO FACIAL NERVE

● Most common cause is Parotid surgery.

● The 2nd most common cause is mastoid surgery.
 RAMSAY HUNT SYNDROME

 Also known as Herpes zoster oticus.

 It is due to reactivation of varicella zoster virus.

* Clinical features
a. ............................................... .
b. 7th nerve- Lower motor
neuron facial palsy

* Treatment-
 Acyclovir and steroid therapy.
 Facial Recovery is seen in ............................................... .

MELKERSSON ROSENTHAL SYNDROME

A. Recurrent facial palsy.

B. Fissured tongue.
C. Swelling of lips.
EAR DEVICES AND IMPLANTS

CLASSIFICATION OF HEARING LOSS

Mild 26 to 40dB
Moderate 41 to 55dB
Moderately severe 56 to 70dB
Severe 71 to 90dB
Profound more than 90dB

1. HEARING AID

It is a sound Amplifier.

Active space
 Hearing aid is not of much use in profound hearing loss.
 For them we have cochlear implant surgery

2. COCHLEAR IMPLANT

 Cochlear Implant does direct electrical stimulation of

cochlear nerve endings (8th nerve).

 Prerequisite of CI surgery- is ......................................... . MCQ

Indication
 Bilateral profound SNHL (>90dB) MCQ

 Ideal age of surgery in a child deaf since birth

(PRELINGUAL DEAF CHILD) is ...........................

COCHLEAR IMPLANTS has two components-

 A. External component (behind the pinna) -It has 4
parts
 1. Microphone.
2. ................................ (circular part which transmit current
to internal component)
3. Speech processor.
4. Battery.
 B. Internal component- it has
only one part
Called Electrode
The surgery involves insertion
of Electrode into ..................
............... of cochlea through
........................ . MCQ

3. AUDITORY BRAINSTEM IMPLANT

 Indication:
Neurofibroma type
2- bilateral vestibular
schwannoma (bilateral 8th
nerve diseased )
 ABI Electrode is placed
in .......................................
.............................................. .
 4.BONE ANCHORED HEARING AID

It is a specialized surgery in which titanium screw is fixed

to the skull bone and then an external sound processor
is attached to the screw through an attachment called

abutment.

BAHA stimulates cochlea directly through BC.

Indications of BAHA

a. ANOTIA with hearing loss

b. EAC ATRESIA with hearing loss
c. EAC STENOSIS.
d. CHRONIC DISCHARGE IN EAR (WET EAR).
e. UNILATERAL SEVERE SNHL.