Anatomy of Ear

ear anatomy 01:46

EXTERNAL EAR

• External ear:
 Pinna - develop from 1st & 2nd Branchial arch
 Made of elastic cartilage, exception lobule & incisura terminalis
• EAC - 24mm: outer 1/3rd cartilage & inner 2/3rd is bony
• In canal:
 Foramen of santorini - infection → parotitis & skull base osteitis
 Fossa of huschka
 Hair cells
 Glands – [i] sebaceous (sebum) & [ii] apocrine (cerumen)
• Sebum & cerumen -> antiseptic
• In canal - sebum + cerumen + dust + dead skin
 Accumulation → ear wax
 Etiology: ciliary motility, anatomical, habits
 Normal - small amount of wax
 Syringing - removal of wax & foreign bodies
 Temp of water - 37°C (body temp)
 At higher or lower temp → vertigo
 Pinna direction: downward, backward & outward
• Arnold nerve (X - C.N) - stimulated by syringing → cough

1
tympanic membrane 1 :
• Shape - oval
• Color - pearly white
• Outer boundary – annulus

• Smaller upper part -pars Flaccida / Sharpnell's membrane

• Pars Tensa - 4 quadrants

1) Antero inferior quadrant

• MC site of tympanic membrane perforation
• Preferred site for surgery - myringotomy with grommet insertion
• Cone of light - brightest part

2) Antero superior quadrant

• MC site of congenital cholesteatoma

3) Posto superior quadrant

• Myringotomy - contraindicated
• 2nd MC site of cholesteatoma
• MC site of traumatic perforation - Rx → conservative

4) Posto inferior quadrant

• Preferred site for myringotomy without grommet

2
middle ear 1:40
• Shape - match box
• Boundaries - 6
• Compartments - 3
• Ossicles – 3

• Upper compartment - epitympanum / attic

• Middle - mesotympanum
• Lower – hypotympanum

• Promontary - bulge of the inner wall

• Tegmen Tympani - Roof
• Floor - juglar vein & IX nerve
• Branch of IX nerve - Jacobsen's → tympanic plexus (supplies middle ear)

ANTERIOR WALL MEDIAL WALL POSTERIOR WALL

• Canal for tensor • 2 bulge - promontary • Door - aditus
tympani muscle & lateral semi- • Facial nerve
• Eustachian tube circular canal • Fossa incudis
• 2 windows - oval & • Pyramid - stapedius
round • Facial recess
• 2 more things - VIII • Sinus tympani
nerve & fissula ante
fenestrum

3
• Secondary tympanic membrane - covers round window
• Eustachian tube:
 36mm
 Outer 1/3rd -bony, inner 2/3rd - cartilage
 Torus tubaris - tensor vali palatni muscle
 In child - shorter, wider, straighter
 Function - balance of pressure & drainage of secretions
 Unbalanced pressure → retraction of tympanic membrane & baro
trauma
 No drainage → otitis media
• Fissula ante fenestrum - MC site of otosclerosis

STAPEDIUS MUSCLE

• Origin - pyramid
• Insertion - neck of stapes
• Nerve supply - nerve to stapedius (VII)
• Function - dampens loud sound → stapedial reflex / acoustic reflex
 Afferent nerve - VIII nerve
 Efferent nerve - VII nerve
• Hyperacusis (intolerance to loud sound) - absence of reflex

4
FACIAL RECESS

• Boundaries:
1) Facial nerve
2) Corda tympani nerve
3) Fossa incudes
• Surgical approach/route to middle ear

SINUS TYMPANI

• Surgery is difficult
• Residual / recurrence of disease

PRUSSACK'S SPACE

• Related to tympanic membrane

• Superior boundary - lateral malleolar fold
• Medial boundary - neck of malleus
• Inferior boundary - lateral process of malleus
• Lateral boundary - pars flaccida / scutum
• MC site of cholesteatoma

INCUS
FOOT PLATE

STAPES

MALLEUS

• Foot plate of stapes develop from otic capsule

• Joints – 2
1) Malleus-incus → saddle type joint
2) Incus-stapes → ball & socket type joint
• Function - impedance matching (amplification of sound)
5
 NORMAL TM RETRACTED TM

POST ANT

- CANAL FOR TT
- EUSTACHIAN TUBE

6
• Antrum:
• Largest cell of mastoid
• Has Kovner's septum - petrous-squamous suture
• Land mark: Mc Ewen's triangle / Supra meatal triangle

inner ear 6: 0

7
• Cochlea - 2.5 coils
• Sensory organ of cochlea - Organ of corti

8
• Upper compartment - scala vestibuli
• Middle - scala media
• Lower - scala tympani

• Ions
 Endolymph - K+
 Perilymph - Na+

INNER HAIR CELLS OUTER HAIR CELLS

• Single row • Multiple rows
• No emission • Auto acoustic emission
• Not damaged easily • Damaged easily - loud sound / oto
toxic drugs

facial nerve anatomy 01:0 :46

• Branches:
1) Greater superficial petrosal nerve - vidian nerve
2) Nerve to stapedius - efferent to acoustic reflex
3) Sensory branch of facial - skin in external auditory canal
4) Corda tympani
5) +6
6) → Motor branches for 4 muscles
7) Parotid (5 terminal branches) - Pes anserimus → supply all facial
muscles
• 1, 3, 4 → sensory nerves
• 2, 5, 6, 7 → motor nerves

• Vidian nerve supplies

1) Lacrimal gland - tears production
2) Glands of nose & sinus

• Corda tympani supplies

1) Taste buds on anterior 2/3rd of tongue
2) Submandibular gland
3) Sublingual gland

