 Case Presentation: Otosclerosis Diagnosis

 A young woman with a history of progressive moderate bilateral

hearing loss presents to the OPD. The hearing loss worsened during her
pregnancy.
 Clues for otosclerosis:
 More common in females, especially in the second to third
decade.
 Bilateral disease.
 Hearing loss worsens during pregnancy.
 Diagnosis: Otosclerosis.
 Treatment of choice: Surgery.
 Surgical procedure: Stapedotomy or stapedectomy.
 Choice between similar options: Stapedotomy or tympanotomy.
 Important clue for decision-making: Look for subtle differences in
choices.
 Bone Anchored Hearing Aid (Baha)
 Bone anchored hearing aid used when normal hearing aids cannot be
used.
 Indications for Baha:
1. Bilateral profound sensorineural hearing loss (not the primary
choice for cochlear implant).
2. Chronic discharging ear (wet ear).
3. Absence of pinna (congenital external auditory canal atresia).
 Appearance of Baha: Consists of a screw, a hearing aid, and an
attachment for anchoring.
 Superior Canal Dyson Syndrome
 Case Presentation: 35-year-old patient with hearing loss, vertigo on
loud sounds, and vertigo on blowing the nose.
 Diagnosis: Superior Canal Dyson Syndrome.
 Unique features:
 Tulio's phenomenon: Vertigo on hearing loud sound.
 Conductive hearing loss due to third window phenomenon.
 Third window phenomenon: Sound energy leaks into the skull through
an additional window (Superior Canal Dyson Syndrome).
 Expected Questions: Tulio's phenomenon, third window phenomenon,
and conductive hearing loss in Superior Canal Dyson Syndrome.
 Cochlea Anatomy: Reason Membrane
 Question: Which membrane separates scala vestibuli and scala media in
the cochlea?
 Answer: Reissner membrane.
 Cochlea parts: Scala vestibuli, scala media, scala tympani.
 Reissner membrane is the separator between scala vestibuli and scala
media.
These key points cover otosclerosis diagnosis, Baha indications, Superior Canal Dyson
Syndrome features, and cochlea anatomy related to the Reason Membrane.
Understanding these concepts is crucial for ENT examination preparation.

 Membranes in the Inner Ear

 Basilar Membrane: Separates scala media and scala tympani in the cochlea.
Organ of Corti is located on it.
 Tectorial Membrane: Covers the organ of Corti in the cochlea.
 Sharpey's (Pars Flaccida) Membrane: Upper part of the tympanic membrane in
the ear.
 Secondary Tympanic Membrane: Another name for the round window
membrane in the ear.
 Otoliths and Linear Balance
 Otoliths (Otoconia): Found in utricle and saccule, known as otolithic organs.
Function in linear balance.
 Macula: Sensory end organ in utricle and saccule.
 Linear Balance: Function related to utricle and saccule.
 BPPV (Benign Paroxysmal Positional Vertigo):
 Autoconia enter semi-circular canals, causing vertigo.
 Most commonly involves the posterior semi-circular canal.
 Diagnostic Test: Dix-Hallpike maneuver.
 Treatment: Epley maneuver (five-position maneuver).
 Crista, Ampulla, and Cupola
 Crista: Sensory end organ in the ampulla of semi-circular canals.
 Ampulla: Dilated end of the canal, contains the crista.
 Cupola: Gelatinous layer covering the crista in the ampulla.
 Blow Out Fracture of Orbit
 Injury: Commonly caused by a cricket or golf ball.
 Fracture Site: Floor or inferior wall of the orbit.
 Radiological Sign: Teardrop sign.
 Prolapse: Orbital contents may prolapse into the maxillary sinus.
 Adenoid Hypertrophy and Glue Ear (Otitis Media with Effusion)
 Clinical Presentation: Child with nasal obstruction, mouth breathing, and
hearing loss.
 Diagnosis: Adenoid hypertrophy with glue ear.
 Other Name for Glue Ear: Otitis Media with Effusion (OME).
 Visual Clue: Air bubbles trapped behind the tympanic membrane in the middle
ear.