9
Geniculate Ganglion
GSPN
N. to Stapedius
Chorda Tympani

Pes Anserimus

10
 Diseases of Throat
adenoid facies 00:47

• High-arched palate
• Prominent upper teeth & crowded teeth
• Pinched nose or collapsed ala
• Hypoplastic maxilla
• Dull expressions
• Rx: adenoidectomy

choanal atresia 01:37

1
• Congenital disease
• Etiology - bucconasal / oronasal membrane
• Part of Charge syndrome
• Life-saving - MC Govern's technique
• MC type U/L, partial & bony

oropharynx diseases 4: 7

QUINCY

• @ peritonsillar abscess
• Hot potato condition
• Rx: Immediate incision & drainage followed by interval tonsillectomy

RANULA

• Retention cyst of sublingual gland

• Rx: Marsupialization

LUDWIG'S ANGINA

• Cellulitis of submandibular space

• Woody hard floor of mouth
• Rx: incision & drainage

Tonsillitis 8:12
Infective Non-infective
• Viral-adenovirus - MC • SLE
• GABHS - strep pyogenes • Stevens Johnsons syndrome
• Epstein-Barr virus
• Bacteroids & fusobacterium

2
TYPES

1) Catarrhal - MC type → viral (adenovirus)

2) Follicular → strep pyogenes
3) Membranous → strep pyogenes
4) Parenchymato → strep pyogenes
5) Fibrinoid → any cause

GABHS – MC cause of throat membrane

DIPTHENIA

TONSILLECTOMY

• Indications:
1) MC recurrent tonsillitis
2) Chronic tonsillitis
3) Hemorrhagic tonsillitis
4) Rheumatic tonsillitis
5) Suspicion of malignancy
6) Quincy
7) Eagle's disease – enlarged styloid process

3
• Contra indications:
1) Acute tonsillitis
2) Bleeding disorder
3) Polio epidemic
4) Cleft palate
5) Cervical problems
6) Hb <10 gms

• Procedure: position - rose position

• Complications:
1) Bleeding (MC)
2) Dislocation of joints
3) Tooth extraction
4) Sepsis
5) Aspiration

Primary bleeding Reactionary bleeding Secondary bleeding

• During surgery • Within 24hrs of surgery • 5-8th day of surgery
• Rx: • Causes: • Cause – infection
1) Apply pressure 1) Dislodgement of clot • Rx: antibiotics, re-
[5- 10mins] 2) Slippage of ligature ligation under GA in OT
2) Cautery • Rx: immediate re-
3) Ligation ligature, under GA in OT

• Dislocation of joint:
1) Tempero-mandibular joint
2) Atlanto-axial joint - Grisel's syndrome

• Types / methods:
1) Snare
2) Bipolar / cautery
3) Cold knife
4) Hormonal knife
5) Debridement
6) Laser
7) Coblation radio frequency

4
5
Spaces 22:24

QUINCY RETROPHARYNGEAL PARAPHARYNGEAL

Larynx 4:1
LARYNGOMALACIA

• MC congenital disease
• A new born with inspiratory stridor
In supine position
In prone position

• Omega shaped epiglottis

• Rx: reassurance

SUBGLOTTIC STENOSIS

• Expiratory stridor
• Grading - Myer & cotton grading
• Rx:
1) Conservative
2) Steroid
3) Local application of mitamycin-C
4) Surgeries

GLOTTIC WEB

• MC site of Ant. glottis

6
voice disorders 2 :
• Dysphonia plica ventricularis
False cord in use
Rx: speech therapy

• Spasmodic dysphonia
@ Laryngeal dystonia
Spasm of adductor muscle
Rx: Inj Botox

• Functional Aphonia
Complete loss of voice
Rx - counselling / psycho therapy

• Puberphonia
@ Falsetto mutation
Adult male with irregular pitch
Rx - speech therapy, Gutzman's technique, type-3 thyroplasty

• Androphonia
Adult female with male-like voice
Rx - speech therapy, Type-4 thyroplasty
Other Rx options - deduction glottoplasty:
1) Wendler glottoplasty / ant web formation
2) Cricothyroid apprximation
3) Laser assisted glottoplasty

• Phonasthenia
Fatigued - inter-arytenoid and (or) thyroarytenoid
Findings - Key hole glottis

• Rhinolaia Aperta
@ Hypernasality
Cause - cleft palate, adenoidectomy

• Rhinolaia Clausa
@ Hyponasality
Causes - polyps, adenoid hypertrophy, tumor

7
vocal cord palsy 3 :30
• Thyroidectomy surgery - MC cause
• Idiopathic
• Tumors
• Ortner's syndrome
• Arthritis

RLN PALSY

• @ Abductor palsy

U/L
• Position - paramedian
• Hoarseness → normal
• No surgery
B/ L
• Position - paramedian
• Dyspnea with good voice
• Type-2 thyroplasty (lateralization),
Kashima's, cordoplasty, woodmen's /
arytenoidectomy

VAGUS PALSY

• @ Adductor palsy

U/L B/ L
• Position - cadaveric • Position - cadaveric
• Hoarseness • Aphonia with aspiration
• Type-1 thyroplasty • Aspiration → total laryngectomy (gold
(medialization), Injections of standard)
teflon

ELN PALSY

• Low pitch voice

• Loose vocal cord
• Askwed position

SLN PALSY

• Same as ELN palsy

• Along with aspiration

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THYROPLASTY

• Type-I
Position - medialization
Indication - adductor palsy & abductor spasm - improve voice

• Type-II
Position - lateralization
Indication - abductor palsy & adductor spasm → relieve dyspnoea

• Type-III
Position - shorten/loosen
Indication - Puberphonia - pitch of voice

• Type-IV
Position - lengthen / tense
Indication - Androphonia - pitch

Laryngitis 4 : 4
ACUTE EPIGLOTTIS

• Pathogen - Strep pyogenes, H. Influenza

• Age - 2-7 yrs
• Presentation:
1) Fever
2) Dyspnea
3) Dysphagia

• Cherry red epiglottis, thumb sign, tripod position

• DOC - 3rd gen cephalosporin

CROUP (ACUTE LARYNGO-TRACHEO-BRONCHITIS)

• Pathogen - Parainfluenza
• Age - <3 yrs
• Presentation:
1) Fever
2) Dyspnea
3) Voice change

• Steeple sign

9
• Rx:
1) Steroid
2) Nebulization with adrenaline
3) Antibiotics

LARYNGEAL TB

• Pathogen - mycobacterium
• Any age
• Presentation:
1) Fever
2) Throat pain

• Turban epiglottis, mouse nibble & cobble stone appearance,

• Rx: ATT

non-neoplastic growth of larynx 1: 4

V C NODULE

• @ Singer's nodue
• Etiology - chronic misuse of voice
• Diplophonia
• At junction of anterior 1/3rd & posterior 2/3rd of vocal cord
• Rx - voice rest → Micro Laryngeal Surgery
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V C POLYP

• Etiology - chronic misuse of voice

• Diplophonia
• At junction of anterior 1/3rd & posterior 2/3rd of vocal cord
• Rx - surgery ± voice rest
1) MLS
2) Pulse dye laser
3) Micro flap technique

RIENKE'S EDEMA

• Etiology - smoking + talkative, hypothyroidism (causes retention of fluid)

• No other complaint
• At Rienke's space
• Rx:
1) Conservative management
2) Micro flap technique
3) Stripping of vocal cord

LARYNGOCELE

• Etiology - trumpet blowers

• Neck swelling, Boyce sign, Bryce sign
• At saccule / ventricle
• Rx – surgery

INTUBATION GRANULOMA

• Etiology - intubation
• No other complaint
• At junction of anterior 2/3rd & posterior 1/3rd of vocal cord
• Rx:
1) CO2 laser +
2) Steroid +
3) Botox +
4) Mitamycin-C

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FOREIGN BODIES

AP AP LARYNX LATERAL - LATERAL - IN

EPIGLOTTIS / BEHIND AIRWAY
CRICOPHARYNX AIRWAY

12
 Inflammatory Diseases of Ear
otitis externa 00:10
OTOMYCOSIS

• Fungal disease
• Etiology - aspergillus niger
• In diabetics
• Black spores + wet blotting paper
• Rx - antifungal drops

RAMSAY HUNT SYNDROME

• Viral disease
• Etiology - herpes zoster infection of geniculate ganglion of VII nerve
• Vesicles + facial palsy
• Rx - Acyclovir + steroids

FURUNCULOSIS

• Bacterial disease
• Etiology - Staph Aureus
• Tragal sign
• Rx - Icthymol glycerol (hygroscopic)

MALIGNANT OTITIS EXTERNA

• Bacterial disease
• Etiology - pseudomonas
• In diabetics
• Granulation in auditory canal
• Investigation
1) MC - CECT
2) IOC - technetum 99 Scintigraphy
• DOC - 3rd gen Cephalosporins + anti diabetics

1
• Perichondrium → pseudomonas
• Cauliflower ear → hematoma (recurrent trauma)
MC in boxers

otitis media 0 :
ASOM

• Etiology - pneumococcus, H. influenza, moraxella

• Nasopharyngitis
• HL + pain
• Red & congested, bulging tympanic membrane, cart when appearance, fluid level
seen, light house sign, reservoir sign
• Rx - nasal decongestion + antibiotics ± myringotomy

SEROUS OTITIS MEDIA

• Etiology - sterile fluid (no pathogens)

• Age group - children
• Adenoid hypertrophy, nasopharyngeal carcinoma (adults)
• Only HL
• Blue to yellow & retracted tympanic membrane, air bubbles, fore shortened handle
of malleus
• Investigation - tympanometry (B-type / flat)
• Rx - myringotomy + grommet insertion ± adenoidectomy

ACUTE MASTOIDITIS

• Etiology - Strep pyogenes / GABHS

2
CHRONIC OTITIS MEDIA

• Etiology - pseudomonas

• Safe CSOM:
Copious discharge (purulent)
Central perforation, pale polyp
Investigation - examination under microscope (EUM)
Rx – myringoplasty
• Unsafe CSOM:
Fowl smelling scanty discharge (purulent)
Marginal perforation, red polyp, red granulations, cholesteatoma,
retraction pocket
Investigation - EUM
Rx - Modified radical mastoidectomy (MRM)

TUBERCLOSIS OF THE MIDDLE EAR

• Etiology - mycobacterium
• Painless & watery discharge
• Multiple perforations, pale granulations
• ZN stain
• Rx - Anti-tubercular therapy

ASOM

3
SOM

BLUE / YELLOW RETRACTED TM AIR BUBBLES

COSM

1) 2)

3) 4)

5)

1) Central perforation
2) Marginal perforation
3) Attic perforation
4) Retraction pocket
5) Multiple perforations