These notes cover various aspects of the anatomy and pathology of the ear, including
membranes, otoliths, BPPV, blow-out fracture of the orbit, and adenoid hypertrophy with glue
ear. Understanding these concepts is crucial for a comprehensive understanding of ear-related
conditions in clinical practice.

 New Name for Glue Ear (Otitis Media with Effusion)

 Also known as serous otitis media or secretory otitis media.
  Four names for glue ear: Glue ear, otitis media with effusion, serous
otitis media, and secretory otitis media.
 Nasopharyngeal Carcinoma (NPC)
 Cause: Epstein-Barr virus (EBV).
 Also referred to as serous otitis media.
 Blow Out Fracture of Orbit
 Injury: Commonly caused by a cricket or golf ball.
 Fracture Site: Floor or inferior wall of the orbit.
 Radiological Sign: Teardrop sign.
 Prolapse: Orbital contents may prolapse into the maxillary sinus.
 Adenoid Hypertrophy and Glue Ear (Otitis Media with Effusion)
 Clinical Presentation: Child with nasal obstruction, mouth breathing,
and hearing loss.
 Diagnosis: Adenoid hypertrophy with glue ear.
 Other Name for Glue Ear: Otitis Media with Effusion (OME).
 Visual Clue: Air bubbles trapped behind the tympanic membrane.
 Atrophic Rhinitis
 Treatment:
 Alkaline nasal douching to remove crusts.
 Surgical intervention: Modified Young's operation (permanent
partial closure of both nostrils).
 Cotton's Maneuver
 Used to check for nasal valve blockage.
 Two fingers on the cheek, lifting upward to assess nasal valve
obstruction.
 Hemlich Maneuver
 Indication: Foreign body aspiration or laryngeal foreign body causing
choking and aphonia.
 Action: Apply pressure on the epigastrium.
 Puberphonia (Mutational Falsetto)
 Treatment: Gutzman maneuver.
 Gutzman maneuver involves pressing the thyroid cartilage backward
during speech therapy.
 Traumatic CSF Leak
 Visual Sign: Target sign or halo sign on filter paper.
 Cause: Tight skin suture around the tracheostomy site.
 Acute Epiglottitis
 Clinical Features: Stridor, drooling, muffled voice, and difficulty in
breathing.
 Management: Urgent intubation; no delay for imaging or antibiotics.
 Rhinophyma
 Hypertrophy of sebaceous glands of the external nose.
  Also called potato nose.
 Differentiated from basal cell carcinoma by its non-cancerous nature.
 Failure to Thrive with Mouth Breathing and Hearing Loss
 Diagnosis: Adenoid hypertrophy with glue ear.
 Management: Adenoidectomy with grommet insertion (D Choice).

These notes cover a range of ENT-related conditions, their diagnoses, and treatment
options. Understanding these concepts is vital for clinical practice and medical
examinations.

Commitment to Answer Choices:

 Always make a commitment to yourself that you will read all four choices in a
question, no matter how simple it may seem.
 Emphasize the importance of reading all choices even if someone else has
typed them.

2. Glue Ear (Otitis Media with Effusion):

 Glue ear leads to hearing loss and fullness in the ear.

 Type B tympanogram (flat) is a characteristic feature of glue ear.
 Another name for glue ear is Otitis Media with Effusion.

3. Juvenile Nasopharyngeal Angiofibroma (JNA):

 Epistaxis (bleeding from the nose) and a reddish nasal mass in a young boy
are indicative of JNA.
 The complete name is Juvenile Nasopharyngeal Angiofibroma.

4. Nasopharyngeal Carcinoma (NPC):

 Neck swelling, one-sided hearing loss, and temporal parietal neuralgia are
common presentations.
 Originates from the fossa of Rosenmuller.
 Metastatic cervical lymphadenopathy is a typical presentation.

5. Hallerman Miller Sign:

 A characteristic radiological sign seen in angiophagroma.

 It involves the anterior bowing of the posterior wall of the maxilla.
6. Bone Conduction in Hearing Loss:

 Bone conduction is poor in sensory neural hearing loss.

 Stapes fixation in otosclerosis causes conductive hearing loss.