4
CHOLESTEATOMA

• Sac of keratinized squamous epithelium in middle ear

• Site - Prussack's space
• Types:
1) Congenital - embryonic residual tissue (Levenson's criteria)
2) Primary acquired - without any pre-existing disease (TM
perforation)
3) Secondary acquired - due to pre-existing disease → TM perforation
(surgery - myringoplasty, tympanoplasty)
4) Tertiary acquired - due to trauma / surgery
• Theories on formation:
1) Retraction pocket or negative pressure - Wittmack's theory
2) Basal cell hyperplasia - Ruede's theory
3) Metaplasia - Sade's theory
4) Invasion / Migration - Habermann's theory (2nd acquired
cholesteatoma)
• Wittmack's - most acceptable
• Retraction pockets has 4 grades
• Graded by TOS

Complications :
EXTRACRANIAL/INTRATEMPORAL
INTRACRANIAL COMPLICATIONS
COMPLICATIONS
• Ossicular damage • Meningitis (MC)
• Mastoiditis (MC) • Lateral sinus thrombophlebitis
• Petrositis • Subdural abscess
• Gradenigo's syndrome • Extradural abscess
• Labyrinthine fistula • Cerebral abscess
• Labyrinthinitis • Otitis hydrocephalus
• Facial nerve palsy

5
ACUTE MASTOIDITIS

• Strep pyogenes
• Findings:
1) Iron-out mastoid
2) Pinna - antero-inferiorly
3) Light house sign
4) Reservoir sign
• IOC - CECT
• X-ray - Schuller's + Towne's
• Findings:
1) Honey comb - normal
2) Clouded – mastoiditis
• Rx - antibiotics, symptomatic ± mastoidectomy (simple/MRM)

GRADENIGO'S SYNDROME

• CSOM present
• CSOM → Petrositis → apex of petrous → involve V & VI nerve → Gardenigo’s
Syndrome
• Features (3D):
1) Discharge - CSOM
2) Diplopia - VI nerve
3) Deep pain (retro orbital pain) - V nerve

LABYRINTHINE FISTULA

• MC site - bulge of LSCC

• Presentation:
1) Vertigo + nausea
2) Nystagmus
3) True +ve fistula test
• MRI
• Rx - immediate MRM & closure of fistula

6
LATERLA SINUS THROMBOSIS / SIGMOID SINUS THROMBOSIS

• Presentation - headache & fever (picket fence)

• Signs:
1) Gre singer's sign
2) Delta sign - plain CT
3) Tobey Ayer sign
4) Crow beck sign
• Rx - MRM & drainage of sinus

CEREBRAL ABSCESS SITES

1) Temporal lobe (MC)

2) Posterior fossa

FACIAL NERVE PALSY

• MC cause - idiopathic / Bell's palsy

• Rx - steroids (2-3 weeks) ± Acyclovir ± physiotherapy (nerve stimulation)
• No response for Rx, then:
1) Nerve stimulation test (electroneuronography)
• Grade I, II, III (mild) - recovery chances >90% → continue steroids
• Grade IV, V - recovery chances <10% → surgery
• Surgery:
1) Decompression
2) End to end anastomosis
3) Grafting
2) Topodiagnostic test
• Gives site of lesion
• Investigation of branches:
1) Lacrimation /Schirmer's test
2) Stapedial reflex
3) Taste / salivation

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 1st - lacrimation

2nd – Stapedeal reflex

4th – Taste & Salivation

• In a patient of Bell’s palsy, if:

1) All three tests are normal – Most likely site → Stylomastoid
foramen
2) First 2 normal, no taste / salivation – Most likely site → vertical
part of facial of facial nerve
3) Lacrimation normal, other two gone – Most likely site → horizontal
part of facial nerve
4) All gone – Most likely site → labyrinthine part of facial nerve

8
 Investigations of Ear Diseases
Tests 00:10
HEARING TEST

1) Tuning fork test - frequency = 512Hz

2) Audiometry - subjective investigation
3) Tympanometry - objective
4) BERA - objective
5) OAE – objective

VESTIBULAR FUNCTION TEST

1) Caloric test
2) Fistula test
3) Electronystagmography
4) Optokinetic test
5) Hint
6) Galvanic test
7) Posturography
8) VEMP - Vestibular Evoked Myogenic Potential

tuning fork tests 01:20

1) Rinne test
2) Weber test
3) ABC test / Schwabach's test
4) Bing test
5) Gelle test → -ve = otosclerosis
6) Stenger's test
7) Chimani-Moos test
8) Teal

1
 Right Ear Left Ear
• AC > BC • AC > BC (false +ve)
• Reduced • Reduced

• SNHL • SNHL - B/L, R > L

• Rinne test, Schwabach's test,
Weber test

Right Ear Left Ear

• AC > BC • BC > AC (false -ve)

• Normal or SNHL • Severe SNHL

• Schwabach's test

pure tone audiometry 0 :2

• Subjective type
• Results in the form of graph
• X = frequency of sound
• Y = loudness of sound (dB)
• Min frequency - 125 Hz & Max - 8000Hz
• Beyond 8000Hz - High frequency PTA
 For ototoxicity
• Graph bars – 4
 Right ear - AC & BC → red color
 Left ear - AC & BC → blue color
 Symbols:
1) Right AC - circle
2) Right BC - < or [
3) Left AC - X
4) Left BC - > or ]

2
• Interpretation
1) Normal hearing - all graphs <25dB
2) CHL - only AC is below 25 dB
3) SNHL - AC & BC below 25 dB
4) Mixed hearing loss - AC & BC below 25 dB
• Threshold:
 0-25 dB - normal
 >25 dB - hearing loss
• Differentiating SNHL from mixed hearing loss:
 Mixed HL - A-B > 15 dB
 SNHL - A-B < 15 dB
• Sudden dip at 2000 in BC - Carhart's Notch → otosclerosis
• Dip at 4000 in AC + BC - Boiler's dip → noise induced HL
• Upward slope in AC + BC → meniere's disease

3
• Right - normal
• Left - SNHL → Meniere's disease

Tympanometry 20:12
• @ Impedance audiometry
• MC used frequency - 220 Hz
• Types:
1) A - normal
2) As - otosclerosis
3) Ad - disruption of ossicles
4) B/flat - fluid in middle ear → serous otitis media
5) C/negative - eustachian tube blocked

4
BERA & otoacoustic emission 2 :02
• Otoacoustic emission - produced by outer hair cells of cochlea
• Common Indications:
1) Screen / confirm hearing loss in new born & infants
2) Differentiate between cochlea & retrocochlea - in patient with
sensory neural loss

• Most preferred - otoacoustic emission

• BERA:
 Total 7 peaks
 Important peak - 5th
 5th peak brain steam - lateral lemniscus

vestibular function test 2 :

CALORIC TEST

• Other names - Bithermal caloric test, Dundas grand test (cold air)
• Cold air CT - in patient with tympanic membrane perforation
• Bithermal test temperature - 30° (cold) & 44° (warm)

5
• Supine with head raised by 30°
 C - cold water (30°)
 O - opposite side
 W - warm water (44°)
 S - same side
• Hypoactive / tumor / trauma - cold
• Hyperactive / labyrinthitis / inflammatory disease – warm

FISTULA TEST

• Uses of Siegle's speculum

 Check the mobility of the membrane
 Instillation of powdered medication in ear
 Elicit signs like fistula sign
 Elicit signs like brown's sign
 During a tuning fork test called Gelle's test

False positive fistula test False negative fistula

True positive fistula test
1. Labyrinthine fistula,
or CSOM
2. Fenestration surgery
TypeV tympanoplasty
3. Post stapedectomy
4. Perilymph fistula
(Hennebert’s sign) test
1. Meniere’s disease 1. Dead labyrinth
2. Fistula which is
blocked by
cholesteatoma

• Dead ear
 Fistula test - false -ve
 Rinne's test - false –ve
6
 Non-Inflammatory Diseases of Ear
Otosclerosis 00:20
• Site - fistula ante fenestrum
• Etiology - measles, Col L A1 gene defect
• Stages - Active stage & Passive stage
 Active stage → 1st stage → Otospongiosis
 Passive stage → 2nd stage → Otosclerosis

• In young ladies (~30 yrs)

• Increases during pregnancy
• Presentation - conductive hearing loss ±
• Family H/o, SNHL (rarely)
• When SNHL is associated with cochlear otosclerosis
• Signs:
1) Schwartz - only in active stage, flamingo pink blush on TM
2) Paracussis Willisi - better hearing in noising areas

• PTA:
1) AC is below 25 mark
2) Carrhart’s notch
3) Cookie bite audiogram
• IOC: Tympanometry (AS type)
• TOC: Stapedectomy / Stapedotomy
 Only indication – passive stage
• C/I:
1) Active stage
2) Cochlear otosclerosis
3) Extreme age
4) Extreme athletes
5) Frequent flyers
• Complication:
1) MC – SNHL
2) Vertigo
3) True positive fistula test
4) Cholesteatoma
5) Facial palsy
• Indication:
1) Active stage
2) Cochlear otosclerosis
1
• DOC – Sodium fluoride
• Hearing aid

CHOLESTEATOMA

CHOLESTEROL GRANULOMA

RISING SUN SIGN

RISING SUN SIGN

inner ear diseases 0:

MENIERE'S DISEASE
• Other names - Endolymphatic hydrops
• Etiology - mutation in short arm of chromosome 6
• Fluctuating SNHL, tinnitus, episodic vertigo
• Vertigo - 24 mins to 24 hrs
• Hennebert sign (false +ve fistula sign)
• Tulio's phenomena
• Recruitment

2
• Investigations: glycerol test, electrocochleography (SP/AP >40%)
• Rx: betahistine, Meniett's device, surgeries

BPPV
• Etiology - otolith in post SCC
• Positional vertigo
• Vertigo - <20secs
• No special features
• Investigations: Dix Hallpike maneuver
• Rx: Epley's maneuver - otolith repositioning

SUPERIOR CANAL DEHISCENT SYNDROME

• Other names - Minor's syndrome
• Etiology - congenital defect
• Vertigo + conductive hearing loss
• Third window effect
• Tulio's phenomena
• Investigations: CT scan / MRI
• Rx: surgery

PRESBYACUSSIS
• Other names - Senile deafness
• Etiology - old age
• SNHL ± tinnitus
• No special features
• Investigations: PTA
• Rx: hearing aid

MENIETT’S DEVICE

• Produces low intensity pulsations

3
• Intra-Tympanic gentamycin
• @ Chemical vestibulectomy
• Placed at round window
• Done for Meniere's & BBPV

• Dix Hallpike maneuver – for diagnosis of BPPV

• Epley’s maneuver – for Rx of BBPV
4
 Minor’s Syndrome
(3rd window effect) Normal

ASSISTIVE DEVICE FOR HEARING

1) Hearing aid - amplify the sound
2) Brainstem implant - speech processor, not amplifier
3) Cochlear implant (in scala tympani via round window) - speech processor, not
amplifier
• Electrodes are implanted