7. Arnold Nerve (Auricular Branch of Vagus):

 Stimulation can lead to syncope (syncopal episode) during ear examination.

 Stimulation can also cause coughing.

8. Battle Sign:

 Bruising over the mastoid area, indicative of skull base or temporal bone
fracture.

9. Radiology - Foreign Body Localization:

 If a foreign body is visible in both front and lateral X-rays, it is in the

esophagus.

10. Endoscopic DCR Bone Punch: - Used in Dacryocystorhinostomy (DCR) surgery

for opening the lacrimal sac into the nose. - Named as Garrison's Endoscopic DCR
Bone Punch.

11. Glomus Tumor: - Pulsatile tinnitus in a female patient is indicative of Glomus

tumor. - Glomus jugular in females and Angiofibroma in young males are two
vascular tumors in ENT.

Final Reminder:

 Focus on common things in the exam. Stick to your initial answers and avoid
overthinking.

These notes cover a range of topics related to ENT, including common conditions,
radiological signs, surgical instruments, and diagnostic approaches.

The lecture covered various medical topics, including:

1. Tonsillitis and Membranes on Tonsils:

 Acute membranous tonsillitis is commonly caused by Streptococcus
pyogenes (Strep throat).
  Conditions causing white membrane on tonsils include streptococcal
tonsillitis, diphtheria, infectious mononucleosis.
 Ludwig's angina is an infection of the floor of the mouth, leading to
chin swelling and Christmas (difficulty in mouth opening).
2. Diphtheria:
 Diphtheria presents with throat pain, fever, cervical lymphadenopathy,
and a whitish membrane on the tonsil that bleeds on scraping.
 Diphtheria membrane is a pseudo-membrane, bleeds on removal, and
extends beyond the tonsil.
3. Mucormycosis in COVID-19 Patients:
 Black nasal discharge and blackish nasal mass extending into the orbit
are indicative of mucormycosis.
 Common in young diabetic, HIV-positive, and COVID-19 patients.
4. Sinus X-ray Views:
 Water view (also called peris view) is commonly used for sinus imaging.
 Water view shows all sinuses except posterior ethmoid air cells and is
particularly good for visualizing the maxillary sinus.
5. Ludwig's Angina:
 Ludwig's angina is an infection of the floor of the mouth, often
originating from dental infections, causing chin swelling and difficulty
in mouth opening.
6. Acute Epiglottitis:
 Thumb sign on X-ray indicates swelling of the epiglottis.
 Streptococcus pneumoniae is now the most common cause due to
immunization, surpassing Haemophilus influenzae type B.
7. Croup (Laryngotracheobronchitis):
 Steeple sign on X-ray indicates narrowing of the subglottic area.
 Management includes humidified oxygen, bronchodilators, steroids,
and antibiotics in a hospital setting.
8. Earache after Tonsillectomy:
 Glossopharyngeal nerve (CN IX) is responsible for earache after
tonsillectomy due to its association with the tonsillar bed.
9. Cochlear Implant:
 Indicated in bilateral profound sensorineural hearing loss not
responsive to hearing aids.
 Cochlear implant electrode is placed in the scala tympani of the cochlea
through the round window.
10. Neurofibromatosis Type 2 (NF2) and Vestibular Schwannoma:
 Cochlear implant is the appropriate treatment for hearing rehabilitation
in patients with NF2 and bilateral vestibular schwannoma.
The lecture covered a range of topics in otolaryngology, providing insights into
various conditions, their presentations, and management strategies.