5
 Nose & Sinuses
gastrointestinal physiology 00:20

• Bones of roof:
1) Cribriform plate
2) Fovea ethmoidalis
• Lining - olfactory epithelium:
 Tumor - esthesioneuroblastoma

• CSF Rhinorrhea
 MC cause - fracture of cribriform plate (trauma)
 Halo sign / target sign
 Tea pot sign
 Dx: glucose >30gm
 Beta-2 transferrin - most specific indicator
 IOC: HRCT & MR cisternography
 Rx - conservative
1
Nasal septum 0 :

• Septal cartilage:
 Unpaired
 Quadrilateral

2
• ECA:
1) Spheno palatine
2) Greater palatine
3) Superior labial
• ICA:
4) Anterior ethmoid
5) Posterior ethmoid

• Kiesselbach's plexus = 1 + 2 + 3 + 4
• MC site of epistaxis
• Epistaxis:
 Artery - spheno palatine
 Caused - Idiopathic
 Trauma to the nose (mc cause)
 Foreign body
 Hypertension adult
 Disorders of platelet, clotting factor, blood vessels
 Drugs - aspirin
 Tumors & malignancy
 Anatomical defects like DNS, spur
 Chronic infection

3
• Transnasal Endo SPA @ TES PAL
• Ligature → ECA
• Bleeding → Anterior ethmoidal ligature
• Recurrent & severe → septa-derma plasty

SEPTAL HEMATOMA

• B/L
• Immediate drainage
 Aspiration
 Incision & drainage

SEPTAL PERFORATION

• MC cause - submucosal resection

4
Lateral wall : 0

• 3 turbinates
1) Superior
2) Middle
3) Inferior - longest
• 4 meatus
1) Supreme (spheno ethmoidal recess)
2) Superior
3) Middle
4) Inferior - nasolacrimal duct
• 5 ostia
1) Maxillary → middle
2) Frontal → middle
3) Anterior ethmoidal → middle
4) Posterior ethmoidal → superior
5) Sphenoid → supreme
• Venus plexus - behind inferior meatus → Woodruff's plexus
• Nasolacrimal duct:
 Direction - down, back, outwards
 Blocked - dacryocystitis, Rx → dacryocystorhinostomy (middle
meatus)
 Cyst - naso-labial cyst

Sinuses :

• Maxilla > ethmoid > sphenoid > frontal

• Maxilla:
 Largest
 15ml volume
 @ antrum of highmove

5
• Ethmoid:
 Multicellular - 8-9 cells
 Largest - bulla ethmoidalis
 Most anteriorly placed - agar nasi
 Below orbit - heller cell
 Near optic nerve - onodi cell

Nerves 2 :

• Sensory nerve
• Olfactory - smell
• Autonomic nervous system → vidian nerve
1) Parasympathetic discharge
2) Sympathetic discharge
• Sensory nerve:
1) Anterior ethmoidal nerve
2) Nasopalatine nerve

6
Rhinosinusitis 2 :

1) Allergic rhinitis - type-1 hypersensitivity, MC allergen - house dust (mite)

2) Vasomotor rhinitis - vidian nerve imbalance → vidian neurectomy
3) Infective rhinitis - fungal, viral, bacterial
4) Irritative rhinitis

ATROPHIC RHINITIS:

• @ Ozeana
• Cause - estrogen, klebsilla ozeana
• Roomy cavity, crust, foul smell, anosmia, bleed
• Crust → nasal block
• Foul smell + anosmia → merciful anosmia
• Rx - estrogen spray, streptomycin
• Alkaline nasal douch = Na Bicarbonate + Na Biborate + Na Chloride
• Surgery:
1) Young's - nostril closed
2) Modified young's - partially closed nostril
3) Lautenslagers - lateral wall of nose is medialized

FUNGAL RHINOSINUSITIS

• Aspergillosis:
 A. Fumigatus
 MC → aspergilloma formation → excision

• Fulminant fungal sinusitis

 A. fumigatus
 Diabetic steroids
 Highly invasive → complication
 IOC - MRI
 Rx - Lyposomal Amphotericin-B + FESS

• Mucormycosis
 Rhizopus
 Cause, IOC & Rx - same as fluminant fungal disease
 Rhino-orbito-cebral mucormycosis
▪ Angio invasive
▪ Necrosis (black)
▪ Orbit & cranial cavity

7
ALLERGIC FUNGAL RHINOSINUSITIS
• Bi-polaris
• Type-1 HS
• Non-invasive in immunocompetent
• Fungus in nose
• Evidence of allergy
• CT → double density scan - poly, Ca+ deposits
• Rx - steroids + FESS

NORMAL POLYP, SINGLE DENSITY DOUBLE POLYP, ASF

BACTERIAL RHINOSINUSITIS
• Acute - pneumococcus, H. Influenza, morexella
• Chronic - staph aureus
• IOC - CT
• X-ray - occipito-mental view
 Closed mouth - water's view → maxilla
 Open mouth - pieuress view → maxilla & sphenoid

DEVIATED NASAL SEPTUM

• Cause - birth trauma
• Nasal block - mainly on same side
• Opposite side - rare
 Due to compensatory HT of inferior turbinate
• Headache - anterior ethmoidal syndrome / Sluder's neuralgia
• Cottle's test
• TOC - septoplasty, SMR

8
 SEPTOPLASTY SMR
• Freer's incision • Killian's incision
• Less complication • More complications
• After 17yrs • After 17yrs

NASAL POLYPS
• Poor blood & nerve supply
• Color - pale, do not bleed
• Painless
• Site:
 Adult - ethmoidal
 Child - maxillary / antero-choanal / Killian's polyp
• Cause – allergy (MC), infection, syndrome
• Samter's triad - ethmoidal polyp, asthma, aspirin sensitivity
• Syndromes:
1) Kartegenner's - bronchiectasis, polyp/sinusitis, situs
inversus/dextrocardia
2) Young's - polyp/sinusitis, bronchiectasis, Azoospermia/infertility

MAXILLARY POLYP ETHMOIDAL POLYP

• Infection • Allergy
• U/L & single • B/L & multiple (bunch of grapes)
• Non-recurrent • Recurrent
• TOC - antibiotics + fess • TOC - steroid + fess

Diseases :0

RHINOLITH
• Old calcified foreign body in nose
• U/L
• Foul smell
• Removed under GA

RHINOPHYMA
• Potato nose
• HT of sebacious gland
• Cosmetic surgery

9
RHINOSCLEROMA
• Klebsilla Rhinoscleromatis / Frisch bascilli
• Woody nose / Hebra nose
• Histopathology: Mikuliez cell & Russell body
• Rx: DOC - streptomycin, cautery excision

RHINOSPORIDIOSIS
• Cause - R. Seeberi
• Aquatic protozoa - costal area
• Strawberry polyp / bleeding polyp
• Rx: cautery excision, DOC - Dapsone

Fractures :

• MC bone - nasal bone ± septal septum fracture

• Septal:
1) Chevrellet - vertical
2) Jarjavary - horizontal

10
 Ash’s Forcep – Septum Fracture

Welson Forcep – Nasal bone fracture

• Maxilla fracture / Lefore / midface fracture

1) LF-I - longitudinal
2) LF-II - pyramidal
3) LF-III - craniofacial dysjunction
• In LF I, II & III:
 Malocclusion of teeth
 Orbital trauma
 CSF rhinorrhea
 CT scan
 Open reduction

Tumors :

• Inverted papilloma:
 @ Ringertz tumor
 Benign tumor of nose with malignant potential
 Male >50yrs
 Epistaxis
 CT scan / MRI
 Rx - Medial maxillectomy → excision with wide margin (1-2cm)

11
• MRI - convoluted cerebriform pattern/cerebral cortical gyrations

• Sino-nasal carcinoma
 MC site - maxilla → squamous cell carcinoma
 2nd MC site - ethmoid → adeno carcinoma (wood workers)
 Male >55yrs
 Epistaxis
 Ohngren's lines - medial canthus to angle of mandible

• Part above line - supra structure → poor prognosis

• Below line - infra structure → good prognosis
• Rx based on histopathology & CT scan
• Rx - surgery → RT

12
 Surgeries of Ear
Surgeries 00:17
• Myringotomy -ASOM
• Myringotomy with grommet insertion - SOM
• Myringoplasty - Safe CSOM
• Ossiculoplasty - Safe & unsafe CSOM
• Tympanoplasty - Safe & unsafe CSOM
• Mastoidectomy - unsafe CSOM

MYRINGOTOMY

1
MYRINGOPLASTY / TYPE | TYMPANOPLASTY
• Indication – safe CSOM
• Contraindication - unsafe COSM
• Graft - Temporalis fascia → MC
Low basal metabolic rate
Tough fascia
Long survival
• Other grafts:
Tragal perichondrium
Concha cartilage
Fat (small perforations)

OSSICULOPLASTY
• Repair of ossicles
• Etiology:
1) Otitis media (safe & unsafe)
2) Trauma - battle sign

PROSTHETICS

2
TYMPANOPLASTY
• Myringoplasty + ossiculoplasty
• Modified Wullstein classification
• Type I:
Myringoplasty - graft over head of malleus
• Type II:
Absent malleus handle
TM over incus
• Type III:
Columela
Stapedo-myringopexy
Only stapes present
TM reconstructed to lie on stapes head (myringostapediopexy)
• Type IV:
TM placed over round window & Eustachian tube to create Cavum
minor with baffle effect
• Type V:
Fenestration surgery
Fixed footplate
Fenestration / fistula on lateral semi-circular canal
Problem - vertigo, nausea, nystagmus, true +ve fistula sign

TYPE-1 TYPE-3 TYPE-4

MASTOIDECTOMY
• Simple
Other names Schwartz / Cortical
Indication - Acute mastoiditis

3
• MRM
1) Canal wall up
2) Canal wall down
• Indication – unsafe CSOM & cholesteatoma

• Radical
Indication - unsafe CSOM & cholesteatoma
3 steps (3E):
1) Exteriorization
2) Except - stapes foot plate
3) Eustachian tube is blocked

4
 Throat Anatomy
Pharynx anatomy 00:17

• Laryngopharynx = Laryngo pharynx + Hypopharynx

• Lower most limit of pharynx – C6
• Layers of pharyngeal wall:
1) Mucosal - MALT (lymphoid tissue)
2) Pharyngobasilar fascia
3) Muscular
4) Buccopharyngeal facia

• Mucosa associated lymphoid tissue → tonsils → Waldeyer's ring

PALATINE TONSILS ADENOID

• 2 in number • Single
• Non-keratinized squamous • Ciliated columnar epithelium
epithelium • Does not have crypts
• Has crypts - 10-15 • No capsule
• Has capsule