Topic: Cochlear Implant Surgery and Related Conditions

1. Cochlear Implant Surgery Prerequisites:

 Cochlear implant surgery is a costly procedure.
 The prerequisite for cochlear implant surgery is normal eighth nerve
(Now Beta).
 The electrode in cochlear implant surgery stimulates the eighth nerve.
 Eighth nerve must be normal for the surgery to be successful.
2. Neurofibroma Type 2 (NF2):
 NF2 is a crucial pathology.
 It involves bilateral vestibular schwannoma, leading to bilateral eighth
nerve tumors.
 Cochlear implant is not effective in the presence of bilateral eighth
nerve involvement.
 Hearing aids are ineffective when the eighth nerve is damaged.
 Brainstem implant surgery is a better option in cases of bilateral eighth
nerve involvement.
 Location for brainstem implant: Lateral recess of the fourth ventricle.
3. Laryngeal Cartilage Calcification:
 All laryngeal cartilages, except the epiglottis, undergo calcification with
age.
 Epiglottis remains a soft, elastic, leaf-like cartilage throughout life.
 Posterior cricoarytenoid muscle is the only abductor of the vocal cord.
4. Congenital Inspiratory Stridor - Laryngomalacia:
 Inspiratory stridor since birth suggests a congenital anomaly.
 Laryngomalacia is the most common congenital anomaly of the larynx.
 Stridor decreases in prone position.
 Cry remains normal as vocal cords are unaffected.
 Treatment is conservative; surgery is not required.
5. Omega-Shaped Epiglottis in Laryngomalacia:
 Laryngomalacia is characterized by an omega-shaped (folded)
epiglottis.
 Inspiratory stridor is a key clinical feature.
6. Unpaired Cartilage of Larynx:
 Thyroid, cricoid, and epiglottis are unpaired cartilages.
 Epiglottis remains soft and does not calcify with age.
7. Trumpet Blower with Neck Swelling - Laryngocele:
 Laryngocele is an air-filled neck swelling.
  Common in individuals who use their larynx intensively (e.g., trumpet
blowers).
 Bryce's sign is observed (sound of air leak when pressed).
8. Handling Unknown Questions in Exams:
 In challenging exams, encounter many unknown questions.
 The best strategy is to focus on fully known and partially known
questions.
 Stay positive, avoid overthinking, and aim for rational answers.
 Retain hope, attempt all questions, and avoid unnecessary changes in
answers.
9. Hereditary Cancer in India - Oral Cavity:
 Chewing tobacco (pan masala) contributes to oral cavity cancer in India.
 Buccal mucosa is the most common site.
10. Killian's Dehiscence:
 Weakness in the inferior constrictor muscle.
 Between the oblique (thyropharyngeus) and circular (cricopharyngeus)
fibers.
 Site of Zenker's diverticulum formation.
11. Bilateral Choanal Atresia:
 Choanae are the posterior openings of the nasal cavity.
 Bilateral choanal atresia leads to respiratory distress in neonates.
 Baby turns cyanotic due to blocked nasal passages.

These notes cover key points on cochlear implant surgery, related conditions,
laryngeal issues, exam strategies, and specific medical conditions.

 Importance of Nasal Breathing:

 Closing the nose can save yourself by opening the mouth for breathing.
 Children are not aware of the alternative breathing through the mouth.
 Neonate Breathing:
 Neonates (one-minute-old) only know nasal breathing.
 Lack knowledge of alternative breathing methods.
 Obligatory nasal breathers.
 Respiratory Difficulty in Neonates:
 Newborns face respiratory difficulty due to being obligatory nasal
breathers.
 Cause of Respiratory Difficulty:
 Bilateral complete choanal atresia in babies.
 Neonates don't realize they can breathe through the mouth.
 Immediate life-saving technique: MacGowan's technique.
 Keep the baby's mouth open using a wide bore nipple or
oropharyngeal airway.
 Cyanosis at Birth:
 Newborns exhibit cyanosis at birth due to nasal blockage.
 Cyanosis resolves when the baby cries (opens the mouth for breathing).
 Mucormycosis in Neonates:
 Blue baby turning pink on crying indicates choanal atresia.
 Immediate management: MacGowan's technique (keeping the mouth
open).
 Diabetic Ear Pain:
 Severe earache and blood-stained ear discharge in a 60-year-old
diabetic.
 Diagnosis: Malignant external otitis.
 Caused by Pseudomonas.
 Protest Triad in Nasopharyngeal Carcinoma (NPC):
 Triad: Temporoparietal pain, conductive hearing loss, neuralgia in
temporal parietal area.
 NPC's key feature: Cranial nerve involvement in the nasopharynx.
 Allergic Tribe (Aspirin Sensitivity):
 Aspirin sensitivity in asthma, nasal polyps, and anastasates allergy.
 Nasal polyps in allergic conditions.
 Sample triad related to aspirin sensitivity.
 Gradynico Syndrome:
 Mnemonic: Gerd Gianna Gradynico.
 Features: Temporoparietal pain, conductive hearing loss, retro-orbital
pain, diplopia.
 Nasopharyngeal carcinoma mnemonic: NPC (Neuralgia, Palsy,
Conductive hearing loss).
 Septal Hematoma:
 Bilateral nasal blockage post-trauma with swelling around the nose.
 Diagnosis: Septal hematoma.
 Treatment: Aspiration of septal swelling to avoid complications.
 Type 1 and Type 2 Thyroplasty:
 Type 1: Medialization for adductor palsy.
 Type 2: Lateralization for abductor palsy.
 Understanding the "mad" mnemonic.
 Conservative Treatment for Traumatic Tympanic Membrane Perforation:
 Traumatic perforation needs conservative treatment.
 Avoid surgery and ear drops, focus on keeping the ear dry for natural
healing.
 COVID-19 and Mucormycosis:
 COVID-19 patients with blackish discharge indicate mucormycosis.
 Drug of choice: Liposomal Amphotericin B.
 Diphtheria and Vocal Cord Palsy:
  Diphtheria causing right-side vocal cord palsy.
 Unilateral vocal cord palsies don't need surgical treatment.
 Encouragement to Students:
 Maintain a stable mindset.
 Revise thoroughly and have confidence in the knowledge gained.