• Longest crypt in tonsil - Crypta magna

1
• Fossa of Rosenmuller - MC site of nasopharyngeal carcinoma
Lies behind the eustachian tube → compresses the tube easily →
Glue ear

Larynx anatomy 0 :

• False vocal cord @ vestibular fold

• True cord @ vocal fold
• Features producing voice:
Lined by squamous epithelium
Rinenke's space – rest of the larynx lined by mucosa
Narrowest part
No lymphatics

ADULT LARYNX INFANT LARYNX

• Lower - C3 to C6 • Higher - C2 + C3
• Tubular • Cone / funnel shape
• Narrowest part is glottis • Narrowest part is subglottis
• Harder cartilage • Softer cartilage
2
 3 UNPAIRED CARTILAGE 3 PAIRED CARTILAGE
• Cricoid - signet ring • Arytenoid
• Thyroid • Cunieform
• Epiglottis - elastic & cannot calcify • Corniculate

• Vocal cord movement:

Inward - adduction
Outward - abduction
Tension (for high pitch) - tight & lose
• Voice production – adduction & abduction
• Adduction muscle - posterior cricoarytenoid
• Abduction muscles:
1) Lateral cricoarytenoid
2) Interarytenoid
3) Thyroarytenoid (main)
4) Cricothyroid (weak)
• Tensor muscles:
1) Thyroarytenoid (weak)
2) Cricothyroid (main)
• Abduction & main adduction muscles are supplied by - recurrent laryngeal nerve
• Main Tensor - external laryngeal nerve (SNL)

Nerves 0: 7

• Vagus nerve – branches:

1) Superior laryngeal nerve (SLN)
2) Recurrent laryngeal nerve (RLN)
• SLN branches:
1) Internal laryngeal nerve - purely sensory → aspiration
2) External laryngeal nerve - purely motor → low pitch voice, loose
vocal cord

• RLN - all other muscles (Except – cricothyroid)

1) Hoarseness of voice
2) Dyspnea
• ILN damage - no palsy
• 4 palsies caused by damage to:
1) Vagus
2) SLN
3) RLN
4) ELN

3
Throat anatomy :1

• Arteries of tonsils:
1) Main - tonsillar branch of facial artery
2) Ascending pharyngeal artery
3) Ascending palatine artery
4) Descending palatine artery
5) Dorsal lingual artery
• Vein - paratonsillar plexus of vein
• Nerve supply:
Main - IX
Small - lesser palatine nerve (V2)

4
INDIRECT LARYNGOSCOPY MIRROR

DIRECT

5
FIBRE OPTIC LARYNGOSCOPY STROBOSCOPE – Vibration / waves of larynx

6
 Tumors of Ear
tumors 00:10
ACOUSTIC NEUROMA / VESTIBULAR
GLOMUS TUMOR
SCHWANNOMA
• MC tumor of middle ear • MC tumor of ear
• Para ganglioma • Schwannoma
• MC site - fingertip & ear • MC site - cerebro-pontine angle from
• CNL + pulsatile tinnitus** inferior vestibular nerve (VIII)
• Signs: • Neurofibromatosis type 2
1) rising sun sign • SNHL + tinnitus
2) Brown's sign • Loss of corneal reflexes –
3) Phelp's sign manifestation
4) Aquino sign • Sign - Histelberger's (VII nerve)
• Investigations: • IOC (gold standard) - Gadulinium MRI
1) CECT • Bera may be useful
2) biopsy - C/I • Rx: Surgery
3) DSA - Digital Subtraction • Histopathology: Antoni A with verocay
Angiography body & Antoni B
• Rx: Surgery • Other Rx - Gamma knife stereotactic
• Histopathology: Zelballen cell Radio Therapy
• MRI - Ice cream cone appearance

RISING SUN SIGN

ACOUSTIC NEUROMA MRI

1
 Tumors of Throat
Benign tumors 00:20
JUVENILE NP ANGIOFIBROMA LARYNGEAL PAPILLOMA
• Spheno palatine foramen • Glottis
• Cause - incomplete regression of • Cause - HPV 6 & 11 [Q]
brancheal arch arteries • A child with hoarseness
• Male child with severe recurrent • IOC - bronchoscopy
epistasis • Rx - microdebridement +
• Antral sign / holman miller intralesional injections of Acyclovir
• Fog face + Interferons
• Investigations:
1) CECT
2) DSA
3) biopsy is C/I
• Rx - embolization → excision (laser
/ bipolar)

PAPILLOMA DSA ANTRAL SIGN

Carcinoma 05:12

NASOPHARYNGEAL CARCINOMA LARYNGEAL CARCINOMA

• MC site - fossa of Rosenmuller • Site - glottis
• Bimodal • >55 yrs male
 Child <20 yrs • MC presentation - hoarseness
 Adult >40 yrs • Rx – stages:
• Cause: 1) I & II – transoral laser micro
1) EBV surgery, RT
2) Genetic 2) III, IV & IVb – concurrent chemo
3) Nitrosamine (smoked fish) radiation, surgery → RT
• MC presentation: 3) IVc – concurrent chemo radiation
1) cervical lymphadenopathy + salvage surgery
2) trotter's triad (soft palate
palsy, facial pain, HL)
• TOC - Chemo radiation

1
 LARYNGEAL CARCINOMA

Tracheostomy 10:0

• For laryngeal obstruction

• Site - ring 2 + ring 3
• Ring 1 → high tracheostomy
 Only for laryngeal carcinoma
• Complications:
 MC - dislodgement of tube, bleeding
 Subcutaneous emphysema
 Difficult decannulation (seen in child, men)

2
3