 Laryngomalacia:
 Treatment is conservative.
 Emphasizes the importance of conservative management.
 Unilateral Vocal Cord Palsy:
 No need for surgery in unilateral vocal cord palsy.
 Traumatic perforation of the tympanic membrane also requires
conservative treatment.
 CSF leaks may resolve on their own; conservative management is
recommended.
 Conservative Treatment Clarification:
 Conservative treatment doesn't mean doing nothing.
 Antibiotics and supportive care are part of conservative management.
 It implies avoiding aggressive interventions or surgery.
 Types of Thyroplasty:
 Type 1: Medialization for adductor palsy (Mad - Middleization
Adductor).
 Type 2: Lateralization for abductor palsy.
 Type 3: Shortening/Loosening for puberphonia.
 Type 4: Lengthening/Tightening for androphonia.
 Mucormycosis in COVID-19 Patients:
 Blackish discharge around the eye indicates mucormycosis.
 Drug of choice: Liposomal Amphotericin B.
 Importance of choosing the correct option in multiple-choice
questions.
 Teriyaki Syndrome Question:
 A fictional syndrome to emphasize not getting caught up in unknown
details.
 Importance of focusing on familiar topics during exams.
 Functional Euphonia:
 Sudden loss of voice in a young girl.
 Diagnosis: Functional euphonia.
 Cough remains normal; patient is "acting."
 Unsafe CSF Leak:
 History of headache related to watching a computer screen (CSF leak).
 Symptoms: Vomiting, confusion, epileptic fits.
 Brain abscess, especially in the temporal lobe.
 Treatment: Neurosurgery.
 Reminder on Brain Abscess:
 Symptoms include headache, vomiting, and epileptic fits.
 CT scan essential for diagnosis.
 Neurosurgery manages brain abscess, not ENT.
 Encouragement to Students:
 Maintain focus during exams.
 Acknowledge the brain's tendency to emphasize the unknown.
 Trust instincts during exams, especially in unfamiliar scenarios.

 Unsafe CSF Leak and Brain Abscess:

 Ear discharge due to unsafe CSF leak.
 Symptoms: Headache, convulsions, confusion, vomiting.
 CT scan reveals brain abscess.
 Treatment: Neurosurgery.
 Foul-Smelling Blood-Stained Ear Discharge:
 Indication of unsafe CSF leak.
 Patient history: Foul-smelling, blood-stained, occasional discharge.
 Fever, headache, pitting edema over mastoid region.
 Classic sign: Grassinger sign (pitting edema over mastoid).
 Diagnosis: Sigmoid sinus thrombosis (intracranial complication of
unsafe CSF).
 Feature of Meniere's Disease:
 Episodic vertigo, tinnitus, hearing loss.
 Meniere's disease presents in episodes.
 Diplacusis in Meniere's Disease:
 Feature of Meniere's disease.
 Duplicousis: Hearing the same sound in two frequencies.
 Differentiate from other hearing conditions.
 Carhart's Notch in Otosclerosis:
 Specialized tuning fork test.
 Otosclerosis indicated by a dip at 2000 Hertz.
 Differentiate from other audiogram patterns.
 Special Dips in Audiogram:
 Rising audiogram: Meniere's disease.
 Sloping audiogram: Presbycusis.
 Two special audiograms with distinct patterns.
 Basal Turn of Cochlea:
 Basal turn senses high-frequency sounds.
 Apex of cochlea senses low-frequency sounds.
 Cochlear anatomy and its frequency sensitivity.
 Tensor Veli Palatine Muscle:
  Muscle responsible for opening Eustachian tube during swallowing.
 Anatomy question emphasizing the role of muscles in ear function.
 Hearing Loss during Pregnancy:
 Otosclerosis worsens during pregnancy.
 Young woman with bilateral hearing loss during pregnancy suggests
otosclerosis.
 Diagnostic Audiogram - Basilar Membrane Pathology:
 High-frequency hearing loss due to basal turn pathology.
 Identify the structure closest to the site of pathology.
 Answer: Oval window.
 Ossicular Identification - Incus:
 Differentiate incus from malleus.
 Incus has a flat body; malleus has a rounded head.
 Visual cues for ossicular identification.
 Cochlear Implant Indication:
 Surgery for deaf children with bilateral profound sensorineural hearing
loss.
 Eighth nerve should be normal.
 Cochlear implant is not for neurofibroma type 2 (NF2).

 Vocal Nodules in a Teacher with GERD:

 Teacher with a history of gastroesophageal reflux disease (GERD).
 Develops voice problems, likely laryngitis.
 Visual diagnosis: Vocal nodule, also known as teacher's nodule.
 Treatment: Voice rest and proton pump inhibitor (PPI).
 Avoid surgery for vocal nodules.
 Instruments in ENT:
 Tongue Depressor:
 Used for examining the oral cavity and oropharynx.
 Lack (L-Shaped):
 L-shaped instrument used in ENT procedures.
 Mollison Self-Retaining Mastoid Retractor:
 Used for ear surgery.
 Post-Tonsillectomy Hemorrhage:
 Primary Hemorrhage:
 During surgery or in the first 24 hours.
 Severe bleeding due to ligature slippage.
 Requires re-exploration.
 Secondary Hemorrhage:
 After 24 hours, mostly after the fifth day.
 Caused by infection.
  Mild bleeding, treated with intravenous antibiotics.
 Grisel Syndrome:
 Occurrence:
 Associated with adenoid tonsillectomy.
 Description:
 Over-extension of the neck during Rose position.
 Leads to C1-C2 subluxation.
 Complication: Grisel syndrome.
 Quincy (Peritonsillar Abscess):
 Characteristics:
 Uvula is angulated.
 Tonsil pushed medially.
 Christmas difficulty and hot potato voice.
 No outer neck swelling.
 Parapharyngeal Abscess:
 Differentiation from Quincy:
 Presents with outer neck swelling.
 Similar symptoms but involves external neck tissues.
 Rhinoscleroma:
 Symptoms:
 Atrophic rhinitis, crusting, bad smell.
 External nose becomes hard.
 Differentiation:
 Rhinoscleroma when the external nose is hard.
 Queen-K Syndrome:
 Differentiation from Quincy:
 Edema of the uvula.
 Different from Quincy disease.
 Mysore Park Syndrome:
 Clarification:
 No such syndrome.
 Focus on known topics for effective preparation.
 Exam Preparation Tips:
 Focus on What You Know:
 Emphasize known topics in revision.
 Build Confidence:
 Confidence comes from thorough revision.
 Aim for self-assurance on exam day.
 Wishing Good Luck:
 Good luck wishes from faculty members.
 Encouragement to revise and perform well.